Effects of Er:YAG and Nd:YAG Lasers with Photobiomodulation on Alveolar Bone Preservation Post-Extraction: A Randomized Clinical Control Trial

Abstract

(1) Background: This study aimed to compare alveolar bone preservation and early healing outcomes following a comprehensive laser-assisted post-extraction protocol compared to conventional extraction alone. In addition, the potential influence of serum vitamin D levels on bone regeneration was assessed. (2) Methods: Thirty tooth extractions were performed and randomized into two groups: a test group (G1, n =15) and a control group (G2, n = 15). G1 received a laser-assisted protocol using Er:YAG and Nd:YAG lasers for granulation tissue removal, socket disinfection, clot stabilization, de-epithelialization, and photobiomodulation (PBM) with the Genova handpiece (LightWalker, Fotona, Slovenia). G2 underwent standard mechanical extractions and socket debridement without laser. (3) Results: Procedures in G1 were on average 8.7 min longer, but patients in this group reported significantly lower postoperative pain during the first three days (p < 0.05). A statistically significant difference in alveolar height was observed at the distal lingual site (25.4 mm vs. 21.7 mm; p = 0.046), with other sites showing a trend toward significance. Cumulative bone preservation, measured by Bone Loss Index (BLI4), was significantly better in the laser group. Notably, a positive correlation was found between serum vitamin D levels and bone preservation: each 1 ng/mL increase in vitamin D corresponded to a 0.18 mm gain in alveolar height (p = 0.021). (4) Conclusions: The comprehensive laser-assisted post-extraction protocol reduced postoperative pain and improved alveolar bone preservation, particularly at the lingual distal site. Serum vitamin D levels positively correlated with healing outcomes, suggesting a potential synergistic role of systemic and local regenerative factors.

1. Introduction

Bone remodeling after tooth extraction is a natural physiological process. Bone is a dynamic tissue undergoing continuous turnover through coordinated activity of osteoclasts and osteoblasts. The portion of the jaw housing the tooth sockets, known as the alveolar process, is composed of bone derived from the dental follicle and formed via intramembranous ossification [1,2]. This bone exists primarily to support teeth; once a tooth is lost, the surrounding alveolar bone—no longer mechanically stimulated—undergoes progressive resorption. Classic studies have documented the healing sequence after extraction: clot, granulation tissue development, and new bone formation over a period of 6–10 weeks [3,4]. However, despite regeneration potential, the net result is often a clinically significant reduction in ridge width and height, especially on the buccal aspects [2]. Without intervention, this dimensional loss can compromise esthetic and functional rehabilitation and may necessitate secondary bone augmentation procedures.

To mitigate this resorption, various ridge preservation strategies have been proposed. These include pre-extraction interventions, such as orthodontic extrusion [5,6], distraction osteogenesis [7], minimally traumatic extraction techniques [8], and post-extraction socket preservation methods; deliberate induction of bleeding ensures clot formation [9]. Various post-extraction ridge augmentation methods can then limit resorption. Among these, socket grafting using autogenous, allogeneic bone grafts (demineralized freeze-dried bone allograft, DFDBA), or xenogeneic bone mineral substitutes for guided bone regeneration (GBR) has been widely studied [10,11,12]. Guided bone regeneration around extraction sites effectively preserves alveolar dimensions [10]. Soft tissue augmentation with connective tissue grafts can further enhance gingival contour stability. Despite numerous available protocols, there is still no clear consensus on the optimal approach or material for preserving alveolar bone volume [11,12]. Systemic factors can significantly influence post-extraction bone healing outcomes. Aging, nutritional status, hormonal imbalance, and especially vitamin D deficiency have been shown to impair bone regeneration [13,14,15]. Vitamin D is crucial for bone metabolism and remodeling, modulating inflammation and immunity. It acts as a pleiotropic hormone found in numerous tissues and exhibits anti-inflammatory and pro-osteogenic effects orally [14,15,16,17,18,19,20]. It enhances mesenchymal stem cell differentiation, osteoblast activity, and immune modulation [21]. Deficiency, which is highly prevalent in elderly populations (affecting up to 75–90% depending on skin tone) [13], has been linked to impaired oral wound healing and increased tooth loss [14,18]. Lifestyle factors compound the problem, with smoking, obesity, osteoporosis, and uncontrolled diabetes associated with delayed healing and increased resorption [19,20,21].

