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Evren Kilinc, DDS, PhD1/James Rothrock, BS2/. Erica Migliorati, DDS, MS3/Saulius Drukteinis, DDS, MS4/. David M. Roshkin

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Q U I N T E S S E N C E I N T E R N AT I O N A L

Potential surface alteration effects of laser-assisted periodontal surgery on existing dental restorations Evren Kilinc, DDS, PhD1+BNFT3PUISPDL #42/ Erica Migliorati, DDS, MS3/Saulius Drukteinis, DDS, MS4/ %BWJE.3PTILJOE %.% .#"51BVM#SBEMFZ %%4 .% .46

Objective: Laser-assisted gingivectomies are performed in proximity to teeth, existing restorations, and implants. In case of accidental exposures, a detrimental surface defect may cause failure. Surface interactions should be evaluated for safety margin determination of certain laser-material combinations. The purpose of this in vitro study was to assess the microscopic and visible effects of CO2 /E:"( BOEONEJPEFMBTFSJSSBEJBUJPOT on various dental materials and tooth tissue. Method and Materials: Study samples were GBCSJDBUFE × 7.5 mm irradiation surface area, 1 mm thickness) from eight material groups (amalgam, base metal, gold, palladium-silver, composite, ceramic, titanium, and extracted tooth slices). Laser irradiations were performed with CO2 /E:"( BOE nm diode lasers using the manufacturer’s recommended settings for gingivectomy at a EFHSFFBOHMFGPSTFDPOET*SSBEJBUFETVSGBDFTXFSFFWBMVBUFEVOEFS4&.BU× BOE × magnifications. Standardized photographs were obtained using a camera NPVOUTZTUFN × high-definition macro lens). The SEM images and photographs were correlated to determine surface interactions. Results:/E:"(EFUSJNFOUBMMZBGGFDUFEBMM metallic materials and tooth structures. CO2 altered amalgam, gold, and palladium-silver slightly, whereas composite, ceramic, and tooth surfaces were detrimentally altered. 5IFONEJPEFBMUFSFEBNBMHBN HPME UJUBOJVN QBMMBEJVNTJMWFS BOEDPNQPTJUFCVU only gold and palladium-silver surfaces were barely traceable. Conclusion: Within the limitations of this in vitro study, surface effects were all instant; therefore, even a short accidental exposure may be destructive in some laser-material combinations. During gingivectomies, CO2OFBSUPPUIDPMPSFESFTUPSBUJPOTBOE/E:"(OFBSNFUBMMJDSFTUPSBUJPOT BOEJNQMBOUTTIPVMECFVTFEDBSFGVMMZ5IFONEJPEFXBTGPVOEUPCFTBGFSEVFUP its reversible alterations in only some materials. Further in vivo studies are necessary to clinically apply the outcomes of this study. (Quintessence Int 2012;43:387–395)

Key words: dental materials, gingivectomy, soft tissue layers, surface

In

peri-

enhancement cases. Especially in patients

odontal surgery may be a part of esthetic

contemporary

clinical

dentistry,

with a high lip line, any periodontal surgery certainly turns into an esthetic surgery as

1

2

Associate Professor, Department of Cariology and Restorative

much as a functional one.1 Dental lasers, as

Dentistry, Nova Southeastern University, Fort Lauderdale,

alternative instruments to traditional scalpels,

Florida, USA.

are commonly used in various esthetic and

Research

Associate,

Biomaterials

Research

Lab,

Nova

Southeastern University, Fort Lauderdale, Florida, USA. 3

Assistant Professor, Department of Periodontology, University of Tennessee, Memphis, Tennessee, USA.

4

Assistant Professor, Department of Periodontology, Nova Southeastern University, Fort Lauderdale, Florida, USA.

functional applications such as gingivectomy, cosmetic gingival contouring, crown lengthening, frenectomy, removal of soft tissue pathology, subgingival curettage, periodontal pocket disinfection, implant surface decontamination, and uncovering of sub-

5

Private Practice, Gainesville, Florida, USA.

