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ORIGINAL ARTICLE
Year : 2015  |  Volume : 9  |  Issue : 2  |  Page : 94-99

Comparison of labial frenectomy procedure with conventional surgical technique and diode laser


Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Satara, Karad, Maharashtra, India

Date of Web Publication26-Nov-2015

Correspondence Address:
R M Patel
Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Satara, Karad - 415 110, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-2868.170565

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  Abstract 

Background: An Aberrant frenum encroaches the gingival health when it is attached too closely to the gingival margin, either due to interference in the plaque control or due to a muscle pull. Such condition has to be treated by frenectomy which can be performed by scalpel, electrocautery, or with soft tissue lasers. Hence, the aim of the study is to compare the degree of postoperative pain and healing experienced by patients during frenectomy procedure with surgical scalpel and diode laser technique. Materials and Methods: A total of 20 subjects ranging from 16 to 40 years of age group with papillary or papillary penetrating frenal attachment in the maxillary anterior region were selected. Enrolled subjects were randomly divided into two groups as follows Group A (n = 10): Comprised of 10 subjects selected for conventional scalpel technique. Group B (n = 10): Comprised of 10 subjects selected for diode laser technique. Various parameters such as pain, inflammation, swelling, difficulty of procedure, and wound healing were evaluated at intervals of 1 week, 1 month, and 3rd month. Results: The results indicated patients treated with the diode laser had less postoperative pain (P < 0.0001) and required fewer analgesics (P < 0.001) as compared to patients treated with the conventional scalpel technique. Wound healing at 7th day and after 1 month for both the groups showed statistical significant difference with better outcome in Group A. However, wound healing at the end of 3 months did not show any significant difference between the groups. Conclusion: Based on current findings and clinical outcome, diode lasers provide better patient perception and an efficient and satisfactory option for procedures such as frenectomy.

Keywords: Diode laser, frenectomy, scalpel, wound healing


How to cite this article:
Patel R M, Varma S, Suragimath G, Abbayya K, Zope S A, Kale V. Comparison of labial frenectomy procedure with conventional surgical technique and diode laser. J Dent Lasers 2015;9:94-9

How to cite this URL:
Patel R M, Varma S, Suragimath G, Abbayya K, Zope S A, Kale V. Comparison of labial frenectomy procedure with conventional surgical technique and diode laser. J Dent Lasers [serial online] 2015 [cited 2017 Sep 19];9:94-9. Available from: http://www.jdentlasers.org/text.asp?2015/9/2/94/170565




  Introduction Top


Frenum is an anatomic structure formed by a fold of mucous membrane and connective tissue fibers that attach the lip and cheeks to the alveolar mucosa and/or gingiva and the underlying periosteum. The frenum that encroaches on the margin of the gingiva may interfere with plaque removal, and tension on this frenum may tend to open the sulcus eventually leading to gingival recession and midline diastema.[1] Depending on the attachment of fibers, frenum has been classified as follows:

  • Mucosal: Fibers that are attached up to mucogingival junction
  • Gingival: Fibers inserted within attached gingiva
  • Papillary: Fibers extended into interdental papilla
  • Papilla penetrating: When the fibers cross the alveolar process and extend up to the palatine papilla.[2],[3]


Clinically, papillary and papilla penetrating frenum are considered as pathological and have been found to be associated with loss of papilla, recession, diastema, and plaque accumulation. In such cases, it is necessary to perform frenectomy for aesthetic and functional reasons. Frenotomy is the incision and relocation of the frenal attachment, whereas frenectomy is the complete excision of the frenum along with its attachment to the underlying bone.[3]

Frenectomy can be done by conventional technique, electrosurgery, or soft tissue lasers.[4],[5] Patients who undergo conventional frenectomy procedures using a scalpel often experience postsurgical pain and discomfort, which is further aggravated when sutures come in contact with food. One feasible alternative that can be considered is a laser assisted frenectomy. Lasers, such as the neodymium doped:yttrium aluminum garnet (Nd:YAG), carbon dioxide (CO2), and erbium-doped (Er):YAG lasers, enable minimally invasive dentistry for soft tissue procedures.[3] Diode lasers are semiconductor and they are indicated for soft tissue surgeries as their wavelength approximates the absorption coefficient of pigmented tissues containing hemoglobin, melanin, and collagen chromophores.[6]

Hence, the aim of the present study was to compare the outcome of scalpel and diode laser technique on degree of postoperative pain and healing experienced by patients after frenectomy procedures.


