Laser-Assisted Frenectomy Using 980nm Diode Laser
Tahrir N Aldelaimi1* and Ali S Mahmood2
1Department of Oral & Maxillofacial Surgery, College of Dentistry, Anbar University, Iraq
2Biomedical Department, Institute of laser for post-graduate studies, University of Bhagdad, Iraq
2Biomedical Department, Institute of laser for post-graduate studies, University of Bhagdad, Iraq
*Corresponding author: Tahir N Aldelaimi, Department of Oral & Maxillofacial Surgery, College of Dentistry, Anbar University, Iraq, Tel: 00964-
7814050913; E-mail: tahrir_aldelaimi@yahoo.com
Received: October 14, 2014; Accepted: November 05, 2014; Published: November 15, 2014
Citation: Aldelaimi TN, Mahmood AS (2014) Laser-Assisted Frenectomy Using 980nm Diode Laser. J Dent Oral
Disord Ther 2(4): 1-6. DOI: http://dx.doi.org/10.15226/jdodt.2014.00130
Abstract
A frenum is a fold of tissue or muscle connecting the lips,
cheek or tongue to the jawbone. Their high attachment may cause
orthodontic problem (Central diastima), prosthodontic problems
(Poor retention of denture), periodontic problems (gingival
recession and inflammation) and speech problem (tongue tied in
ligual frenum). A frenectomy is the removal of one of these folds of
tissue and it is a common procedure in the specialty of maxillofacial
surgery. Laser-assisted frenectomy is a much more comfortable for
the patient because it means that no scalpel or stitches are required.
This clinical study was carried out at department of Maxillofacial
Surgery, Ramadi Teaching Hospital; 25 patients including 16 (64%)
male and 9 (36%) female with age range from 3 months to 18 years
old with mean age 6.5 years old. Chirolas 20W diode laser emitting
at 980 nm; the laser is delivered through a fiber optic 400 µm. Beam
profile is a single-mode Gaussian (TEM00), with a spot size (0.9 mm)
was used to performed laser-assisted frenectomy. Our preliminary
clinical findings include sufficient hemostasis, coagulation properties
and precise incision margin with all of the surgical procedure. The
postoperative advantages, i.e., lack of swelling, bleeding, pain or, scar
tissue formation, the good wound healing and overall satisfaction
were observed in the clinical application of laser-assisted frenectomy.
The clinical application of the diode (980 nm) laser in oral and
maxillofacial surgical procedures proved to be of beneficial effect for
daily practice, it can be considered practical, effective, easy to used,
offers a safe, acceptable, and impressive alternative for conventional
techniques of frenectomy.
Keywords: Laser surgery; Frenectomy; Labial frenum; Lingual frenum; Laser application; Oral surgery
Keywords: Laser surgery; Frenectomy; Labial frenum; Lingual frenum; Laser application; Oral surgery
Introduction
Since the first report on laser radiation by Maiman (1960),
many potential fields for its application have been investigated
[1,2]. Among these, medical laser surgery certainly belongs to the
most significant advances. Various kinds of lasers have already
become irreplaceable tools of modern medicine. Although
clinical applications were first limited to ophthalmology and
dentistry, the other fields of medical laser treatment have
meanwhile considerably widened. Soon after laser invention
was demonstrated, researchers began to examine Maiman's
vision of the laser as a useful instrument for medicine. Their efforts laid the foundation for the present clinical use of lasers
in medicine [3-5]. The specialty of maxillofacial surgery has
benefited from the use of lasers since the mid-1960s, with
the first documented use of a laser in 1977; lasers are quickly
becoming the standard of care for many surgical procedures,
given the advantages of improved precision, visualization, and
reduced discomfort and lasers are versatile and valuable devices
in various disciplines of dentistry-prosthetics, periodontics,
pedodontics, endodontics, implantology, cosmetic and operative
dentistry, and oral and maxillofacial surgery [3,6]. Lasers are
becoming more commonplace and even routine, either as
adjunctive treatment methodologies or as stand-alone additions
to the dental armamentarium. The growing number of dental
laser practitioners, propelled by the increasing body of evidence
concerning the safe, effective, and appropriate use of lasers in
dentistry and maxillofacial surgery, will continue to advance the
application of Einstein's "splendid light" in their operations, to the
benefit of patient and practitioner alike. For many procedures,
lasers are now becoming the treatment of choice by both clinicians
and patients, and in some cases, the standard of care [7]. Despite
the common way of stimulated emission, that characterizes
all laser emission, semiconductor laser are quite different
from other types of lasers in both operating performance and
pumping mechanism. Diode lasers emit light in the range of near
infrared region to the visible red region. The main advantages
of semiconductor laser are its compactness, simplicity and
efficiency. They require very little auxiliary equipment and can
be readily linked to optical fibers that able the diode laser to be
used for medical purposes [8]. A frenum is an anatomic structure
formed by a fold of mucous membrane, connective tissue, and
sometimes muscle fibers. The most important of these are the
labial frenae in the mid-line of the upper and lower jaw, the
buccal frenae in the premolar region and the lingual frenum of
the mandible. The frenum embryologically originates as remnant
of the central cells of the vestibular lamina at the midsagittal
area. The labial frenum connects the lip to the gingival tissue
covering the alveolar periosteum of both maxilla and mandible.
