Laser Assisted Labial Frenectomy- A Case Report

 

Divya Subramanyam

MDS, Pediatric Dentist, Senior Lecturer, AMDECH

 

ABSTRACT:

Frenectomy is one of the most common oral surgical procedures performed in dentistry. The labial frenectomy is performed to remove aberrant frenum attachment. Aberrant frenal attachment is a major concern for the patient as it can interfere with aesthetics, plaque control and result in mucogingival abnormalities. Frenotomy or frenectomy should be selected depending upon the type and location of frenum attachment. Diode laser has found to be successful in performing surgical procedures and it is cost effective. This case report presents the management of a mandibular high labial frenum attachment in a child patient using 980 nm diode laser.

 

 

 

INTRODUCTION:

The frenum is a mucous membrane fold that attaches lip and the cheek to the alveolar mucosa, the gingiva, and the underlying periosteum. The presence of highly attached frenum is one of the aetiological factors for the persistence of an aesthetic and functional difficulties.¹

 

It is due to genetic aetiology and/or environmental factor.² Placek et al., 1974 classified frenum attachment into 4 types, Mucosal, gingival, papillary, papilla penetrating.³ If frenal attachment is too close to the marginal gingiva, tension on the frenum may pull the gingival margin away from the tooth causing gingival recession. This condition may favour plaque accumulation and inhibit proper tooth brushing.⁴

 

Aberrant frenum is found to be associated with loss of interdental Papilla, gingival Recession, persistence of Midline Diastema, difficulty in Brushing, malalignment of teeth, Compromised retention of appliances. Therefore, correction of abnormal frenum has become a topic of interest.⁴ These aberrant frenum can be removed either by frenectomy or frenotomy. The procedure of complete removal of the frenum, including its attachment to the underlying bone is known as frenectomy while the incision and the relocation of the

 

frenal attachment is known as frenotomy. Labial frenectomy is a common surgical procedure performed routinely in the field of dentistry. It can be accomplished either by the conventional scalpel technique, electrosurgery or by using lasers. The conventional scalpel technique carries the risks of surgery like bleeding and patient compliance.⁵ The laser is a modern technology which was developed by Maiman in 1960. Though, it was first successfully used in the oral cavity in 1977 with improvements and innovations over time.⁶ Lasers are quickly becoming the standard of care for many surgical procedures because of its improved precision, visualization, reduced haemorrhage, less post- operative complications thereby enhancing the patient’s compliance.⁷ Photothermal interaction with tissue is the basic concept of laser used for surgery. Different types of lasers are used according to their different wavelengths and their interaction with tissues for both hard and soft tissues in the oral cavity.⁸ Diode laser is most commonly used because of its high absorbance by pigmented tissues with hemoglobin, melanin and collagen chromophores. It showed excellent results as an adjunct to the conventional methods in the management of inflamed periodontal tissues and endodontics.⁹ It is also possible to perform many procedures under laser without the need of anesthesia. It is well accepted by the patient, since it has less discomfort. This case report describes a clinical case of high labial frenal attachment of the lower lip, treated by laser frenectomy.

 

 

 

CASE REPORT:

Nine-year-old male child referred to the Department of pedodontics from orthodontist for assessment of the lower anterior labial frenum and had difficulty during intake of food.

 

The clinical examination revealed the presence of thick and high frenal attachment; attached gingiva penetrating type of attachment. (Figure 1)

 

It was decided to perform laser frenectomy under local anaesthesia using laser (Figure 2)

 

