On a daily basis, the general den-tist is faced with the need to provide awide range of procedures. These proce-dures can range from routine restorationsto advanced forms of periodontal or oralsurgery. The general dentist must con-stantly update his or her base of knowl-edge for the rapid, ever-changing proce-dures and materials becoming available.

Radiosurgery is the term used todescribe the most advanced form ofelectrosurgery. It is the removal of softtissue with the aid of radio frequency(RF) energy. This electromagnetic ener-gy operates between the frequencies of3.0 megahertz (MHz) to 4.0 MHz, with4.0 MHz being the optimal frequency.The older electrosurgical instruments,when performing similar procedures,operated at lower frequencies of 1.0MHz to 2.9 MHz. Research by Manessand his group has shown that these lowerfrequencies produce more lateral heat tothe surrounding tissues and should beavoided when in close proximity to bone.1

Use of the older electrosurgery equip-ment should be considered contraindi-cated for contemporary periodontal,implant, and any other delicate surgery,and the clinician should consider updat-ing to the newer radiosurgery instru-ments for reliable, more precise, and lesstraumatic tissue removal.

The waveforms used in radiosurgeryinclude “fully filtered” for incising tissueand “fully rectified” for incising tissuewith concurrent coagulation being per-formed. A “partially rectified” waveform isused only for hemostasis of the soft tissue.

The field of radiosurgery continues tomake advancements. Monopolar radio-surgery is used for cutting tissue with theuse of a fine wire electrode to make anincision. Bipolar electrosurgery is usedfor excision as well to establish coagula-tion in a field of blood. Bipolar radio-surgery is the latest advancement in thefield. This form of surgery can now beaccomplished with the use of a high-fre-quency RF unit.

Bipolar surgery is used for excision aswell as hemostasis of soft tissue. The bipo-lar electrode consists of two parallel wires,one to make the incision and the other toact as the antenna to receive the RF ener-gy. This modality is believed to minimizetransmission of the RF to the surround-ing tissue and thereby minimizing any

lateral heat. This modality has been rec-ommended when exposing an implantas well as coagulating in the presence ofan implant because the signal is ab-sorbed by the adjacent electrode tip. Thisabsorption minimizes any heat transferto the implant should the electrode inad-vertently touch the implant.2

The older bipolar electrosurgery tech-niques were initially used in medicinebecause coagulation could be accom-plished in a field of blood. The signaltraversing the two electrode tips locat-ed so closely together made pinpointcoagulation an easy task. The develop-ment of different shaped electrode tipspaved the way for controlled incisionsto be accomplished.

The latest development is to couplethe bipolar electrodes with the moredesirable radiosurgical wave. This wave-form operates at a higher radio frequencyof 4.0 MHz than the bipolar electro-surgical signal of 2.0 MHz. Researchhas shown that high-frequency radio-surgery produces less tissue alterationand lateral heat to the surrounding tis-sue than the low-frequency electrosur-gical signal.3 Bipolar radiosurgery is amajor advancement over the earlierbipolar electrosurgery.

Ellman International (Oceanside, NY)has taken bipolar surgery one step fur-ther by developing an instrument that isboth monopolar and bipolar. The clini-cian who is familiar and comfortablewith monopolar radiosurgery can con-tinue to use this modality for all generaldental procedures. When treatment is inclose proximity to implants or large metalrestorations, the bipolar modality can be

readily used. The instrument, known asthe Radiolase II™, comes equipped withdifferent handpiece styles and connec-tions to prevent accidental use of thewrong modality, and it complies with allinternational safety standards. It has anadjustable audible tone when the instru-ment is activated to minimize any acci-dental incising of the tissue. Disposablesingle-use electrodes are included withthe instrument; however, the auto-clavable electrodes of earlier models andthe new silver alloy electrodes can beused as well.

Using a scalpel blade, the point ofapplication is the precise point at whichthe incision is made. Similarly, with thehigh-energy RF energy from the elec-trode tip, the incision is controlled andeasily visible at the point of application,with the lateral energy reducing rapidlyfrom the high intensity at the applied tipas the energy is dispersed into the tis-sues. This means that the effect of theapplication can be accurately observedwith the ability to fine-tune the instru-ment for optimum performance andwith respect for tissue safety.