In addition to systemic support, the use of laser therapy has gained attention as a promising adjunct in alveolar healing. High-power lasers, such as Er:YAG (2940 nm) and Nd:YAG (1064 nm), can be used during and after extractions to decontaminate sockets, stabilize the clot, and stimulate tissue repair through photobiomodulation (PBM) [22]. The Er:YAG laser is highly absorbed by water and hydroxyapatite, allowing for effective removal of granulation tissue and superficial decontamination with minimal thermal damage to adjacent bone, as demonstrated in both preclinical and clinical studies [23,24,25,26,27]. This combination of selective ablation and antimicrobial action makes it highly effective for precise degranulation and disinfection of the extraction socket. Histological animal studies also confirm that Er:YAG effectively removes inflamed granulation tissue without inducing thermal damage while supporting early new bone formation. The Nd:YAG laser, with deeper penetration and strong absorption in pigmented tissues, provides efficient coagulation and hemostasis, promoting clot stability and exerting bactericidal effects in deeper socket areas—as supported by histologic studies in periodontal treatments (e.g., LANAP^®) [28,29] and recognized thermal coagulation properties owing to its penetration depth [30]. Subsequent photobiomodulation (PBM) therapy, applied with low-level laser parameters, acts at the mitochondrial level, stimulating cytochrome c oxidase, enhancing ATP synthesis, reducing oxidative stress, and modulating inflammatory mediators. PBM promotes osteoblastic proliferation and accelerates bone remodeling during the healing phase. PBM mechanisms include mitochondrial stimulation, ATP production, modulation of reactive oxygen species (ROS), and activation of growth factor signaling [22,31]. In vitro and in vivo studies have shown enhanced osteoblastic proliferation, accelerated bone regeneration, and reduced inflammation with PBM [32,33,34,35,36,37,38]. This sequential application reflects a biologically rational approach to the phases of post-extraction healing—beginning with decontamination and degranulation, followed by stabilization of the socket environment, and finally regenerative stimulation. Studies by Rosero et al. (2020), Daigo et al. (2020), and Abd-Elhaleem Othman et al. (2024) have investigated various wavelengths and combinations of diode lasers in alveolar socket preservation with promising results [36,37,38]. However, these studies often lack standardized protocols or fail to account for systemic modulating factors.

Despite the growing body of preclinical and clinical evidence supporting laser use in alveolar preservation, comprehensive protocols that integrate multiple laser wavelengths in combination with host-modulating factors remain limited. While Križaj Dumić et al. (2021) evaluated a combined Er:YAG and Nd:YAG protocol involving debridement, de-epithelialization, and PBM [27], there remains a need to explore more structured and biologically informed multi-step protocols. We therefore hypothesize that an integrated laser-assisted approach—employing sequential Er:YAG for degranulation, Nd:YAG for clot stabilization, and PBM for biological stimulation and modulated by systemic vitamin D status—can enhance bone regeneration following tooth extraction compared to conventional healing. The null hypothesis is that the application of this laser-assisted protocol has no effect on ridge dimensional changes or healing outcomes, regardless of vitamin D status. By addressing this gap, we aim to determine whether this biologically modulated approach can offer enhanced healing outcomes and reduce the need for secondary augmentation procedures.

2. Materials and Methods

2.1. Ethical Approval

The study was designed as a randomized and controlled trial. Approval from the Local Ethics Committee of Wroclaw Medical University was obtained (permission number: 431/2023N). The research was conducted in accordance with the ethical principles outlined in the World Medical Association Declaration of Helsinki. All patients included in the study provided informed consent and confirmed their agreement to comply with the postoperative follow-up protocol.

2.2. Patients

A total of 30 patients requiring tooth extraction were enrolled in the study. Each patient underwent one extraction, resulting in 30 extractions overall. Patients were randomly assigned into two equal groups: a test group receiving laser-assisted extraction (n = 15) and a control group undergoing conventional extraction without laser assistance (n = 15).

In the laser group, 15 extractions were performed using a combined Er:YAG and Nd:YAG laser protocol. The extractions included 8 mandibular first molars (tooth 36) and 7 s molars (tooth 46). The group consisted of 8 male and 7 female patients, with a mean age of 49 years and 6 months (range: 32–70 years).

In the control group, 15 extractions were performed using conventional mechanical methods. The extractions included 4 mandibular first molars (tooth 36), 9 s molars (tooth 46), and 2 other molars (teeth 47 and 37). This group included 7 male and 8 female patients, with a mean age of 45 years and 1 month (range: 30–59 years) (see

Table 1. Baseline characteristics of patients in the laser and control groups.

Group	Patients	Mean Age	Min–Max Age	Male	Female	Tooth 36	Tooth 46	Teeth 47 and 37
Control	15	45 years 1 months	30–59 years	7	8	4	9	2
Laser	15	49 years 6 months	32–70 years	8	7	8	7	0

).

All extractions were performed flaplessly using periotomes and elevators to preserve the buccal plate and soft tissue. Only sockets classified as Type 1 (intact buccal and lingual bone walls) were included, as verified by clinical inspection and CBCT evaluation. Healing was allowed to proceed spontaneously without grafting or membrane coverage to ensure standardized healing conditions.

