Lasers in Implant Dentistry, Part 2 - · PDF fileLasers in Implant Dentistry, Part 2...

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does not inferendorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment and acceptedstandards of care. Participants are urged to contact their state dental boards for continuing education requirements.

Authored by Glenn A. van As, BSc, DMD

Upon successful completion of this CE activity, 3 CE credit hours may be awarded

Volume 34 No. 8 Page 94

Lasers in Implant Dentistry,Part 2

CONTINUING EDUCATION

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In the July 2015 issue of Dentistry Today, I began the first partof this 2-part article with a discussion of how lasers havebecome a go-to part of the dental armamentarium in many

aspects of our practice. Diode lasers have become the “soft-tissuehandpiece” and an electrosurgery replacement in many practicesdue to their portability, cost effectiveness, reliability, and abilityto work around metals such as dental implants.1-2 The erbiumfamily of lasers (Er,Cr:YSGG and Er:YAG), originally promoted fortheir ability to provide anesthetic reduced restorations,3 havebecome valuable for their ability to ablate anything with waterin it, making them truly “all-tissue lasers.”3-5 These lasers canprovide benefits to restorative dentistry and soft-tissue ablation,but their ability to safely remove bone and soft tissue and workaround metals has made this family of lasers for many dentiststheir go-to device when recontouring hard and soft tissue isnecessary in conjunction with dental implants.

In the first part of this 2-part series, I covered my ownclassification of the role of lasers in implant dentistry by the

stage of the procedure where the lasers are used (Figure 1). Theinitial article focused on the role of lasers in the earlier portionsof implant surgical placement, including the benefit of lasersprior to implant placement for the degranulation anddisinfection of extraction sockets. In addition, erbium laserscan be used early on for ablating bone for lateral window sinuslifts. During actual implant placement, these all-tissue laserscan be used to create flaps instead of scalpel blades, withimproved visibility, due to their ability to provide hemostasisand for the fine mist of water + air spray that keeps the surgicalsite clean. All-tissue erbium lasers can ablate bone, which canallow them to be useful for the early stages of osteotomies. Inaddition, research from Kesler et al6 has shown that this familyof lasers can be of benefit to guided bone regeneration (GBR)when used to decorticate the bone in allowing for increasedrelease of osteogenic growth factors when compared to bursfor perforation of the cortical plates.

The initial article closed with a focus on the value of erbiumlasers to gently and safely level bone around fixtures, and tohelp with soft-tissue recontouring around healing abutments.The increasing interest in the value of low level laser therapy(LLLT) from 810-nm diode lasers to help with biostimulation(wound healing) and bioinhibition (pain decrease) as well astheir effect on decreasing neurosensory deficits was broached.

In the second part of this article, the focus will be on the roleof lasers within dental implantology after the surgical phase iscompleted. The importance of lasers to help with the uncoveryof buried fixtures, and during the prosthetic phase ofimpressions and final insertions cannot be underestimatedwhere frequently soft tissue must be revised. Finally, andperhaps most importantly, new evidence in the last few yearshas shown that lasers might be a key portion of the growingneed to treat ailing implants that have suffered bone loss andhave peri-implantitis. The difficulty of detoxifying implantthreads with traditional methods may be overcome with lasers,and studies show re-osseointegration onto laser treated surfacesis definitely possible, thus enabling practitioners to salvagecases which might otherwise by treated with explanation,grafting, and starting over at considerable time, expense, anddiscomfort for patients.7

LASER USAGE DURING IMPLANT UNCOVERY After the surgical phase of implant therapy is complete, insome cases the fixtures are buried in a 2-stage approach.Although as clinicians we love to complete as many surgicalplacements in a single stage, with a healing abutment in placeat the time of fixture placement so that soft-tissue modelingcan occur from the very first step, this is not always possible.

Lasers in Implant Dentistry,Part 2

About the Author

Dr. van As graduated from the faculty of dentistry atthe University of British Columbia, Vancouver, Canada,and was an assistant clinical professor there from1989 to 1999. His memberships include but are notlimited to the British Columbia Dental Association, theCanadian Dental Association, the Academy ofMicroscope Enhanced Dentistry, the Academy of Laser

Dentistry, and the American Academy of Cosmetic Dentistry. He has built ahigh-tech, high-touch, full-time dental practice where the entire dental teamis committed to using the latest technologies available to provide the highestlevel of clinical excellence in dentistry. He has lectured internationally andprovided hands-on workshops and has published internationally on multipletopics involving dental lasers and microscopes. He is an active member onmany web forums dealing with lasers and microscopes in the general dentalpractice, acts as a consultant for many high technology companies, and is areviewer of articles for dental magazines. He was distinguished with the LeonGoldman award in 2006 for worldwide clinical excellence in laser dentistryand has been one of Dentistry Today’s Leaders in Continuing Education since2012. He can be reached via email at [email protected] or the websitedrvanas.com.