The size of the frenum varies among individuals, as does the
location where the frenum inserts into the alveolar mucosa and/
or gingiva. The level of frenal attachments may vary from the height of the vestibule to the crest of the alveolar ridge and even
to the incisal papilla area in the anterior maxilla. While the lingual
frenum attaches the tongue to the floor of the mouth or to the
alveolar mucosa of mandible. The frena under normal conditions
do not have pathological consequences. However, in some cases
they can present clinical problems, fundamentally of orthodontic,
prosthetic, phonetic or periodontal nature [9,10]. The aims of this
study was to apply and assess the clinical usefulness of the laserassisted
frenectomy using diode laser 980 nm .
Materials and Methods
This clinical study was carried out at Department of
Maxillofacial Surgery, Ramadi Teaching Hospital, Anbar Health
Directorate, Anbar Province, Iraq. A total of 25 patients including
16 (64%) male and 9 (36%) female with age range from 3 months
to 18 years old with mean age 6.5 years old. The details of the
laser assisted frenectomy procedures were explained verbally
to patients and their parent and each patient (and/or parent)
was given a written instructions and questionnaire sheet. All
patients (and/or parent) signed an agreement informed consent
for using laser in surgery. All patients were evaluated by clinical
examinations and documented by digital photos and asked to fill
the questionnaire sheet upon follow up visit and all patients were
prepared for laser surgery and viral screen (HBsAg, HCV, and
HIV) was requested. The Chirolas 20 W, 980 nm diode laser was
used. All personnel participating in the surgery wore protective
safety eyeglasses and masks. The same surgical technique was
used for all patients, who were operated on under sedative
analgesia using injectable midazolam (5 mg/ml) I.V. in a dose of
(0.03-0.1) mg/Kg; the dose and dose range depend on individual
patient response. Xylocaine Spray 10% was sprayed over and
around operation site frequently. Diode laser in CW mode, Power
of 10 W, with a power density of 7961.78 W/cm2 was used.
For laser-assisted labial frenectomy; the upper lip was pulled
upward by the assistant hands, then frenum was tightened. The
incision was started with the frenum from the attached gingivae
and interdental papilla on the labial surface between the central
incisors extending upward from inner side of upper lip to the
depth of vestibule ending in a rhomboidal raw area, separating
the fibers from the periosteum. In some patients, there was a large
space between the central incisors, so the inter-dental papilla
between the incisors and the fibrous band between two maxillae
had to be removed, until the periosteum was reached. At the
end of the operation the edges and the raw area were irradiated
(in defocused beam) for coagulating tissue and producing a
denatured layer as a biological dressing. After end of laser
exposure, the surgical site was wiped off with normal saline wet
cotton roll (Figure 1 a,b,c,d and e). While for laser assisted lingual
frenectomy; the tongue was retracted upwards and posteriorly.
The frenum was grasped and tightened by placing the operator
fingers (index & middle) as close to the base of the tongue as
possible and retract the ventrum of the tongue and for better
visualization. The tip of fiber optic was hold in perpendicular
or oblique direction to the frenum in contact mode between the
laser tip and tissue surface. The procedure was completed by
cutting first above and down avoiding the vessels and glands in
the floor of the mouth. After end of laser exposure, the surgical
Figure 1a: Labial frenum.
Figure 1a: Application of laser.
Figure 1c: Laser cutting.
Figure 1d: End of Surgical operation.
