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1.IntroductionPrevious measurements in our laboratory1, 2 suggest that transverse excited atmospheric pressure (TEA) dental laser systems operating at 9.6 or are ideally suited for dental hard tissue applications. Moreover, lasers may be more versatile because they are suitable for soft tissue vaporization with hemostasis, precision removal of carious and noncarious dental hard tissue, caries inhibition treatments by localized surface heating, and surface conditioning for bonding. Although, the erbium:yttrium aluminum garnet (Er:YAG) and erbium:yttrium scandium gallium garnet (Er:YSGG) lasers can efficiently ablate dental hard tissue, they are expensive and somewhat limited in application, that is, they are not as well suited for caries prevention treatments as lasers and are not applicable for soft tissue surgery due to poor hemostasis. The laser is strongly absorbed by the mineral of dental hard tissues near , due to the phosphate group of hydroxyapatite. The absorption coefficient of dental enamel has been determined to be approximately at and 5250 at ,3 which is approximately 10 times higher than for the conventional laser wavelength used in medicine todayand is markedly higher than for any other laser wavelengths throughout the visible and IR spectra (see Fig. 1 ). Excessive deposition of heat in the tooth may lead to eventual loss of pulpal vitality, thus any viable laser-dental procedure has to minimize the accumulation of heat in the tooth. The accumulation of heat in the tooth can be minimized by using a laser wavelength tuned to the maximum absorption coefficient of the tissue irradiated and by judicious selection of the laser pulse duration.4 The pulse duration should be on the order of the thermal relaxation time for axial heat conduction of the deposited energy in the tissue surface to minimize thermal diffusion during the laser pulse. For laser pulse durations greater than , the laser energy is conducted away from the enamel surface into the interior of the tooth during the laser pulse, resulting in inefficient surface heating and possible pulpal damage. The thermal relaxation time for enamel and dentin at is 2 and , respectively (see Fig. 1). If the pulse duration is too short, then the deposited power density may be too high, causing the generation of a plasma in the plume of ablated material that shields the surface and reduces the efficiency of ablation. This is what occurs with the conventional TEA laser due to the gain-switched spike.1 As the ratio of to is increased, more energy is shifted from the initial gain-switched spike to the nitrogen tail of the laser pulse temporally stretching it to achieve the desired length. In a previous study with a stretched TEA laser, we observed an increase in the ablation rate from per pulse to per pulse after stretching the pulse length from .1 Several studies have demonstrated that pulsed lasers with pulse durations in the range of can be used to efficiently ablate dental hard tissues with minimal heat deposition in the tooth.5, 6 Krapchev 7 achieved ablation efficiencies of approximately 0.1 and for enamel and dentin, respectively, using a laser with a pulse duration of .3 Melcer8 showed that the ablation rate of a TEA laser could be markedly increased by extending the pulse duration from to approximately . They measured an increase in the ablation rate at the saturation fluence from to over for enamel ablation. However, the thermal relaxation time for enamel at a wavelength of is and it is not advantageous to operate with a pulse duration on the order of less than as is the case for the 9.3- and laser wavelengths. Featherstone and Nelson9 demonstrated that TEA lasers operating at the wavelengths could be used effectively to inhibit enamel demineralization. Forrer 10 found that the ablation efficiency of porcine rib bone was higher and the ablation thresholds markedly lower at and than for the wavelength. Ertl and Müller6 reported similar results with enamel. Thus, for short TEA laser pulses, the ablation efficiency of enamel and dentin should be higher at and than at the standard wavelength resulting in reduced heat deposition in a tooth for similar irradiation conditions. Previous measurements showed that a TEA laser with a pulse duration of reported took one-fifth the absorbed laser energy to melt enamel at , than at .11 Lasers can be highly effective for the processing of bone and dentin. It is well understood, that by matching the laser pulse duration to the thermal relaxation time of the deposited laser energy, peripheral thermal damage can also be minimized.4 A major advantage the laser has over a bone saw is its inherent ability to cut more precisely. Lasers also have