Disclosure: Dr. van As discloses having received honoraria and equipment from the following companies: BIOLASE, Global Micro scopes, AMD Lasers, andZolar Lasers.

Effective Date: 08/01/2015 Expiration Date: 08/01/2018

There are situations in which a cover screwmust be inserted into the implant fixtureand soft-tissue coverage with an un-interrupted healing period is required for a2-stage surgical approach. Two-stage surgerymay be required if initial primary stabilityis low, if less than 2 mm of soft tissue existsabove the bony crest, or if bone grafting isdone at the time of surgical placement.

Some clinicians feel that their trustymonopolar electrosurgery units can be usedto remove overlying soft tissue aboveimplants. Wil cox et al8 showed thatmonopolar electrosurgery units couldprovide quickly localized heat effects abovethe critical 10°C range that could potentiallydamage the osseointegration of implants inbone. They8 suggested that monopolarelectrosurgery units not be used aroundimplants. Massei et al,9 in their study in2004, showed that a 3-second exposure tomonopolar electrosurge on the fixture,applied without local anesthetic, wasenough for all 20 implants in the study to beeasily counter rotated with settings of lessthan 35 Ncm, and with minimal bonenecrosis 2 weeks after exposure to theelectrosurge. In fact, they9 discussed“thermo-explantation” due to electrosurgeryas a method for perhaps simply removingimplants when fixture removal wasrequired. In contrast, studies show diodelasers, when used with lower settings, can beused safely around dental implants.10-12 Yehet al11 have shown that when diodes wereused at settings of 0.5 to 1.0 W ContinuousWave that they could be used to uncoverfixtures. Romanos et al13 showed thatcaution must be used with diode lasers, as heat buildup canoccur rapidly within 15 to 20 seconds, so the authors suggeststopping every 15 seconds or so and using water on the surgicalsite and a high-volume suction to control heat buildup in thesurgical site when using diode lasers to uncover fixtures.

The author,10 in 2011, discussed 2 different methods foruncovering implants with a laser. The first technique is called the“manhole” technique and is best suited for the posterior regionwhere adequate healthy attached and keratinized tissue exists. Inthis case, the overlying tissue can be removed in a circular fashion

to expose the underlying cover screw. Diode lasers and other soft-tissue wavelengths offer precise ablation with ideal hemostasis,and when used in this technique, often impressions for the finalimplant restorations can be taken the same day as the uncoveryappointment. The benefit of the diode laser uncovery in inlimiting the number of sutures and shortening the number ofappointments required as the traditional 2- to 3-week healingperiod after flap uncovery with sutures is avoided (Fig ures 2 to 5).

When working in the aesthetic zone or in areas whereattached and keratinized tissue overlying fixtures is minimal,

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Lasers in Implant Dentistry, Part 2

Figure 1. Categorization devised by author to organize value of lasers in implant dentistry basedon the timing of the procedure.

Figure 2. Preoperative condition at stage 2;ready to uncover dental implant.

Figure 3. Diode laser uncovery of ET III(HIOSSEN) implant to expose cover screw at1.0 W Continuous Wave.

Figure 4. Open-tray impression taken sameday as uncovery.

Figure 5. Immediate postoperative result of inserted crown 2 weeks after uncovery.

clinicians may be wise to utilize techniques that attempt to“move rather than remove” remaining tissue. Arnabat-Domín -guez et al,14 in 2010, demonstrated a technique of using theEr,Cr:YSGG wavelength (BIOLASE) to uncover im plants with abuccal roll technique to aid with augmenting tissue insituations where there was insufficient gingival attachment.The author has termed this technique the “trap door” laseruncovery, and it can be utilized to increase both volume of softtissue or amount of keratinized tissue. To increase the amountof keratinized tissue, a soft-tissue incision is made with the laserin 2 interconnecting incisions on the mesial, palatal, and distal,and the overlying tissue over the implant is lifted up anddisplaced to the facial of the healing abutment (Figures 6 to 11).If the thickness of soft tissue needs to be augmented, the erbiumlaser is used first to de-epithelialize the overlying tissue andthen the same incisions are made but the tissue is tucked into apouch on the facial of the abutment to augment the amount offacial-lingual volume of tissue. This technique can beparticularly valuable in the maxillary anterior in combinationwith connective tissue grafts to augment facial volumeoverlying the implant when remaining soft-tissue volume isthin and fixture shine-through is a distinct possibility.