All cases (n = 30) were analyzed postoperatively, with no loss to follow-up. Complete postoperative monitoring was achieved for all enrolled participants, resulting in a full follow-up cohort of 30 patients and 30 extractions. Randomization was performed using a computer-generated random number sequence (www.randomizer.org, accessed on 16 July 2025). Group allocation was concealed in sequentially numbered, opaque envelopes that were opened immediately prior to surgery by the operator. The clinician performing the extraction was aware of the group assignment, while the CBCT evaluators and outcome assessors remained blinded throughout the data collection and analysis phases. Additionally, the statistician conducting the final data analysis was also blinded to group identity, ensuring full objectivity in the interpretation of results. A consort flowchart summarizing experimental procedures and subjects is shown below (Figure 1). The diagram illustrates the flow of participants through each stage of the randomized clinical trial, including enrollment, group allocation (laser vs. control), follow-up, and final analysis. All 30 participants completed the study without loss to follow-up, and outcome assessments were performed in a blinded manner. Inclusion and Exclusion criteria you can find in

Table 2. Inclusion and exclusion criteria for the study.

Inclusion dental criteria were as follows: First or second mandibular molar qualified for extraction Simple single-tooth extraction (due to fracture or lack of prosthetic treatment options) Vertical or horizontal fracture Presence of periapical granuloma No prior root canal retreatment

Inclusion general criteria were as follows: Good general health

Exclusion dental criteria were as follows: Active periodontal disease Destroyed inter-root septum PD > 4 mm Poor oral hygiene API > 50% Patient underwent immediate implant procedure

Exclusion general criteria were as follows: Smokers, alcohol abuse Diabetes Pregnancy Use of photosensitizing medication Use medication that would compromise bone healing (glucocorticoids, e.g., prednisone; chronic non-steroidal anti-inflammatory drugs; anticoagulants, e.g., heparin and warfarin; immunosuppressants, e.g., cyclosporine; chemotherapy drugs; proton pump inhibitors, e.g., omeprazole; and bisphosphonates) Rheumatological arthritis Immune diseases Any systemic diseases associated with bone metabolism

.

The required sample size was determined using G*Power 3.1 software (Kiel University, Kiel, Germany) based on an effect size of d = 0.94 from preliminary internal pilot data (unpublished). This pilot involved six patients undergoing similar laser-assisted post-extraction protocols (three in the test group and three in the control group), with CBCT-based measurements of alveolar bone height used as the outcome variable. A two-tailed significance level of 0.05, a power of 80%, and an allocation ratio of 1:1 indicated a minimum of 15 subjects per group.

2.3. Laser Procedure

In the laser group, Er:YAG and Nd:YAG lasers (LightWalker, Fotona, Slovenia) were used immediately after tooth extraction. Each of the lasers was responsible for the following procedures:

• Removal of inflamed granulation tissue and debridement of the alveolus were performed using the Er:YAG laser with the H14 handpiece and a cylindrical tip of 1.3 mm diameter in non-contact mode with a non-activated tip. The laser operated with a pulse duration of 300 µs (Short Pulse mode, SP), energy of 160 mJ, frequency of 15 Hz, and water/air settings of 4/2. The calculated fluence was approximately 12.05 J/cm², and the power density was 184.61 W/cm² (Figure 2a).
• Deep disinfection of the alveolus was performed using the Nd:YAG laser with a 300 μm fiber in non-contact and non-activated mode. The laser operated with a pulse duration of 300 µs (SP), power of 2 W, and frequency of 20 Hz. The calculated fluence was approximately 143 J/cm², and the power density was 2829.42 W/cm² (Figure 2b).
• De-epithelialization of the keratinized gingiva to the mucogingival junction was performed using the Er:YAG laser with the H14 handpiece and a cylindrical tip of 1.3 mm diameter in non-contact mode and a non-activated tip. The laser operated with a pulse duration of 300 µs (SP), energy of 120 mJ, frequency of 20 Hz, and water/air settings of 4/2. The calculated fluence was approximately 9.04 J/cm², and the power density was 184.61 W/cm² (Figure 2c).
• Stabilization of the blood clot was performed using the Nd:YAG laser with a 300 μm fiber in non-contact and non-activated mode. The laser operated with a pulse duration of 500 µs (Long Pulse mode, LP), power of 4 W, and frequency of 15 Hz. The calculated fluence was approximately 377 J/cm², and the power density was 5658.84 W/cm² (Figure 2d).
• Photobiomodulation (PBM) was performed using the Nd:YAG laser with the Genova flat-top handpiece (spot size 0.95 cm²) in Micro Short Pulse (MSP) mode. The laser operated with a power of 0.5 W and a frequency of 10 Hz. PBM was applied to the post-extraction socket in three points/locations: buccally (vestibular side), lingually, and occlusally (from the top of the socket). Each point was irradiated for 60 s per session. The delivered fluence per session was approximately 31.58 J/cm², and the power density was 0.53 W/cm². PBM was performed on days 0, 3, 5, and 7 post-extraction (Figure 2e).

2.4. Radiographic Measurement and Pain Assessment

Cone beam computed tomography (CBCT) scans were obtained immediately after extraction and at 4 months postoperatively using standardized imaging parameters (MyRay, SternWeber Warsaw, Poland). Measurements were performed using MyRay software (https://www.myray.it/en/) by the same operator to ensure consistency.