the potential to make precise cuts with very high aspect ratios (depth/diameter) and are well suited for endoscopic delivery and robotic control for selective ablation. In addition, lasers have been shown to leave a layer of chemically altered hard tissue that is more resistant to acid dissolution. A possible limitation of the laser is the potential for thermal damage to peripheral tissues near the site of irradiation that may inhibit or delay wound healing. It has been shown that excessive thermal damage to the underlying collagen matrix of dentin compromises bonding to restorative materials during cavity preparations. Determination of the laser parameters that minimize peripheral thermal damage is paramount for the safe and effective use of lasers on protein rich hard tissues such as dentin and bone. In two previous studies, we investigated the use of nanosecond UV laser pulses at , Q-switched Er:YAG and Er:YSGG laser pulses at 2.94 and , and short TEA laser pulses for minimizing thermal damage to dentin and bone during laser ablation.12, 13 The best results were attained for the Q-switched erbium laser pulses and the short highly absorbed laser pulses. There have been several studies over the past concerning the ablation of dentin and bone with minimal thermal damage involving a wide range of lasers and some have utilized laser pulses that are shorter than the time constant for heat diffusion, so that the deposited laser energy is confined to the absorbed region during the laser pulse. 5, 7, 8, 10, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 Although short Q-switched Er:YAG and Er:YSGG lasers are effective for the ablation of dentin and bone without peripheral thermal damage, such lasers can only be operated efficiently with fairly low repetition rates. UV lasers such as excimer lasers and femto- and picosecond lasers can be operated at high repetition rates; however, at most, only of hard tissue are removed per pulse making them quite inefficient.25, 26 lasers can be operated at very high repetition rates for the rapid removal of dental hard tissues and they can be operated with short pulses to minimize thermal damage. Ivanenko used a Q-switched industrial laser operating at with a repetition rate and a pulse duration in the range of tens of nanoseconds for the rapid processing of bone.27, 28 More recent work by that group utilized longer laser pulses of duration from an RF-excited laser for the processing of bone.18, 29 We have calculated the thermal relaxation time for , 9.6-, and laser pulses absorbed by dentin to be 5.5, 3.3, and , respectively, based on the absorption coefficients that we previously measured using time-resolved radiometry.2 We expect similar time constants for bone due to its similar composition to dentin. Those data suggest that thermal damage to dentin and bone can be limited by using - and laser pulses with a pulse duration on the order of . The purpose of this study was to determine whether enamel, dentin, and alveolar bone could be ablated efficiently at clinically relevant rates (i.e., per pulse), without thermal damage at high repetition rates using TEA laser pulses. In summary, the purpose of this study is to demonstrate that TEA laser pulses at with a duration of can be used at high repetition rates for the ablation (cutting) of dental hard tissues with minimal peripheral thermal or mechanical damage and without excessive heat accumulation and that those laser pulses can be efficiently transmitted through hollow waveguides for clinical delivery. 2.Materials and Methods2.1.Laser ParametersAn industrial marking laser, Impact 2500 from GSI Lumonics (Rugby, United Kingdom), operating at , due to optical coatings on the resonator optics, which are capable of high repetition rates up to , was used for these experiments. The laser was modified for operation in a single-spatial mode optimized for the longer laser pulses by LightMachinery (Ottawa, Canada) by installing an intercavity aperture and modified resonator optics. This laser also incorporates a solid-state switch for very stable and reliable high-voltage switching, solving the stability and heat dissipation problems encountered previously with thyratron-based systems. The laser gas handling system is sealed with an automatic gas exchange after of operation. Fluence ranging from and pulse energies of per pulse were used. The laser pulse temporal profiles shown in Fig. 2 were measured with a room temperature HgCdTe detector from Boston Electronics PD-10-6-3 (Boston, Massachusetts). The laser pulse was in length for a 4% gas mixture (20% ) and for the 2% gas mixture (22% ) with the use of a 75% reflectivity output coupler. Half the energy was contained in the initial and 80% of the energy was