LASER USAGE DURING FINAL RESTORATIONSSoft tissue can be a significant barrier to the ideal seating of finalimplant restorations. Soft tissue can impede the full completeseating of both screw-retained restorations if the tissue covers theshoulder and connection of the fixture. In addition, in cementedres torations, soft tissue can be a significant problem whenmargins of abutments are subgingival for aesthetic reasons. Acemented res toration that comes loose can be a major headachefor clinicians where recementing the restoration properly can beall but impossible with traditional means of soft-tissuemanagement. In addition, at times, healing abutments can comeloose during the healing phases of treatment or even can be lost,and soft tissue quickly invades the space; this tissue is easily

removed with many lasers including diode lasers, CO2 lasers, andthe all-tissue erbium lasers. Since soft-tissue lasers are betterabsorbed by hemoglobin, they tend to be better from a hemostasisstandpoint, but they do ablate through a photothermal effectwithout water, and this can lead to increased thermal damage ifconservative settings are not utilized.

In an effort to simplify the management of soft tissue whenseating im plant restorations, many clinicians prefer to provide

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Figure 6. Pre-op condition for 3 implants thatrequire uncovery at stage 2.

Figure 7. “Manhole” uncovery for first premolar and “trap door” uncovery for distal 2implants.

Figure 8. Immediate impression for provisionalrestorations.

Figure 9. Bis-acrylprovisional restorationsshow increasedattached tissue ondistal 2 implants.

Figure 10. Finalporcelain restorationsin place.

Figure 11. Final post-op radiograph showingcrestal sinus lift (CAS-KIT [HIOSSEN]) for firstmolar and 3 ET IIIImplants from Hiossen.

screw-retained final restorations for their implants’ supportedprosthesis. In theory, this reduces the need to remove soft tissuearound an abutment as the crown can be cemented to the abutmentunder carefully controlled settings to minimize the risk ofsubgingival cement, which Wilson15 has demonstrated, canhave serious negative sequelae to peri-implant mucosa and bone(cement sepsis).

All lasers can be used to modify soft tissue around bothfixtures and abutments. Jin et al16 showed that the Er,Cr:YSGGwas superior to the diode laser in soft-tissue surgery when itcame to thermal damage, and Ryu et al17 demonstrated that theEr,Cr:YSGG laser has many advantages for oral surgery due to alow inflammatory response and minimal damage of the tissuecompared to CO2 lasers.

The ability to recontour soft tissue around both implantfixtures and abutments can be a true “lifesaver” for both initialplacements of the final restorations and for recementation ofrestorations (Figures 12 to 14).

LASER USAGE AFTER IMPLANT PLACEMENTImplant treatment has evolved during the last few decades with atremendous advancement in our knowledge and, as a result,successful aesthetic and functional cases are now more routine.Having said this, there are still cases where inflammation in theperi-implant soft tissue (mucositis) or bone (peri-implantitis)causes significant problems such as persistent pain, bleeding,infection, bone loss, and (if left untreated) implant failure. Atieh etal18 looked at the frequency of peri-implant diseases and found thatthe frequency of peri-implant mucositis was in 63.4% ofparticipants and 30.7% of im plants. The more serious disease ofperi-implantitis was found in 18.8% of participants and 9.6% ofimplants (Figure 15). Etiological factors for peri-implantitis includepoor oral hygiene, occlusal overload, lack of attached keratinizedsoft tissue, smoking, subgingival cement, systemic factors(diabetes), and poor implant placement.19,20

Padial-Molina et al21 classified early peri-implantitis as

probing depths of 5 mm or less with less than 2 mm of bone loss.They suggested that nonsurgical treatment ap proaches mighthelp in these early cases. They21 classified moderate bone losscases as those where probing depths increased to 6 to 7 mm andthere was greater than 2 mm of bone loss but less than 50% oftotal bone loss around the implant. In these cases, theysuggested a surgical flap for visualization, with degranulation,and detoxification of the implant surface followed by GBR andwhere needed, augmentation of tissue with connective tissuegrafting. In ad vanced cases, where probing depths were greaterthan 8 mm and bone loss exceeded 50% of the total amountaround the fixture, then implant removal and GBR is thestandard recommendation (Table 1).21