Alveolar socket morphology was evaluated in the mesial and distal root regions based on cross-sectional views (Figure 3a,b). The following vertical and horizontal parameters were recorded:

-

Buccal bone height (BBH)—distance from the mandibular base to the crest of the buccal alveolar wall (Line 1 in Figure 3a);

-

Lingual bone height (LBH)—distance from the mandibular base to the crest of the lingual alveolar wall (Line 2 in Figure 3a);

-

Alveolar width (AW)—distance between the buccal and lingual crests (Line 3 in Figure 3a,b);

-

Interradicular septum height (ISH)—vertical distance from the mandibular base to the peak of the septum between roots (Line 4 in Figure 3c).

In addition, a Bone Level Index (BLI) was calculated as the average of buccal and lingual bone heights to summarize vertical bone preservation at each site: BLI = BBH+LBH/2.

Figure 3 illustrates the location and orientation of each measurement. Figure 4 presents the measurement protocol and reference line for cross-sectional CT views used for standardization.

At 4 months postoperatively, CBCT scans were repeated using the same equipment and settings. Measurements were repeated at identical sites to assess dimensional changes over time.

Pain was assessed using a visual analog scale (VAS), completed by patients on days 1, 2, 3, and 7 post-extractions. Analgesic use (drug name and dosage) was also recorded.

Vitamin D concentration was measured preoperatively using a rapid immunochromatographic test (Valida Pro, Rostock, Germany) from a fingertip capillary blood sample. The result was read after 15 min and categorized on a two-point scale.

In this study, the first and second molars in the lower jaw were removed. In order to make accurate measurements, the sockets were divided into mesial and distal sockets. A separate parameter measured was the interradicular septum. Its maintenance during extraction was included in the criteria. In addition to the height of the alveolar walls, the width of the alveolar bone in the mesial and distal root area was also measured.

The distances from the bottom of the mandible to the top of the alveolar bone of the buccal side (1) and lingual side (2) were measured (Figure 4a). The alveolar bone width (3) (Figure 4a,b) was the distance between the reference lines 1 and 2 in the mandible. The last measurement was the height of the interradicular septum (4) (Figure 4c), measured from the bottom of the mandible to the top of the septum. The reference line was set at the floor of the nasal cavity in the maxilla instead of the bottom of the mandible. Four months after extraction, a CBCT test was performed with the same apparatus using the same parameters and carried out by the same operator to perform the measurements as above.

During the study, special attention was paid to the study of pain sensation after tooth extraction. To assess the symptoms, the visual analog scale (VAS) was used, and patients were asked to note the amount and names of analgesics. The results were handwritten by the patients on a 10 cm long line, which presented the value 1 as no pain and 10 as the worst pain. Patients completed the Scala VAS during the first three days after the procedure and on the seventh day.

Prior to surgery, on the day of tooth extraction, capillary blood was collected from each patient to assess vitamin D levels using the Valida Pro rapid test (Rostock, Germany). The results were not disclosed to patients during the study period to avoid potential behavioral influence, such as vitamin D supplementation. All 30 enrolled patients were included in the correlation analysis of vitamin D levels and alveolar bone dimensional outcomes. The test used a unique pair of monoclonal antibodies, enabling selective detection of vitamin D with high sensitivity and specificity. It was performed from a single drop of capillary blood, with the result displayed on a two-point scale within 15 min (Figure 5).

2.5. Statistical Analysis

To evaluate the normality of the data distribution, the Kolmogorov–Smirnov test was conducted at a 95% confidence level. The comparison of treatment times and the relationship between procedure duration and analgesic intake across the groups were analyzed using the Student’s t-test for independent samples. Spearman’s rank correlation coefficient (rS) was employed to assess the association between vitamin D levels and the height of the socket and septum walls. Furthermore, the Wilcoxon signed-rank test and the Mann–Whitney U test were used to compare changes in the height and width dimensions of the alveolar wall and interradicular septum between the groups, both on the day of the procedure and after a 4-month follow-up period. All statistical analyses were performed using Statistica software (version 12, StatSoft, Krakow, Poland). All tests were two-tailed, and the significance level was set at p = 0.05. Due to the exploratory nature of the study and limited sample size, no correction for multiple comparisons was applied. Accordingly, the results should be interpreted with caution.

3. Results

3.1. Surgery Time

To compare the duration of the surgical procedure between the laser (G1) and control (G2) groups, a Student’s t-test for independent samples was performed. The analysis revealed a statistically significant difference in surgery time between the groups. In the laser group, the mean surgery time was 37.0 min (SD = 6.4), with a range from 25.0 to 49.1 min. In contrast, the control group demonstrated a shorter mean surgery time of 28.3 min (SD = 4.3), with a range from 20.7 to 34.9 min. The mean difference in procedure duration between groups was 8.7 min, favoring the control group. This difference was statistically significant (p = 0.0002), indicating that procedures performed with laser assistance took significantly longer than conventional extractions (Figure 6).

