EJPD 2017 Clinical Focus

both in permanent and in primary dentition [Flores,

Paediatric laser 2002]. The literature shows that boy sustain more
traumatic dental injuries than girls [Andreasen, 2007;
dentistry. Bani, 2016].
The revised classification of traumatic dental injuries
Part 3: Dental of the World Health Organization includes injuries to
teeth, supporting structures, and gingival and oral
trauma mucosa, and it is based on anatomical, therapeutic
and prognostic considerations (Table 1) [WHO, 1995;
Flores, 2001; Andreasen, 2007].
Careful collection of dental history, a good clinical
examination, diagnostic imaging, photographic
C. Caprioglio * documentation, pulp testing are required for a
G. Olivi** complete medicolegal report.
M.D. Genovese***
M.C. Vitale****
Laser in dental traumatology: hard
*Visiting professor University of Pisa, Pisa, Italy tissues and pulp
Private practice, Pavia, Italy
**Visiting professor, Università Cattolica del Sacro Cuore, Rome, Italy Laser application offers multiple advantages in
Private practice, Rome, Italy dental traumatology involving pulp and hard tissues.
*** Private practice, Rome, Italy - Pulp temperature increases only minimally during
****Assistant professor, Department of Clinical, Surgical, Diagnostic erbium laser treatment [Keller and Hibst, 1991;
and Paediatric Sciences, Section of Dentistry, Unit of Orthodontics and Hibst and Keller, 1996; Dostalova et al., 1997;
Paediatric Dentistry, University of Pavia, Italy Ozturk et al., 2004, Khouja, 2017].
- Laser irradiation provides high decontamination of
e-mail: claudiagiulia.caprioglio@gmail.com - olivilaser@gmail.com

DOI: 10.23804/ejpd.2017.18.03.14 1.Traumatic injuries to the hard dental tissues and pulp
Crown infraction
Uncomplicated crown fracture
Complicated crown fracture
abstract Uncomplicated crown-root fracture
Complicated crown-root fracture
Dental traumas are frequent and sometimes complex Root fracture in the apical third
events, and at times real emergencies. There are no well- Root fracture in the middle third
coded guidelines for laser applications in these clinical Root fracture in the coronal third
events. Laser-assisted therapy can offer new treatment 2.Traumatic injuries to the periodontal tissues
possibilities, simplify dental procedures, reduce post- Concussion
operative sensitivity and the need for post-operative Subluxation
Extrusive luxation
medications because of the laser-induced biostimulating
Lateral luxation
and anti-inflammatory effects.
Intrusive luxation
Avulsion
3.Injuries to the supporting bone
Keywords Dental trauma; Laser dentistry;
Comminution of the maxillary alveolar socket
Low level laser therapy; Paediatric dentistry.
Comminution of the mandibular alveolar socket
Fracture of the maxillary alveolar socket wall
Fracture of the mandibular alveolar socket wall
Fracture of the maxillary alveolar process
Introduction Fracture of the mandibular alveolar process
Fracture of the maxilla
Approximately 20% of children suffer a traumatic Fracture of the mandible
injury to their primary teeth and more than 15% 4.Injuries to gingiva or oral mucosa
injure their permanent ones [Andreasen et al., 2007; Laceration of gingival or oral mucosa
Glendor, 2008; Kramer et al., 2016; Bagattoni, 2017]. Contusion of gingival or oral mucosa
Maxillary central incisors (50%) and maxillary lateral
incisors (30%) are the teeth most frequently affected, TabLE 1 Classification of traumatic injuries.

European Journal of Paediatric Dentistry vol. 18/3-2017 247

Caprioglio C. et al.