in the first . The laser pulse duration was approximately half the duration mentioned above, approximately , with the same two gas mixtures if a higher reflectivity (85% reflectivity) output coupler was used. The laser energy was calibrated and measured using a laser energy and/or power meter, EPM 1000, Coherent-Molectron (Santa Clara, California) with a ED-200 Joulemeter from Gentec (Quebec, Canada). The laser was focused with a planoconvex ZnSe lens of focal length to a beam diameter of approximately . The laser beam diameter at the position of irradiation was determined by scanning with a razor blade across the beam. Two- and three-dimensional images of the laser spatial profile were acquired using a Spirocon Pyrocam III pyroelectric array (Logan, Utah). Both laser beam profile and spatial profile showed that the laser was operated in a single-spatial mode, Gaussian spatial beam (see Fig. 3 ). High spatial beam quality is a prerequisite for efficient coupling into hollow waveguide beam delivery systems. 2.2.Laser Ablation Rate DeterminationThin sections, approximately thick, of human enamel and dentin from unerupted human molars and premolars and adult porcine alveolar bone were prepared using a MicroLux diamond band saw with water cooling from Micro-Mark (Berkeley Heights, New Jersey) and a Isomet 2000 precision saw from Buehler (Lake Bluff, Illinois). Each section was mounted over the edge of a glass slide and a ED-200 Joulemeter was placed directly behind each section to function as a perforation sensor. The number of pulses required to perforate each section was recorded to determine the ablation rate. It is important to point out that the single pulse ablation rate depends on the method of measurement with the highest rates measured for a single incident pulse on the tissue. However, such measurements require accurate measurement of the depth ablated. Sample perforation measurements are easier to carry out, however the ablation rate determined using this method is highly dependent on the sample thickness with the rate decreasing with increasing sample thickness. We have found that a thickness works well for laser pulses that ablate per pulse, requiring a minimum of several laser pulses to perforate the tissue samples. 2.3.Laser Incisions in Human Enamel, Dentin and Porcine BonePlano-parallel enamel blocks, , approximately thick, were prepared from human unerupted molars. Surfaces were polished with 1200 carbide grit, and smear layers produced from polishing on the sample surfaces were removed by sonication. Dentin and bone sections with a thickness of at least were cut using diamond saws and samples were kept well hydrated before ablation and either cooled using a computer-controlled water spray or left dry during ablation. Bone samples were kept frozen before ablation. A low-volume and low-pressure air-actuated fluid spray delivery system consisting of a EFD 780S-SS spray valve, a Valvemate 7040 controller, and a fluid reservoir from EFD Inc. (East Providence, Rhode Island) controlled by a computer was used to provide a uniform spray of water on the tissue surface. Lateral incisions long were produced in our dentin and bone sections by scanning the laser in spots spaced at intervals, each spot receiving 10 pulses. A computer-controlled stage was used to create controlled movement of the samples for the incisions. Three incisions were made for each frequency (10, 50, 100, 200, 300, and ) for both wet and dry conditions in both dentin and bone. Figure 10 shows examples of the incisions in dentin and bone. After ablation, tissue sections and enamel blocks were embedded onto epoxy resin disks with LX-112 epoxy resin from Ladd Research (Williston, Vermont), that were subsequently serially polished with 1200 carbide grit, and 6, 3, 1, and 0.3 diamond suspensions, using Ecomet 2 and Fibromet polishers from Buehler. 2.4.Residual Heat Measurements with Thermal Imaging AnalysisEnamel blocks, , thick, were prepared from bovine incisors. Surfaces were polished with 1200 carbide grit and each block was glued onto the edge of a glass slide (Fig. 4 ). A thermal camera Omega, from Indigo System Corporation (Goleta, California), incorporating an uncooled microbolometer focal plane array with digital output was placed behind the block to measure the thermal emission during laser ablation in the wavelength band from . The magnitude of the residual energy remaining in the tooth as heat during enamel ablation was directly calculated by taking the ratio of the rise in signal due to thermal radiation on the opposite side of laser irradiated block for ablative versus nonablative laser pulses. Every image consisted of , and a region of interest, where the pixels correlate with the block surface, was