3.2. Pain After Procedure

A statistically significant relationship was observed between the duration of the procedure and the use of analgesics only in the control group.

After the procedure, the patients completed the VAS pain scale on the 1st, 2nd, 3rd, and 7th day after extraction. VAS pain scores recorded on days 1, 2, 3, and 7 are summarized in

Table 3. Postoperative pain intensity (VAS scores) in the laser and control groups. Values shown as median [Q1–Q3]; statistical comparison performed using the Mann–Whitney U test.

Day	Laser	Control	p-Value
1st	2.5 [2, 3]	5 [3, 6]	0.001
2nd	1.5 [1, 2]	4 [3, 5]	<0.001
3rd	1 [1, 1]	2 [2, 3]	0.001
7th	1 [1, 1]	1 [1, 1]	1.000

Me [Q1; Q3]—median (Me) and lower (Q1) and upper (Q3) quartiles.

and visualized in Figure 7. Median pain intensity was significantly lower in the laser group on days 1–3 (all p ≤ 0.001), while scores were equivalent on day 7 (p = 1.000).

3.3. The Relationship Between the Duration of the Procedure and the Intake of Analgesics

To assess the association between the duration of the extraction procedure and postoperative analgesic use, the Student’s t-test for independent samples was applied. Patients were divided based on whether they took painkillers on days 1, 2, or 3 following the procedure. On the first and second days, patients who reported taking analgesics had undergone significantly longer procedures compared to those who did not (p = 0.017 and p = 0.004, respectively). This trend was particularly evident in the control group, where procedure duration was significantly longer in patients who took analgesics on both the first (p = 0.002) and second days (p = 0.001). In contrast, no significant association was observed in the laser group. On the third day, the number of patients taking analgesics was minimal (n = 1), and no meaningful comparisons could be made, although the control group again showed a non-significant trend (p = 0.179).

Although the surgery duration was significantly longer in the laser group due to additional PBM steps, the average 8.7 min difference may not be clinically meaningful. The observed correlation between surgery time and pain medication intake, found only in the control group, likely reflects differences in surgical trauma unrelated to laser use and should be interpreted with caution. The results are presented in

Table 4. Descriptive statistics of the duration of the procedure (min) in groups differing in the use of painkillers and laser and the results of comparisons (t-tests for independent samples).

The Day After the Procedure	Group	Taking Painkillers		Result of Test
		Yes	No
First day	All	n = 9 36.2 ± 5.5	n = 21 31.1 ± 7.0	p = 0.067
	Laser	n = 4 40.6 ± 5.2	n = 11 35.6 ± 6.4	p = 0.196
	Control	n = 5 32.6 ± 2.2	n = 10 26.1 ± 3.4	p = 0.002
	Result of test	p = 0.017	p = 0.001	×
Second day	All	n = 5 35.7 ± 5.0	n = 25 32.0 ± 7.2	p = 0.285
	Laser	n = 1 44.5 ± 0.0	n = 14 36.4 ± 6.3	p = 0.233
	Control	n = 4 33.5 ± 1.3	n = 11 26.4 ± 3.3	p = 0.001
	Result of test	p = 0.004	p < 0.001	×
Third day	All	n = 1 34.0 ± 0.0	n = 29 32.6 ± 7.0	p = 0.841
	Laser	-	n = 15 37.0 ± 6.4	-
	Control	n = 1 34.0 ± 0.0	n = 14 27.9 ± 4.2	p = 0.179
	Result of test	-	p < 0.001	×

.

3.4. Measurement of the Alveolar Wall

The comparative evaluation of the measurements of the alveolar wall height immediately after removal and after 4 months showed that the analyzed dimensions decreased significantly in both the study group and the control group. The basic positional statistics (medians and quartiles) and the results of comparisons are presented in

Table 5. Statistics of the height and width dimensions of the alveolar wall and interradicular septum on the day of the procedure and after 4 months in the study group (laser) and the control group (control) and the results of significance tests (Wilcoxon and Mann–Whitney tests).