  Materials and Methods Top


This clinical comparative study was carried out between September 2014 and March 2015 in the Department of Periodontology, School of Dental Sciences Krishna Institute of Medical Sciences, Karad. The research protocol was initially submitted to the Institution Ethical Committee and review board and ethical clearance was obtained.

Patient selection

Twenty subjects with age ranging from 16 to 40 years, who required frenectomy, were randomly selected for the study.

Systemically healthy subjects with maxillary papillary or papillary penetrating type frenum attachment with good oral hygiene were only included in the study.

Subjects were divided randomly into Groups A and B using flip coin technique:

  • Group A: Comprised of 10 subjects selected for conventional scalpel technique
  • Group B: Comprised of 10 subjects selected for diode Laser technique.


All the procedures were carried out by a single operator.

For the conventional classical technique (Archer (1961) and Kruger (1964)),[6] the area was anesthetized with 2% lignocaine with 1:80,000 adrenaline (LOX 2% Adrenaline). The frenum was held with a pair of hemostats, and the whole band of tissue together with its alveolar attachment was excised with a #15 blade [Figure 1] and [Figure 2]. After freeing any remaining fibrous adhesions to the underlying periosteum, the wound was closed with 3-0 silk interrupted sutures [Figure 3]. The area was covered with a periodontal dressing (COE–PAK, GC America Inc., ALSIP, IL, USA). Subjects were recalled on the 7th day for suture removal [Figure 4].
Figure 1: Papillary penetrating frenum preoperative

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Figure 2: Excision of the frenum with scalpel

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Figure 3: Suturing of the site

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Figure 4: One week postoperative view

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For the diode laser technique,

the 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 and moved, in a paint brush stroke, from the base to the apex of the frenum thereby excising it [Figure 6] and [Figure 7]. 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. The area was covered with a periodontal dressing (COE–PAK, GC America Inc., ALSIP, IL, USA). Subjects were recalled on the 7th day for suture removal [Figure 8].

Both groups received postoperative instructions and were prescribed also told to use an analgesic containing diclofenac sodium and advised to use when needed.

Method of scoring

A single operator recorded severity of bleeding (1: None, 2: Slight, 3: Moderate, 4: Severe)[7] and pain during the procedure and at postoperative days 1 and 7. The subjects were asked to rate the degree of pain during eating or speech, on a 10-cm horizontal visual analog scale (VAS) by placing a vertical mark to assess position between the two endpoints. The left end point was nominated as "no pain," and the right end point was nominated as "worst pain imaginable." On completion of the procedure, the operator was asked to assess difficulty encountered during procedure (1: Very easy, 2: Easy, 3: Difficult, 4: Impossible).[7] On the 7th day swelling, wound healing (1: Complete epitheliazation, 2: Incomplete epitheliazation, 3: Ulcer, 4: Tissue defect or necrosis),[7] and number of analgesics used were assessed. After the 1st month and 3rd month reevaluation of wound healing [Figure 5] and [Figure 9] was performed using same indices [7] for both the groups.
Figure 5: Three months postoperative view

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Figure 6: Papillary penetrating frenum preoperative

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Figure 7: Excision of the frenum with laser

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Figure 8: One week postoperative view

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Figure 9: Three months postoperative view

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Statistical analysis

A statistical analysis was performed using a Statistical Package for Social Sciences (SPSS) software version 19 (IBM Corporation, Armonk, New York, USA). Nonparametric tests were chosen for continuous variables because the data were not distributed normally. Comparisons between groups were applied using the Mann–Whitney U-test. Results were represented as mean ± standard deviation and median (minimum-maximum). P < 0.05 was considered significant.


  Results Top


Of 20 subjects, 12 were females and 8 were males with mean age of 32.4 ± 7.75. Comparison of the mean VAS score of the level of pain, for both groups, observed on the 1st and the 7th day of the study is summarized in [Table 1]. The analysis showed that VAS score of pain on day 1 and 7 were significantly lower in the laser group as compared to the conventional technique (P = 0.0027 and P = 0.0149, respectively). Numbers of analgesics used by Group A were significantly higher (P < 0.05) than Group B.
Table 1: Mean scores of pain perception after conventional and laser technique

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In [Table 2], comparison of bleeding during surgery and difficulty of performing procedure was assessed among both the groups, Group B showed relatively less bleeding and was easy to perform than Group A and the difference was statistically significant.
Table 2: Mean scores of bleeding during surgery and difficulty of procedure experienced by operator