The single-use, disposable electrodetip, originally developed for applicationin the medical field, is one of the latestadvances in radiosurgery, and many regardit as the safest cutting tip available. It isbased on the same principle as that ofdisposable scalpel blades. Single-use indesign, the tips will not tolerate heatsterilization and should not be cold-ster-ilized because their sterility cannot beassured. One advantage of a single-use,disposable electrode tip is that there isalways a clean, unbent electrode with

which to work. Gone are the days of bro-ken loop electrodes and bent straight-wire tips. Disposable tips also eliminatethe chance of a needlestick, which is apotential risk when cleaning straight-wire electrode tips for reuse.4

A new silver alloy electrode has recent-ly been developed to specifically reducetissue damage and heat generated to thesurgical site. The silver alloy electrodehas been shown to produce thermaldamage no greater than 10 µm in depth,compared to the older tungsten elec-trodes that produced thermal damage ashigh as 30 µm in depth. Another impor-tant advantage of the silver alloy elec-trode is its ability to minimize tissuesticking to the electrode tip. This ensuresa clean cutting tip, providing a more pre-cise, microfine incision.

CASE PRESENTATIONA 46-year-old man presented with thecomplaint that he was unable to fullyextend his tongue. On clinical evaluationhe was diagnosed with ankyloglossia(limited movement of the tongue),which is caused by a broad lingualfrenum attachment on the base of thetongue. This enlarged frenum createsspeech and eating problems and can eas-ily be addressed by a general dentist

2 INSIDE DENTISTRY—JULY/AUGUST 2006

CLINICALBrIeFs

Quick considerations for treatment success.

2006: Advances in Radiosurgery Jeffrey A. Sherman DDS, FICD, FACD

Jeffrey A. Sherman, DDS, FICD, FACDExecutive Director

World Academy of Radiosurgery

Private Practice

Oakdale, New York

Figure 1 A preoperative photograph showingan extensive lingual frenum at the base of thetongue. This frenum limited the tongue’s move-ment and inhibited speech.

Figure 2 The Ellman Radiolase II, a 4.0 MHzradiosurgical instrument offering both monopolarand bipolar radiosurgery capabilities.

Figure 3 A silver alloy #118 Vari-tip straight-wire electrode was used to incise the frenum.

skilled in the use of radiosurgery. Thelingual frenum was excised with the useof silver alloy electrodes and theRadiolase II (Figure 1 through Figure 5).A fully recti�ed �ltered waveform wasused to make the incisions and incise thefrenum. T he partially recti�ed waveformwas used to establish coagulation (Figure6 and Figure 7). A postoperative dressingwas placed on the surgical site and homecare instructions were given to thepatient (Figure 8).

CONCLUSIONRadiosurgery continues to make advance-ments that allow it to be the modality ofchoice in the dental o�ce. This modalityo�ers cutting, coagulation, and cuttingwith hemostasis without the high cost ofa laser.

DISCLOSUREThe author’s textbook Oral Radiosurgeryand “Video Atlas of Oral Radiosurgery”are sold by Ellman International.

REFERENCES 1. Maness WL, Rober FW, Clark RE, et al. Histo -

logical evaluation of electrosurgery incisionswith varying frequency and w aveform. JProsthetic Dent. 1978;40(3):304-308.

2. Shuman, IE. Bipolar ver sus monopolarelectrosurger y: clinical applications. Dent.Today. 2001;20(12)74-81.

3. Sherman JA. Oral Radiosurg ery: AnIllustrated Clinical Guide. London: Mar tinDunitz; 1997.

4. Centers for Disease Control and Prevention.Guidelines for infection control in dentalhealth-care settings - 2003. MMWR. De-cember 19, 2003; 52(RR-17):1-76.

INSIDE DENTISTRY — JULY/AUGUST 2006 3

Figure 4 Illustration showing tongue re�ectionusing a tissue forceps or a 2 x 2 piece of gauze.

Figure 5 A silver alloy #118 Vari-tip electrodewas used with a fully �ltered waveform to inciseand remove the frenum. The fully �ltered waveformwas selected because it produces the least later-al heat to the surrounding tissue. A surgical suctiontip is in close proximity to the surgical site to elimi-nate odor and remove blood.

Figure 6 Drawing depicting the frenum beingtotally removed with the #118 electrode.

Figure 7 A #113F pencil-shaped silver alloyelectrode was used with the partially recti�edwaveform to establish pinpoint coagulation.

Figure 8 A #135 ball-shaped silver alloy elec-trode was used with the partially recti�ed wave-form to establish broad areas of coagulation.

Figure 9 To act as a postoperative dressing tothe surgical site,several layers of a tincture ofmyrrh and benzoin were liberally applied to thesurgical site, air-drying between layers.

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