Dimension (mm)	On the Day of the Procedure	4 Months After the Procedure	Result of the Test
High septum—with laser	24.7 (23.4–27.9)	24.2 (22.0–26.8)	p = 0.001
High septum—no laser	23.0 (20.7–26.1)	20.2 (20.0–24.8)	p <0.001
Result of the test	p = 0.206	p = 0.125	×
High mesial buccal—with laser	26.2 (24.4–29.7)	25.8 (23.7–28.6)	p = 0.001
High mesial buccal—no laser	24.6 (22.8–27.6)	22.5 (20.8–26.3)	p = 0.001
Result of the test	p = 0.245	p = 0.056	×
High mesial lingual—with laser	27.9 (24.9–30.3)	25.8 (23.8–28.3)	p = 0.001
High mesial lingual—no laser	23.7 (23.0–28.8)	21.9 (21.0–26.4)	p = 0.001
Result of the test	p = 0.184	p = 0.125	×
Width mesial root—with laser	8.8 (8.1–9.4)	8.1 (7.8–8.7)	p = 0.001
Width mesial root—no laser	9.6 (7.5–10.5)	8.7 (7.3–10.2)	p = 0.001
Result of the test	p = 0.395	p = 0.648	×
High distal buccal—with laser	27.0 (24.0–28.5)	25.4 (23.2–27.3)	p = 0.001
High distal buccal—no laser	23.7 (22.0–25.5)	21.3 (20.1–25.5)	p = 0.001
Result of the test	p = 0.081	p = 0.051	×
High distal lingual—with laser	26.1 (23.4–27.9)	25.4 (22.8–27.6)	p = 0.001
High distal lingual—no laser	23.7 (21.3–27.2)	21.7 (20.2–24.9)	p = 0.001
Result of the test	p = 0.237	p = 0.046	×
Width distal lingual—with laser	8.4 (8.1–9.6)	8.1 (7.5–8.7)	p = 0.001
Width distal lingual—no laser	9.0 (7.8–10.7)	8.7 (7.5–9.9)	p = 0.001
Result of the test	p = 0.468	p = 0.384	×

. Although statistically significant differences were observed only for the distal lingual height (p = 0.046), multiple dimensions showed a favorable trend toward greater preservation in the laser group, including mesial buccal height (p = 0.056) and distal buccal height (p = 0.051). These results are consistent with a potential clinical benefit, though further research with larger samples is warranted (see Table 5).

A statistically significant difference between the test and control groups was observed only for the high distal lingual wall at 4 months post-extraction (25.4 mm vs. 21.7 mm, p = 0.046). However, it is worth noting that the differences in high mesial buccal and high distal buccal wall heights were close to the threshold of statistical significance (p = 0.056 and p = 0.051, respectively) (see

Table 6. Δ values (T4M − T0) for alveolar bone measurements based on median values. The table presents changes in septum and socket dimensions for both groups. Only the change in distal lingual wall height reached statistical significance between groups (p = 0.046).

Parameter	Δ Laser (mm)	Δ Control (mm)	Between-Group Δ (mm)	p-Value
Septum height	−0.5	−2.8	2.3	0.125
Mesial buccal wall height	−0.4	−2.1	1.7	0.056
Mesial lingual wall height	−2.1	−1.8	0.3	0.125
Mesial socket width	−0.7	−0.9	0.2	0.648
Distal buccal wall height	−1.6	−2.4	0.8	0.051
Distal lingual wall height	−0.7	−2.0	1.3	0.046
Distal socket width	−0.3	−0.3	0.0	0.384

).

3.5. Cumulative Bone Loss Assessment Using Bone Loss Index (BLI4)

To assess cumulative changes in bone volume, a dimensionless Bone Loss Index (BLI4, %) was calculated based on seven linear measurements. The results showed that bone atrophy was significantly lower in the laser-treated group compared to the control. The absolute bone loss (BLI4 in mm) was 6.0 mm in the laser group and 10.8 mm in the control group (difference: 4.8 mm; p = 0.002). The relative bone loss (BLI4 in %) was also significantly lower in the laser group (3.6%) than in the control group (6.8%) (p < 0.001) (see Figure 8).

3.6. Vitamin D Level

Subsequently, the measurements of the results of each of the seven parameters measured in tomography were carried out, along with the level of vitamin D in the patients’ bodies. It was observed that an increase in vitamin D concentration by 1 ng/mL was accompanied by an increase in the height of the alveolar walls by an average of 0.18 mm (see

Table 7. Spearman’s rank correlation coefficient (rS) values between vitamin D levels and the height of the socket and septum walls.

Vitamin D (ng/mL) Versus:	rS	t (N − 2)	p-Value
High septum (mm)	0.428	2.458	0.021
High mesial buccal (mm)	0.428	2.460	0.021
High mesial lingual (mm)	0.432	2.488	0.019
Width mesial root (mm)	0.019	0.061	0.316
High distal buccal (mm)	0.412	2.349	0.026
High distal lingual (mm)	0.424	2.433	0.022
Width distal root (mm)	−0.047	−0.244	0.809

and Figure 9).

In the analysis of the presented results, a significant correlation of vitamin D levels with all altitudes is observed (p < 0.05).