Figure 1e: End of treatment.
site was wiped off with normal saline wet cotton roll (Figure 2
a,b,c,d and e). After surgery, all the patients were given verbal
instructions that including; avoid taking hot, spicy, citrus and
hard foods for a few days, soft diet instructions, meticulous oral
hygiene is practiced, patients were asked to fill in a questionnaire
chart for the study. Because of local circumstances and crisis of
Anbar province with restriction of hospital sterilization and to
overcome any infection; Cephalexin (Capsules 250 mg; 500 mg),
(Syrup 125 mg/ml; 250 mg/ml) were prescribed for 3 days, and
Ibuprofen (Capsules 250 mg), (Suspension 20 mg/ml) was used
as analgesia (on need) during the postoperative period, practice
the physio-exercises i.e. separate the lip from the gingival tissue
by pulling up the lip and move the tongue upwards and laterally
frequent times a day and commitment to follow up appointments
in the exact date. All patients were examined at 3 days, 1 week, 2
week, and 4 week after surgery to assess pain, bleeding, edema,
functions and overall satisfaction. In the follow-up appointments,
Clinical observations, assessments and documentation by digital
photos were done by the operator during examination. In addition
to the data collected from the questionnaire sheets including the patient's notes at the operation day and during follow up visits.
Results
A total of 25 patients including 16 (64%) male and 9 (36%)
female with an age range of 3 months to 18 years old with mean
age 6.5 years old at Department of Maxillofacial Surgery, Ramadi
Teaching Hospital, Anbar Health Directorate. The details of the
laser assisted frenectomy procedures were explained verbally
to patients. Patients was examined and evaluated clinically and
prepared for surgery. Demographic and clinical data, including
information concerning patient's age, sex, clinical presentation,
past dental history, medical history were recorded (Figure 3).
All the patients were undergone sedative analgesia and topical
anesthesia spray during the surgical operation therefore no
patient experience pain during the surgical operation and only
2 (8%) patients experience mild pain during first three days
postoperatively when postoperative pain was assessed clinically
and by the patient self-assessment by subjected assessment of
pain using the scale of ( 0 = no pain; 1 = mild pain; 2 = moderate
Figure 2a: Lingual frenum.
Figure 2b: Lingual frenum.
Figure 2c: Lingual frenum.
Figure 2d: End of Surgical operation.
Figure 2e: End of Surgical operation.
pain; and 3 = sever pain) and systemic analgesic usage as
prescribed on need only; otherwise no patient experience pain
during one week, two weeks and four weeks postoperatively.
The intra-operative field was bloodless and there was no need
to use sutures, after laser-assisted frenectomy, in all cases; which
give us clear surgical field. In this clinical study, the surgical
procedure was well tolerated by all the patients who were very
co-operative during laser treatment. The wound was left open
(to be healed by second intention) covered with coagulative
layer which was clearly formed on the irradiated tissue surface,
that effectively eliminated bleeding after the operation that was
assessed using the scale of ( 0 = no bleeding; 1 = mild bleeding; 2
= moderate bleeding; and 3 = severe bleeding) . The coagulated
tissue changed into a layer of scab tissue within 3 days, and the
raw area was contracted from the margins of the surgical wound
to its center gradually, closing inward until the wound surface
was clinically healed within 10-14 days. Clinical assessment of
the postoperative edema using the scale of (0 = no edema; 1 =
edema bleeding; 2 = moderate edema; and 3 = severe edema);
there was mild edema (E/O and /or I/O) that noticed in 4
(16%) during first three days after the surgery; then it subsided
gradually, otherwise no patient showed edema during one week,
two weeks and four weeks postoperatively. At each follow-up
appointment, the operator was asking each patient to describe
and rank their functional abilities disturbance that include
speaking, eating, and brushing using scale of (0 = No function; 1
= mild function; 2 = moderate function; and 3 = sever function).
Postoperative Functional abilities were within normal limit
except in 4 (16%) patients who was speaking with mild limitation
in functional abilities with first three days postoperatively; e.g.
painful eating, soreness during brushing, swallowing, while no
patient revealed limited or disturbed functional abilities during
one week, two weeks and four weeks postoperatively. In general
patients were comfortable with no pain, either intra-operatively
or post-operatively with fewer functional complications. Only 7
(28%) revealed good (50-75%) overall satisfaction and 18 (72%)
showed excellent (76-100%) overall satisfaction during the
Figure 3: Patient Characteristics.
first three days postoperatively, while all patients; 25 (100%);
showed marked excellent overall satisfaction throughout one
week, two weeks and four weeks postoperatively .