6

Professor, Department of Oral Diagnostic Sciences, Nova

merged implants.2–6 Laser-assisted surgeries may be preferred in esthetic cases because

Southeastern University, Fort Lauderdale, Florida, USA.

of some advantages such as less scar forCorrespondence: Dr Evren Kilinc, Department of Cariology and Restorative Dentistry, Nova Southeastern University, 3200 S. University Drive, Fort Lauderdale, FL 33328. Email: [email protected]

VOLUME 43 t /6.#&35 t MAY 2012

mation and less postoperative swelling. They were also reported to provide more precise

387

Q U I N T E S S E N C E I N T E R N AT I O N A L Kilinc et al

and visible surgical sites due to sealed

METHOD AND MATERIALS

blood vessels, less pain for the patient, and reduced bacterial transmission.2,6–11 Despite

CO2 /E:"( BOEONEJPEFTPGUUJTTVF

their advantages, soft tissue lasers were

lasers were used on eight material groups

also shown to affect the surrounding tissues

consisting of dental materials and tooth

and cause craterlike defects on enamel

structure. Each laser unit was used by the

and cementum during periodontal surgeries,

same operator using the manufacturers’ set-

which may be a problem in esthetic areas.12–16

tings for gingivectomy. The laser units and

This issue may affect a great number of

operation settings are displayed in Table 1.

general clinicians in addition to periodon-

Eight material groups were used for the

tists, since increasing numbers of general

study. Sample groups included seven den-

practitioners are known to have incorporated

UBMCJPNBUFSJBMT × 15 mm dimensions ×

dental laser technology to their practices.

1 mm thickness) and tooth slices obtained

/VNFSPVT QBUJFOUT XIP VOEFSHP QFSJ-

from extracted caries-free molars (1 mm

odontal surgery present with existing direct

thick). Polished samples of base metal,

or indirect restorations and dental implants

gold, palladium-silver, titanium, and ceram-

immediate to the surgical sites, yet the poten-

ic were provided by the manufacturer.

tial surface effects of lasers has not been

Dental amalgam and composite samples

widely reported. An unintentional but defi-

were fabricated according to the manufac-

nitely possible laser-surface interaction may

turer’s instructions by the same investigator.

cause various levels of restoration or implant

A custom-made polyoxymethylene (Delrin,

surface deformities. These alterations may

Small Parts) split mold was used to fabricate

cause esthetically unacceptable situations

the samples. Composite samples were poly-

and may also promote bacterial adhesion.17–21

NFSJ[FEJOPWFSMBQQJOHDZDMFTPGTFDPOET

The damage to the adjacent restorative mate-

according to ISO standards.24 Fabricated

rial could even be to such an extent that it

amalgam and composite samples were

may require removal of an otherwise accept-

TBOEFE EPXO UP VOJGPSN  œ  NN

able restoration. Most of the existing studies

thickness under standardized conditions

in the literature evaluate the surface effects

7JDUPS #FUB  #VFIMFS  VTJOH    

of lasers on only one or two dental materials

  BOE  HSJU TJMJDPO DBSCJEF TBOE-

and mostly using only one type of laser.   

QBQFS $BSCJNFU  #VFIMFS  "NBMHBN QPM-

More extensive studies that would cover vari-

ishing was performed using brownie and

ous types of materials and lasers may provide

greenie points (Shofu Dental). Composite

a more clear perspective for better-informed

polishing was perfomed using Enhance

clinical decisions.

points (Dentsply Caulk), Sof-Lex disks (3M

The purpose of this in vitro study was

ESPE), and Jiffy composite polishing brush-

to assess the potential effects of direct

es (Ultradent). A digital caliper was used to

irradiations of some commonly used soft

measure and confirm standard disk thick-

tissue lasers on various types of direct and

ness for all samples. The material groups

indirect restorative materials and titanium.

are displayed in Table 2.

Scanning electron microscopy (SEM)

A custom-made polyoxymethylene sam-

and digital photography methods were uti-

ple holder facilitated upright positioning of

lized to evaluate the surface alteration of

each material sample.

carbon dioxide (CO2

 OFPEZNJVNEPQFE

In all of the 24 study groups, laser irra-

ZUUSJVN BMVNJOVN HBSOFU /E:"(

 BOE

EJBUJPOT XFSF QFSGPSNFE GPS  TFDPOET

ONEJPEFMBTFSTPOEFOUBMCJPNBUFSJBMT

The laser beam was aimed at a 45-degree

such as ceramic, composite, dental amal-

angle to the vertical axis of the sample to

gam, base metal, high noble metal, noble

better simulate the clinical scenario (n = 8).

metal, and titanium in addition to sectioned

Each irradiation surface area was restricted

teeth. The safety of each laser on each

UP× 7.5 mm dimensions (Fig 1).

type of material or tooth was determined. The lasers altering the surface topography,

Irradiations were strictly timed to ensure a DPOTJTUFOUœNNTFDJSSBEJBUJPOTQFFE

especially to a detrimental extent, were

/E:"( BOE EJPEF GJCFS UJQT XFSF DMFBWFE

addressed and discussed.