For many cases, the most difficult part of treatment is theprocess of completely removing the soft tissue (degranulation)and detoxifying the implant surface. Traditionally, the processof implant detoxification has been completed through chemicalapproaches (saline, citric acid, chlor hexidine, hydrogenperoxide, and antimicrobials) or mechanical ap proaches(abrasive pumice, air abrasive powder, implantoplasty, or lasermethods).22 Could lasers perhaps hold a better method fordisinfection and degranulation of these difficult-to-treat sites?

NONSURGICAL TREATMENT OF PERI-IMPLANTITISNonsurgical approaches to treating peri-implant diseases arepreferred by most clinicians in that it offers a simpler and less

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Figure 12. BIOLASE IPlus laser being used tosafely recontour peri-abutment soft tissue to allowfull seating of cemented crowns on implants.

Figure 13. Immediate post-op appearance ofabutments after soft-tissue recontouring.

Figure 14. Final postoperative appearance ofrestorations.

Figure 15. Peri-implantitis lesionaround an ailing lowerright second molarimplant presents adifficult challenge forthe clinician.

invasive approach. Ren vert et al23demonstratedthat me chanical nonsurgical approaches could bebeneficial when inflammation was contained tothe soft tissue only (mu cositis). Unfortunately,when bone loss starts to happen around dentalimplants, the disease has progressed from amucositis to the more serious peri-implantitisand traditional minimally invasive nonsurgicaltechniques utilizing subgingival irrigation andmechanical therapy were not as effective forlong-term resolution. Minor benefits were seenwith a laser approach, so Ren vert et al23

suggested further research be done in this area.Roncati et al24 demonstrated that a 810-nm

diode laser at the low level settings of 1.0 Wpulsed with an uninitiated tip for up to 6minutes per site, followed with hand scalingand subgingival irrigation with chlor hexidine rinse and done 2days consecutively in a row, could be a feasible alternative inthe management of early cases of peri-implantitis. The cases didhave up to a 5-year follow-up, and the suggestion was that thediode laser was detoxifying implant surfaces, weakening thebond of calculus to the implant surface to allow for easierremoval and that it might stimulate the production of fibro -blasts and osteoblasts, increasing collagen production duringhealing through the benefits of LLLT (biostimulation).

Other wavelengths have been also investigated for thenonsurgical treatment of peri-implantitis lesions. Tosun et al25

have shown that complete or near complete elimination ofbacteria on the surface of implants can be completed in vitrousing diode lasers as well as CO2 and Er:YAG wavelengths. Basedon the research for the effective and successful regeneration of periodontal lesions demonstrated by Yukna et al26 known as LANAP (Laser Assisted New Attach ment Procedure[Millennium Dental Technologies]) and confirmed in otherstudies,27-29 a similar protocol was developed for the closed flaplaser treatment of peri-implantitis lesions using the soft-tissueNd:YAG wavelength (1,064 nm) by Nicholson et al.30 Thisprotocol is known as LAPIP (Laser Assisted Peri-Implan titisProcedure [Millennium Dental Technologies]) and utilizes theprotocol developed for periodontitis with the Nd:YAG laser in asimilar fashion for ailing implants. Nicholson et al30 found thatof the original 26 cases in their study, the final 16 cases thatwere followed to completion showed radiographic evidence ofan increase in crestal bone mass around the im plant anddecreased probing depths. There was control of infection andreversal of bone loss and rescue of the incumbent implant inall cases (Figure 16).

In looking at the promising re search for nonsurgicaltreatment using diode and the surgical pulsed Nd:YAG soft-tissue lasers, one must be careful to use well-defined operatingparameters and training to avoid causing thermal reactionssuch as melting, cracks, and crater formation on the titaniumsurface.12,31

Another wavelength with promise for nonsurgicaltreatment of early peri-implant lesions is the Er,Cr:YSGG (2,780nm). This wavelength, with its water spray combined with tipsthat fire radially (Figure 17) has demonstrated promise in atleast one study.32 The radially firing tip was used in anonsurgical approach in 28 implants and 11 patients. Results at

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Table 1. Diagnosis and Treatment of Peri-Implant Diseases,per Padial-Molina et al21

Classification Clinical Parameters Treatment

Early 5 mm or less PD Nonsurgical + Antibiotics+ < 2 mm bone loss

Moderate 6 to 7 mm PD, Surgical Flap > 2 mm bone loss + DD +/- GBR +/- CTG

Advanced > 8 PD Implant Explanation + > 50% bone loss + GBR

KEY: PD = probing depths, DD = degranulation and detoxification,GBR = guided bone regeneration, CTG = connective tissue grafting.

