Electrosurgery and their Applications in Periodontics
by Dinh X. Bui, D.D.S., M.S.
of the conventional “steel” cut has been the
subject of many investigations. It started with the d’Arsonval
discover in 1891 of the high frequency current, that is
current oscillating at 10,000 cps or more, can be passed
through living tissue without producing a nervous or muscular
response. In 1908, the first electronic scalpel was initiated
when DeForest devised the first vacuum tube high frequency
apparatus. The prototype of the instrument used today was
developed in 1923 by Wyeth, and was capable of cutting tissue
with little penetration, allowing primary healing, as the
thin layer of dehydrated tissue on each side of incision
was absorbed. Today, there is four different types of electrical
current used; they are, electrodesiccation, fulguration,
electrocoagulation, and electrosection or acusection. On
the other hand, the use of laser has been new for dentistry,
even though surgical lasers have been used in medicine for
over a decade in the surgical specialties of Otolaryngology,
dermatology, plastic surgery, gynecology, opthalmology,
neurosurgery, urology, thoracic, and cardiovascular surgery,
gastrointestinal surgery, orthopedics, and most recently
in oral and maxillofacial surgery. Four type of laser has
been developed for medical applications: CO2, Neodymium/YAG
(yttrium-aluminum-garnet), argon, and ruby. The lasers are
named according to the material used for the lasing medium.
This paper discuss the history, rationale, histological
study of wound healing in usage of electrosurgical and laser
Four types of
currents in electrosurgery indicates four clinical applications.
Electrodessication is the monoterminal technique (only active
electrode is used) using the low voltage, dehydrating current.
The operator has no control over the amount of tissue destruction
(a characteristic of low voltage current). Electrofulguration
is a monoterminal technique which also used a dehydrating
current, only that the active electrode does not touch the
tissue but rather brought near the tissue surface to produce
the sparks which produce an eschar. The operator thus can
control the penetrating destruction of heat. Electrocoagulation,
on the other hand, is the biterminal technique utilizing
the partially rectified or fully modified rectified concentrated
current to coagulate the organic content of the tissue without
penetrating deeply the adjacent tissue. Similarly, the electrosection
is also a biterminal technique which utilized the fully
rectified high frequency current to create incision without
accompanying coagulation. The best unit used today utilizes
the fully rectified and filtered current produced a precise,
undamped current for both incision and coagulation.
can be used to perform gingivectomy and gingivoplasty. Although
at the initial stages the cold knife gives a cleaner wound
and a more rapid healing, in later stages, both modalities
appeared to be good. However, extra caution must be carried
out to avoid contact with the bone since irreparable damages
will occur. The only advantage of electrosurgery today is
the coagulation to reduce bleeding and resulting in a clean
field with better visibility for the surgery.
has investigated electrosurgery effects on the periodontal
tissue in creating incision or coagulation. Pope in 1968
found that repair following electrosurgery persists for
much longer time compared to the scalpel surgery healing.
The experiment is carried out on the four adult mongrel
dogs with the fully rectified current of undamped waveform.
This is a split mouth design, with electrosurgery procedure
on the left side of the mouth and the scalpel surgery on
the right side of the mouth. The results indicated that
there is more severe and greater degree of bone injury,
indicated by a larger number of osteoclast and osteoblasts
in the area. The duration of complete repair was retarded
as compared to that of the scalpel surgery.
Imbert in 1970 compare the effect of gingival resection
with electrosurgery and periodontal knives. Again four adult
dogs was used in a split mouth design. Electrosurgery with
a filtered, fully rectified current of undamped waveform
was used on the right side, whereas the scalpel surgery
was carried out on the left sides. Two types of laceration
were evaluated, the deep and the shallow resection. In the
shallow resection, there is more granulation tissue an more
bleeding in the first two weeks after the surgery in the
case of electrosurgery. Both techniques presented the similar
microscopic appearances in the wound area after six and
12 weeks and the underlying bone at that time was unaltered.
In the area of deep resection, after six weeks, the electrosurgery
side showed gingival inflammation, recession, and bone height
destruction in all areas. Bone necrosis and sequestration
was found in the maxillary molar area, ulceraton of gingiva,
and the pronounced destruction of buccal alveolar plate.
