Review articles

By Dr. Debora Loli
Corresponding Author Dr. Debora Loli
Sapienza University of Rome - Department of Oral and MaxilloFacial Sciences, - Italy
Submitting Author Dr. Debora Loli

esthetic orthodontics, diode laser, gingival recontouring, aphthous ulcer manager, frenectomy, impacted teeth

Loli D. The Diode Laser: A useful aide for esthetics in orthodontics. WebmedCentral ORTHODONTICS 2017;8(11):WMC005409

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 20 Nov 2017 11:48:45 PM GMT
Published on: 23 Nov 2017 12:16:57 PM GMT


Contemporary orthodontics continues to merge with modern-day technology and the growing focus on dental esthetics in today’s culture. Laser technology got in these years a more and more important role in modern dentistry and, recently, also in orthodontics the utilization of laser devices was proposed. In the last two decades, there was an explosion of research studies in laser application. All diode wavelengths are absorbed primarily by tissue pigment (melanin) and hemoglobin. Conversely, they are poorly absorbed by the hydroxyapatite and water present in the enamel. Specific procedures include aesthetic gingival re-contouring, soft tissue crown lengthening, exposure of soft tissue impacted teeth, removal of inflamed and hypertrophic tissue, frenectomies, and apthous ulcers.


In previous years, orthodontists have been limited in what they could do to improve treatment outcomes by the lack of technology and knowledge.

In recent years, the advent of the soft-tissue diode laser had made several soft-tissue procedures easily accessible and doable for orthodontists.

Laser is an acronym for ‘light amplification by stimulated emission of radiation’. Fundamentally, a laser beam is a focused source of electromagnetic radiation, or light energy.

Three main types of lasers are used in dentistry: the CO2, erbium, and diode laser. Diode lasers are almost exclusively used for soft tissue surgery1.

Diode lasers convert electrical energy into light energy. Diode lasers are known as semiconductors, as they use a media of gallium and arsenide, and occasionally indium and aluminum, whose ability to conduct electricity is between that of conductors and insulators. By doping the laser medium with impurities (dopants), stimulated emission occurs. The wavelengths produced by diode lasers range between 810nm and 980nm. Light energy at these wavelengths is easily absorbed by melanin (soft tissue pigmentation) and hemoglobin, and poorly absorbed by enamel. Therefore, diode lasers are highly effective in soft tissue ablation, hemostasis, and sealing lymphatics, with low risk of damaging teeth and bone, making them ideal for soft tissue laser surgery2. Compared with other laser types, diode lasers are compact, reliable, and have a long operatory lifetime, and are packaged in portable units typically weighing less than 4.5 kg. Connecting to the main unit is a thin, pencil-sized hand-piece containing a 200–400µm fiberoptic tip. Newer models have handpieces that receive single-use, twist-on laser fiberoptic tips, providing a higher potential standard of cleanliness and eliminating time-consuming stripping and cleaving of the fiberoptic tip.

The energy absorbed in the target cells is immediately subjected to heating, welding, coagulation, protein denaturation, drying vaporization and carbonization 3. Pulsed mode laser delivery allows intermittent cooling, less tissue damage and less discomfort 3. Maximum procedures can be performed at a setting of 1 to 1.2 watts. Power settings can be increased to 2 watts in areas of dense tissue. It is recommended to use lowest power setting that can effectively remove the tissue. This prevents collateral thermal damage of adjacent tissue4.

Therefore, the diode laser controls bleeding exceptionally at the surgical site. The laser tip gently contacts the surgical site, allowing the operator to have tactile feedback. 3

Other advantages of the diode include low costs and the fact that these procedures typically require only a topical anesthetic. The laser cauterizes the surgical site, while cutting so that a periodontal dressing is not necessary for healing.

Instead, the CO2 laser can be difficult to use because the tip does not directly contact the surgical site; instead, it must be used at a slight distance and a delay is present from when the incision is made to when it can be seen3,5,6.

The erbium laser has a very high wavelenght and is effective in soft tissue removal; however, it does not control bleeding well 3,5,7.

Advantages of the diode laser are useful for orthodontists to enhance treatment results for example in cases of slowly erupting teeth and gingival overgrowth, unaesthetic gingival contours and margins, aphtosus ulcer management, frenectomy and removal of operculae.8


 One of the main treatment goals of orthodontics has been the ability to produce an esthetic smile in a timely manner. The Diode laser allows to finish cases much more efficiently and to a higher esthetic standard. Several soft-tissue procedures along with their indications and methods will be addressed in this systematic review. We have used PubMed and Scopus. 37 articles were analyzed. Keywords are: esthetic orthodontics, diode laser, gingival recontouring, aphthous ulcer manager, frenectomy, impacted teeth. 


