A frenum is a fold of mucous membrane, maybe with enclosed muscle fibers, which attaches the lips and cheeks to the alveolar mucosa or gingiva and underlying periosteum. In case of aberrant frenum attachment, it has to be relieved for better function and aesthetics. There are various techniques to relieve aberrant frenum. In this case series, we assessed the outcome of laser frenectomy and VAS scores for pain perception. On comparing all the cases we concluded that the laser frenectomy can be used as a better alternative to the scalpel technique for frenectomy and showed superior results in pain perception, patient comfort, and healing.

Keywords: Diode Laser, Diastema, Frenectom

J  Srihari

Poornima  Rajendran

S  Madhupretha

Journal of Multidisciplinary Dental Research

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J Multi Dent Res. 2024;10(2):56–59Journal of Multidisciplinary Dental ResearchCASE REPORTDiode Laser-Assisted Maxillary Labial Frenectomy: A Case Series With 6-monthsFollow-UpS Madhupretha1, Poornima Rajendran2,∗, J Srihari31Post Graduate Student, Department of Periodontics, Sri Ramakrishna Dental College and Hospital, Coimbatore, 641006, TamilNadu, India2Senior Lecturer, Department of Periodontics, Sri Ramakrishna Dental College and Hospital, Coimbatore, 641006, Tamil Nadu, India3Professor & Head, Department of Periodontics, Sri Ramakrishna Dental College and Hospital, Coimbatore, 641006, Tamil Nadu,IndiaA R T I C L E I N F OArticle history:Received 06.09.2024Accepted 31.10.2024Published 15.12.2024∗ Corresponding author.Poornima Rajendranpoorni89.27@gmail.comhttps://doi.org/10.38138/JMDR/v10i2.19A B S T R A C TA frenum is a fold of mucous membrane, maybe with enclosed muscle fibers, which attaches the lips andcheeks to the alveolar mucosa or gingiva and underlying periosteum. In case of aberrant frenum attachment,it has to be relieved for better function and aesthetics. There are various techniques to relieve aberrantfrenum. In this case series, we assessed the outcome of laser frenectomy and VAS scores for pain perception.On comparing all the cases we concluded that the laser frenectomy can be used as a better alternative tothe scalpel technique for frenectomy and showed superior results in pain perception, patient comfort, andhealing.Keywords: Diode Laser; Diastema; Frenectomy1 INTRODUCTIONA frenum is a fold of mucous membrane, maybe withenclosed muscle fibers, which attaches the lips and cheeksto the alveolar mucosa or gingiva and underlying perios-teum. (1) It is classified according to various aspects byvarious authors. The most commonly used classificationaccording to the site of attachment of muscle fibers isgiven by Placek et al (2) in 1974 as follows : mucosalattachment of the frenum, means an attachment of thefrenum to the mucogingival junction; gingival attachment,means attachment of the frenum to the attached gingiva;papillary attachment, means an attachment of the frenum tothe papilla; papillary penetrating attachment is in those caseswhen the attachment of the frenum passes right up to thepapilla, while inserting in attached gingiva.The other classification base on morphology was given bySewerin in 1971as follows: (3) normal frenum, simple frenumwith a nodule, simple frenumwith appendix , simple frenumwith nichum, bifid frenum, persistent tectolabial frenum,double frenum, and wider frenum.In 2014 Mohan et almodified this classification and gaveas follows: (4)• Simple frenum- single, double, triple• With nodule- at labial third, middle third, or alveolartird• With appendix- at labial third,middle third, or alveolarthird• Tectolabial - simple, with nodule, or with an appendix• With Nichum - Inverted- Y-shaped• Bifid• Trifid• With two or more variations• Finally, the absence of frenumAccording to Olivi et alclinical indications for frenum,removal include the following: (5) Anomalous frenum associ-atedwith inflamed