Surgical frenectomy using laser was explained to the parents and informed consent was obtained. Complete hematogram was tested and was found to be within normal limits. Topical anaesthetic gel was applied prior to local anaesthesia administration. Surgical area was anesthetized with 2% lignocaine with 1:80,000 adrenaline (LOX 2% Adrenaline). The diode laser (Photon Plus; Zolar Tech Technology and MFG Co. Inc., Canada, wavelength 980 nm) at power setting of 10 W fiber tip was used in a contact mode. The laser fiber was applied vertically and laterally to the frenum initially causing disruption of the mucosa continuity, therby allowed performing a deeper cut of the frenum in a horizontal dimension. It was excised from the base to the apex of the frenum. Any remnant fiber over the periosteum was removed by gently sweeping the laser tip and the ablated remnant tissue was cleaned with gauze soaked in saline. Figure 2 The whole procedure was performed in about four minutes. No sutures were required. Haemostasis was obtained with laser (Figure 3). The patient had no pain post-operatively. Postoperative instructions were given and was advised to use analgesics when needed. Follow up was done after one week, healing was found to be uneventful (Figure 4)

 

 

Figure 1: Pre-operative view

 

Figure 2: Application of diode laser

 

 

Figure 3: Appearance of the surgical area immediately after frenectomy

 

Figure 4: Post-operative view- follow up

 

DISCUSSION:

Aesthetic concerns of people has led to an increased importance in seeking dental care for achieving perfect smile, especially in children and teens. Abnormalities in the frenal attachment leads to improper function and aesthetic. Different types of the labial frenum attachment and its significance in periodontal health is an important aspect of treatment planning. The prevalence of mucosal type of the labial frenum attachment in the mandibular arch is found to be the most common (91.6%), the second most frequent type is the gingival type of attachment (6.5%), least common is the papillary type (0.2%).¹⁰ The conventional surgical technique for frenectomy involves excision of the frenum using a scalpel. Depending upon the type of frenum various modifications have been recommended like Miller’s technique, V-Y plasty and Z-plasty. The scalpel technique may leave a lsurgical scar which may lead to periodontal problems and becomes unaesthetic. The development of new technologies for a safe and efficient treatment to the patient, with a better prognosis is of major importance nowadays. Lasers are used in various disciplines of dentistry-prosthetics, periodontics, pedodontics, endodontics, implantology, cosmetic and operative dentistry, and oral and maxillofacial surgery. In this case, we performed laser frenectomy, since it has major advantage of absence of haemorrhage, absence of pain or edema and discomfort intra-operatively as well as post-operatively in comparison to the conventional method. Because, it has good affinity to the tissue and reduces post-operative complications.¹¹ Diode laser with wavelength of 980nm was used in this case. Mechanism of action involves photo thermal interaction with the tissue radiant, where light is absorbed by the tissue and transformed to heat energy changing the tissue structure. Laser light is converted to thermal energy causing laser tissue interaction, which produces reactions like incision, vaporization, to coagulation.¹² Different wavelengths can be used, but the principal concept to remember for all wavelengths is that the minimum effective energy must be used because the lower the energy applied, the less the damage on the targeted tissue and the faster the healing process.^13,14 In this case report, Laser frenectomy was effective and surgical area healed after one week, reinserting itself in the possible correct anatomic position. The patient did not have any post operative complications, thus demonstrating the laser effectiveness. Surgical excision of frenum using laser is well accepted by the patients, reduced surgical time, no suture placement, reduced postoperative pain and discomfort, minimal scarring, less recurrence rates.¹⁵ Another benefit is the possibility of avoiding needle-infiltrated anesthesia, reducing the associated fear in pediatric patients.

 

CONCLUSION:

Frenectomy is performed to maintain adequate function and aesthetics. Various techniques can be employed for frenectomy, but appropriate method should be selected according to the type of attachment and the potential complications associated with it. Cost-effectiveness should also be considered before treatment planning. Lasers assisted frenectomy are preferred mostly in recent times, since it is minimally invasive, requires minimal anesthesia, minimal discomfort, no sutures and, no antibiotics and great patient satisfaction.

 

CONSENT:

Written informed consent was obtained from the parents of the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

 

CONFLICTS OF INTEREST:

The author declares no conflict of interest.

 

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Received on 05.02.2019           Modified on 05.03.2019

Accepted on 30.03.2019         © RJPT All right reserved