selected before each series of measurements. The average value of all the pixels within the region of interest was computed and recorded continuously throughout the laser treatment. The accuracy of this approach was validated and calibrated by comparison of the thermal emission from the block with simultaneous micro-thermocouple measurements. Figure 4 shows the temperature rise that was simultaneously measured using the thermal camera and a thermocouple cemented to the enamel surface. Nonablative laser pulses were delivered at a fluence of and a repetition rate of . The average residual heat deposition values were for the thermocouple readings and for the thermal camera readings. In order to measure the residual energy remaining at each respective fluence of interest, each block was irradiated with two laser pulse trains: nonablative and ablative. The first train of pulses irradiated the surface of the block with 3000 low-energy nonablative laser pulses delivered at a repetition of (Fig. 5 ). The measurements were repeated after the block had equilibrated (returned to room temperature), then a second train of ablative pulses were delivered to the surface of the block at the fluence of interest. In order to vary the fluence while keeping the total energy delivered and total delivery time, of , constant, the repetition rate, total number of laser pulses, energy per pulse, and the spot size were varied. These measurements are similar to those described in Ref. 30. 2.5.Polarized Light Microscopy (PLM)Images of tissue surfaces were taken before and after laser irradiation with a Secolux BF/DF/DIC microscope manufactured by Leitz-Wetzlar (Germany). A low-volume and/or low-pressure air-actuated fluid spray delivery system consisting of a 780S spray valve, a Valvemate 7040 controller, and a fluid reservoir from EFD, Inc. was used to provide a uniform spray of fine water mist onto the enamel surfaces at . Each incision, approximately long and wide, was prepared by scanning the laser beam, operating at , across the sample at , with a separation between each longitudinal scan. Polarized light microscopy was used to determine the degree of thermal damage produced while creating our lateral incisions. Thermally damaged dentin and bone appears dark brown to black due to carbonization of protein (collagen). Under examination with a polarized microscope with crossed polarizers, thermal damage to the mineral and protein phases result in loss of birefringence. Thin sections were taken from each sample incision sectioning our samples using the Isomet 2000 diamond saw. Sections were made perpendicular to the direction of the lateral incisions to view them in cross section. After cutting, sections were imbibed with water and viewed in the optical microscope using crossed polarizers and a Red I wave plate. Thin sections were examined visually using a Westover Scientific Series 7 optical microscope (Westover Scientific, Mill Creek, Washington) with an integrated digital camera, Canon EOS Digital Rebel XT (Canon Inc., Tokyo, Japan) and IMAGE PRO PLUS software (Media Cybernetics, Silver Spring, Maryland). A moire ruling with 100 lines per millimeter was used to calibrate the length measurements on the images. Figure 11 shows images at magnification of wet and dry dentin and bone. The wave plate introduces a phase retardation of so that addition and subtraction colors introduced by the tissue birefringence induce resolvable changes in color. In the case of thermal damage, increased attenuation of the illumination light causes altered tissue to appear black, which is easier to discern under polarized light. Subtle changes in birefringence should introduce resolvable color changes. However, we were unable to resolve such changes and there was a sharp demarcation between normal tissue and the thermal damage zone.12, 13 A complete loss in birefringence of dentin without any other changes in optical properties would have resulted in a subtle change in color around the rim of the crater. In cross section, the char layer appears as loosely attached debris along the crater walls, and some is probably lost during the sectioning procedure. The remaining layer is of uniform thickness and it most likely represents increased scattering and absorption due to denaturation and partial thermal decomposition of the collagen matrix. 