the exposed site (bactericidal effect) [Turkun et al., Pulp capping

2006; Moritz, 2006]. Among the clinical trials and histological investigations
- Laser ablation removes the smear layer and debris, in animal models, Santucci [1997] was the first to
leaving the dentinal tubules open and thus allowing report the high success rate (90% after 6 months) in
the adhesion process [Delmè and De Moor, 2007; vivo using Nd:YAG laser and a glass ionomer cement
Olivi et al., 2009]. for pulp capping. Later studies [Moritz, 1998] reported
The entire treatment can be performed with erbium different success rates (89-93%) after 1 and 2 years
laser, including preparation and conditioning for the using a CO2 laser versus calcium hydroxide. Olivi et al.
reattachment of the fragment. [2006-2007] have investigated in vivo different laser
Laser therapy improves the psychological approach sistems and calcium hydroxide, reporting success rates
and the compliance of the patient, reducing discomfort of 80% for Er,Cr:YSGG, 75% for Er:YAG and 63% for
and inducing laser analgesia by raising the pain calcium hydroxide alone. Recently, Cengiz and Yilmez
threshold [Boj, 2005; Genovese and Olivi, 2008]. [2016] have investigated Er,Cr:YSGG laser irradiation
Crown infractions are rare; non-ablative laser energy at low energy, with no agents and reported success
in a defocused mode reduces the enamel-dentin rates after 6 months of 100% the laser, 73,3% for
permeability, the bacterial load and thus sensitivity. calcium hydroxide alone group and 66,6% for a resin-
The procedure can be repeated after 7 to 15 days. based tricalcium silicate material alone. Yazdanfor et al.
Enamel-crown fracture without pulp exposure [2015] have investigated a diode-laser-assisted method
(uncomplicated fracture) can be treated by using compared to conventional procedure, reporting 60%
Erbium lasers [Caprioglio, 2010-2011; Olivi, 2010]. survival rate for the conventional method and 100%
Erbium laser is used for enamel and dentin for the diode 808 nm procedure after one year.
conditioning: signs of submorphological damage are Several studies on different animal models have been
related to the thermal vaporisation of the organic performed by Jawardena et al. [2001] using Er:YAG
dentinal fibres and of the peripheral interprismatic laser; Hasheminia et al. [2010] reported better healing
enamel structure; acid etching is needed. using Er:YAG laser with MTA in comparison with MTA
A complicated crown fracture exposes the pulp: alone. Suzuki et al. [2011] have investigated super-
treatment depends on the size of the exposure and the pulsed CO2 laser preirradiation on exposed rat pulp in
timeframe between the traumatic injury and treatment three groups, one irradiated and directly capped with
[AAPD, 2005-2006; Caprioglio, 2014; Smaïl-Faugeron, a self-etching adhesive system, one capped with the
2017]. The options include: pulp capping (Fig. 1), self-etching adhesive system and the third was capped
partial pulpotomy, pulpectomy and root canal therapy. with commercially available calcium hydroxide, and
If the exposed area is very small (< 1 mm2) and the the self-etching adhesive system was applied to the
treatment is rapidly provided, pulp capping is the first cavity, reporting no significant differences between the
choice of treatment: different laser wavelenghts can groups. However, the CO2 laser irradiation showed a
be used for decontamination and coagulation of the tendency to delay the formation of reparative dentin.
exposed pulp.
Laser pulpotomy and pulpectomy
Pulpotomy is a very common technique in primary
teeth, however several investigations using different
wavelenghts reported controversial results [Mendoza
2017].
Pulpotomy can be performed by using CO2, Nd:YAG,
Erbium and diode lasers.
Two sistematic reviews presented different results. De
Coster et al. [2013] reviewed 7 articles and concluded
that lasers (632/980 nm diode lasers, Nd:YAG, Er, YAG,
CO2) were less successful than conventional pulpotomy
techniques. Another study by Lin et al. [2012] including
37 studies and 22 meta-analyses highlighted that
formocresol ferric sulfate and MTA had significantly
better results in primary molar pulpotomy than calcium
hydroxide and laser therapy in a 18-24 month follow-up
study, with MTA as the first choice. More recent studies
reported more positive results for lasers. Yadav et al.
fig. 1 Complicated crown fracture of the maxillary lateral [2014] reported a better outcome of diode pulpotomy
incisor, treated with defocused treatment for coagulation and and electrosurgical pulpotomy versus ferric sulfate
dentin melting (Erbium laser at 100 mJ). pulpotomy after 9 months. A randomised clinical

248 European Journal of Paediatric Dentistry vol. 18/3-2017

 EJPD 2017 Clinical Focus: PAEDIATRIC LASER DENTISTRY

fig. 2 Complicated fig. 3

complete crown Avulsion of
fracture in a the maxillary
4-year-old patient. left central
Gingivoplasty and lateral
and tooth margin incisors in a
preparation are 3-year-old
performed by using girl. KTP laser
an Erbium laser. irradiation
(LLLT).

trial [Gupta et al., 2015] showed good clinical and Semi-conductor diode type lasers (803 to 980 nm) are
radiographical results for laser pulpotomy performed near-infrared lasers that at low power can be used for
on 30 primary molars. The importance of the sealing effective treatment of pain and inflammation and to
material was reported by different authors [Niranjani et promote tissue repair with great tissue penetration
al., 2015; Uloopi et al., 2016]. [Boj, 2011; Caprioglio, 2011; Ghaderi, 2017]. They can
There are few studies on laser use for pulpectomy influence a large number of cell systems (fibroblasts,
(Indexed on PubMed) in primary teeth (see Part 2). macrophages, lymphocytes, epithelial cells,
endothelium) and can also have a series of benefits on
the inflammatory mechanism, reducing the exudative
Laser in traumatic injuries to soft phase and stimulating the reparative process [De
tissues Souza, 2016].
LLLT modifies nerve impulse stimulation and
Traumatic injuries to supporting structures (alveolar transmission and increases the metabolism of
bone, gingiva, ligaments, periodontium, fraenum and endorphins, acetylcholine, serotonin, and cortisol,
lips), defined as indirect traumas, can be effectively resulting in reduced stimulation and perception of
treated using lasers, especially the visible and near pain [Schindl, 2000; Simunovic, 2000; Pinheiro et al.,
infrared types. These lasers are used for their ability 2004-2006]. LLLT increases production of adenosine
to decontaminate the periodontal defect following a triphosphate (ATP) as well as overall cell activity.
dental luxation or subluxation, for decontamination of Laser light increases mitochondrial ATP and can also
the socket after an avulsion, for the ability to perform react with beta growth factors [Karu, 1987-1988;
gingivectomy and/or gingivoplasty or surgical incisions Pinheiro, 2006]. LLLT modifies blood flow and induces
(e.g. to remove a tooth fragment embedded in the soft angiogenesis, and the modification of limph drainage
tissue) (Fig. 2). reduces inflammation.
In all types of luxation injuries, lasers provide not The study of these new treatments might lead to
only a bactericidal and detoxification effect (Er:YAG, the definition of guidelines and protocols with specific
Nd:YAG, and diode), but also favourable conditions for doses and application sites.
the attachment of the periodontal tissue, expecially in
the permanent dentition [Simunovic, 2000; Schindl,
2003; Carvalho et al., 2012; Matos et al., 2016]. In References
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