CFGPSF FBDI TBNQMF JSSBEJBUJPO /P DMFBWJOH

388

VOLUME 43 t /6.#&35 t MAY 2012

Q U I N T E S S E N C E I N T E R N AT I O N A L Kilinc et al

Table 1

Laser devices and settings

Instruments

Model (manufacturer)

Settings

Tips

CO2

Ultraspeed (DEKA)

18 )[ MFWFM 8  gingivectomy I setting

Perio insert, cylindric tip

/E:"(

"%5%-BTF6QHSBEF 8

8 )[

NJDSPOGJCFSUJQ

ONEJPEFMBTFS

0EZTTFZ/BWJHBUPS *WPDMBS7JWBEFOU

8 DPOUJOVPVTXBWF )[

*OJUJBUFENJDSPOUJQ

Table 2

Dental material groups used in the study

Material Dental amalgam

Name

Manufacturer

Valiant Ph.D.

Lot no. -9$.3

Ivoclar Vivadent

#BTFNFUBM

*14E4JHO

Ivoclar Vivadent

M19918

(PME

"RVBSJVT)BSE

Ivoclar Vivadent

- .

Palladium-silver

IPS d.Sign 53

Ivoclar Vivadent

-

Titanium

(SBEF

Atlantic Metals & Alloys

Ceramic

IPS Empress Esthetic (ETC 2 shade)

Ivoclar Vivadent

(

Composite

Tetric Evoceram (bleach M shade)

Ivoclar Vivadent



Tooth



5*(3





Fig 1 The angulated positioning of the laser handpiece on the material sample.

was necessary for the CO2 laser. The CO2

lens). The original photographs appeared

laser was operated under a water flow fol-

BQQSPYJNBUFMZUJNFTUIFJSBDUVBMTJ[F

lowing the manufacturer’s recommendations. A camera mount system was used to capture standardized photographs from

Irradiated

surfaces

were

evaluated

VOEFS 4&. '&*1IJMJQT 2VBOUB   BU NBHOJGJDBUJPOTPG×BOE ×.

B QSFTFU NN EJTUBODF " EJHJUBM DBN-

The definition and severity of the mark-

era and a high-definition macro lens were

ings that varied between the lasers and

VTFE GPS JNBHJOH /JLPO 1  /JLPO

dental materials were compared using the

64" 0QUFLB × high-definition macro

photographs and SEM images.

VOLUME 43 t /6.#&35 t MAY 2012

389

Q U I N T E S S E N C E I N T E R N AT I O N A L Kilinc et al

Amalgam irradiations 1IPUPHSBQI ×)

Base metal irradiations 4&. ×)

4&.  ×)

1IPUPHSBQI ×)

CO2

CO2

/E:"(

/E:"(

Diode

Diode

Fig 2

Amalgam surfaces.

RESULTS

Fig 3

4&. ×)

Base metal surfaces.

the photographs, SEM images showed that they generated very fine markings of approx-

The potential surface alteration effects of CO2  /E:"(  BOE ON EJPEF MBTFST were evaluated from optical and micro-

imately 13 and 6 microns, respectively. (PME TBNQMFT TIPXFE UIBU BMM MBTFST caused visible surface dents (see Fig 4).

TDPQJDQPJOUTPGWJFX3FTVMUTBSFEJTQMBZFE

*O QBSUJDVMBS  UIF /E:"( MBTFS EBNBHFE

by the dental material for better comparison

the material’s surface to a greater extent

of the lasers (Figs 2 to 9).

of approximately 375 microns. According

*OBNBMHBN POMZUIF/E:"(MBTFSQSP-

to the SEM evaluations, the markings were

duced a craterlike detrimental effect, which

approximately 15 times wider than the CO2

would most likely necessitate the removal

MBTFS BOE  UJNFT XJEFS UIBO UIF EJPEF

of the restoration (see Fig 2). The markings

Diode markings were measured to be the

show that this particular laser irradiation

finest and the most reversible ones.