2.6.Synchrotron Radiation—Fourier Transform Infrared Spectromicroscopy (SR-FTIR)FTIR spectroscopy used in the specular reflectance mode is well suited for resolving thermally induced changes in dental hard tissue as a result of laser irradiation. Chemical changes in the mineral phase and loss of water and protein can be clearly seen as a result of thermal damage during laser irradiation. High spatial resolution is achievable with a high brightness synchrotron radiation source such as the advanced light source (ALS) at Lawrence Berkeley National Laboratory. IR spectra of laser treated dentin and bone in both wet and dry conditions were obtained at ALS. All samples had been irradiated at . A Nicolet Magna 760 FTIR interfaced to a Nic-Plan IR microscope, equipped with a motorized sample stage connected to beam line 1.4.3 of ALS at Lawrence Berkeley National Laboratory was used to acquire spectra of the incisions produced with the lasers. Plano-parallel sections approximately thick were cut at right angles to the laser incision. Each section was embedded onto diameter LX-112 epoxy resin disks, which were subsequently serially polished with 1200 grit carbide and 3 and diamond suspensions. Specular reflectance spectra were acquired with a spatial resolution of by scanning the spot imaged by the FTIR microscope across the laser intensity profile from the normal dentin to the resin outside the incision. 2.7.Hollow Waveguide Transmission MeasurementsQuartz hollow waveguides, from Polymicro Technologies, LLC (Phoenix, Arizona), long and hollow-core diameters of 300, 500, 750, and were coupled to the laser using ZnSe lenses and a laser energy and/or power meter was used to measure and record the transmitted energy. The measured transmitted energy reflects losses due to both coupling in and out of the waveguide in addition to the attenuation of the length of the waveguide. 3.Results3.1.Laser Ablation Rate DeterminationAblation studies were performed at with TEA laser pulses of duration (4% gas mixture with 75% output coupler) for enamel, dentin, and alveolar bone. See Refs. 31, 32 for measurements for the laser pulses of duration (2% gas mixture). The gain switched spike present in the beginning of the pulse initiated the onset of a plasma, which reduced the ablation effectiveness at high fluence. Ablation rates as a function of the incident laser fluence are shown in Fig. 6 for all three tissues: enamel, dentin, and alveolar bone. These rates are for the perforation of thick sections with no application of a water spray. The spot size was varied from by moving the sample away from the focal spot in order to achieve the targeted fluence, and the repetition rate was . The ablation rate of enamel saturated at a maximum rate of approximately /pulse for irradiation intensities above for the 4% gas mixture. The ablation rate for dentin and bone was approximately twice as high, per pulse. 3.2.Residual Heat Deposition MeasurementsFigure 5 shows an example of the residual heat deposition measurements performed at a nonablative fluence of and an ablative fluence of with the 4% of gas mixture. Ablative laser pulses have a lower residual heat deposition than nonablative pulses due to energy transformed into kinetic and internal energy of the ablated material. The mean and individual values of the residual heat that were measured for increasing irradiation intensities are plotted in Fig. 7 for enamel and dentin. For laser pulses near the threshold for ablation, the residual heat remaining in the tooth is high. Previous measurements have shown that ablation rapidly stalls after only a few laser pulses at irradiation intensities just above the ablation threshold.33, 34, 35 The initial few laser pulses ablate some material before ablation stalls and subsequent laser pulses contribute significantly to heat accumulation. As the incident fluence increases, ablation proceeds without stalling and the values converge to a minimum value due to plasma or debris shielding. The minimum value represents the most efficient ablation attainable for this wavelength and pulse duration in bovine enamel. This value for enamel is approximately 34%, which indicates that over 66% of the deposited laser energy is carried away by the ablative laser pulses delivered at . The magnitude of the fluence at which the residual heat reaches a minimum value, 34%, is closely correlated with the maximum ablation rate for enamel, which occurs near (Fig. 6). The ablation rate saturates because additional laser energy is absorbed or reflected by the highly opaque plasma, preventing further removal. The minimum value for dentin is significantly lower than for enamel, below 20% most probably due to the more volatile water and collagen content. 