The use of Erbium:YAG laser for caries

removal in paediatric patients following

Minimally Invasive Dentistry concepts
R. KORNBLIT*-**, D. TRAPANI*, M. BOSSÙ*, M. MULLER-BOLLA***,

J.P. ROCCA**, A. POLIMENI*

ABSTRACT. The Er:YAG laser has proven to be effective and efficient in dental hard tissue ablation. The Minimally
Invasive Dentistry (MID) approach in caries removal is to stop the disease process and to restore lost tooth
structure and function, maximizing the health potential of the tooth. One of the most important concepts of the
MID is to preserve as much as possible the dental tissue and this approach is even more important in primary
dentition where the dimensions of the crown are smaller and the dimension of the pulp chamber is bigger in
relationship to the crown. After treating 30 children’s teeth (primary molars and first permanent molars) with the
Er:YAG laser, we come to conclusion that laser treatment possesses the requirements of Minimal Invasive
Dentistry: the possibility to ablate small area of infected layer guarantees maximum conservation of the tooth
structure; using the antibacterial property of the Er:YAG laser we can decontaminate the affected layer that
retains its remineralising potential; the lack of smear layer after vaporization with laser assures a better retention
of the composite resin to the dentine; preparing the enamel surface with laser before etching gives a better
marginal seal of the composite restoration.

KEYWORDS: Minimally Invasive Dentistry, Er:YAG laser, Caries ablation.

Introduction In the past, carious treatment approach was mainly a

In the 21st century caries is still one of the most
frequent mouth disease in childhood Roman
population due to the lack of information, health
education and health promotion [Panetta et al., 2004].
A previous study by the National Institute for Food and
Nutrition Research (INRAN), demonstrated a
consistent percentage of the variability exists in DMFT
related to the frequency of carbohydrates intake and
dental caries [Arcella et al., 2002].
The carious dental lesion is the result of bacterial
infection where the acids produced by bacteria, as they
metabolize sugar and cooked starches, de-mineralise the
tooth’s structure [Kleinberg, 1979; van Houte, 1980].
*Department of Paediatric Dentistry, University of Rome (La Sapienza).
**Laser Technology and Oral Environment Laboratory, Nice, Sophia Antipolis
University, UFR Odontologie.
***Public Health Department, Univerisity of Nice, Sophie Antipolis.
e-mail: roly.kornblit@tiscali.it
surgical removal of the infected and affected tissue
followed by reconstruction with a dental restorative
material (mostly amalgam). This approach was
necessary because of the limitation of other available
materials and the lack of proved alternative therapies
[Laurens, 1950]. It is important to remember that, at
that time, diagnosis of carious lesions was carried out
at more advanced disease stages compared to the
incipient lesions detected today, and instrumentation
was limited to slow rotary and hand instruments [Skeie
et al., 2004].
The preparation of the cavity was performed with
excessive tooth structure reduction even for relatively
small lesions, removing not only the caries but also
healthy dental tissue in order to follow the concepts of
extension for prevention, resistance and retention
[Jahn and Zuhrt, 1990; Osborne and Summit, 1998].
Modern dentistry has moved to a minimally invasive
approach, in which caries is managed as an infectious
disease and the focus is on maximum conservation of

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R. KORNBLIT ET AL.

the tooth structures [Peters and McLean, 2001;

Brostek and Bochenek, 2006].
The introduction of adhesive dental materials made
possible the conservation of tooth structure using
minimal invasive preparation, because adhesive
materials don’t require any incorporation of
mechanical retention features.
Minimally invasive dentistry (MID) adopts a
philosophy that integrates prevention, remineralization
and minimal intervention for the placement and
replacement of restoration. MID reaches the treatment
objective using the least invasive surgical approach
with the removal of minimal amount of healthy tissue
[Ericson et al., 2003].
In paediatric dentistry tooth structure preservation is
even more important as the crowns of primary teeth FIG. 1 - Er:YAG laser –
are smaller than the permanent ones. The erupted Fidelis plus Fotona
permanent teeth, during childhood, have a large pulp
chamber.
Using Er:YAG laser in removing carious tissue, to be
restored with resin based composite, can be the right
method for minimal invasive preparation.