damaged the surface instantly in approxiNBUFMZBNJDSPOEJBNFUFS EFNPOTUSBU-

Palladium-silver samples were visibly BGGFDUFE CZ /E:"( BOE ON EJPEF

ing that even an accidental exposure may

MBTFST TFF'JH /E:"(MBTFSNBSLTXFSF

CF DSJUJDBM 5IF ON EJPEF MBTFS NBSL-

deeper and approximately 395 microns,

ings were barely visible without any mag-

which was about 9 times wider than the

nification. Markings initiated by CO2 were

diode markings. The CO2 laser irradiation

visible as fine scratches and demonstrated

markings were not visible to the naked eye.

approximately an 18-micron diameter in the SEM imaging.

Titanium surfaces were visibly affected POMZ CZ UIF /E:"( MBTFS JSSBEJBUJPOT TFF

#BTF NFUBM TVSGBDFT XFSF POMZ WJTJCMZ

'JH   5IF FGGFDU PG /E:"( MBTFS JSSBEJB-

BGGFDUFE CZ /E:"( MBTFS JSSBEJBUJPOT TFF

tion showed surface cracks with an approxi-

Fig 3). The markings were circular by defini-

NBUFMZNJDSPOXJEUIEJBNFUFS5IF$02

tion and appeared shallower compared with

laser did not have any visible effect. In fact,

/E:"( BNBMHBN JSSBEJBUJPOT &WFO UIPVHI

it was difficult to differentiate surface irregu-

both CO2 and diode laser irradiation mark-

larities from laser irradiations on the SEM

ings were not visible to the naked eye or in

due to the imperfections in the polish. Diode



VOLUME 43 t /6.#&35 t MAY 2012

4&.  ×)

Q U I N T E S S E N C E I N T E R N AT I O N A L Kilinc et al

Gold irradiations

PdAg irradiations

1IPUPHSBQI ×)

4&. ×)

4&.  ×)

1IPUPHSBQI ×)

CO2

CO2

/E:"(

/E:"(

Diode

Diode

Fig 4

Gold surfaces.

Fig 5

Titanium irradiations

4&. ×)

4&.  ×)

4&. ×)

4&.  ×)

Palladium-silver surfaces.

Composite irradiations

1IPUPHSBQI ×)

4&. ×)

4&.  ×)

1IPUPHSBQI ×)

CO2

CO2

/E:"(

/E:"(

Diode

Diode

Fig 6

Titanium surfaces.

Fig 7

Composite surfaces.

lasers did not show any detectable effect

surfaces were carbonized and damaged to

in the digital images, but the SEM evalua-

a great extent with a diameter of approxi-

tion revealed scattered markings of a cir-

NBUFMZNN/E:"(MBTFSBMTPDBVTFE

DVMBS OBUVSF XJUI BQQSPYJNBUFMZ NJDSPO

a visible effect, but the damage appeared

diameter.

to be around one-quarter that of CO2. The

The

effect

of

lasers

varied

greatly

diode laser did not show any visible effects

depending on the composite material (see

to the naked eye; nevertheless, SEM evalu-

Fig 7). Composite surfaces were irreparably

ations showed a smaller diameter irradia-

affected by the CO2 laser irradiations. The

UJPOQBUIPGBQQSPYJNBUFMZNJDSPOT

VOLUME 43 t /6.#&35 t MAY 2012

391

Q U I N T E S S E N C E I N T E R N AT I O N A L Kilinc et al

Ceramic irradiations

Tooth irradiations

1IPUPHSBQI ×)

4&. ×)

4&.  ×)

1IPUPHSBQI ×)

CO2

CO2

/E:"(

/E:"(

Diode

Diode

Fig 8

Ceramic surfaces.

During the visual examination of the

Fig 9

4&. ×)

Tooth surfaces.