3.3.Peripheral Thermal Damage in Enamel, Dentin, and Bone (PLM and SR-FTIR)Figure 8 shows reflected light images of incisions produced in enamel at a repetition rate of scanning at with and without the water spray at a fluence of . The base of each incision appears to be uniformly melted. SR-FTIR spectra acquired in the area of the enamel in the melted region show that highly crystalline hydroxyapatite has been formed in that region even on the incisions produced with the water spray (Fig. 9 ). The loss of carbonate and narrowing of the phosphate peak near are indicative of conversion to the more highly crystalline, pure phase hydroxyapatite that manifests a greater resistance to acid dissolution. Incisions produced at lower scanning speeds without water manifested greater thermal damage with the formation of chalky-white asperities that are most likely nonapatitic CaP phases formed due to disproportionation of hydroxyapatite at high temperature. SR-FTIR spectra of such asperities did not resemble spectra of hydroxyapatite.36, 37 A comparison of incision depth in dentin for varying repetition rates showed no significant variation up to , the maximum repetition rate investigated. This demonstrates that high repetition rates can be employed without interference from ejected material in between pulses. Minimal thermal damage to dentin and bone was observed in both wet and dry conditions for high scanning rates at the highest repetition rate . Figure 10 shows reflected light images of incisions produced in both dentin and bone at at a fluence of . Very clean uniform incisions without discoloration were produced with use of the water spray. Charring occurred without the water spray. Thin sections were cut across all the incisions in dentin and bone for examination with PLM (Fig. 11 ). PLM showed thermal damage zones of less than for dry dentin and less than for wet dentin for all repetition rates investigated up to . Thermal damage zones for bone were slightly higher: for dry bone and for wet bone. Thicker sections were embedded and examined with SR-FTIR with a spatial resolution of . Incisions were produced at a fluence of . Results were also compared for lower irradiation intensities of 40 and . The thermal damage zones at 40 and were both smaller than those found at at . Graphs of the thermal damage in dentin and bone for irradiation intensities of 80, 40, and all at were reported in our SPIE proceedings paper.32 Figure 12 shows reflected light images of incisions produced in dentin at at a repetition rate of with with and without the water spray. There is charring visible for the incisions produced without the water spray. The incisions produced with the water spray are much shallower than the dry incision pulses; however, they are clean without discoloration due to thermal damage. SR-FTIR spectra were acquired across the edge of the incisions shown in Fig. 12. Spectra taken at intervals across the incision wall as shown in Figs. 13 and 14 manifest few chemical changes due to peripheral thermal damage. These results show that within a resolution of , minimal changes in the amide structure of the dentin could be detected. Therefore, FTIR showed no spectral changes within around the periphery of the incisions of our samples in wet and dry conditions at . 3.4.Hollow Waveguide Transmission MeasurementsThe transmission rates through long 300-, 500-, 750-, and quartz hollow waveguides (Table 1 ) were measured. The bending diameter for the hollow waveguides was approximately . The highest transmission was achieved for the waveguide with a bending diameter of . Table 1The transmission properties of quartz hollow waveguides of 300-, 500-, 750-, and 1000-μm diameter, a length of 2m , and a bending diameter of 45.5cm for λ=9.3-μm laser pulses of 18-μs duration. The focal length of the lens used for coupling into the waveguide is indicated in the left column.
4.DISCUSSIONThese studies demonstrate that a pulsed TEA laser operating at high repetition rates with a pulse duration of can ablate dental hard tissues efficiently and at a practical rate to be used clinically with minimal peripheral thermal damage if a low-volume water spray is used. It was necessary to greatly reduce the fraction of energy disposed in the initial gain-switched spike in the laser pulse to avoid plasma formation that restricts the ablation rate to per pulse. The single pulse ablation rate varied from a maximum of per pulse for enamel depending on the laser gas mixture and the reflectivity of the output coupler. The highest rate was obtained for the 2% gas mixture with the 75% reflectivity output coupler ( pulse duration). Dentin and bone ablation rates were typically twice as high than for enamel: per pulse. Such laser pulses may be ideally suited for the irradiation of specific high risk areas of the dentition that are highly susceptible to tooth decay and early caries lesions to reverse or prevent the progression of tooth decay in those areas. Measurements of the residual heat remaining in the tooth after each ablative laser pulse at the optimal irradiation intensities for efficient ablation indicate that only 34 and 20% of the