Figure 16. Pre-op andpost-op Laser AssistedPeri-Implant Procedure(LAPIP) radiographsusing the Nd:YAG laserdemonstratingsignificant radiographichealing (lanap.com/lapip_home.php)(courtesy of MillenniumDental Technologies).

Figure 17. Radiallyfiring tip used with Er,Cr:YSGG wavelengthfor peri-implantitistreatment.

short-term follow-ups of 2 and 6 months showed a significantde crease in bleeding on probing and pocket depths at 2 and 6months. The technique relies on the removal of epithelium onboth the inner wall of the pocket and the outer surface of theepithelium, as well as bacterial decontamination in the pocketand, in addition, the removal of calculus with the laser insidethe pocket made possible with the use of the erbium family oflasers (Figures 18 to 21). Although nonsurgical treatment ofperi-implantitis may show promise as a phase 1 treatment,particularly for early peri-implant lesions, further research isnecessary to demonstrate which wavelengths are best, and idealsettings in clinical studies for those wavelengths.33

SURGICAL TREATMENT OF PERI-IMPLANTITISIf the bone loss around a fixture is moderate or severe, then adecision must be made first if the implant is worth saving.Clinically, if 50% of the bone has been lost, then traditionallythe treatment that is suggested is explantation of the implant andgrafting to attempt another implant for long-term success.21Froum et al34 has provided a landmark paper on surgicalcorrection of 51 peri-implantitis cases with a follow-up of be tween3 and 7.5 years. In their paper, Froum et al34 cite a 7-step protocolfor surgical treatment of these lesions (Table 2) which has andetoxification procedure for the implant which is time intensiveand messy (air abrasion) (Table 3).

The use of lasers to help with potentially disinfectingimplants was discussed by Berk et al35 where they showed that:“The Er,Cr:YSGG laser seems to be an effective tool for peri-implant treatment by means of removal of biofilm; however,further in vivo and in vitro studies are also required to gain a betterunderstanding of osteoblastic cell behavior on different types ofcontaminated implant surfaces, and to confirm clinicalapplications and to optimize parameters.”

Recent research, published in established journals byYamamoto and Tanabe36 have demonstrated that the erbiumfamily of lasers is able to completely remove the contaminated

titanium oxide layer (Ti-Unite) when optimal settings are used(100 mJ/mm2 + 20 Hz with water spray). In addition, there was aminimal 3°C rise in temperature with laser irradiation, and that the potential in beagle dogs existed for re-osseointegrationto occur on the laser surfaces after 6 weeks was shownhistologically. In a follow-up to this study, Nevins et al37

demonstrated with animal research (foxhounds) that the Er:YAG laser (2,940 nm) could strip away the contaminatedtitanium oxide layer in artificially induced peri-implant lesionsand that both hard- and soft-tissue inflammation progression wasarrested. In this research group’s most recent study,38 the Er:YAGlaser was used on 2 patients clinically, with short-term follow-upsof 10 months with promising results. This case series of 2 patientsshowed that antibiotic therapy reduced the bacterial amountfrom the peri-implantitis sites significantly, and that Er:YAG lasertherapy, along with the bone augmentation, enhanced boneregeneration in the peri-implant bony defects.

There are very few long-term clinical studies on patients andsignificant differences between laser and conventional therapieshave not yet been shown. According to current research, althoughthe erbium lasers show the most promise for surgical treatment ofperi-implantitis—particularly in de fects that are narrow anddeep—there still is a need to clarify in detail the complete impactof these wavelengths on titanium and to prove superiority overtraditional treatment modalities. Al though these wavelengths doshow technical and therapeutic advantages as both an adjunctive

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Figure 18. Early probing depth increased onimplant-supported crown with discomfort topalpation on the facial.

Figure 19. Radiographic appearance with onlyearly bone loss present.

Figure 20. Radially firing tip and de-epithelializedouter wall of pocket.

