Case series: laser treatments for soft tissue problems in children.
Abstract: BACKGROUND: Many soft tissue pathologies in children can be treated by paediatric dentists. New technologies such as laser surgery enable simpler treatments to be carried out than with conventional techniques. CASE REPORTS: A case series of 7 children aged 6 to 14 years old were treated for various soft tissue problems including crown lengthening, exposure of an unerupted molar, lingual and maxillary fraenectomies, gingivectomy, excision of a pyogenic granuloma and for a pulpotomy. TREATMENTS: All children were treated using a Er,Cr:YSGG laser for removal of appropriate soft tissues. FOLLOW-UP: All cases healed satisfactorily and were followed up for 3 to 4 years. CONCLUSION: It is essential to have a good knowledge of laser operation and of which type of laser is most appropriate for each lesion.

Key words: Laser paediatric dentistry, erbium lasers, C[O.sub.2] lasers, diode lasers, laser soft tissue treatments.
Article Type: Case study
Subject: Lasers in surgery (Health aspects)
Soft tissue injuries (Risk factors)
Soft tissue injuries (Diagnosis)
Soft tissue injuries (Care and treatment)
Soft tissue injuries (Patient outcomes)
Soft tissue injuries (Case studies)
Children (Diseases)
Children (Risk factors)
Children (Diagnosis)
Children (Care and treatment)
Children (Patient outcomes)
Children (Case studies)
Authors: Boj, J.R.
Poirier, C.
Hernandez, M.
Espasa, E.
Espanya, A.
Pub Date: 04/01/2011
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2011 Source Volume: 12 Source Issue: 2
Geographic: Geographic Scope: Spain Geographic Code: 4EUSP Spain
Accession Number: 277106753
Full Text: Introduction

Many benign pathologies or oral anomalies that affect children's soft tissues can be treated by dentists. Conventional treatment of these pathologies involves the use of the cold knife, cautery knife (electrocautery) or cryosurgery (using a gas expansion system or a cotton bud soaked in liquid nitrogen) [Ishida and Ramos-Silva, 1998]. Recent advances have shown that laser treatment can be added as an alternative or complement to conventional methods [Gontijo et al., 2005]. There is extensive literature on soft tissue management using lasers and those with indications and contraindications have been discussed previously by Boj et al. [2011].

Advantages of lasers. Lasers have a number of advantages over conventional surgery for soft tissues [Boj et al., 2011] as they reduce the amount of local analgesia required [Martens, 2003] and the need for sutures is eliminated. Using lasers improves wound healing, which occurs faster and with less scarring than after conventional treatments. Healing is fastest after the application of erbium lasers, as they have a low thermal effect and reduce the requirement for antibiotics [Turkun et al., 2006].

Local analgesia. According to Jacobson et al. [2003; 2004] local analgesia is not required with erbium lasers. The patient's comfort and collaboration is increased by the fact that both hard and soft tissues can be treated in the same operation. Most authors [Hadley et al., 2000; Jacobson et al., 2004] use this laser to treat hard tissues. However, in the cases presented here, it was used to manipulate soft tissues exclusively. Local analgesia was administered in all of these cases: 2% lidocaine with epinephrine 1:100,000.

The use of lasers for soft tissue problems is described herein by a series of case reports. The WATERLASE[TM] Er,Cr:YSGG laser (Waterlase Biolase[R], Biolase technology, San Clemente, California, USA) was used in the cases described below. This Er,Cr:YSGG laser was approved by the FDA in 1998 [Jacobson et al., 2003] and for use in soft tissues.

Case series reports

Case report 1. Crown lengthening. After a pulp treatment of the permanent maxillary right first molar in a 10 year-old patient, it was found that the disto-gingival margin of the cavity was too far sub-gingival to carry out the restoration correctly, as a dry surgical field for resin adhesion could not be obtained. In addition, as the second molar had failed to erupt, a wedge could not be fitted to adapt the distal wall (Fig. 1a). The Er,Cr:YSGG laser was used to remove disto-lingual gingival tissue, which clearly exposed the margin of the cavity (Fig. 1b) and produced a surgical field with no bleeding. Thus, the retraction cord could be placed and the restoration with composite resin carried out in the same session. Figure 1c shows the completed restoration.