Materials and methods

We treated for caries 30 teeth of children between
the age of 4 and 12 years, following the requirements
of MID in paediatric conservative dentistry. The teeth
treated were first and second primary molars and first
permanent molar. The caries treated had a depth from
just in dentine to half-way of the dentine thickness (at
least 1 mm from the pulp chamber).
In all the 30 treated teeth we used topical anesthesia
(Emla, 5 g, AstraZeneca) applied for 3 minutes on the
vestibular and lingual/palatal marginal gengiva before
placing a rubber dam clamp (Ivory, Heraeus Kulzer,
Usa) and a rubber dam (Dental Dam, Medium,
Hygenic, Coltene/Whaledent Inc.).
No local anesthetic was used before treatment. In 4
cases, as the child complained of pain during laser
treatment, we proceeded with a local anesthesia
(Carbosen with adrenaline, 20 mg/ml + 10 mgc/ml;
Galenica Senese).
For caries removal we used the Er:YAG laser,
produced by Fotona (Fig. 1), that is a solid state crystal
laser where the host crystal is Yttrium Aluminum
Garnet doped with Erbium ions that replace the
Yttrium ions. The pulse repetition rate ranges between
2 Hz and 50 Hz, the laser pulse energy ranges between
40 mJ and 1000 mJ, adjustable in 10mJ increments
and the power ranges between 0.25 W and 12 W. In
Fotona Fidelis family of dental lasers the Er:YAG laser
pulses are grouped in four pulse width (so called
FIG. 2 - R-02 handpiece (no contact).
modes of operation): VSP (Very Short Pulses), 140 µs,
SP (Short Pulses), 330 µs, LP (Long Pulses), 550 µs,
VLP (Very Long Pulses) 920 µs.
The wavelength of Er:YAG laser is 2940 nm that
coincides with the absorption peak of water. The
Er:YAG laser is adapted for hard dental tissue
ablation, where the main chromophores, for
wavelength of 2940 nm absorption, are water and
hydroxyapatite (HA) [Cozean et al., 1997]. Maximum
absorption in water results in an effective
microexplosion mechanism accompained by an
increase in pressure (hydrocinetic energy). The
explosive vaporisation creates a cloud of ablation of
the carious tissues. The ablative action is also due to a
photoacoustic effect caused by the microexplosions of
water on target tissue.
The parameters we used were: VSP mode (140 µs
per pulse), Energy from 120mJ to 200mJ, Frequency
from 2Hz to 20Hz, Fluence from 24 J/cm2 to 40 J/cm2,
with the mirror handpiece R-02 (no contact) (Fig. 2).
Both patient's and operator's eyes were protected by
glass lents (Univet, 705.00.00.00.BL, certificated CE,
Dir. 89/686/CEE).
All the teeth were restored in the same appointment

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using acid etch Scotchbond Etchant (3M Espe, Dental
Products), adhesive Scotchbond 1 XT (3M Espe,
Dental Products) and composite Z100 MP Restorative
(3M Espe, Dental Products). In no case was
underlying used. The resin composite underwent
conventional polymerisation with a halogen light 52
W, spectrum 400-515nm (Polylight 3 Steril,
Castellini), curing for 40 seconds each layer of the
resin composite (at least two layers for filling) with the
light tip at 8 mm distance from the tooth surface.
In all the 30 treated teeth we ablated the caries in
focus mode using the Er:YAG laser with the mirror
handpiece R2 at a distance between 0.8 to 1 cm from
the tooth with slow fluid continuous movements. The
preparation of the cavities was limited to vaporising
the infected layer leaving the affected one, without any
ablation of healthy tooth structure.
We managed to guide the laser beam under the intact
enamel in order to remove the carious dentine. We
checked the removing of the amorphic dentine with
the probe and in some cases we finished to remove the
infected layer using a dental excavator (ASA stainless
1700-2).
The follow-ups at 7 and 28 days aimed to evaluate
any post-operative complications. We checked the
sensivity to temperature changes and the vitality of the
FIG. 3 - Female, 7 years, treated teeth 36,
VSP mode, 150 mJ, 15 Hz; pretreatment.
FIG. 6 - 7 days control.
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • VOL. 9/2-2008
THE USE OF ERBIUM: YAG LASER
treated teeth. All the clinical work was done at the
U.O.C. of Paediatric Department of the University of
Rome, La Sapienza.
Results
None of the teeth treated with the materials and
method above described (Fig. 3-21) presented at the
follow-up controls at 7 and 28 days any post-operative
complication like pain or sensivity and all the teeth
preserved their vitality.
Discussion
Modern operative paediatric dentistry should be
based on a minimally invasive approach where caries
removal and cavity preparation should be performed
with minimal tissue removal. The conservation of hard
dental tissue increases the life of the restored tooth
[Yip and Samaranayake, 1998].
Lots of studies showed that the use of Er:YAG laser
is efficient, effective, safe and suitable for caries
removal and cavity preparation [Matsumoto et al.,
2007; Liu et al., 2006; Freitas et al., 2007].
Many authors reported that preparation done with
laser instrument generate similar heat increases under
FIG. 4 - After laser treatment. FIG. 5 . Immediatly after treatment.
FIG. 7 - 28 days control.
83
 R. KORNBLIT ET AL.

FIG. 8 - Female, 6 years, treated teeth 55, FIG. 9 - During treatment. FIG. 10 - After laser treatment.
VSP mode, 200 mJ, 20 Hz; pretreatment.

FIG. 11 - Treatment completed. FIG. 12 - 7 days control. FIG. 13 - 28 days control.

FIG. 14 - Female, 8 years, treated teeth FIG. 15 - Pretreatment. FIG. 16 - During treatment.
55, VSP mode, 150 mJ, 20 Hz;
pretreatment.

FIG. 17 - After laser treatment. FIG. 18 - Treatment completed.