DISCUSSION

ceramic surfaces, only CO2 laser-irradiated ones were visibly affected. SEM evaluations

When a laser light reaches tissue, it can

showed multiple microcracks and deformi-

reflect, scatter, be absorbed, or be trans-

ties, revealing irreversible surface damage

mitted to the surrounding tissues in a dif-

(see Fig 8). The long-term effect of the dam-

ficult-to-control direction.25 Existing direct

age on clinical longevity was considered

and indirect restorations are commonly

more intense than it would appear to the

present in close proximity to laser-assisted

OBLFEFZFJOBDMJOJDBMTFUUJOH5IF/E:"(

gingivectomy operation sites. Some other

and diode lasers did not cause any surface

studies demonstrated that a possible sur-

damage on ceramic.

face damage on a dental restoration may

Tooth surfaces were uniformly and det-

lead to esthetic problems as well as micro-

SJNFOUBMMZ BGGFDUFE CZ /E:"( JSSBEJBUJPOT

cracks, fractures, and bacterial adhesion,

(see Fig 9). SEM images showed carbon-

which also may either lead to secondary

ized, cracked, melted surfaces where the

caries formation at the cavosurface margins

diameter could not be measured due to

or periodontal problems.16,17,26 In today’s

its size. The CO2 laser caused detrimental

dentistry, where dentists are constantly

effects on most of the surfaces, but some

trying to reduce chairside time, removal

selective irradiated areas were not affected.

of sound restorations due to unplanned

The diode laser affected a limited area of one

clinical complications is not feasible and

of the samples. All other diode-irradiated

can be cumbersome. This particular study

surfaces appeared intact both in the photo-

evaluated three commonly used soft tissue

graphs and SEM evaluations.

lasers on various universally placed dental

392

VOLUME 43 t /6.#&35 t MAY 2012

4&.  ×)

Q U I N T E S S E N C E I N T E R N AT I O N A L Kilinc et al

biomaterials and tooth surfaces, which pro-

the severity was not evident even with the

vided a larger set of data to discuss.

approximately tenfold magnification of the

The purpose was to compare and provide

digital images. The surface cracks in the

a more informed selection between laser

ceramic, which were only detectible in the

devices when there is more than one option

SEM image would most likely affect the clini-

or to aid the decision process as to whether

DBM TVSWJWBM USFNFOEPVTMZ )ZQPUIFUJDBMMZ

a laser-assisted gingivectomy method is

speaking, the patient may present with a

feasible depending on the type of pre-

fractured ceramic veneer shortly after a CO2

existing restorations.

laser gingivectomy procedure, and the clini-

The in vitro methods can give only an

cian may not form a correlation between the

idea about the potential surface alteration

two. These composite and ceramic findings

effects since the laboratory environment

were expected because nonmetallic resto-

cannot be compared with an in vivo envi-

rations were reported to be prone to surface

ronment. This study does not claim to fully

alteration by the CO2 laser. Also, the CO2

simulate the oral situation or provide the

laser was previously shown to produce sur-

feedback of a clinical study; nevertheless,

face cracks in the ceramic material.22

the authors believe that such in vitro studies

When the patients have pre-existing tita-

facilitating a micrographic view may pro-

nium implants, amalgam fillings, or restora-

vide more detailed information that would

tions with palladium-silver collars, the use

be missing in a clinical setting. The results

PG /E:"( MBTFST TIPVME CF SFDPOTJEFSFE

of this study would be very valuable in

These materials were irreversibly damaged

conjunction with the results of a follow-up in

JO BO JOTUBOU NBOOFS CZ UIF /E:"( 5IF

vivo study. The investigators used an expe-

/E:"( MBTFS JT B TIPSUXBWFMFOHUI MBTFS 

rienced operator rather than a laser setup

and the beams of this laser are known to be

for better simulation of the oral environment

better absorbed by metallic surfaces com-

following a pilot study with consistent mark-

pared with CO2 laser beams.8 This risk has

ings. An experimental setup would require

been pointed out by some researchers.8,23

a much larger surface irradiation area for

Full metal or metal-ceramic restorations with

constant readings but could also provide

metal collars fabricated in gold or base

reliable results.

metal would possibly be irreversibly dam-

5IF TFDPOE JSSBEJBUJPOT NBZ OPU

aged with the use of this laser. The damage

completely represent an accidental expo-

PO BNBMHBN SFTUPSBUJPOT CZ UIF /E:"(

sure during a surgical operation since the

laser is well reported in previous stud-

operator’s tactile senses would probably

ies.27,28 The possible release of the mercury

avoid such an exposure for longer than 2 to

vapor from the amalgam surface should

TFDPOET/FWFSUIFMFTT UIFTFFWBMVBUJPOT

also be considered in such a situation, and

showed that the surface damages were

proper suctioning should be performed.27

all instant. In other words, an accidental

The metallic samples in this study were also

exposure of 2 seconds and an irradiation

affected by the CO2 and diode lasers but the

PGTFDPOETEJEOPUEJGGFSJOUFSNTPGUIF

alterations appeared reversible. The safety

topography on a given surface. Therefore,

of lasers can vary greatly with different

the authors believe that the results of these

parameters.18,29 The parameters of the CO2

evaluations have clinical significance dur-

and the diode lasers in this study can be

ing laser-assisted gingival surgeries.