The majority (84%) of orthodontists and general dentists regarded the use of a soft tissue laser by orthodontists as appropriate.9

As an adjunctive procedure, laser surgery has helped many orthodontists to enhance the design of a patient’s smile and improve treatment efficacy. Before incorporating soft-tissue lasers into clinical practice, the clinician must fully understand the basic science, safety protocol, and risks associated with them.10

The soft-tissue laser allows orthodontists to improve tooth proportionality and gingival shape and contour and this is very useful in finishing a case to a better esthetic in accordance to the smile line and smile arch of patient.3,11,12

About the esthetic concepts of tooth proportionality, the ideal maxillary central incisor should be approximately 66% to 80% width compared with height. It is important to assess if a tooth disproportion is due to a short clinical crown height, gingival overgrowth, or delayed passive eruption. In these cases gingival recontouring or dental restoration may be optimal solution.11

About the esthetic concepts of placement contact’s point and embrasure, we need to remember that from the midline to posterior contact’s point becomes apical and embrasure larger.11

About the gingival shape, maxillary lateral incisors have a shape like symmetrical half-oval; therefore their gingival zenith should be located within their longitudinal axis. Instead, the gingival shape of the maxillary centrals and canines is elliptical and gingival zenith is located distal respect of axis.11

If there is an excess gingival tissue, gingival recontouring allows place the brackets in an ideal position quickly.12,13

In addition gingival recontouring can help to reduce inflammation due to poor oral hygiene, allowing the patients to access more areas to brush and to keep gingivitis under control. There is excess tissue for example when large extraction spaces are closed and the patient has poor oral hygiene.12,13

Kravitz and Budi 14 described gingivectomy with laser. When applying topical anesthetic, dry the mucosa with gauze; apply 0.2 mL (equivalent to 1 cotton swab head) of topical anesthetic to the mucosa for no longer than 5 to 7 minutes, because prolonged application can cause tissue irritation; confirm anesthesia with a perio probe and use a probe to mark height guides. Hold the laser tip perpendicular to the tissue at the gingival margin and use a continuous wave stroke to remove the tissue surface one layer at a time. Traditionally, a minimum of 1 mm sulcular depth of attached tissue was considered critical for maintenance of periodontal health and prevention of gingival recession. These opinions were based largely on the study by Lang and Löe15 on the significance of keratinized gingiva. However, more recent longitudinal studies have shown that, in the absence of gingival inflammation, the incidence of recession around teeth without attached gingiva was not greater than that observed in areas with attached gingiva.16-20 Experimental studies have even shown that gingivectomies extending into alveolar mucosa can regenerate as much as 50% with the formation of new attached marginal gingiva.21,22 Therefore, although the preservation of attached tissue is preferred, a certain quantity of attached gingiva might not be essential for maintenance of periodontal health.23,24 Immediately after the procedure, the patient should rinse with mouthwash and gently massage the surgical area with a soft-bristle toothbrush. If tissue discoloration persists, hydrogen peroxide can be applied with a cotton swab or cotton roll. Bleeding and discomfort are minimal. Chlorhexidine and analgesics are rarely prescribed. Complete tissue healing takes place in 1 week. The patient should be seen for a postoperative follow-up after 2 weeks. Frenectomy with laser is indicated when patients with a large diastema often have a low frenum that can contribute to the excessive spacing.31,32,33 Orthodontists will treat the diastema by closing the space and stabilizing with fixed or removable retention in addition to a frenectomy. The process is less painful, no sutures are needed and bleeding is controlled. As the frenum is in the new position, the scar tissue can help to maintain the space closure. The technique for a frenectomy is to hold the upper lip until the frenum is taut and lase the frenum horizontally 3 mm from the frenum base, using continuous waves until the lip is released, creating a V-shaped crater. Continue to lase deep enough to prevent reattachment. Clean the surgical site with hydrogen peroxide on a cotton ball.