On the knife treated side, the well form gingival sulcus
obtained with slight recession, and gingival inflammation
in the connective tissue with reduction in bone height is
minimal. The conclusion of the experiment is that electrosurgery
when performed with deep resection can result in extensive
gingival recession, bone necrosis, and furcation involvement
an the tooth mobility when used close to the bone. Such
damage did not occur followed the use of peridontal knives.
In 1976, Sozio
conducted a control electrosurgical currents and wound healing
to examine the tissue healing at one to six months in order
to see whether the electrosurgical wound healed as completely
as the blade would. Three incisions were made on guinea
pigs, one with the blade, one with filtered current, and
one with the nonfiltered current. Histological data were
collected at immediately postop, 24 hours, 48 hours, four
days, seven days, 14 days, one month, and six months. Scalpel
wounds demonstrated more rapid healing in early stages than
the electrosurgical counterparts.
al. in 1976 found that the gingival electrosurgery can result
in permanent periodontal damage which includes the burning
of cementum, loss of connective tissue attachment, and significant
recession of gingival margin. Maness et. al. in 1978 evaluates
the effects of varying frequency and waveform of electrosurgical
device on wound healing. The histologic analysis showed
that the machine with the full wave rectification and lowest
frequency of operation produced greater tissue alteration
than the full wave rectified with higher frequencies. The
continuous output waveform produced less tissue alteration
than the modulated type at the same frequency of operation.
A band of coagulation necrosis 5Omicrons wide along the
margin of incision is found.
Adkins, and David Keys investigates histologically the reaction
of alveolar bone after gingival incision by electrosurgery
using undamped fully rectified current on 25 guinea pigs
and found that at 12 hours post op there is more soft tissue
necrosis, more extensive inflammatory reaction, and greater
destruction of the periosteum after electrosurgery. Necrosis
of bone seen extensively at 48 hours. By 96 hours, the electrosurgical
tissue were still lined with coagulum, but repair of the
scalpel wounds had begun.
clinical researches on human subject has revealed more encouraging
results. Malone et al. compared the initial incision of
the tissue and the postoperative healing and reveal that
the healing was comparable to the scalpel in the 2.5mm depth
cut. Thus he concluded that the electrosurgery is the safe
and effective method. Aremband and Bryan Wade study of wound
healing in gingivectomy with electrosurgery and knives in
27 patients reveals that there is no observable difference
between the two modalities following a 3 week post op period.
Pain was insignificant and experienced equally in both modalities.
Cytological evaluation revealed no difference in epithelial
cell maturity in both modalities. Histological examination
revealed difference in both connective tissue and epithelial
maturation between individuals, but not between the sides
subjected to different types of surgical modalities. Periodontal
knives does result in less gingival fluid exudate in the
third week post-surgery.
In short, electrosurgery
is only recommended for soft shallow excision of the tissue.
Its use near the bone is contraindicated for reason of necrosis
and retarded wound healing. On the other hand, laser surgery
introduced a promising technology that would combine the
rapid healing of the scalpel surgery and the minimal bleeding
of electrosurgery. Laser unique characteristic lies in the
fact that the laser light is emitted at a specific wavelength
of energy and travels in a predictable pattern. The laser
energy is produced in a laser cavity which consist of an
active medium (the source of laser energy which can be solid,
liquid, or gas), the incident energy source (stimulate the
atoms of active medium), and the optical resonator (redirect
the escaping incoherent photons of active medium into the
directional, monochromatic, coherent form of light). When
the concentrated energy of lasers is absorbed by tissue,
a rapid thermal effect results in vaporization and carbonisation
of the tissue.
There are two
techniques in laser that are commonly used: excision or
vaporization. Excision is prefered because it allows histologic
confirmation of the diagnosis and indicates whether the
lesion has been completely removed. Vaporisation has the
risk of leaving behind the small fragment of the tissue,
especially in the area of thick epithelium, of which the
deeper layer may not be completely eradicated. Biological
and clinical studies have shown that the wounds produce
by C02 laser results in minimal damage to adjacent tissue
and minimal inflammation. No dressing is required, and the
laser area should be left exposed in the mouth. Skin graft
of the laser wound is uneccessary as reported in various
studies. The acute inflammatory reaction is delayed and
minimal, and few myofibroblasts are present in the base
of the wound during healing. These cells are the effectors
of wound contraction and thus there is little contraction
following removal of oral mucosa with laser. There is minimal
scarring, resulting in little duration or restriction in
movement of the soft tissues. There is less bleeding with
laser as compared to the scalpel cut, since the blood vessels
of .5mm or less in diameter are sealed spontaneously, thus
aided to the surgeon visibility and precision during the
surgery. However, laser surgery does have some disadvantage.