Figure 21. Healing at 2 months with no signs clinically ofinflammation.

tool and possibly as an alternative to othermethodologies, further clinical studies arenecessary. Studies with longer periods of follow-ups, intense control of plaque index, and varioussessions of laser treatments are needed to clearlyillustrate the benefits of laser therapy for thetreatment of ailing im plants.39

CLOSING COMMENTSThis 2-part series was written to show, through aclassification system de signed by the author, howlasers available in dentistry might be beneficial todental implantology based on the phase oftreatment. The ability of lasers to be an adjunctivetool to improve treatment outcomes, beforeimplant placement for extraction socket grafting(degranulation and disinfection) and for GBR(decortication), is exciting, possibly reducing theneed for systemic antibiotics. During the surgicalphase of implant placement, lasers are beneficialfor starting osteotomies and for remodeling ofhard and soft tissue around the fixtures.Increasing amounts of research are demon-strating that LLLT can help with biostimulation (wound healing)and bioinhibition (pain relief) in surgery while being beneficialwhen dealing with neurosensory deficits. The role of all lasers foruncovery in stage 2, for soft-tissue recontouring around implantfixtures, and finally for the growing role of lasers in both thenonsurgical and surgical treatment of peri-implantitis demon-strates that lasers can be a significant “tool in the toolbox” for allaspects of implant therapy in helping to make the clinician’s lifesimpler with improved treatment outcomes.�

References1. van As GA. The diode laser as an electrosurgery replacement.

Dentaltown. June 2010:56-64. 2. van As GA. Lasers in dentistry: an application that found its

purpose. Oral Health Journal. March 2011:30-38.3. van As G. Erbium lasers in dentistry. Dent Clin North Am.

2004;48:1017-1059, viii.4. Ishikawa I, Aoki A, Takasaki AA. Potential applications of

Erbium:YAG laser in periodontics. J Periodontal Res.2004;39:275-285.

5. van As G. Laser removal of porcelain veneers. Dent Today.2012;31:84-89.

6. Kesler G, Shvero DK, Tov YS, et al. Platelet derived growthfactor secretion and bone healing after Er:YAG laser boneirradiation. J Oral Implantol. 2011;37(spec no):195-204.

7. Levin L. Dealing with dental implant failures. J Appl Oral Sci.

2008;16:171-175.8. Wilcox CW, Wilwerding TM, Watson P, et al. Use of

electrosurgery and lasers in the presence of dental implants.Int J Oral Maxillofac Implants. 2001;16:578-582.

9. Massei G, Szmukler-Moncler S. Thermo-explantation. A novelapproach to remove osseointegrated implants. Eur Cell Mater.2004;7(suppl 2):48.

10. van As G. The diode laser in second stage implant recovery.Dent Today. 2011;30:144.

11. Yeh S, Jain K, Andreana S. Using a diode laser to uncoverdental implants in second-stage surgery. Gen Dent.2005;53:414-417.

12. Catone GA. Lasers in periodontal surgery. In: Catone GA,Alling CC, eds. Laser Applications in Oral and MaxillofacialSurgery. 1st ed. Philadelphia, PA: Saunders; 1997:181-196.

13. Romanos GE, Everts H, Nentwig GH. Effects of diode andNd:YAG laser irradiation on titanium discs: a scanning electronmicroscope examination. J Periodontol. 2000;71:810-815.

14. Arnabat-Domínguez J, Bragado-Novel M, España-Tost AJ, et al.Advantages and esthetic results of erbium, chromium:yttrium-scandium-gallium-garnet laser application in second-stageimplant surgery in patients with insufficient gingivalattachment: a report of three cases. Lasers Med Sci.2010;25:459-464.

15. Wilson TG Jr. The positive relationship between excesscement and peri-implant disease: a prospective clinicalendoscopic study. J Periodontol. 2009;80:1388-1392.

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Table 2. Froum Protocol for Surgical Treatment of Peri-Implantitis34

Table 3. Froum Implant Protocol for Implant SurfaceDecontamination34 (Step 3 of Table 2)

16. Jin JY, Lee SH, Yoon HJ. A comparative study of wound healingfollowing incision with a scalpel, diode laser or Er,Cr:YSGGlaser in guinea pig oral mucosa: a histological andimmunohistochemical analysis. Acta Odontol Scand.2010;68:232-238.

17. Ryu SW, Lee SH, Yoon HJ. A comparative histological andimmunohistochemical study of wound healing following incisionwith a scalpel, CO2 laser or Er,Cr:YSGG laser in the guinea pigoral mucosa. Acta Odontol Scand. 2012;70:448-454.

