September 5, 2018
by Andre Chartrand, BSc, DMD
For some years now, dentistry has shaped people’s lifestyles. The well-being, the self-esteem and the image that we project have become very important. Television, increasingly present in our homes, is helping to boost our conﬁdence through series and beauty programs.
Although dentistry is only one part of the transformations performed, the fact remains that the general population is discovering many opportunities available to them in our dental practices to improve their oral health while upgrading the projected image.
Advertising, both institutional and professional, has given new hope to some patients struggling with unusual pathologies. The demands of our patients are becoming increasingly aesthetic oriented and require a more elaborate treatment plan than simply putting veneers or crowns in place. During the intra-oral and extra-oral examination, the practitioner must look at the smile as an integral part of the face. Whether it is the shape of the teeth, their hue, the gingival margin, the smile line, the shape of the lips, all these criteria are important to create harmony.
Over the years, lasers have undergone a remarkable evolution. More and more research has proven beyond any doubt the very great utility of these devices. Increasingly informed, the general population uses various laser treatments for all kinds of health problems (vision correction, dermatological and anti-aging treatments, etc.). It is, therefore, common to receive these new patients in our ofﬁces for a “laser consultation” for various reasons.
Considered as a common lesion by the practitioner, the venous lake and/or the oral haemangioma (Fig. 1) is often relegated to the “unimportant lesion” section during a complete or routine examination of our patients. However, when patients are questioned, they will give us some comments about the apparent and unsightly lesion.
Since this is a vascular-type lesion, the general practitioner is typically not equipped (in knowledge and instrumentation) to deal with this problem and, perhaps, not aware of the treatments available under these circumstances. What’s more, this lesion is often found at the level of the lips, which are the centre of the aesthetic zone (face).
Multiple different approaches, such as sclerotherapy, embolization, cryotherapy, and surgery have been used to remedy this situation despite the risk of excessive bleeding and formation of residual scar tissue, thus discouraging the dental surgeon from any action on this type of lesion.
Now, thanks to the advent of lasers and the many studies governing their use 1-8, we can treat this type of lesion more safely, non-surgically, while minimizing the risk of scar tissue formation. On the other hand, for this type of (non-surgical) treatment, not all lasers and wavelengths are effective.
In the last decades, CO2, Nd:YAG and diode lasers have enhanced both treatment and prognosis of vascular malformations, but the diode laser seems to have a signiﬁcant advantage in treating this type of pathology. Due to the wavelength absorption characteristics of this laser, targeting entities with higher pigment, the energy absorption is rapid at the level of the vascular membrane of the lesion, as well as by haemoglobin, while leaving the surrounding tissues unscathed. The use of a low energy density is essential and particularly important for preserving the vermilion of the lip or other mucosal constituents covering the vascular lesion.
This approach combines two different techniques, the trans-mucosal thermo-coagulation (TMT) and the intra-lesional photo-coagulation (ILP). 6-8 The TMT is achieved when the laser irradiation is transmitted without contact of the ﬁbre (uninitiated tip) with the tissue (Fig. 2). With this technique, the energy is applied in a circular motion or scanning movement without keeping the ﬁbre ﬁxed on the same point for more than 5-10 seconds, thus allowing the energy to be absorbed partly by the chromophores of the vascular wall and the haemoglobin. 3,4
The ILP is achieved when the laser irradiation is transmitted by contact of the ﬁbre (initiated tip) with the tissue (Fig. 3) and released directly into the lesion. We will, therefore, perforate the lesion and force the evacuation of its contents (blood). This technique is useful for deep and large lesions located on the lip, tongue, cheek and mucosa.
With this approach, the unwanted post-operative risks and complications, such as abundant or prolonged bleeding, scar tissue formation in the mucosa or aesthetic areas, are minimized.
This procedure is more efﬁcient with a diode of short wavelength (810 nm). The energy delivered will be absorbed more rapidly at the targeted tissue, compared to a longer wavelength (940, 980, 1064 nm). The procedure is very simple, but must be done in a very precise order without compromising the integrity of the surrounding tissues. 1
The TMT approach is the ﬁrst step of this non-invasive treatment of the vascular lesion. 8 When the energy has been absorbed at the level of the vascular walls (rich in chromophores), the lesion becomes lighter and a shade of grey or white colour is observed. When this lesion is “bleached”, it has reached its ideal degree of absorption and is now ready to be emptied of its contents (Fig. 4).
We will then apply the IPL approach and perforate the lesion (initiated tip) and force the evacuation of its contents (blood), by simple pressure of the ﬁngers (Fig. 5).
The contraction of the vascular walls of the lesion, combined with the evacuation of its contents, will lead to the complete regeneration of the treated (targeted) tissues without any formation of scar tissue.
Trans-mucosal Thermo-coagulation (TMT).
Intra-lesional Photo-coagulation (ILP).
This procedure should be done under local anaesthesia for patient’s comfort and to minimize bleeding during drainage of the lesion (Fig. 7).
The type of anaesthesia used will be established according to the practitioner’s choice and should be made at the level of the fold of the labial mucosa and attached gingivae.
Using a minimum energy dose of 0.9 W CW (continuous wave) with a 400 µm uninitiated tip, the energy is transmitted into the lesion in a circular motion, thus allowing the energy to be absorbed by the chromophores of the haemangioma membrane and haemoglobin.
Subsequently, with the tip initiated and with the same minimum energy dosage (0.9W CW), we proceed to the perforation of the lesion. Following this perforation, by simple pressure of the ﬁngers, we will try to empty the lesion of its contents (Fig. 9).
Once the drainage has been obtained, the patient must be repositioned in a sitting position to stop the bleeding (gravitational effect)
Thereafter, the postoperative instructions will be given to the patient, thus allowing the vascular and mucosal system to regenerate well. A follow-up of postoperative control will be done after two to three weeks following the intervention (Fig. 10).
Post-op two weeks.
Benign Oral Vascular Lesion – Pre-Op
Transmucosal Thermocoagulation (TMT)
Intra-lesional Photocoagulation (ILP)
2 week post-op
The use of the diode laser provides signiﬁcant advantages over more conventional treatment methods such as sclerotherapy, excision, cauterization and cryotherapy. The risks associated with these types of treatments are much greater and often result in permanent side effects, while the use of the diode (with adequate parameters) minimizes the risk of unwanted side effects and should be considered as the gold standard technique, permitting results unattainable with conventional treatments. OH
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About the Author
Dr. Chartrand graduated from the University of Montreal, School of Dentistry in 1984. He maintains a full-time private practice in cosmetic and restorative dentistry in Longueuil, Canada while having as a landmark incorporation of laser technology in dentistry. He bought his first laser in 1989 and now owns several different lasers. Dr. Chartrand is an invited professor at the University of Montreal Dental School, teaching laser dentistry to undergraduate students and doctors for the Continuing Dental Education program.
Dr. Chartrand has enhanced his laser knowledge and experience by implementing the most advanced technologies, including performing routine and complex soft tissue surgical procedures in virtually bloodless field.
He has several published articles in national and international dental journals. Recognized as a renowned dental laser user, he is frequently invited as a speaker to participate at numerous conferences and congress nationally and internationally.
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