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The comparison of wound healing at 7th day and after 1 month for both the groups showed statistical significant difference with better outcome in Group A. However, wound healing at the end of 3 months did not show any significant difference between the groups [Table 3].
Table 3: Mean scores of wound healing by conventional and laser technique

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  Discussion Top


In the era of periodontal plastic surgery, more conservative and precise techniques are being adopted to create more functional and aesthetic results. The presence of an aberrant frenum being one of the etiological factors for the persistence of a midline diastema, the focus on the frenum has become essential. The aberrant frenum can be treated by frenectomy or by frenotomy procedures.[8],[9] The soft tissue laser is now a viable alternative to the scalpel in soft tissue surgery.

Lasers such as Nd:YAG, Co2, and Er:YAG had been used for frenectomy procedures. Among these, Co2 laser is the one most frequently used.[10],[11],[12] In the present study, diode laser, which characteristically uses a blend of gallium, arsenide, and other elements such as aluminum and indium, was used. The wavelength of this laser is feebly absorbed in water but extremely absorbed in hemoglobin and other pigments. Diode laser is considered as an excellent soft tissue laser as it does not interact with dental hard tissues.[6],[13] However, there are very few studies comparing the postoperative effects of laser and conventional techniques, which can justify the use of lasers for intraoral soft tissue surgery.[6]

In our study, subjects treated with the DIODE laser had significantly less postoperative pain both on day 1 and day 7 as compared to scalpel surgery as well as number of analgesics used were lower in the laser group. These findings were consistent with the studies carried out by Haytac et al.[1] and Butchibabu et al.[6] wherein they suggested that soft tissue laser treatment used for frenectomy operations provides better patient perception in terms of postoperative pain and function than that obtained by the scalpel technique.

It is theorized that decreased pain perception after the use of laser may be due to the protein coagulum that is formed on the wound surface, thereby acting as a biologic dressing and sealing the ends of the sensory nerves.[14],[15]

The increased pain perception associated with the scalpel frenectomy might be attributed to the fact that it is a more intrusive surgical procedure involving blood loss, wide surgical wound and suturing. The sutures also contribute to the discomfort postoperatively since they interfere with regular functions such as speech and intake of food.[6],[8]

In the present study, the healing pattern of laser wounds after the seventh day and 1 month was found to be delayed as compared to scalpel wound which reached to statistically significant difference. However, after 3 months there was no significant difference in healing between scalpel and laser group. Delayed healing in case of laser and electrocautery can be attributed to damage produced by lateral heat. Lateral heat damage is the area of coagulation necrosis produced around the incision line due to unwanted heat production.[16],[17],[18] These results were similar to the studies carried out by Frame et al.[20] and Buell et al.[21] and contrary study carried out by Fisher et al.[14] suggested that laser-created wounds heal more quickly and produce less scar tissue than conventional scalpel surgery.

There is abundant evidence confirming markedly less bleeding particularly of highly vascular oral tissues, with laser surgery. The laser technique offers some advantages, such as a relatively bloodless surgical and postsurgical event; the ability to precisely coagulate, vaporize, or cut tissue; sterilization of the wound site; minimal swelling and scarring; no suturing in most cases; little mechanical trauma; reduction of surgical time; decreased postsurgical pain; and high patient acceptance.[19],[20],[21] In the present study, subjects treated with the DIODE laser had significantly relatively less bleeding and was easy to perform than conventional scalpel surgery.


  Conclusion Top


This clinical study indicates that diode lasers provide better patient perception in terms of reduced operative time, pain, and bleeding than encountered by the scalpel. Based on current findings and above mentioned factors and in spite of certain demerits, diode laser is still a dependable alternative as it is an efficient, secure, and satisfactory option for soft tissue surgeries such as frenectomy. Diode laser also has few demerits such as lateral heat damage, delayed wound healing, skill of the operator, and higher cost.

However, there is a need for further longitudinal studies with larger sample size to establish the exact efficacy of laser technique over the conventional scalpel technique for frenectomy procedure.