gingiva, resulting frompoor oral hygiene;anomalous frenum associated with gingival recession; Max-© 2024 Published by International Dental Educationists’ Association (IDEA). This is an open access article under the CC BY license(https://creativecommons.org/licenses/by/4.0/)56Madhupretha et al. J Multi Dent Res. 2024;10(2):56–59illary frenum associated with a diastema after the completeeruption of the permanent canines; Abnormal or anomalousmaxillary frenum(class III or IV), resulting in the presence ofa diastema during mixed dentition; Anomalous mandibularfrenum with high insertion, causing the onset of gingivalrecession.There are various techniques to relieve frenum likeconventional, V-Y plasty, Z plasty, frenectomy using Laser,and electrosurgery. The conventional frenectomy using ascalpel showed more discomfort and pain to the patient dueto many bleeding sites.Out of these various techniques, laser frenectomy is lessinvasive, safe, easy, predictable, and reproducible, with lessdiscomfort and post-operative complications. So, the presentstudy aimed to evaluate Diode laser-assisted frenectomy ineffective healing and post-operative comfort using VisualAnalogue Scale (VAS) by Hayes and Patterson (6) with afollow-up of 6 months.2 CASE SERIESThe clinical study was done at the Department of Peri-odontics in Sri Ramakrishna Dental College and Hospital,Coimbatore. A total of six patients were included. Allpatients were informed and explained about the laserfrenectomy procedure and signed the informed consent thatincluded the procedure and consequences of the surgery.Thepatients had various chief complaints and some cases werereferred from the Department of Orthodontics for removalof the aberrant frenal attachment.Thepatientswere clinicallyexamined and the frenum was classified according to thePlacek 1974 classification.The diode laser of 980nm at a power ranging between2 to 2.5 Watts was used for the frenectomy procedure.The patients who underwent the laser-assisted frenectomywere protected with eyeglasses and masks. Upon receivingwritten informed consent, all patients were treated underlocal anesthesia with lidocaine 2% with adrenaline 1:80000.The lip was retracted and the frenum was tensed (Figures 1and 2).Then using the laser fiber tip, the frenumwas relievedfrom the attached gingiva and interdental papilla betweencentral incisors to the attachment in the upper lip up tothe vestibule (Figures 3 and 4). Figures 5 and 6 reveals theimmediate post-operative view of the patient.Then adequatehemostasis was achieved, and the patient was given post-operative instructions and was explained about the VAS forpain and post-operative comfort level assessment.All the patients who underwent the procedure were askedto fill out the VAS forms provided on the 1st, 3rd, and 7th day.All the patients were recalled for a follow-up visit at 1 week,3 months, and 6 months.Fig. 1: Preoperative image of Subject I showing positive tensiontest with high maxillary labial frenal attachmentFig. 2: Preoperative image of Subject II showing positive tensiontest with high maxillary labial frenal attachment and prominentmidline diastemaFig. 3: Intraoperative image maxillary labial frenectomy per-formed using diode Laser in subject IFig. 4: Intraoperative image maxillary labial frenectomy per-formed using diode Laser in subject II57Madhupretha et al. J Multi Dent Res. 2024;10(2):56–59Fig. 5: Immediate post-operative image after laser frenectomyshowing relief in the frenal tension pertaining tomaxillary labialfrenum of Subject IFig. 6: Immediate post-operative image after laser frenectomyshowing relief in the frenal tension pertaining tomaxillary labialfrenum of Subject II3 RESULTSAt 1 week, the healing was uneventful. In VAS, theinterpretations are 0 means no pain or discomfort; 0.1-3.0 means slight pain or discomfort; 3-6 moderate pain ordiscomfort, and 6-10 severe pain or discomfort. The patientswere