18. Atieh M, Alsabeeha NH, Faggion CM Jr, et al. The frequency ofperi-implant diseases: a systematic review and meta-analysis.J Periodontol. 2013;84:1586-1598.

19. Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Nine- tofourteen-year follow-up of implant treatment. Part III: factorsassociated with peri-implant lesions. J Clin Periodontol.2006;33(4):296-301.

20. Smeets R, Henningsen A, Jung O, et al. Definition, etiology,prevention and treatment of peri-implantitis—a review. HeadFace Med. Sep 3, 2014;10:34. DOI: 10.1186/1746-160X-10-34.

21. Padial-Molina M, Suarez F, Rios HF, et al. Guidelines for thediagnosis and treatment of peri-implant diseases. Int JPeriodontics Restorative Dent. 2014;34:e102-e111.

22. Suarez F, Monje A, Galindo-Moreno P, et al. Implant surfacedetoxification: a comprehensive review. Implant Dent.2013;22:465-473.

23. Renvert S, Roos-Jansåker AM, Claffey N. Non-surgicaltreatment of peri-implant mucositis and peri-implantitis: aliterature review. J Clin Periodontol. 2008;35(suppl 8):305-315.

24. Roncati M, Lucchese A, Carinci F. Non-surgical treatment ofperi-implantitis with the adjunctive use of an 810-nm diodelaser. J Indian Soc Periodontol. 2013;17:812-815.

25. Tosun E, Tasar F, Strauss R, et al. Comparative evaluation ofantimicrobial effects of Er:YAG, diode, and CO2 lasers ontitanium discs: an experimental study. J Oral Maxillofac Surg.2012;70:1064-1069.

26. Yukna RA, Carr RL, Evans GH. Histologic evaluation of anNd:YAG laser-assisted new attachment procedure in humans.Int J Periodontics Restorative Dent. 2007;27:577-587.

27. Harris DM, Gregg RH II, McCarthy DK, et al. Laser-assistednew attachment procedure in private practice. Gen Dent.2004;52:396-403.

28. Nevins M, Kim SW, Camelo M, et al. A prospective 9-monthhuman clinical evaluation of Laser-Assisted New AttachmentProcedure (LANAP) therapy. Int J Periodontics Restorative Dent.2014;34:21-27.

29. Nevins ML, Camelo M, Schupbach P, et al. Human clinical andhistologic evaluation of laser-assisted new attachmentprocedure. Int J Periodontics Restorative Dent. 2012;32:497-507.

30. Nicholson D, Blodgett K, Braga C, et al. Pulsed Nd:YAG lasertreatment for failing dental implants due to peri-implantitis.dx.doi.org/ 10.1117/12.2041037. Accessed May 6, 2015.

31. Block CM, Mayo JA, Evans GH. Effects of the Nd:YAG dentallaser on plasma-sprayed and hydroxyapatite-coated titaniumdental implants: surface alteration and attemptedsterilization. Int J Oral Maxillofac Implants. 1992;7:441-449.

32. Al-Falaki R, Cronshaw M, Hughes FJ. Treatment outcomefollowing use of the erbium, chromium:yttrium, scandium,gallium, garnet laser in the non-surgical management of peri-implantitis: a case series. Br Dent J. 2014;217:453-457.

33. Aoki A, Mizutani K, Schwarz F, et al. Periodontal and peri-implant wound healing following laser therapy. Periodontol2000. 2015;68:217-269.

34. Froum SJ, Froum SH, Rosen PS. Successful management ofperi-implantitis with a regenerative approach: a consecutiveseries of 51 treated implants with 3- to 7.5-year follow-up. IntJ Periodontics Restorative Dent. 2012;32:11-20.

35. Berk G, Franzen R, Atici K, et al. Evaluation of contaminatedimplant surfaces by Er,Cr:YSGG laser. Journal of Implant andAdvanced Clinical Dentistry. 2013;5:19-26.

36. Yamamoto A, Tanabe T. Treatment of peri-implantitis aroundTiUnite-surface implants using Er:YAG laser microexplosions.Int J Periodontics Restorative Dent. 2013;33:21-30.

37. Nevins M, Nevins ML, Yamamoto A, et al. Use of Er:YAG laserto decontaminate infected dental implant surface inpreparation for reestablishment of bone-to-implant contact. IntJ Perio dontics Restorative Dent. 2014;34:461-466.