Discussion
Photothermal interaction with tissue is the basic concept
of surgical laser. In this process, radiant light is absorbed by
the tissue and transformed to heat energy changing tissue
structure. Laser light within was converted to thermal energy
on contact with the tissue, causing laser tissue interaction, that
when appropriately applied, can produce reaction ranging from
incision, vaporization, to coagulation [3,4]. This wavelength has
affinity for melanin or dark pigments, and is strongly absorbed
by the blood hemoglobin, which contributes to their thermal
effect. Therefore, this laser works more efficiently when the
energy applied in the presence of pigments. This was the reason
that homeostasis occurs with this wavelength. In the preliminary
study, Diode laser creates a wound that can be characterized as
thermal injury. The fiber was kept in steady motion and in contact
mode that was used directly over the target tissue. The heated
tip of optical fiber was used as a knife to create thermal effects.
So keeping the fiber in one spot will gradually heat a growing
mass of tissue in that spot and will produce a laser wound. The
depth of penetration of the laser wound made by a contact probe
will vary with the power used and duration of exposure time.
Medical applications of lasers have focused particular interest
on the interactions of infrared laser light in biological tissue. The
physical heterogeneity of biological tissue results in considerable
regional variation in light absorption and scattering, two of
the critical processes that determine the pattern of heating.
Since lasers were first introduced into dentistry, there have
been investigations done to establish the laser parameters (i.e.,
wavelength, power density, continuous or pulsed mode, time of
exposure, and spot size) that are most effective and least harmful
for treating the soft and hard tissues of the oral cavity. Laser
treatment has served as an alternative or adjunctive treatment
to more conventional therapies because of its many advantages,
including ablation or vaporization, homeostasis, and sterilization
[7,8]. There are several factors related to tissue such as optical
characteristics of the tissue, color, vascularity, consistency and
thermal tissue properties that determine the effect of laser on
the tissue. For routine clinical dental treatments, pain control is
quite important for patient physical and mental well-being, as
well as for the effectiveness of therapy. The laser a coagulation
effect on small vessels that provides hemostasis and seals the
sensory nerve endings, providing the needed anesthesia was
reduced in this clinical series study [11,12]. Care was taken when
multiple passes were necessary, using wet cotton roll and this
was done in all the cases during the procedure. Almost none of
the patients complained of pain during operations that agreed
by Kato et al. [3,5]. In this present study, the use of 980 nm
diode laser allowing increased surgical precision and accuracy,
thereby reducing unnecessary damage to underlying tissues,
and the procedure was with no bleeding in all cases, resulting
in improving visualization of the surgical field, eliminating the
need for postoperative sutures, and shortening the operation
time, probably the efficiency of the laser allows sealing lymphatic and blood vessels that renders a bloodless surgical field [13-15]
Studies. Hemostasis occurs because the generated heat coagulates
the tissue at the wound edges. Generally it is desirable to have
no bleeding but it is also desirable to have the coagulated region
as thin as possible. Hemostasis occurs because of denaturation
of plasma proteins, hemoglobin and peri-vascular tissue locally.
Also coagulation produces hemostasis by contraction of the
vessel wall. This hemostasis may account for the minimal fluid
extravasation observed, with a minimal inflammatory response
around the tissues under surgical management. There was no
need for sutures in all the cases because of the formed coagulated
layer over the raw area with no evident bleeding, and to avoid
the primary intention healing and reattachment [12,14]. In this
clinical work, all patients were satisfied with good acceptance
with respect to patient perceptions after laser and conventional
surgical frenectomy and suggested that laser surgical frenectomy
was superior to the conventional technique regarding patient
perception and postsurgical discomfort. In addition, all patients
returned to their normal day activities because of diminution
of surgery time, depletion of blood loss and pain besides that
patients were provided with minimally invasive surgery, where
tissue injury is reduced to a minimal degree [3-5,16]. In this study,
there was no post-surgical edema, because of laser-induced
hemostasis and reduced tissue injury, except in three patients
who had a mild edema that subsided after three days because
of a relatively larger raw area, resulting in a more inflammatory
response [12,17,18], since it is the result of a reduced swelling
and a minimal inflammatory response and this can be explained
by precision surgical laser procedures without any adverse effect
on surrounding normal tissue, and the ability of lasers to seal
lymphatic channels results reduced postoperative edema, which
in turn results in less postoperative discomfort, also the sealing
of nerve endings resulting in reduced inflammatory response,
and the formation of a fibrin clot over the surgical wound that
protects the wound from external irritation, causing less pain
after surgery and avoiding the use of analgesic drugs [11]. Patients
treated with laser surgery have no functional complications
since there was no damage to adjacent healthy tissues, with less
wound contraction during healing; meaning that there is less
mucosal scarring, resulting in satisfactory mobility of the soft
tissue and consequently, there is a minimal oral dysfunction
[13,14,18,19]. One of the main benefits of using dental lasers
is the ability to interact selectively and precisely with diseased
tissues, that explains the less degree of surrounding tissue injury,
no significant complications, limited scarring and contraction
and probably bio-stimulation effect of laser.