The mild postoperative discomfort usually delayed up to
one or two weeks. Epithelial regeneration is delayed, and
the wounds take a longer time to reepithelialize than following
conventional surgery. Another disadvantage is the high cost
of equipment. This delayed of wound healing is thought to
be the result of the lack of wound contraction and thus
failure of the area to reduce in size. The procedure usually
will take longer time especially in gingivoplasty where
abundant of tissue removal is required.
by Dr. J.W. Frame in using CO2 laser to eradicate 130 pathologic
lesions of the oral tissue reveals that following laser
treatment, the acute inflammatory reaction is minimal and
its onset is delayed. There is little swelling, edema, and
no airway distress. Healing is generally excellent, and
because of the limited contraction and scarring that occurs,
there is little restriction in mobility of the soft tissue
or interference with oral function. Comparing to the scalpel
incision, however, it does not possess any greater ability
than the scalpel to cure these conditions.
of carbon dioxide laser and conventional scalpel excision
in wound healing in the rat abdomen by Robert B. Shira (1990)
indicated that there was a minimal inflammatory response
around the laser wounds while there was a fairly brisk inflammatory
reaction around the scalpel wound initially after 1 days.
Both the scalpel and the laser wound were fully epithelialized
clinically by 14 days. Histologically, there also was a
relative absence of inflammatory response around the laser
wound with minimal cell destruction. At a cellular level,
the wound in both cases epithelialized at day 7. There is
a precise thermo-destruction of tissue 190 micrometer around
the laser beam and an area of thermo-damage, which is reversible,
for another 500 micrometer beyond. Tissue temperature in
laser measured to be up to 140 degree Celsius. The sealing
and lymphatic and blood vessel by laser resulted in minimal
extravasation of fluids and ultimately minimal inflammatory
response. In contrast the scalpel wound allow extravasation
of blood and lymph fluid, resulting in more swelling and
more inflammatory response, which takes longer to resolve.
Laser thus can be a recommended technique for soft tissue
oral and maxillofacial surgical procedure.
is another area that has been promoted as a revolutionary
procedure in periodontics. Its rationale includes its ability
to vaporize not only the subgingival bacterial flora but
also the necrotic gingival tissue, thus maximizing the healing
potential of the site. (Myers, 1989). The technique involved
the laser fiber (a glass fiber 200 to 300 micrometer in
diameter) is inserted to the known depth of the periodontal
pocket, being oriented parallel to the root surface. The
laser is activated and the fiber slowly withdrawn using
a sweeping motion. The process is repeated, using the overlapping
insertion points to attempt to achieve a coverage of root
surface. Energy usage are of typical range of 1-2 W, 20Hz
pulse frequency, pulse energy 62.5-lOOmJ/pulse. Irradiation
time is about 1-2 minutes per tooth or 3 seconds per mm2
area of root surface. In the review article by Laurence
Walshin 1993, laser curettage is found to be not sufficient
for removal of calculus. Lin et al. in 1992 in a clinical
study demonstrated that laser curettage was less effective
than scaling for removal of calculus. Dr. Walsh also disputed
the claim that laser can be used in conjunction with conventional
root planing technique to facilitate the removal of subgingival
calculus. There is heat penetration into the tooth structure
during the laser procedure, thus damage both the cementum
and the dentin. The result is the peeling of the cementum
an exposure of underlying dentin and dentinal tubule when
laser treatment was followed by root planing. Laser curettage
is not faster, especially in achieving the smooth surface
as obtained by the conventional hand instrumented root planing.