instructed to give the score accordingly. The mean VASscores showed 2 ± 0.63, 1 ± 0.63, and 0.33 ± 0.52 on 1st,3rd, and 7th day respectively (Tables 1 and 2). The 3rd and6th month follow-up visits showed complete healing of theoperative site (Figures 7 and 8).Table 1:The VAS scores for six patients on Day 1, Day 3 and Day7Subjects Day 1 Day 3 Day 7I 2 2 1II 2 1 0III 1 1 0IV 3 1 0V 2 1 1VI 2 0 0Table 2: VAS scores of pain (Mean ± SD) for 6 participants atDay 1, Day 3, and at Day 7Parameter VAS score for painDAY 1 2 ± 0.63DAY 3 1 ± 0.63DAY 7 0.33 ± 0.52Fig. 7: 6 months post-operative image of the maxillary labialfrenum showing complete healing and negative tension test inSubject IFig. 8: 6 months post-operative image of the maxillary labialfrenum showing complete healing and negative tension test inSubject II4 DISCUSSIONLasers have emerged to be the most sought-after technologythat can be used for a variety of dental procedures. Whenperforming some periodontal treatments such as gingivec-tomy, gingivoplasty, frenectomy, frenotomy, operculectomy,and laser-assisted flap surgery, this equipment is used ininstead of the traditional scalpel technique. For frenectomy,a variety of soft tissue lasers, including diode, Er:YAG(Erbium-doped yttrium-aluminum-garnet), and Nd:YAG(Neodymium-doped yttrium aluminum garnet) lasers, havebeen used.Of these, diode laser is the one that is utilisedmostfrequently. There are four wavelengths for the diode lasers:810–830 nm, 940 nm, 980 nm, and 1064 nm. (7) We used a980 nm laser in this work, with a power output of two to 2.5Watts.With its distinct benefits, laser procedures offer newinsights into periodontics and help to mitigate some ofthe challenges associated with using the standard scalpelmethod. Better hemostasis and reduced patient pain percep-tion provide a clear field for precise and painless incisions.This enhances patient cooperation and lessens anxiety and58Madhupretha et al. J Multi Dent Res. 2024;10(2):56–59panic related to surgical operations. (8)There are various studies in the literature comparing con-ventional frenectomy using a scalpel and laser frenectomy.Lebret et al 2021 did a systematic review that aimed atcomparing the various parameters between scalpel and lasertechniques for a frenectomy. (9) They included studies thatcompared the pre–operative, and post-operative parametersand concluded that patient satisfaction was highest in laser-assisted frenectomy procedures with shorter duration ofoperating time, no suturing, less post-operative pain, anddiscomfort.This less pain anddiscomfort in laser frenectomywere explained by the fact that the laser causes proteincoagulation that forms a biological dressing sealing theextremities of the sensory peripheral nerves. (9)Zaaba et al in 2021 did a study to evaluate healingfollowing frenectomy done by scalpel and laser in 51outpatients. (10) They assessed the healing following theprocedures using the healing score index with photographsup to 3 weeks. They concluded that the laser frenectomyshowed better healing outcomes than the conventionalscalpel technique. Due to longitudinal incisions done usingthe scalpel technique, more edema and swelling wereassociated with the scalpel technique. Whereas in lasertechnique, less scar tissue formation and minimal swelling.Thus, the procedure with laser could provide the idealoutcomes with fewer complications.Considering all the above-mentioned consequences weused the laser frenectomy technique for our cases andmeasured the outcome using VAS scores.The results showedsatisfactory outcomes following laser frenectomy procedureswith less pain perception, and more comfort in the healingperiod without any swelling and edema from the patient’sperspective. This is in accordance with the study done byVincent et al in 2023 in thirty-six subjects to assess variousparameters like ooze from the surgical site, pain, woundhealing, and