Tooth extractions are a standard dental procedure for non-restorable teeth, hyperdontia, or malpositioned third molars. Routine extraction approach requires considerable force to expand the alveolar bone socket and sever the anchoring periodontal ligaments. Thus, extractions involve exerting large magnitudes of force on the mandible or maxilla. This exposes patients to significant discomfort and poses a serious risk to individuals, especially those with brittle bones such as with osteoporosis [1]. Osteoporosis is characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. It is estimated that over 14 million people in the United States have osteoporosis, and approximately 200 million people worldwide [2,3]. The incidence increases in elderly individuals with 1 in 4 over the age of 65, most notably postmenopausal women that have significant risk for fractures [4]. Mitigating risk factors is, therefore, a critical focus in dental care. Additionally, osteoporotic patients receive several medications, such as bisphosphonates, to reduce bone loss. However, these drugs also hinder post-extraction healing and can induce osteonecrosis that is termed medication-related osteonecrosis of the jaw (MRONJ) [5]. Thus, atraumatic extraction techniques are an optimal approach for these patients.

Lasers were introduced to clinical dentistry in the late 1980s [[6], [7], [8], [9], [10], [11], [12]]. Clinical use of lasers spans various surgical applications such as gingivectomies, frenectomies, sulcular debridement, removal of dental calculus to disinfection procedures such as laser-assisted irrigation of root canals, periapical areas, furcation, and complex periodontal defects. Non-surgical laser applications include photodynamic therapy (destructive) and photobiomodulation (inhibition or stimulation) [13,14]. Despite their broad scope of applications, they were formally recognized by the American Dental Association in 2023 [15]. This recognition can be primarily attributed to an improved understanding of the laser-biological tissue interactions that have enabled the appreciation of synergistic clinical benefits [[16], [17], [18]]. These include less bleeding, reduced swelling and discomfort, improved procedural precision, and improved tissue healing. Significant innovations in dental surgical lasers for both hard and soft tissue have improved their operability and ease of use. The superior width and depth control of surgical dental lasers is increasingly acknowledged, which highlights a critical need for nuanced contemporary training.

There are several dental lasers available today that are usually categorized by their source such as diodes, Nd:YAG, Er:YAG, Er,Cr:YSGG, and CO2. While all lasers have similar components such as an energy source, gain medium to amplify optical power, and transmission apparatus, there are discrete differences based on the wavelength-specific tissue interactions. It is imperative to emphasize that all lasers can ablate soft tissues, albeit with varying efficiency based on their inherent biological chromophore interactions. As lasers have demonstrated effectiveness for soft tissue procedures, this rationale has been extended to ablating tooth-supporting structures within the alveolar socket, such as gingiva, periodontal ligaments, and crestal alveolar bone. A few prior reports have examined the role of lasers in assisting tooth extraction procedures that have noted feasibility [[19], [20], [21]]. All of these studies have been performed with the Erbium lasers. Moreover, there has been little direct investigation of the precise mechanical attributes of the laser-assisted extraction approach. Further, diode lasers are very popular due to their cost and minimal footprint, while CO2 lasers have been the mainstay in surgery for many decades. Both of these lasers have not, to our knowledge, been explored for tooth extractions thus far.

This motivated the current study to explore the feasibility and mechanical forces involved with individual laser devices for tooth extraction. We chose the porcine premolars as a model system, as they are highly homologous to human molars in their anatomy and morphological features. We hypothesized that surgical lasers could provide a minimally invasive approach to ablate tooth-supporting structures, including gingival tissue, periodontal ligaments, and crestal alveolar bone, enabling atraumatic extraction. We assessed clinical tooth mobility using the Miller’s index, forces applied during extraction using a strain gauge and assessed histology to review the laser-tissue changes.