38. Yoshino T, Yamamoto A, Ono Y. Innovative regenerationtechnology to solve peri-implantitis by Er:YAG laser based onthe microbiologic diagnosis: a case series. Int J PeriodonticsRestorative Dent. 2015;35:67-73.

39. Ashnagar S, Nowzari H, Nokhbatolfoghahaei H, et al. Lasertreatment of peri-implantitis: a literature review. J Lasers MedSci. 2014;5:153-162.

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POST EXAMINATION QUESTIONS

1. Er,Cr:YSGG and Er:YAG lasers have become valuablefor their ability to ablate anything with water in it,making them truly “all-tissue lasers.” a. True b. False

2. In fact, Massei et al discussed “thermo-explantation”due to electrosurgery as a method for perhaps simplyremoving implants when fixture removal wasrequired. a. True b. False

3. Tissue erbium lasers cannot ablate bone, renderingthem useless for the early stages of osteotomies. a. True b. False

4. Romanos et al showed that caution must be used withdiode lasers as heat buildup can occur rapidly within15 to 20 seconds. a. True b. False

5. Wilcox showed that monopolar electrosurgery unitscould provide quickly localized heat effects above thecritical 10°C range that could potentially damage theosseointegration of implants in bone. a. True b. False

6. Studies show diode lasers, when used with lowersettings, cannot be used safely around dental implants. a. True b. False

7. Since soft-tissue lasers are better absorbed byhemoglobin, they tend to be better from a hemostasisstandpoint, but they do ablate through a photothermaleffect without water, and this can lead to increasedthermal damage if conservative settings are not utilized. a. True b. False

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Traditional Completion Option:You may fax or mail your answers with payment to Dentistry Today (see Traditional Completion Information on following page). Allinformation requested must be provided in order to process the program for credit. Be sure to complete your “Payment,” “PersonalCertification Information,” “Answers,” and “Evaluation” forms. Your exam will be graded within 72 hours of receipt. Upon successfulcompletion of the post-exam (70% or higher), a letter of completion will be mailed to the address provided.

Online Completion Option:Use this page to review the questions and mark your answers. Return to dentalcetoday.com and sign in. If you have not previously purchased the program, select it from the “Online Courses” listing and complete the online purchase process. Oncepurchased the program will be added to your User History page where a Take Exam link will be provided directly across from theprogram title. Select the Take Exam link, complete all the program questions and Submit your answers. An immediate grade reportwill be provided. Upon receiving a passing grade, complete the online evaluation form. Upon submitting the form, your Letter of Completion will be provided immediately for printing.

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This CE activity was not developed in accordance with AGDPACE or ADA CERP standards. CEUs for this activity will notbe accepted by the AGD for MAGD/FAGD credit.

8. Atieh et al looked at the frequency of peri-implantdiseases and found that the frequency of peri-implantmucositis was in only 26.4% of participants and 10.7%of implants. a. True b. False

9. Roncati et al demonstrated that a 810-nm diode laserat the low level settings of 1.0 W pulsed with anuninitiated tip for up to 6 minutes per site, followedwith hand scaling and subgingival irrigation withchlorhexidine rinse and done 2 days consecutively ina row, could be a feasible alternative in themanagement of early cases of peri-implantitis. a. True b. False

10. Recent research, published in established journals byYamamoto and Tanabe, has demonstrated that theerbium family of lasers was not able to completelyremove the contaminated titanium oxide layer. a. True b. False

11. There are many long-term clinical studies on patientsand no significant differences between laser andconventional therapies have been shown. a. True b. False

12. Increasing amounts of research are demonstratingthat low-level laser therapy can help with bio-stimulation (wound healing) and bio-inhibition (painrelief) in surgery while being beneficial when dealingwith neurosensory deficits. a. True b. False

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Lasers in Implant Dentistry, Part 2PROGRAM COMPLETION INFORMATION

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ANSWER FORM: VOLUME 34 NO. 8 PAGE 94Please check the correct box for each question below.

1. o a. True o b. False 7. o a. True o b. False 2. o a. True o b. False 8. o a. True o b. False 3. o a. True o b. False 9. o a. True o b. False 4. o a. True o b. False 10. o a. True o b. False 5. o a. True o b. False 11. o a. True o b. False 6. o a. True o b. False 12. o a. True o b. False

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This CE activity was not developed in accordance with AGDPACE or ADA CERP standards. CEUs for this activity will notbe accepted by the AGD for MAGD/FAGD credit.

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