Acknowledgment

The authors acknowledge the staff and students of the Krishna Institute of Medical Sciences, Karad.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: A comparison of carbon dioxide laser and scalpel techniques. J Periodontol 2006;77:1815-9.  Back to cited text no. 1
    
2.
Huang WJ, Creath CJ. The midline diastema: A review of its etiology and treatment. Pediatr Dent 1995;17:171-9.  Back to cited text no. 2
    
3.
Devishree SK, Gujjari SK, Shubhashini PV. Frenectomy: A review with the reports of surgical techniques. J Clin Diagn Res 2012;6:1587-92.  Back to cited text no. 3
    
4.
Pick RM, Colvard MD. Current status of lasers in soft tissue dental surgery. J Periodontol 1993;64:589-602.  Back to cited text no. 4
    
5.
Research, Science and Therapy Committee of the American Academy of Periodontology. Lasers in periodontics. J Periodontol 2002;73:1231-9.  Back to cited text no. 5
    
6.
Butchibabu K, Koppolu P, Mishra A, Pandey R, Swapna LA, Uppada UK. Evaluation of patient perceptions after labial frenectomy procedure: A comparison of diode laser and scalpel techniques. Eur J Gen Dent 2014;3:129-33.  Back to cited text no. 6
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7.
Ishii S, Aoki A, Kawashima Y, Watanabe H, Ishikawa I. Application of an Er:YAG laser to remove gingival melanin hyperpigmentation: Treatment procedure and clinical evaluation. J Jpn Soc Laser Dent 2002;13:89-96.  Back to cited text no. 7
    
8.
Fiorotti RC, Bertolini MM, Nicola JH, Nicola EM. Early lingual frenectomy assisted by CO2 laser helps prevention and treatment of functional alterations caused by ankyloglossia. Int J Orofacial Myology 2004;30:64-71.  Back to cited text no. 8
    
9.
Pick RM, Colvard MD. Current status of lasers in soft tissue dental surgery. J Periodontol 1993;64:589-602.  Back to cited text no. 9
    
10.
American Academy of Periodontology. Lasers in periodontics (position paper). J Periodontol 2002;73:1231-9.  Back to cited text no. 10
    
11.
Pick RM, Pecaro BC, Silberman CJ. The laser gingivectomy. The use of the CO2 laser for the removal of phenytoin hyperplasia. J Periodontol 1985;56:492-6.  Back to cited text no. 11
    
12.
Matthews DC, McCulloch CA. Evaluating patient perceptions as short-term outcomes of periodontal treatment: A comparison of surgical and non-surgical therapy. J Periodontol 1993;64:990-7.  Back to cited text no. 12
    
13.
Desiate A, Cantore S, Tullo D, Profeta G, Grassi FR, Ballini A. 980 nm diode lasers in oral and facial practice: Current state of the science and art. Int J Med Sci 2009;6:358-64.  Back to cited text no. 13
    
14.
Fisher SE, Frame JW, Browne RM, Tranter RM. A comparative histological study of wound healing following CO2 laser and conventional surgical excision of canine buccal mucosa. Arch Oral Biol 1983;28:287-91.  Back to cited text no. 14
    
15.
Fenner J, Martin W, Moseley H, Wheatley DJ. Shear strength of tissue bonds as a function of bonding temperature: A proposed mechanism for laser-assisted tissue welding. Laser Med Sci 1992;7:39-43.  Back to cited text no. 15
    
16.
Goharkhay K, Moritz A, Wilder-Smith P, Schoop U, Kluger W, Jakolitsch S, et al. Effects on oral soft tissue produced by a diode laser in vitro. Lasers Surg Med 1999;25:401-6.  Back to cited text no. 16
    
17.
Funde S, Baburaj MD, Pimpale SK. Comparison between laser, electrocautery and scalpel in the treatment of drug-induced gingival overgrowth: A case report. IJSS Case Rep Rev 2015;1:27-30.  Back to cited text no. 17
    
18.
Meenawat A, Verma SC, Govila V, Srivastava V, Punn K. Histological and clinical evaluation of gingival healing following gingivectomy using different treatment modalities. J Int Clin Dent Res Organ 2013;5:31-5.  Back to cited text no. 18
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19.
Frame JW. Removal of oral soft tissue pathology with the CO2 laser. J Oral Maxillofac Surg 1985;43:850-5.  Back to cited text no. 19
    
20.
Buell BR, Schuller DE. Comparison of tensile strength in CO2 laser and scalpel skin incisions. Arch Otolaryngol 1983;109:465-7.  Back to cited text no. 20
    
21.
Kaur P, Dev YP, Kaushal S, Bhatia A, Vaid R, Sharma R. Management of the upper labial frenum: A comparison of conventional surgical and lasers on the basis of visual analogue scale on patients perception. J Periodontal Med Clin Pract 2014;01:38-46.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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