Author
Michael K. Koceja, DDS
Camas, Washington

Introduction:

Tori exostoses can provide unique clinical challenges. The large protuberance of bony tissue on the lingual aspect of the mandible can interfere with the patient’s diet, speech, and overall life satisfaction – and removing these protuberances can be a traumatic and difficult procedure. 

Typically, these bony outcroppings should remain undisturbed but there are occasions where excision becomes a clinical necessity.  This usually requires referral to an oral surgeon for excision, who then turns to traditional methods that rely on invasive methods.  The procedure is completed using high-speed burs, bone chisels, and other apparatuses that while efficient and effective, can result in discomfort and trauma for the patient.  As a result of these factors, most patients with mandibular tori growths postpone and even avoid clinical treatment.1

A more effective, atraumatic means of ablation and excision could result in patients embracing a treatment protocol that could result in greater life satisfaction and other benefits associated with the removal of these meddlesome bony growths.

The Er,Cr:YSGG all-tissue laser (BioLase, Irvine, Calif.) has been shown to safely and effectively ablate the full spectrum of oral tissues – soft tissues, hard tissue, and bone,.  The intention of this clinical presentation is to demonstrate the Er,Cr:YSGG laser’s use in a clinical setting for the atraumatic and effective excision of severe mandibular lingual tori exostosis.

Background of Laser Use in Dentistry

Since the mid-1960s, researchers and dentists have investigated the use of lasers in dentistry, both for soft tissue and hard tissue. Certain lasers were cleared by the U.S. Food and Drug Administration for use on soft tissue as early as 1987, but because of the thermal nature of these soft tissue lasers, and their absorption effects in enamel and dentin, they were deemed unsafe for use on any oral tissues other than gingiva.  However, by 1997, a laser based on an erbium wavelength was cleared by the U.S. FDA for use on dentin and enamel.   These types of lasers are referred to as “hard tissue lasers.”  Later, in 1998, a new laser wavelength emerged that proved effective in cutting both oral soft tissue and hard tissues such as enamel and dentin.

By 2002, this Er,Cr:YSGG “all-tissue” laser wavelength also gained approval from the U.S. FDA for use in ablating, resecting and recontouring oral osseous tissues.  This wavelength uses a combination of laser energy and water to cut hard tissue such as bone.  As a result, the heat generated by other laser wavelengths is mitigated and there is little to no necrosis or tissue trauma.  In addition, the Er,Cr:YSGG laser wavelength has a high affinity for seeking both the water and hydroxyapatite present in oral hard tissue.  When these two elements absorb Er,Cr:YSGG laser, the molecules effectively expand and vaporize, causing an ablative effect in the target tissue. 

This latest advancement in all-tissue laser dentistry provides an effective treatment option for removing bony growths such as tori exostosis.

Case Presentation

A 35-year-old male patient presented with a bilateral toris mandibularis – benign bony outgrowths projecting extensively from his mandible (Figure 1).  The patient was in good health, taking no medications or having any known allergies.  

The layer of gingival tissue covering the bony growths had thinned and were ulcerating when eating and during normal activity.  Healing of these ulcerated areas was slow and painful for the patient. The patient also complained of trapping food beneath the tori and the inability to remove food from the underlying areas.
The patient agreed to a treatment plan that utilized an Er,Cr:YSGG laser to excise the exostosis, contour the underlying bone, apply low-level amounts of laser energy to promote and stimulate bony healing, followed by traditional surgical suture.

The Er,Cr:YSGG laser was used in all steps of the tori removal, including creation of a surgical flap, excision of the tissue, and post-operative steps.

Pre-Incision Laser Conditioning

Prior to surgery, the operative site was first conditioned with low levels of laser energy.  Using settings of 0.5 W, 0% air, 0% water, and 30hz (pulses per second), this “bathing” was accomplished by holding the Er,Cr:YSGG laser handpiece 3 to 4 mm from the tissue surface and moving it in a slow, smooth motion around the surgical site.  While this step of the procedure produced no visual affect on the surface of the tissue, the laser energy infused the site with photoacoustic energy, which activated and stimulated cellular tissue prior to actual ablation.

Next, local anesthesia was administered, consisting of 3.6 cc of Scandonest, which contains 3% plain Septocaine.  A mandibular block and local infiltration were administered to create profound anesthesia.

Creating a Full-Thickness Flap

After anesthesia was achieved, the Er,Cr:YSGG laser was set to 0.5 W, 0% air, 0%water and 20 hz to outline the surgical flap by blanching the soft tissue. This technique allowed the operator to visualize the placement of the incision prior to actual execution.