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FIG. 19 - 7 days control.
water-cooling compared to the preparation with high-
speed instruments [Cavalcanti et al., 2003]. In all the
in vitro researches the intrapulpal temperature change
during cavity preparation and caries removal using
Er:YAG laser with water-cooling was lower than
5.5°C. This temperature is considered a critical value
for pulp vitality [Cavalcanti et al., 2003; Geraldo-
Martins et al., 2005; Park et al., 2007].
The aiming beam of Er:YAG laser (incorporated in
the system) has an ablating spot diameter of 0.8 mm
(in fact the ablating area is even smaller), so that
irradiating dental hard tissue with laser in focal mode
allows to ablate areas no larger than 0.8 mm in
diameter (Fig. 21).
Removing such small surfaces of dental caries
cannot be done with the burs because even the smallest
one, when drilling, takes off more tissue. Additionally
the burs remove tissue tridimensionally comparing to
the laser beam that vaporises only the irradiated
surface (Fig. 22).
Having the possibility to ablate small areas with the
Er:YAG laser helps reaching one of the most important
goal of MID that is the maximum preservation of
dental tissue.
FIG. 21- The spot (0.8 mm) of R2 laser handpiece (no contact).
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • VOL. 9/2-2008
THE USE OF ERBIUM: YAG LASER
FIG. 20 - 28 days control.
In modern dentistry the caries lesion is composed of
two layers. The infected layer, which is heavily
contaminated by bacteria, is composed of soft
amorphic dentin (denatured collagen matrix) without
any potential ability to remineralise. The underlying
layer, the affected one, less contaminated by bacteria,
is partially demineralised with an intact collagen
matrix conserving the potential to remineralise
[Banerjee et al., 2001].
Since caries affected dentin contains intact
undenatured collagen fibers and has the ability to
remineralise, the goal is to eliminate the infected
caries layer preserving the affected one. The boundary
between the two areas is not always obvious either in
clinical pratice or laboratory research [Banerjee et al.,
2001].
The diamond and tungsten carbammide burs usually
remove the infected and affected dentine at the same
time. It is impossible to distinguish between the two
zones, sometime even extending into the underlying
intact dentine.
When using the Er:YAG laser we have a better visual
control of the ablating area and the possibility to
vaporise such small areas of 0.8 mm diameter (Fig. 23-
FIG. 22 - a magnification of a traditional bur.
85
R. KORNBLIT ET AL.
24). It is easier to vaporise only infected tissue and to
stop when the affected zone is reached. In this way, as
suggested by MID, we can preserve the affected but
repairable tissue.
In a study by Pereira et al. the results indicated that
the bond strength of Single Bond to both normal and
caries-affected dentin was not significantly different.
Additionally, the thickness of the hybrid layers
produced by both adhesive systems was thicker for
caries-affected dentin.
The bactericidal effect of laser system on dentin
surface was demonstrated by many authors and in lots
of studies [Folwaczny, 2003; Schoop et al., 2004].
Various microbiological studies tested the bactericidal
ability of different laser systems [Schoop et al., 2004;
Sahar-Helft, 2007]. The best results were obtained
with Er:YAG laser that showed a complete reduction
of E. Coli in 75% of the samples and a significant
reduction of E. Faecalis. These results confirm the
conclusions of other bacteriological studies in that
Er:YAG laser is a suitable system for the
decontamination of dentin surface in cavity
preparation as compared to conventional methods
where it is difficult to eliminate infection from dentin
even after removing all the decayed tissue.
Other studies reported the absence of bacteria up to
1 mm into the dentin, after laser irradiation [Schoop et
al., 2004].
The good disinfectation of the contaminated dentin
prevents failure of the restoration process (secondary
caries). Decontaminating the affected layer after
removing the soft amorphic dentine can help in
preventing possible future pulp complications.
The introduction of resin-based composite
restoration in dentistry helped to reach the goals of
MID. Dentine surface conditioning removes the smear
FIG. 23 - Good visibility of an incipient caries treatment
with Er:YAG laser beam (saving healthy tissue).
86
layer and opens the dentinal tubules, after bur
preparation, forming a defined hybrid layer and resin
tags of the composite material into the opened tubules.
The ablation of dental hard tissue with Er:YAG laser
leaves the dentin surface without smear layer (unlike
after bur preparation) [Curti et al., 2004]. The lack of
smear layer allows the formation of hybrid layer and
resin tag hybridisation into the opened dentinal tubules
resulting in a better retention of the adhesive
composites. Additionally some studies showed an
enlargement of dentinal tubules [Bertrand et al., 2004;
de Souza-Gabriel, 2006].
It is important to remark that a better adhesion to the
dentin surface is even more important in primary teeth
where we have smaller amount of dental tissue.
When using an adhesive system after laser
preparation of the tooth, the enamel surface prepared
by laser should be followed by acid etching. This
allows less microleakage at the interface enamel-
composite [Yamada et al., 2002; Lupi-Pégurier et al.,
2007; Boj et al., 2004; Borsatto et al., 2004].
Conclusion
The Er:YAG laser can be a very good option in
removing dental caries following all the concepts of
Minimally Invasive Dentistry in primary dentition.
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