There is no evidence that the periodontal pocket environment
was detoxified or made sterile by the laser curettage. While
Nd:YAG lasers are capable of ablating small quantities of
tissue, the absorption characteristics of this laser wavelength
are not well suited to tissue ablation. The poor absorption
of this wavelength in moisture environment results in penetration
of energy into tissue, producing destructive thermal change
and little vaporization of tissue. Laser curettage is not
recommended as an effective treatment for aggression of
the periodontal disease, since the ultimate etiology of
periodontal disease is plaque control. In vitro study has
indicated that the laser treatment inhibited fibroblast
reattachment to the Nd:YAG laser treated tooth surface.
Nd:YAG laser induced physical and chemical changes to root
surface and reduce the biocompatibility of the root surface.
Laser curettage thus are found to damage the teeth (charring,
carbonisation, peeling of cementum, pulpal injury) and soft
tissue. The lased enamel surface is rough, crazed, or cratered.
The lased enamel is also softer with significant ultrastructural
changes which consists of different shape and larger size
of crystal and loss of prismatic structure.(Ferreira et.
als. 1989) There is no data to evaulate the bacterial recolonization
of the sites treated by laser curettage as compare to the
site treated by conventional method of scaling and root
planing. In short, Dr. Walsh recommended further investigation
and studies are required prior to adopted the laser curettage
technique as of long term therapeutic benefit. The weight
of evidence available at present time does not support the
value of the technique as an alternative to the conventional
the usage of laser as the mean in treating gingival hyperplasia,
various reports with encouraging results have been published.
Dr. Halter, Kirshner, and Susanin in 1992 published case
study of laser surgery application for the immunosuppressive
gingival hyperplasia. Since patient is immunocompromise,
the possible danger of excessive bleeding and slow healing
from conventional surgery prompted the consideration of
laser for tissue removal. Bleeding was not excessive, less
tissue trauma and healing is more rapid than the scalpel
or electrosurgery. S. Barak and I. Kaplan in 1988 also published
case report of the use of CO2 laser in the excision of gingival
hyperplasia caused by nifedipine. The advantage lies in
the hemostatic and sterilizing effect while post operative
edema and pain is negligible. The advantage included debulking
without bleeding, simultaneous sterilization, minimal postoperative
pain which is particularly important in elder patient. There
was no sign of recurring gingival hyperplasia after one
year of follow up. Robert Pick, Bernard Pecaro, and Charles
Silberman in 1985 also published the case report of C02
laser usage to perform gingivectomy in 12 patients. One
of these cases involved hemophilliac patient, which expectedly
will have bleeding problem. Again, the results is encouraging.
The surgery is bloodless since the laser beam coagulate
the blood vessels of .5mm or smaller. Surgical time thus
is reduced due to better visibility. There is instant sterilization
of the area, therefore decreasing bacteremia. There is noncontact
surgery, thus no mechanical trauma to the surgical site.
Histologic studies have shown that the thermal effects of
laser energy in the adjacent nontarget tissue consists of
three layers; the inner thin zone of carbonized tissue,
the zone of dessicated and destroyed tissue, and the outer
zone of edematous, possible reversibly damaged tissue. The
width of the three zones is less than .5mm They also mentioned
the disadvantage of the laser included the hospitalization
and the cost of equipment. Delay in healing when use of
CO2 laser in skin, subcutaneous, fascial, and muscular tissue
is expected since superb coagulation of very small vessels
and lymphatics occurs. Another disadvantage is loss of tactile
feedback in using the instrument. Nevertheless, they recommended
laser use in hyperplastic condition, bloodless incision,
partial thickness dissections, and for the removal of soft
tissue grafts from the palate leaving a dry wound, thus
avoiding any postoperative bleeding complications.
the American Academy of Periodontology, the research, science,
and therapy committee in 1992 indicated that the only periodontal
use supported by researches is gingivectomy utilizing CO2
laser. There is abundant evidence confirming markedly less
bleeding, particularly of highly vascular oral tissues,
with laser surgery. Postoperative pain seem to be reduced
in laser surgery due to the protein coagulum that is formed
on the wound surface, acting as a biologic dressing and
sealing the ends of the sensory nerves. Precaution of eye
injury is noted since the laser beam may reflected from
the mirrors or retractors and reflected toward the eye.
Patient throat and delicate oral tissue must be protected
by wet gauze packs from accidental impact. The AAP research
committee dismissed the use of laser as root curettage instrument.
Cost effectiveness is poor since laser technology is far
more expensive than the conventional scalpel usage.
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