Case report 2. Fenestration/mucosal exposure. In this case a mandibular first right molar in a 6 year-old child was involved presenting on eating pain in the mandibular right retromolar area and causing dietary problems. On examination, gingival hyperplasia caused by masticatory trauma was observed in the coronal portion of the dental follicle of the mandibular right first molar that was about to erupt (Fig. 2a). The molar was exposed by removing gingival tissue from the occlusal surface with an Er,Cr:YSGG laser. Figure 2b shows the entire occlusal surface of the molar once the surgery had been completed. There was no bleeding and the gingival appearance 15 days after the surgery at follow-up was excellent (Fig. 2c). The child could eat a normal diet, as shown by the remains of chocolate that were observed.


Case report 3. Lingual fraenectomy. An adolescent patient aged 13 years of age presented with speech problems. An examination revealed reduced mobility of the tongue due to a short lingual fraenum. In maximum extension, the tongue did not reach the maxillary incisors and it had a bifid appearance (Fig. 3a). Consequently, a fraenectomy was performed with an Er,Cr:YSGG laser (Fig. 3b). On completion, a low-level diode laser was used (Fig. 3c) to reduce post-operative inflammation and facilitate healing, as the high mobility of this area could lead to post-operative pain, which would prevent the patient from carrying out early speech therapy exercises. At follow-up there was a certain degree of pallor in the surgical area 2 months after surgery (Fig. 3d). However, tongue mobility was normal. The maxillary incisors could now be reached by the tip of the tongue and the appearance was no longer bifid.


Case report 4. Maxillary labial fraenectomy. An adolescent patient aged 12 years of age presented with a maxillary labial fraenum that had a low insertion (Fig. 4a), that could have caused an orthodontic relapse. The fraenectomy was performed with an Er,Cr:YSGG laser to remove the labial mucosa part of the fraenum, to carry out an ostectomy and to section the transeptal fibres as far as the palatal tissue (Fig. 4b). As the wound was to heal by second intention, the following were applied after the fraenectomy: a cold tea bag for its haemostatic properties (Fig. 4c), followed by a soft laser (Fig. 4d) for its anti-inflammatory properties; and vitamin E (Fig. 4e) for its healing effect. These procedures were undertaken to improve the post-operative period. At follow-up, Figure 4f shows the normal gingival appearance 2 months after surgery. The diastema had closed without difficulty.


Case report 5. Gingivectomy in a patient with a fixed appliance. An adolescent patient aged 12 years with a fixed orthodontic appliance presented with generalised gingival hyperplasia due to bad dental hygiene (Fig. 5a). A gingivectomy was performed using the Er,Cr:YSGG laser, to give the correct shape to the gingival festoon (Fig. 5b). The removed fragments of fibrous gingival tissue are shown in Figure 5c. At follow-up the gingival appearance, 15 days after the surgery, was very satisfactory, which enabled the dental hygiene of the patient to improve (Fig. 5d).


Case report 6. Pulpotomy. Apexogenesis in permanent teeth where there is an open apex presents difficulties. However with the use of a laser pulpotomy can be effected. A 7-year-old patient presented with a deep cavity in the mandibular left first permanent molar with no symptoms (Fig. 6a). As caries removal was performed a pulp exposure was found (Fig. 6b). Good haemostasis in the vital pulp was obtained. As the apex was open, apexogenesis was performed. The entrance to the three canals was irradiated with the Er,Cr:YSGG laser to coagulate and disinfect the area (Fig. 6c). Above this, zinc oxide eugenol, glass ionomer cement and composite were placed. Subsequently, a preformed metal crown was fitted.


Case report 7. Pyogenic granuloma. A 12 year-old patient presented with gingival bleeding. An examination revealed a gingival hyperplasia with a major inflammatory component that covered the entire mandibular left first premolar (Fig. 7a). Figure 7b shows the immediate post-operative appearance after removal of the lesion with an Er,Cr:YSGG laser. There was no bleeding, despite the enormous vascular component of such lesions. Figure 7c shows the removed tissue. Biopsy confirmed the diagnosis of pyogenic granuloma. At follow-up the gingival appearance 7 months after the surgery was normal (Fig. 7d) and there had been no recurrence of the lesion.