discomfort or acceptance of the procedure. (11)The parameters were evaluated at day 1, day 7 and at day 14.The pain perception between these two procedures withVAS score analysis showed less score for pain perceptionobserved in the laser frenectomy group at all the recall visits.This was explained by the fact that the sensory nerve endingswhich are responsible for pain perception were sealed bythe heat generated with laser procedure and renders itunable to anastomose with one another. From the operator’sperspective, the procedure is more convenient as it has lesstime consumption, a clear operating field, and more controlover the procedure.5 CONCLUSIONThe laser frenectomy has various advantages over thescalpel technique in pain perception, healing, discomfort,hemostasis, and time consumption. Thus, laser can beconsidered as an ideal alternative to conventional scalpeltechnique as it satisfies the treatment needs with fewercomplications.REFERENCES1) Newman MG, Carranza FA, Takei HH, Klokkevold PR. Carranza’sclinical periodontology. Brasil. Elsevier. 2006. Available from: https://books.google.co.in/books/about/Clinical_Periodontology.html?id=2KkTAQAAMAAJ&source=kp_book_description&redir_esc=y.2) Mirko P, Miroslav S, Lubor M. Significance of the labial frenumattachment in periodontal disease in man. Part 1. Classificationand epidemiology of the labial frenum attachment. Journal ofPeriodontology. 1974;45(12):891–894. Available from: https://doi.org/10.1902/jop.1974.45.12.891.3) Sewerin I. Prevalence of variations and anomalies of the upperlabial frenum. Acta Odontologica Scandinavica. 1971;29(4):487–496.Available from: https://doi.org/10.3109/00016357109026535.4) Mohan R, Soni PK, KrishnaMK, GundappaM. Proposed classificationof medial maxillary labial frenum based on morphology. DentalHypotheses. 2014;5(1):16–20. Available from: http://dx.doi.org/10.4103/2155-8213.128108.5) Olivi G, Chaumanet G, Genovese MD, Beneduce C, Andreana S.Er,Cr:YSGG laser labial frenectomy: a clinical retrospective evaluationof 156 consecutive cases. General Dentistry. 2010;58(3):126–133.Available from: https://pubmed.ncbi.nlm.nih.gov/20478790/.6) Yeung AWK, Wong NSM. The historical roots of visual analog scalein psychology as revealed by reference publication year spectroscopy.Frontiers in Human Neuroscience. 2019;13:1–5. Available from: https://doi.org/10.3389/fnhum.2019.00086.7) Convissar RA. Principles and Practice of Laser dentistry. MarylandHeights, MO, USA. Mosby Elsevier. 2016. Available from:https://www.sciencedirect.com/book/9780323297622/principles-and-practice-of-laser-dentistry.8) Poornima R. Comparison of Two Different Techniques to AchieveGingival Depigmentation: A Case Series With 6-months Follow-up.Clinical Dentistry. 2024;XVIII:31–36. Available from: https://doi.org/10.33882/ClinicalDent.15.35369.9) Clément L, Elsa G, Mélodie AP, Jean-Christophe F, Sylvain C,Mathilde F. Perioperative outcomes of frenectomy using laser versusconventional surgery: a systematic review. Journal of Oral Medicineand Oral Surgery. 2021;27(3):1–9. Available from: https://doi.org/10.1051/mbcb/2021010.10) Zaaba NAAB, Rajasekar A, Sundari KKS. Evaluation of healingfollowing frenectomy. Bioinformation. 2021;17(12):1138–1143.Available from: https://doi.org/10.6026/973206300171138.11) Vincent K, Aslam S, Abida R, Thomas T, Cherian MP, SomanS. Evaluating the Clinical Efficacy of Maxillary Labial FrenectomyProcedure Using Diode Laser (980 nm) and Conventional Scalpel:An Observational Study. Journal of Pharmacy and Bioallied Sciences.2023;15(Suppl 1):S688–S692. Available from: https://doi.org/10.4103/jpbs.jpbs_85_23.59

Diode Laser-Assisted Maxillary Labial Frenectomy: A Case Series With 6-months Follow-Up

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Diode Laser-Assisted Maxillary Labial Frenectomy: A Case Series With 6-months Follow-Up

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