ReferencesTop
- Carruth JAS. The principles of laser surgery. Scott Brown's otolaryngology. 5th edition Basic Sci. ch. 23, 1987.
- Charschan SS. Laser in Industry. Western Electric Company, Incorporated, Van Norstrand Reinhold Company. 1972, p. 52-55.
- Catone GA, Alling C. Laser Application in Oral and Maxillofacial Surgery. Philadelphia, W. B. Saunders Company, first edition, 1997. p. 30-40, 115-146, 181-193.
- Kishen A and Asundi A. Fundamentals and Applications of Biophotonics in Dentistry, Series on Biomaterials and Bioengineering. Vol 4, London Imperial College Press, 2007. 123-151.
- Markolf H, Neimz. Laser-tissue interactions: fundamentals and applications, 3rd revised edition 2007 Springer Ch.1-3, 1-100.
- Whinnery JR. Lasers Invention to Application. National Academy Press Washington, D.C, 1988. Ch.4, 100-106.
- Baxter GD, Diamantopoulos C, O'Kane S, Shields T. D, Allen J. Therapeutic Lasers Theory and Practice. Harcourt Publishers Limited, first edition. pp. 56-64. 1999.
- Miserendino LJ, Pick M. Laser in Dentistry. Quintessence publishing Co. pp. 35-54, 114-120. 1995.
- Hashim ZM and Al-Fatlawi FA. Contributing Factors of Median Diastema in Iraqi Adults. M.Sc. thesis, department of POP, college of Dentistry, University of Baghdad 2006.
- Kotlow L. Diagnosis and Treatment of ankyloglossia and tied maxillary fraenum in infants using Er: YAG and 1064 diode lasers. Eur Arch Paediatr Dent. 2011; 12(2):106-112.
- Pie-Sanchez J, Espana-Tost AJ, Arnabat-Dominguez J, Gay-Escoda C. Comparative study of upper lip frenectomy with the CO2 laser versus the Er, Cr:YSGG laser . Med Oral Patol Oral Cir Bucal. 2012; 17(2): 228- 232.
- Tuncer I, Ozcakir-Tomruk C, Sencift K, and Cologlu S. Comparison of Conventional Surgery and CO2 Laser on Intraoral Soft Tissue Pathologies and Evaluation of The Collateral Thermal damage. Photomed Laser Surg. 2010; 28 (1): 75-79. doi: 10.1089/ pho.2008.2353.
- White JM, Goodis HE, Rose CL. Use of the pulsed Nd:YAG laser for intraoral soft tissue surgery. Lasers Surg Med. 1991;11(5):455-61.
- Kotlow LA: Using the Erbium: YAG Laser to correct abnormal lingual frenum attachments in newborns. Journal of the Academy of Laser Dentistry, 2004; 12(3):22-23.
- Kotlow LA. Lasers in Pediatric Dentistry. Dent Clin North Am. 2004; 48(4): 889-922.
- Kara C. Evaluation of patient perceptions of frenectomy: a comparison of Nd:YAG laser and conventional techniques. Photomed Laser Surg. 2008; 26(2):147-52. doi: 10.1089/pho.2007.2153.
- Pick RM, Pecaro BC. Use of the CO2 Laser in Soft Tissue Dental Surgery. Lasers Surg Med. 1987; 7(2); 207-213.
- Puthussery FJ, Shekar K, Gulati A, Downie IP. Use of carbon dioxide laser in lingual frenectomy. Br J Oral Maxillofac Surg. 2011; 49(7): 580-581. doi: 10.1016/j.bjoms.2010.07.010.
- Fornaini C, Rocca JP, Bertrand MF, Merigo E, Nammour S, Vescovi P. Nd: YAG and Diode Laser in the Surgical Management of Soft Tissues Related to Orthodontic Treatment. Photomed Laser Surg. 2007; 25(5); 381- 92.