Soft tissues can sometimes cover a tooth and impede its eruption into the arch. Sometimes the impacted tooth is nearly erupted into the mouth and the soft tissue laser can be used to remove overlying tissue so that the orthodontist can bond a bracket and begin moving the tooth immediately12,13.  After applying topical anesthetic, probe the surgical site to locate the tooth and mark, then with carefully remove the tissue with light, continuous waves until the underlying tooth is exposed. After exposure wipe the area with 3% hydrogen peroxide with a microbrush or cotton roll. A bond can be placed immediately after exposition of tooth.13

Apthous ulcers can occur in single or multiple numbers and affect the non-keratinised mucosa 34. Clinically, present as one or several rounds of ulcerated lesions, surrounded by erythema, covered by a whitish pseudomembrane with variable symptoms and history of recurrences.35 The ulcers occur in three clinical forms: minor, major and herpetiform.34 Several therapies have been advocated to manage these lesions such as topical corticosteroids (triamcinolone acetonide, hydrocortisone acetate and clobetasol propionate), chlorhexidine mouth rinses, tetracycline oral rinses, thalidomide, fluocinonide, colchicines and the immune boosting agent levamosile, vitamin therapy and topical interferon α-2a. Laser therapy is used as an alternative method in treatment. The exact underlying etiology and pathogenesis of RAS is not completely understood. Many etiological, predisposing and precipitating factors such as genetic factors, immunological problems, hypersensitivity to foods, deficits of folic acid, iron, zinc, vitamin B1, vitamin B2, vitamin B6 or vitamin B12, Behçet's syndrome, gastrointestinal disorders such as Crohn's disease, coeliac disease or ulcerative recto colitis, immunodeficiencies such as HIV infection and others, stress, trauma, cessation of smoking, the luteal phase of the menstrual cycle and oral healthcare products containing sodium lauryl sulfate have been identified to play a role in the etiology .36The orthodontist has the ability to lase them and ulcers can heal within 1 day after treatment. The laser is activated for 30 seconds at a very low wattage and kept at a distance of 1 to 2 mm away from the lesion. The laser is nonpainful and allows the patients to have a faster recovery. 12,13,34,37


The diode laser is a useful instrument with a greater advantage over conventional surgery in the management of soft tissue procedures. Dental laser research has emerged to maturity and presages a substantial contribution to the future of clinical dental practice. Orthodontists and other dentists can now benefit from several different advantages that lasers provide and can finish cases much more efficiently and with higher esthetic standard.