4. Discussion

The results of this study demonstrated that the comprehensive laser-assisted protocol, which included photobiomodulation (PBM), bone socket cleaning, deep disinfection, clot stabilization, and soft tissue de-epithelialization, provided additional positive effects on the healing process. Despite the treatment duration being extended by approximately 8 min on average in the laser-assisted group, patients reported experiencing less postoperative pain compared to those in the control group who underwent conventional extraction without laser application. Although treatment duration is an important consideration for patient comfort, existing literature also supports improved patient well-being following laser treatments, despite longer procedural times. In this study, the 8.7 min increase in treatment time observed in the laser group likely reflects the additional PBM steps and is not considered clinically meaningful. While a correlation between surgery duration and analgesic intake was observed in the control group, this association did not reach significance in the laser group and may reflect procedural variability rather than a causal relationship. Given the limited sample size and variability in medication use, these findings should be interpreted with caution and require validation in larger cohorts. Atraumatic tooth extraction—defined as removing teeth while minimizing trauma to the surrounding alveolar bone—naturally requires more time, even for skilled clinicians. Importantly, increased procedural duration does not correlate with greater pain or impaired healing outcomes. However, the precise impact of procedural duration alone on alveolar wall resorption remains undetermined. A notable limitation of this study was the relatively small sample size, suggesting that further investigations with larger patient cohorts are necessary. Additionally, future research should consider potential differences in healing outcomes between maxillary and mandibular extraction sites. Standardizing analgesic protocols to utilize substances that minimally influence bone healing would also be beneficial.

These comprehensive laser procedures effectively reduced alveolar wall resorption following tooth extraction. To date, numerous studies have primarily explored the stimulatory effects of PBM on alveolar healing post-extraction. For example, studies on rats demonstrated that Nd:YAG laser irradiation created favorable conditions for osteoblast differentiation, evidenced by elevated osteocalcin expression, highlighting the potential mechanisms through which Nd:YAG laser promotes bone healing [35]. In addition to osteogenic stimulation, photobiomodulation with Nd:YAG lasers has been shown to upregulate angiogenic factors such as VEGF (vascular endothelial growth factor), thereby enhancing neovascularization within healing bone tissue. Angiogenesis is essential for delivering oxygen, nutrients, and signaling molecules required for efficient tissue regeneration. Furthermore, laser-induced modulation of fibroblast activity can influence collagen turnover, promoting better alignment and maturation of the extracellular matrix, which supports the mineralization process [39]. Similarly, Kim et al. reported that Nd:YAG laser irradiation enhanced postoperative bone regeneration by approximately 45%, benefiting both empty bone defects and those filled with collagen sponges [40]. These findings suggest that the regenerative effects of Nd:YAG lasers may be mediated by a synergistic cascade involving osteogenic activation, vascular proliferation, and matrix remodeling. Systematic reviews by Kulkarni et al. confirm that PBM consistently accelerates alveolar bone repair after extraction, increasing osteogenic markers (e.g., Runx2 and osteocalcin), promoting angiogenesis, reducing inflammation, and enhancing collagen matrix organization—processes possibly mediated via VEGF upregulation and controlled fibroblast activity [2].

Leveraging existing evidence on the broad applicability of Er:YAG and Nd:YAG lasers in dentistry, including their use in ceramic debonding, biofilm disruption, and periodontal therapies [23,24,25,26,27,41], this study uniquely combined these lasers in a post-extraction protocol to capitalize on their photoacoustic and antibacterial properties. The Er:YAG laser was employed for socket debridement and soft tissue de-epithelialization, while the Nd:YAG laser facilitated deep bone disinfection, clot stabilization, and PBM [42,43,44,45,46,47]. Additionally, recent evidence has shown that Nd:YAG photobiomodulation not only enhances healing but also exerts significant antibacterial effects by reducing oral biofilm viability, suggesting a dual regenerative and antimicrobial mechanism [42]. Although promising, additional research is essential to clarify the specific contribution of each laser intervention to bone regeneration outcomes.

Patient compliance with follow-up PBM sessions was consistent throughout this study. Existing research indicates that even a single PBM session using low-level lasers can significantly improve patient quality of life and reduce postoperative swelling [48]. Križaj Dumić et al. additionally reported that patient age might influence the extent of laser therapy benefits, noting more pronounced improvements in older patients compared to younger ones [27]. Most available clinical evidence on post-extraction photobiomodulation therapy involves diode lasers emitting in the red or near-infrared (NIR) spectrum (typically 630–980 nm) [49]. A systematic review by Kulkarni et al. (2019), which analyzed ten randomized clinical trials in humans, found that most studies demonstrated significant improvements in radiographic bone density, socket fill, and soft tissue healing following diode-based PBM, with reported benefits emerging as early as 21 days postoperatively [2]. These conclusions were further supported by Le et al. (2023), who reviewed nine RCTs and reported that PBM improved bone remodeling parameters in 89% of studies, particularly when infrared lasers (808–830 nm) were used in the early post-extraction phase [50]. In addition, Özer and İnci (2024) demonstrated that PBM using a 940 nm diode laser accelerated wound healing and reduced pain following primary molar extractions in children [51]. Clinical trials by Reza et al. (2021) and Liu et al. (2024) also confirmed the efficacy of diode PBM in enhancing wound healing, reducing postoperative discomfort, and improving patient satisfaction following dental surgeries [52,53]. However, unlike most of these studies, where PBM was applied in isolation, our study incorporated PBM as one element of a comprehensive, staged laser protocol. This included Er:YAG-assisted removal of granulation tissue and infected debris, as well as de-epithelialization of the socket margins, which helps delay external epithelial closure and prolongs the regenerative window within the alveolus. Additionally, laser cleaning of the bone surface removed the smear layer, an irregular amorphous film that can obstruct osteoblastic colonization and cementum formation—Er:YAG has been shown to effectively remove this layer and create a biologically favorable bone surface [54]. The de-epithelialization step is further supported by periodontal studies showing that laser disruption of the gingival epithelium can inhibit epithelial downgrowth and improve connective tissue and bone regeneration [55,56,57]. These steps were followed by Nd:YAG-assisted clot stabilization and repeated PBM sessions. This biologically coordinated sequence was intended not only to reduce symptoms but also to actively create a microenvironment conducive to bone regeneration. Therefore, the regenerative effects observed in our cohort likely reflect a synergistic combination of laser-assisted debridement, clot preservation, modulation of epithelial dynamics, and photobiomodulation—although this interpretation must be viewed as exploratory, given that only one out of seven measured dimensional parameters reached statistical significance. Future studies employing a three-arm design—comparing conventional extraction, mechanical extraction plus PBM, and the full multimodal laser-assisted protocol—are warranted to delineate the independent and synergistic effects of individual laser components, particularly photobiomodulation.