energy remains in the tooth for enamel and dentin, respectively. In contrast, the energy remaining in the tooth after ablation using longer pulses from the more conventional and free running Er:YAG and Er:YSGG laser pulses is higher on the order of 50 to 60% based on our previous measurements.30 The reflectivity is also much lower on the order of 5 to 13%.34 Therefore the residual energy remaining in the tooth for those laser systems is twice as high, which increases the volume of water that is needed to offset heat accumulation. This study also demonstrated that TEA laser pulses are well suited for the precise removal of dentin and bone for dental restorations and implants at high repetition rates without peripheral thermal damage. PLM and SR-FTIR indicated that there was minimal peripheral thermal damage. As was observed in our previous studies,12, 13 there was negligible charring of dentin for laser pulses of less than duration, and that is comparable to the best results that have been previously reported in the literature for bone for free electron,38, 39 TEA ,14, 10 excimer,40 and Er:YAG15, 41, 42, 43 laser pulses used with water cooling. Although short Q-switched Er:YAG lasers also yield excellent results, they are expensive, difficult to operate without damaging the optics due to the high water absorption, and presently operate only at a few hertz. Moreover, recent studies indicate that they have the potential of causing peripheral mechanical tissue damage due to the large acoustic transients produced during ablation.44, 45, 46 There was no mechanical damage observed for any of the laser irradiation parameters. Additionally, the magnitude of the noise generated by both the conventional TEA laser and the Q-switched Er:YAG is sufficient to be irritating and may exceed tolerable levels in the clinical environment.6 Many of the current pulsed lasers operating for industrial or medical application utilize RF power sources that are more expensive to produce. Moreover, such RF power supplies are not well suited for efficiently producing laser pulses with pulse durations as short as a few microseconds. Er:YAG and Er:YSGG lasers are inherently expensive due to the cost of the erbium laser rods. Moreover, the high single pulse energies are required for the drilling of enamel, typically greater than a . Another advantage of laser technology in general over current erbium technology is that the peak repetition rate is not limited by the gain media to . The unfavorable lifetimes of the upper and lower laser levels limit the efficiency at higher repetition rates. Higher repetition rates have been achieved using diode pumping; however, longer pump pulse widths were required.47 Rates up to were utilized in this study and rates above are feasible. Thus, if improved cutting speeds are desired, the laser beam can always be rapidly scanned at a high repetition rate. TEA laser technology utilizes DC power supplies that greatly reduce the intrinsic cost of these devices. This Lumonics TEA laser uses a solid-state high voltage switch instead of a thyratron, which reduces the cost, cooling requirements and increases stability and reliability of the laser system. Because the laser does not contain any very expensive components, such as a laser rod or thyratron, the laser can potentially be produced at a low price. The single-pulse enamel ablation rates are not as high as the longer pulse laser and Er:YAG laser systems, which can ablate at rates exceeding /pulse with higher fluence and energy; however, high repetition rates can be easily achieved with this TEA laser to enhance the removal rate. Previous studies of Ivanenko 27, 28, 48 demonstrated that shorter Q-switched laser of nanoseconds duration could be used for bone ablation with minimal thermal damage. However, the pulses were too short and plasma shielding restricted the ablation rate. In more recent studies by the same group, a high repetition rate, , RF-excited laser operating at was used with repetition rates 200 and to cut bone in vivo in an animal study.18, 29 The pulse duration was and the single pulse energy was per pulse and high-speed galvanic mirrors were used to scan at a rate of ( was used in this study) to produce incisions without carbonization. Taking this approach the peripheral thermal damage should be similar to that achieved with running the laser in the same position at a repetition rate of . If we compare with peripheral thermal damage studies of Dela Rosa 12 that were conducted at low repetition rates, there was a significant difference in the zone of peripheral thermal damage in dentin between the shorter (less than ) and the longer pulses when a water spray was not used. The thermal damage zone for both pulse lengths was