  1. Kravitz ND. The Application of Lasers in Orthodontics. Kravits Orthodontics.
  2. Kravitz ND, Kusnoto B (2008) Soft-tissue lasers in orthodontics: an overview. American Journal of Orthodontics and Dentofacial Orthopedics 133: S110–14
  3. Sarver DM, Yanosky MR. Principles of cosmetic dentistry in orthodontics: part 2. Soft tissue laser technology and cosmetic gingival contouring, Am J Orthod Dentofacial Orthop. 2005; 127:85-90.
  4. Rucha Bhatkhande Kulkarni, Abhijit Misal and Richa Mishra Soft tissue diode laser in orthodontics.  International Journal of Applied Dental Sciences 2017; 3(2): 91-94
  5. Lawrence A. Kotlow DDS, Lasers in pediatric dentistry, Dent Clin N Am 48 (2004) 889–922
  6. Wilder-Smith P, Arrastia AM, Liaw LH, Berns M. Incision properties and thermal effects of three CO2 lasers in soft tissue. Oral Surg Oral Med Oral Pathol 1995;128:583–8.
  7. Kotlow L. The use of the erbium hard & soft tissue laser in the pediatric dental practice. J Southeast Soc Pediatr Dent 2001;17:12–4.
  8. Neal D. Kravitza and Budi Kusnotob   Soft-tissue lasers in orthodontics: An overview   Am J Orthod Dentofacial Orthop 2008;133:S110-4
  9. Burke B, Hamdan AM, Tufekci E, Shroff B, Best AM, Lindauer SJ Perceptions of soft tissue laser use in orthodontics.Angle Orthod. 2012 Jan; 82(1):75-83.
  10. Borzabadi-Farahani A. The Adjunctive Soft-Tissue Diode Laser in Orthodontics. Compend Contin Educ Dent. 2017 Apr;38(eBook 5):e18-e31.
  11. Sarver DM: Principles of cosmetic dentistry in orthodontics. 1 Shape and proportionality of anterior teeth. Am J Orthod Dentofacial Orthop 2004; 126:749-753.
  12. Yanosky MR: The soft-tissue laser: managing treatment and enhancing aesthetics. Available at:, August 2006.
  13. Sarver DM, Yanosky MR: Principles of cosmetic dentistry in orthodontics: Part 3. Laser treatments for tooth eruption and soft tissue problems. Am J Orthod Dentofacial Orthop 2005;127: 262-264.
  14. Gracco A, Tracey S, Lombardo L, Siciliani. Soft tissue laser in orthodontics. G.Prog Orthod. 2011; 12(1):66-72. Epub 2011 Mar 17.
  15. Lang NP, Löe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol 1972;43:623-7.
  16. Wennström JL. Lack of association between width of attached gingiva and development of gingival recessions. A 5-year longitudinal study. J Clin Periodontol 1987;14:181-4.
  17. Schoo WH, van der Velden U. Marginal soft tissue recessions with and without attached gingiva. J Periodontol Res 1985;20:209-11.
  18. Kisch J, Badersten A, Egelberg J. Longitudinal observation of “unattached,” mobile gingival areas. J Clin Periodontol 1986;13:131-4.
  19.  Freedman AL, Green K, Salkin LM, Stein MD, Mellado JR. An 18-year study of untreated mucogingival defects. J Periodontol 1999;70:1174-6.
  20. Freedman AL, Salkin LM, Stein MD, Green K. A 10-year longitudinal study of untreated mucogingival defects. J Periodontol 1992;63:71-2.
  21.  Wennström J. Regeneration of gingiva following surgical excision. A clinical study. J Clin Periodontol. 1983;10:287-97.
  22. Monefeldt I, Zachrisson B. Adjustment of clinical crown height by gingivectomy following orthodontic space closure. Angle Orthod 1977;47:256-64
  23. Wennström JL, Lindhe J. Role of attached gingiva for maintenance of periodontal health. Healing following excisional and grafting procedures in dogs. J Clin Periodontol 1983;10:206-21.
  24.  Wennström JL. Mucogingival considerations in orthodontic treatment. Semin Orthod 1996;2:46-54.
  25. Gontijo I, Navarro RS, Haypek P, Ciamponi AL, Haddad AE.The applications of diode and Er:YAG lasers in labial frenectomy in infant patient  J Dent Child (Chic). 2005 Jan-Apr;72(1):10-5
  26.  Kafas P, Stavrianos C, Jerjes W, Upile T, Vourvachis M, Theodoridis M, Stavrianou I. Upper-lip laser frenectomy without infiltrated anaesthesia in a paediatric patient: a case report.Cases J. 2009 May 20;2:7138. doi: 10.1186/1757-1626-2-7138
  27. Gargari M, Autili N, Petrone A, Prete V. Using the diode laser in the lower labial frenum removal. Oral Implantol  2012 Apr;5(2-3):54-7. Epub 2012 Nov 16
  28. Colvard M, Kuo P. Managing aphthous ulcers: laser treatment applied. J Am Dent Assoc. 1991 Jun; 122(6):51-3.
  29. De Souza TO, Martins MA,  Bussadori SK, Fernandes KP, Tanji EY, Mesquita-Ferrari RA, Martins MD. Clinical evaluation of low-level laser treatment for recurring aphthous stomatitis. Photomed Laser Surg. 2010 Oct;28 Suppl 2:S85-8. doi: 10.1089/pho.2009.2661.
  30. Tezel A, Kara C, Balkaya V, Orbak R An evaluation of different treatments for recurrent aphthous stomatitis and patient perceptions: Nd:YAG laser versus medication. Photomed Laser Surg. 2009 Feb; 27(1):101-6.
  31. Misra N, Maiti D, Misra P, Singh AK. 940 nm diode laser therapy in management of recurrent apthous ulcer. BMJ Case Rep. 2013 Apr 17;2013
  32. Parkins F, O’Toole T, Yancy J. Laser treatments of aphthous and herpetic lesions. J Dent Res 1994;73:190.  Suter VGA, Sjölund S, Bornstein MM.
  33.  Effect of laser on pain relief and wound healing of recurrent aphthous stomatitis: a systematic review. Lasers Med Sci. 2017 May;32(4):953-963.

  34. Zeini Jahromi N, Ghapanchi J, Pourshahidi S, Zahed M, Ebrahimi H.Clinical Evaluation of High and Low-Level Laser Treatment (CO2vsInGaAlP Diode Laser) for Recurrent Aphthous Stomatitis.J Dent (Shiraz). 2017 Mar;18(1):17-23.

  35. Nasry SA, El Shenawy HM, Mostafa D, Ammar NM.Different modalities for treatment of recurrent aphthous stomatitis. A Randomized clinical trial.J Clin Exp Dent. 2016 Dec 1;8(5):e517-e522. eCollection 2016 Dec.

  36. Anand V, Gulati M, Govila V, Anand B.Low level laser therapy in the treatment of aphthous ulcer. B.Indian J Dent Res. 2013 Mar-Apr;24(2):267-70.

  37. van As G. The diode laser in treating ulcerative oral lesions. Dent Today. 2011 Dec;30(12):112. 

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