Considering its greater penetration depth (1064 nm), Nd:YAG laser irradiation may be particularly effective for enhancing alveolar healing post-extraction. However, most current PBM research involves diode lasers at varying wavelengths, highlighting the need for further investigation into Nd:YAG laser applications specifically.

The current study, involving 30 tooth extractions, aimed to standardize results by focusing exclusively on mandibular first and second molars. Among the seven measured parameters, only one demonstrated statistical significance, while two additional points approached significance. To confirm these preliminary findings, future studies with expanded patient groups are warranted. Moreover, comparative analyses between maxillary and mandibular extraction sites should also be explored.

In this study, serum vitamin D levels were measured in all 30 patients on the day of surgery, prior to the extraction procedure, using a rapid immunochromatographic test (Valida Pro, Rostock, Germany). Patients were blinded to their results to prevent any influence on behavior, such as supplementation. The correlation analysis was performed on the full sample (n = 30) and repeated after excluding one statistical outlier (patient #11). Corresponding descriptive statistics and Spearman correlation coefficients are included in the Results Section to ensure transparency. These additions strengthen the interpretability of the vitamin D findings in relation to alveolar bone preservation. A notable strength of this study involved vitamin D level measurements taken both on the extraction day and after four months. Vitamin D plays a critical role in bone metabolism by promoting calcium absorption in the intestines and renal calcium reabsorption, thus reducing bone resorption. Additionally, vitamin D supports bone repair and stimulates bone growth factors [14]. A statistically significant correlation between vitamin D levels and alveolar bone heights was observed (p < 0.05). This finding aligns with previous research linking systemic vitamin D status to enhanced osseous healing outcomes in the jaw. For example, Michalak et al. (2021) and Michalak et al. (2025) demonstrated that adequate serum vitamin D improves bone regeneration in patients with medication-related osteonecrosis of the jaw (MRONJ), while Krawiec et al. (2021) emphasized the importance of assessing vitamin D levels during dental treatment planning due to its widespread deficiency and impact on bone turnover [58,59,60]. While the rapid immunochromatographic test enabled standardized chairside screening, we acknowledge its limitation as a two-point scale assay. Future studies should consider quantitative methods such as 25(OH)D ELISA to provide more detailed correlation analyses and enable threshold-specific interpretation. Unfortunately, vitamin D deficiency is prevalent in Poland, affecting approximately 70% of the population [61]. Previous research has extensively explored vitamin D’s role in periodontal health; for instance, Krall et al. found lower tooth loss risk among elderly subjects supplementing with vitamin D [62]. Additionally, vitamin D deficiency has been linked to slower tooth movement during orthodontic treatments [63], emphasizing its importance in effective bone remodeling, particularly in younger populations [64].

Maxillary and mandibular bones differ structurally and qualitatively, with mandibular bone predominantly classified as D1 or D2 and maxillary bone as D3 or D4 (Misch’s classification). Future research should further investigate and compare the impact of laser protocols on healing outcomes across these distinct anatomical sites. Future studies should also control for patient-related variables such as smoking status, systemic diseases (e.g., diabetes), or medications affecting bone turnover, as well as inter-operator variability, which may influence surgical precision and healing responses.

5. Conclusions

The present study suggests a trend toward improved alveolar bone preservation when using a combination of high-power Er:YAG and Nd:YAG lasers following tooth extraction. While only one-dimensional parameter reached statistical significance, complementary indices of bone loss support the potential regenerative benefit of the laser-assisted protocol. To accurately determine the specific contributions of each laser treatment component, additional studies involving larger patient cohorts are necessary.

This research specifically evaluated alveolar healing following molar extractions; future investigations should include premolar extractions to enhance the generalizability and significance of these findings, thus advancing clinical practices and protocols in this area.