less than for both pulses with the water spray. Even though a water spray is desired for the ablation of dentin and bone to lessen carbonization and to prevent the accumulation of nonapatitic asperites during the ablation of enamel, it is difficult gauge and control the amount of water at the ablation site. Moreover, a layer of water on the tissue reduces the ablation rate and the minimum amount of water needed to prevent carbonization should be used. The shorter and more highly absorbed laser pulses ( or pulses of duration) are likely to require less water cooling to prevent peripheral thermal damage as suggested by the results reported by Dela Rosa 12 acquired without the water spray. The wavelength also plays an important roll in reducing thermal damage because one cannot expect the zone of thermal damage to be less than the depth of absorption. The absorption depth of - or photons in dentin is —bone should be similar—while at , the absorption depth is . Therefore the utilization of the - or wavelengths should also help reduce the zone of thermal damage. However, if pulses are on the order of or longer, wavelength-dependent effects will be less evident as the thermal diffusion length approaches or greater for longer pulses. The thermal diffusion length for 10- and laser pulses in dentin is 2.5 and , respectively. Therefore, the thermal damage zone in dentin and bone should not significantly increase by stretching the laser pulse from to . Moreover, most of the energy content in the laser pulse is in the first for the more efficient 4% gas mixture. If it is necessary to increase the ablation rate, either the single pulse energy or the repetition rate can be increased. If the single pulse energy is to be increased, it is necessary to use IR laser pulses with a pulse duration greater than to avoid plasma shielding effects and excessive acoustic effects. If the spot size for shorter pulses is increased, the loud acoustic recoil effects potentially increase markedly as well and the laser becomes prohibitively loud. Pulse energies exceeding per pulse have been explored for erbium pulses of duration; however, for the higher single pulse energies, the mechanical-recoil effects increase to the point that they are disturbing to the patient and thermal injury may result.49, 50 Moreover, by increasing the spot size and increasing the single pulse ablation rates to more than per pulse, precision and selectivity must be sacrificed and greater thermal and mechanical peripheral damage are likely. lasers can be operated with repetition rates in the kilohertz regime. Therefore, even though the shorter laser pulses employed in this study with a pulse duration on the order of the thermal relaxation time of the deposited energy in the outer layer of tissue and a single pulse energy lower than the threshold for plasma formation have single pulse ablation rates about a factor 2 to 4 times lower than the free-running erbium laser pulses, the laser repetition rate can be easily increased to compensate for the lower ablation rate per pulse. The disadvantage of the later approach is that the laser beam must be scanned, which adds a further level of complexity to the ablation system and may increase the size of the hand piece and delivery system. However, scanning the laser beam can be advantageous for further reducing thermal and mechanical damage as has been clearly demonstrated in these measurements and by Frentzen 18 Moreover, less water is required for cooling, effectively increasing the ablation rate. Future laser–hard tissue ablation systems are likely to be effectively coupled with optical diagnostic systems for selective caries removal and precise incision depth control. Kavo (Biberach, Germany)51 has developed an integrated caries ablation–and caries fluorescence–based clinical laser system combining their Diagnodent Caries Detection and Er:YAG laser systems. However, a computer-controlled scanning-based system would be more desirable to implement such an approach. We have used this TEA laser integrated with a computer-controlled scanning system and a fiber-optic spectrometer to selectively remove composite from tooth surfaces.52 Laser systems that operate with high repetition rates and have ablation rates on the order of per pulse are ideally suited for this approach. If each laser pulse removes more than a per pulse, selectivity would not be as feasible. AcknowledgmentsThis study was supported by National Institutes of Health/National Institute of Dental and Craniofacial Research Grant No. R01DE14554 and Department of Energy Grant No. AC03-76SF00098. The author would also like to acknowledge the help of Michael Martin at LBL. ReferencesD. Fried,
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