`Periodontal plastic surgery' - thermal effect analysis using Erbium:YAG Kesler's handpiece. Histochemical evaluation by Picrosirius red stain and polarization microscopy for collagen determination - in vivo study

Recent technological advances lead to an increase in the options for the treatment of the periodontal diseases. Lasers utilized for gingival soft tissue resurfacing mainly for esthetics purposes, require careful histopathological evaluation of the effects on tissue. Up to date no comparative clinical or histological studies have been performed, aiming at demonstration of the effects of laser irradiation on connective tissue, especially its most important component - the collagen fibers. The alteration in the structures of this tissue plays the most important role in the healing process. The aim of the present study is to evaluate the influence of Erbium: YAG - Kesler's hand piece on gingival tissue. This handpiece is designed for gingival resurfacing, in cases of `Gummy smile' and gingival pigmentation. The following irradiation parameters were used: energy per pulse - 500 mJ, repetition rate 10 pps, spot size 3 mm. Gingival biopsies specimens of 10 patients, 6 with `Gummy smile' and 4 with gingival pigmentation were examined before laser treatment, and at 7 and 14 days after laser treatment. The tissues were fixed in LNRS, embedded in paraffin, and sectioned into 5 μm thickness, dewaxed in xylol and stained with H&E and Picrosirius Red (PSR). The sections were examined by polarization microscopy. PSR is a collagen stain that differentiates collagen fiber density by the range of colors from green through yellow to red, and/or fiber size. This was utilized in the present study to evaluate the hypothesis that Erbium - YAG (Er: YAG) laser energy is capable of remodeling the collagen fibers in the gingival connective tissue through a photothermal process. We found a significant difference between the structures of collagen fibers at the first week and at 14 days post treatment. In the normal gingiva the predominant polarization colors were in the red-orange range, signifying tightly packed, mature collagen. During the first postoperative week, collagen fibers exhibit mainly polarization colors in the green to green-yellow range implying less packed intermediate collagen fibers. After two weeks, collagen fibers required their preoperative polarizing texture. These findings strongly suggest that the `quality' rather than the quantity of gingival collagen fibers play an important role in order for collagen shrinkage and reproduction to occur.