Diode Lasers for Impacted Teeth Minimally-Invasive Exposure: Comparison
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Please note this is a comparison between Version 1 by Ali Borzabadi-Farahani and Version 2 by Amina Yu.

 The use of diode lasers for oral surgery soft tissue procedures is associated with less pain and bleeding, quick recovery, and better surgical site visibility.  For uncovering superficially impacted teeth with no overlying bone layer, the conventional surgical exposure and orthodontic traction often involve reflecting the surgical flap with a scalpel, releasing incisions apical to the adjacent teeth, and managing surgical site bleeding, pain, and postoperative swelling. The management of impacted teeth is time-consuming (two to three years) and expensive.

  • diode laser
  • impacted canine
  • impacted premolars
  • surgical orthodontics

[1]1. Introduction

Excluding the third molars, the impaction of permanent teeth is reported with a prevalence of 2.9% [1][2][1,2] to 13.7% [1][2][3][4][5][6][7][8][1,2,3,4,5,6,7,8], with canines and second premolars being the most involved [1][3][4][5][6][7][8][1,3,4,5,6,7,8]. Failure of eruption or tooth impaction can be due to local or systemic factors [9][10][9,10]. The impaction of mandibular canines and premolars occasionally occurs and it is often associated with crowding in the dental arches [1]. Mandibular second premolars can become impacted, leading to complications such as root resorption of the adjacent first molars or continued root development in close proximity to the inferior dental alveolar nerve, which is a surgical challenge [11]. The impaction of mandibular canines is less common compared to the maxillary canines, with an incidence between 0.92% and 5.1% [12]. Impacted mandibular canines may be associated with odontomas (up to 20%) and lateral incisor anomalies (16%) [12]. Surgical extraction (89% in some studies) and orthodontic traction (20–32%) are cited as the suggested treatment modalities, with the orthodontic traction showing a failure rate of about 17% [12].
For uncovering superficially impacted teeth with no overlying bone layer, the conventional surgical exposure and orthodontic traction often involve reflecting the surgical flap with a scalpel, releasing incisions apical to the adjacent teeth, and managing surgical site bleeding, pain, and postoperative swelling. The management of impacted teeth is time-consuming (two to three years) and expensive. Surgical exposure requires the retraction of soft tissues, allowing for adequate visualization of the surgical site, bonding of the impacted tooth with a bracket or attachment, and, if possible, simultaneous orthodontic traction [13]. Surgical site bleeding complicates the orthodontic bonding process, and clinicians should deal with intra- and post-operative pain, swelling, and the possible risk of site infection [13].
Where applicable, the alternative approaches are to use the diode lasers or elecrosurgery for surgical exposure of impacted teeth if they are not deeply impacted and covered by bone [14][15][14,15]. Diode lasers produces a surrounding zone of thermal necrosis and healing, promoting healing and sterilization of the surgical site (14,15). Electrocautery produces adequate hemostasis, but results in greater and deeper thermal damage and has no self-sterilizing properties (14,15). Compared to conventional exposure using a scalpel, patients who received laser exposure showed little need for intra-operative local anaesthesia, experienced reduced post-surgical pain (fewer took analgesics), and did not show any post-surgical side effects such as bleeding and oedema [16]. Compared with a scalpel, the initiated fibre-optic tip of the diode laser device easily cuts, ablates, and reshapes the oral soft tissues, with no or reduced bleeding and less pain, as well as no or less need for suturing [15][16][17][18][15,16,17,18]. This is mainly due to laser penetration in the surrounding tissues during high-level laser treatment, stimulating tissues and cells without producing irreversible thermal changes in the tissues (photobiomodulation), resulting in wound healing in the surrounding tissues [17].
However, it is not clear what type of information is available for clinicians when comparing the surgical exposure of impacted teeth or the management of teeth with delayed eruption using diode laser surgical exposure or the conventional scalpel method. Therefore, the purpose of thits scoping review was to systematically map the available evidence and identify the gaps in theour knowledge on the efficacy of impacted-tooth laser surgical exposure compared to conventional scalpel surgical exposure in terms of the reduction in pain, bleeding, oedema, and the need for infiltration anaesthesia.