considered as safe for titanium. This finding

According to the evaluations, in the presence of adjacent tooth-colored restorations such as composite and ceramic, CO2

would agree with some studies that found CO2 and diodes safe for the implants.  Tooth samples sectioned mesiodistally

lasers should be operated with great cau-

JODMVEFEEFOUJOBOEFOBNFMTVSGBDFT#PUI

tion, because the surface alterations were

enamel and dentin surfaces were detrimen-

detrimental. The severely damaged clinical

UBMMZBGGFDUFECZUIF/E:"(MBTFSBOEJOB

view of irradiated composite restorations

uniform manner. The finding is in agreement

would be alarming and hard to miss for the

with some studies that showed microcracks

operator. On the other hand, the ceramic

JO EFOUJO BGUFS /E:"( JSSBEJBUJPO16 On

surface alterations could be deceiving since

the other hand, the CO2 laser selectively

VOLUME 43 t /6.#&35 t MAY 2012

393

Q U I N T E S S E N C E I N T E R N AT I O N A L Kilinc et al

damaged the irradiated surfaces. The man-

CONCLUSION

ufacturer’s recommended settings for the gingivectomy included a pulsed wave for

Within the limitations of this in vitro study,

this laser. Pulsed waves were shown to

laser-assisted periodontal surgeries, if not

be safer on tooth surfaces compared with

operated attentively, may be the cause of

the continuous mode, which is considered

unwanted and esthetically unacceptable

to be more destructive.13 Some areas on

surface alterations. Laser-initiated surface

the tooth samples were not affected by

alterations on all dental materials were all

the CO2 laser at all, but the affected areas

instant; therefore, even a short acciden-

were severely altered. The diode lasers

tal exposure may be destructive in some

were previously shown to be safer on the

groups. CO2 lasers around tooth-colored

tooth structures when operated with set-

SFTUPSBUJPOT BOE /E:"( MBTFS BSPVOE

tings similar to those used in this study.31

implants, amalgams, and metal indirect res-

/FWFSUIFMFTT  UIF IJHIFS QPXFST JO EJPEF

torations should be operated carefully dur-

lasers were also found destructive for the

JOHHJOHJWFDUPNJFT5IFONEJPEFMBTFS

tooth surfaces.32 In this study, almost all of

was found to affect most of the materials

the diode laser irradiations appeared to be

but appeared safer due to more reversible

safe on the tooth sections, but one certain

alterations. If the teeth are not shielded dur-

area of just one irradiation was detrimentally

ing laser-assisted gingivectomies, it is rec-

affected. The selective damages in the two

ommended to apply routine postoperative

latter lasers may be due the differences in

polishing procedures to almost all types of

the humidity level on the surfaces of the

restorations. Further clinical studies are nec-

extracted teeth. The samples were kept in

essary to validate the findings of this study.

distilled water at all times other than the actual irradiation, but testing time may have dehydrated some areas and worsened the effect.33 Furthermore, some studies show

ACKNOWLEDGMENT

that polished tooth surfaces such as in an intact tooth surface would be less affected

This study was supported by Ivoclar Vivadent.

by the CO2 compared with sectioned tooth slices; therefore, the results could have been different if the samples were polished.34 The number, size, and direction of

REFERENCES

the dentin tubules may affect the severity of the laser.33 When the irradiation surface is vertical to the directions of the dentin tubules, the laser was demonstrated to show higher ablation.33 The clinical results on vital teeth may vary. The results of this study recommend

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different laser selections for different types

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nique. Dent Today 2005;24:132–135.

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Med 1998;22:302–311. 5. Sarver DM, Yanosky M. Principles of cosmetic dentistry in orthodontics: Part 2. Soft tissue laser technology and cosmetic gingival contouring. Am J Orthod Dentofacial Orthop 2005;127:85–90. 6. Parker S. Surgical laser use in implantology and endodontics. Br Dent J 2007;202:377–386.

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7. Sarver DM. Use of the 810 nm diode laser: Soft tis-

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8. Kato T, Kusakari H, Hoshino E. Bactericidal efficacy of

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