Once the operator was satisfied with the proposed incision line, the laser settings were adjusted to a “soft tissue incision” mode.   Soft tissue incision was adequately performed with settings of 1.5 W, 8% water, 12% air, and 30 hz.  Using these settings, a full thickness flap was created by lightly touching the gingival tissue with the tip of the laser and slowly tracing the outline created in the previous step.  Because of the Er,Cr:YSGG laser’s hemostatic effect2, there was less blood in the surgical field than with traditional methods, which greatly improved visibility (Figure 2). 

Excision and Removal of Mandibular Tori

Using a periodontal elevator, the soft-tissue flap was reflected to expose  a medium-to-large-sized two-lobed, mandibular, lingual tori.  One of the main advantages of using an all-tissue laser device like an Er,Cr:YSGG laser is that it can precisely cut osseous tissue with minimal effect to surrounding structures, as well as having no detrimental thermal transfer, charring or damage to the bone at the margin.5

To begin sectioning and the removal of the tori with the laser device, the settings were adjusted to 4.0W, 40% water, 20% air and 20 hz. The operator then followed the contours of the tori at the interface with the normal contour of the mandble with the tip of the laser handpiece in light contact with the surface of the tori, sectioning the osseous tissue.  Once the bone is sectioned the tori was gently removed using an periodontal elevator (Figure 3). 

After the growth was removed, it was necessary to recontour and smooth the tissue bed.  This was achieved by adjusting the settings of the laser to 3.0W, 20% water, 20% air and 30 hz (figure 5), and increasing  the distance of the laser tip from the tissue to allow the clinician to gently ablate away any sharp osseous edges or angles.

The “Laser Bandage”

Once contouring of the osseous tissue site was completed, the settings of the laser were adjusted to 0.5W, 0% water, 0% air and 30 hz. The laser was used to trace the edges of the incision as well as lightly “painting” the surface of the tissue bed to help promote healing and disinfecting prior to suture, a technique commonly referred to as a “laser bandage.”  The tissue is then approximated and sutured using 4-0 surgical silk.

Post Operative Care and Analysis

After the procedure, the surgical site exhibited no edema, minimal bleeding, and no other adverse effects from the laser surgery.
In the clinical case presented herein, the patient did report slight discomfort and was issued two tablets of 400 mg of ibuprofen prior to departure.   Post-operative instructions included:  soft diet, salt water rinses and a prescription of ibuprofen 800 mg, with instructions to administer one tablet every 4-6 hours, not to exceed 4 in a 24-hour period.  The patient was contacted the night of the surgery and reported mild discomfort, controlled by the ibuprofen, no edema and no other complications.

At the one-week post-op checkup, the sutures were removed.  Healing was uneventful. The patient was checked again at two-weeks, and healing appeared clinically complete (Figure 4).  The patient was very happy with the outcome and scheduled the opposite side for similar surgery.

Conclusion

More and more general dentists and specialists are considering the use of dental lasers to improve the quality of care provided to their patients.   The purpose of this article and case presentation was to demonstrate the versatility of the Er,Cr:YSGG laser in completing both soft tissue and hard tissue aspects of a typical surgical procedure.  This versatility, when coupled with the longstanding clinical uses of the Er,Cr:YSGG laser for restorative, endodontic, periodontic and cosmetic procedures, reinforces the notion that an all-tissue laser can become an integral part of a dental practice.

Disclosure

Dr. Michael Koceja served as a beta test site for the Waterlase MD Er,Cr:YSGG all-tissue laser device. He is also an instructor on numerous laser wavelengths for BioLase and other laser firms.  He received no financial compensation for this article.

Figures

Figure 1 – A pre-operative view shows extensive bilateral toris mandibularis.

Figure 2 – A surgical soft-tissue flap is created and reflected to expose the bony outgrowth in the lower left quadrant.

Figure 3a – Immediate post-operative view of surgical site where the tori exostosis has been removed.

Figure 4 – Post-operative view of the site at a two-week recall appointment.

Figure 5 – Summary of procedural settings for removal of tori exostoses using a Er,Cr:YSGG water laser device

Step	Power	Air	Water	Hertz	Description
Pre-operative tissue conditioning	0.5W	0%	0%	30 hz	Conditions cellular tissue for ablation and surgery; also has mild anesthetic effect
Outline the proposed incision path	0.5W	0%	0%	20 hz	Gently touch the soft tissue to create a light outline of the proposed incision.
Soft-tissue incision	1.5W	8%	12%	30 hz	Lightly touch the gingival surface and follow the proposed incision path created in the previous step.
Sectioning and removal of tori	4.0W	40%	40%	20 hz	Hold the laser tip approximately 1 mm from the tissue while sectioning the tori.
Recontouring of tissue bed	3.0W	20%	20%	30 hz	Increase distance from site to gently ablate any rough or sharp ossesous contours.
Laser bandage	0.5W	0%	0%	30 hz	Prior to suture, trace the surgical incision with the laser tip, then bathe/paint the tissue bed with laser energy for approximately 30 seconds to promote healing.

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