2. Diode Lasers Used for Minimally Invasive Exposure of Impacted Teeth or Teeth with Delayed Eruption

Most reports of the surgical laser exposure of impacted teeth involve maxillary canines and incisors, which are relatively safe to operate on. However, reports on the laser exposure of mandibular impacted teeth close to vital nerves such as the mental nerve are limited [19][24]. The present reponert highlights the benefits of using in-office diode lasers for the exposure of mandibular impacted teeth near the mental nerve, where a precise surgical exposure is needed. This provides better surgical site visibility, is less traumatic and minimally invasive, and eliminates scalpel surgery complications (for examplei.e., possible nerve damage, infection, and swelling). Ideally, soft tissue laser surgery involves the right combination of ablating, incising, and excising the soft tissue, the provision of the much-needed coagulating effect, and no or very limited interaction with hard tissue [15][18][15,18].
Frequently used dental soft tissue lasers are mainly diode lasers due to their smaller devices and lower cost [15][18][15,18]. Diode lasers (800–980 nm) provide deep soft tissue penetration and very good coagulation/haemostasis, with minimal dental hard tissue interaction [15][17][18][15,17,18]. Carbon dioxide lasers (10,600 nm) offer good ablation of both hard and soft tissues, with shallow soft tissue penetration of 0.2 mm, superficial carbonization and coagulation at a much higher cost, and less control over bleeding, necessitating the use of surgical dressing [20][25]. Erbium lasers (Er:YAG laser (2940 nm) and Er,Cr:YSGG laser (2780 nm)) are relatively expensive; they penetrate soft tissues as shallow as 5 μm, creating precise ablation with minimal thermal effects and a low inflammatory response, but with weak coagulation properties and bleeding at the surgical site [15][17][18][15,17,18]. The Nd:YAG laser (1064 nm), a deeply penetrating type of laser with a relatively thick coagulation layer on the lased soft tissue surface and with strong haemostasis, is another laser with minimal dental hard tissue interaction [15][18][15,18].
There is growing evidence that photobiomodulation with diode laser light (808–940 nm), which is associated with the use of most diode lasers, results in a greater number of newly-formed osteoblasts and matrices, increases in collagen synthesis, and microvascular re-establishment [21][22][19,26]. Diode lasers are the ideal choice for the orthodontic set-up because of the smaller size of the laser device, good penetration (photobiomodulation) and haemostasis, as well as the relatively lower cost involved [15][18][15,18].
When hard tissue lasers (erbium (Er:YAG; 2940 nm) and neodymium (Nd:YAG; 1064 nm)) were used after tooth extraction (to degranulate, disinfect, de-epithelialize, clot stabilize, and photobiomodulate the extraction socket), improved post-extraction bone healing/density and considerably less pain, bleeding, or swelling were observed [23][27].
The conventional surgical exposure of teeth involves making apically positioned flaps, releasing incisions apical to the adjacent teeth and managing intra- and post-operative bleeding, post-operative pain, and suturing, as well as any post-operative infections [1][13][1,13]. The conventional flap procedures are relatively aggressive in nature and associated with a degree of alveolar bone loss, compromising the integrity of periodontium. The full-thickness mucoperiosteal flap often requires suturing and the placement of a protective dressing (pack) over the surgical site while it heals [24][28], and the patient may need sedation or general anaesthesia. This is costly and stressful for patients. The use of a scalpel may involve suturing that comes with a risk of suture loss or loosening, and sutures often need to be removed 1–2 weeks post-operatively [24][25][26][27][28,29,30,31]. The diode laser creates a bloodless surgical site that allows for immediate orthodontic bonding of the impacted tooth without the need for surgical dressing, as was highlighted in this review. This reduces the treatment time and provides an open exposure method that is associated with less pain during orthodontic treatment, shorter treatment time, and fewer complications post-surgery [18][28][18,32]. There is also less need for infiltration anaesthesia, with an improved postoperative comfort and healing potential [16].
Aside from the management of gingival enlargement/hyperplasia, cosmetic gingival contouring, and the exposure of impacted teeth [15][18][15,18], diode lasers are used to uncover temporary anchorage devices. Diode lasers are also used for frenectomy, operculum removal of mandibular molars, to facilitate banding or bracket bonding, or the treatment of post-orthodontic minor aphthous ulceration [18][29][30][31][18,33,34,35]. In addition, when a precise and stable soft tissue position after surgery is needed, a diode laser has been shown to be more reliable, offering a more stable tissue margin compared to a scalpel [32][36].
When using a laser to expose the impacted teeth, it is important to keep the exposed crown in the keratinised mucosa and preserve the keratinized mucosa as much as possible to avoid future complications such as the development of a thin gingival biotype [15][17][18][15,17,18]; this will make cleaning of the site much easier, preventing complicating food accumulation afterwards [15][17][18][15,17,18]. In both cases presented, the option of the apically repositioned flap, involving hospital admission and a much longer referral/treatment time, was provided to patients; however, the families decided to opt for the in-office laser exposure. Adjunctive use of a 940 nm diode laser in orthodontics for soft tissue procedures is limited [15][18][30][31][15,18,34,35] in the literature, and there are few studies comparing diode laser surgical exposure and conventional methods of tooth surgical exposure [16][28][33][34][16,20,22,32]. Considering the minimally invasive nature of diode laser exposure, there is a need for clinical trials to further investigate and identify the right wavelength, power, and anaesthesia method for using diode lasers. This review Iand case report further highlights the use of a diode laser for precise, minimally invasive, and bloodless surgical exposure that is associated with ease of immediate bonding, faster recovery, and minimal pain compared to conventional surgery using a punch or scalpel [35][37].

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