The application of laser technology to paediatric dentistry is gaining ground. Its success has been demonstrated in clinical procedures, including operations and restorations of temporary and permanent teeth, pulp and periodontal treatments, and surgery [Miserendino and Pick, 1995; Parkins, 2000; Strauss, 2000; Martens, 2003; Stabholz et al., 2003; Kotlow, 2004; Boj et al., 2005b] and the use of lasers in children and adolescents have been fully reviewed [Martens, 2011; Olivi and Genovese, 2011].

There is extensive recent literature on soft tissue management with C[O.sub.2] lasers in children [Kopp and St Hilaire, 2004; Huang et al., 2007; Kato and Wijeyeweera, 2007], as this procedure is considered safe and has many intra-operative and post-operative advantages [Tamarit et al., 2005]. Some authors have used the Nd:YAG laser in children [Braggett et al., 1999], whilst others consider that the combination of Nd:YAG and diodes is more effective [Matsumoto and Hossain, 2002; Fornaini et al., 2007].

In recent years, the number of papers on the use of Er,Cr:YSGG lasers in paediatric dentistry has increased as this type of laser is commonly used for hard tissue applications. However, if the settings are altered, it can also be applied to soft tissues, as presented in the case reports here and in other papers published by Boj et al. [2006, 2007a, 2007b, 2008, 2009]. The Er,Cr:YSGG laser is a hydrokinetic system based on photon liberation in an air-water spray, which causes strong explosions in the water droplets. The optical fibre delivery system ends in a sapphire crystal tip. The handpiece is similar to that of a conventional turbine, which facilitates clinical management. Cutting effectiveness is attained when the tissue is 1-1.5 mm from the tip.

This laser is thus very useful in oral surgery in paediatric dentistry, as it involves a reduction in the amount of local analgesia and in the duration of intervention, the technique is easy, and the laser produces a haemostatic effect that enhances visibility of the surgical area, which is a major advantage in children's small mouths. Scarring is minimal (no tissue retraction). The laser eliminates the need for sutures and reduces post-operative oedema, bleeding, infection and pain, and thus the use of medication [Boj et al., 2007a]. The same laser at a different output can be used to manipulate hard tissues. Therefore, it is a very versatile laser in paediatric dentistry [Hadley et al., 2000; Boj, 2005b]. For labial fraenectomies, Gontijo et al. [2005] used a combination of a diode laser to manipulate soft tissues and the Er:YAG laser for the periosteum and the final collagen fibres.

In the past, soft tissue surgical procedures were often rejected in children, as problems with co-operation meant that they could not be performed without general anaesthetic [Kotlow, 2004]. Several authors have stated that the use of lasers in soft and hard tissues causes less discomfort and is well-accepted by young patients and their parents. Thus, lasers can reduce psychological trauma and fear during the dental visit [Matsumoto and Hossain, 2002; Boj et al., 2005a; Gontijo et al., 2005]. As illustrated here in a series of 7 cases the use of the laser is ideal for soft tissues needing surgery in paediatric patients.


In most cases, laser technology improves efficiency, quality and the prognosis of treatments, which can increase the collaboration of paediatric dentistry patients, but it is essential to have a good knowledge of laser technique and which type of laser is most indicated for each oral lesion. In addition, it is of great use in anticoagulant, immuno-depressed and transplant patients as it prevents haemorrhage and bacteraemia.


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J.R. Boj *, C. Poirier *, M. Hernandez *, E. Espasa *, A. Espanya **

Depts of * Paediatric Dentistry, ** Oral Surgery, Dental School, University of Barcelona, Spain.

Postal address: Prof. Juan Boj. Department of Paediatric Dentistry, Dental School, University of Barcelona, Campus de Bellvitge, c. Feixa Llarga s/n, 08907 Hospitalet de Llobregat, Barcelona, Spain.

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