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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 86-90

Interceptive treatment of the aberrant labial frenulum in the transition dentition stage using 808nm diode laser


1 Private Pediatric Dental Practice, Aligarh, India
2 Department of Pediatric and Preventive Dentistry, Dr. Ziauddin Ahmad Dental College and Hospital, Faculty of Medicine, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission06-Dec-2021
Date of Acceptance25-Aug-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Dr. Mohammad Kamran Khan
Hamdard Nagar-A, Civil Lines, Aligarh-202001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_35_21

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  Abstract 


The aberrant labial frenulum is one of the etiological factors for midline diastema. Such frenulum needs timely detection and early intervention in transition dentition to intercept the developing midline diastema in growing children. A conservative and minimal-invasive approach should be considered for managing the abnormal frenulum in the pediatric age group. This article presents a clinical case report on the successful and effective treatment of aberrant maxillary labial frenulum in a 10-year-old pediatric patient using the diode laser of 808 nm wavelength without infiltrative local anesthesia and sutures. The follow-up evaluation demonstrated optimum healing without any complications. The patient demonstrated cooperation and satisfaction with the laser surgery and its excellent healing outcomes.

Keywords: Diode laser 808 nm, labial frenectomy, laser dentistry, laser-assisted frenectomy, minimal-invasive dentistry, pediatric dentistry


How to cite this article:
Khan MK, Jindal MK. Interceptive treatment of the aberrant labial frenulum in the transition dentition stage using 808nm diode laser. Int J Oral Health Sci 2022;12:86-90

How to cite this URL:
Khan MK, Jindal MK. Interceptive treatment of the aberrant labial frenulum in the transition dentition stage using 808nm diode laser. Int J Oral Health Sci [serial online] 2022 [cited 2023 Feb 1];12:86-90. Available from: https://www.ijohsjournal.org/text.asp?2022/12/2/86/364229




  Introduction Top


Optimum oral health is essential for good quality of life because it may influence the nutrition, smile, phonetics, and social interaction of an individual.[1] Malocclusion, especially involving the anterior teeth in the transition dentition stage has been reported to influence psychosocial well-being in children.[1] The transition dentition phase should be meticulously monitored and intervened accordingly whenever necessary for the development of normal occlusion.[2] Interceptive orthodontics are known as the dental procedures by which the elimination of existing interferences (factors) involved in the developing malocclusion of dentition is carried out.[2] The planned intervention for developing malocclusion at the mixed dentition stage usually helps in eliminating the need of complex dental treatment modalities in future.[2] Fourteen percent–49% of children with malocclusion have benefited from interceptive management.[2]

Midline diastema is an anterior malocclusion condition which can be due to genetic and racial predisposition, aberrant maxillary labial frenulum and its abnormal high attachment, presence of (mesiodens) supernumerary teeth, oral musculature disharmony (imbalance), presence of deleterious oral habits, or may be due to iatrogenic factors.[3] Timely recognition and management of abnormal labial frenulum are also included in the interceptive management for midline diastema.

Placek et al.(1974) have classified frenum depending on the extension of attachment of fibers, such that mucosal type, gingival type, papillary type, and papilla penetrating type. Clinically, papillary and papilla penetrating frenum are considered pathological which leads to various oral manifestations. A frenum is considered pathogenic when it is exceedingly wide or when there is no apparent attached gingiva along the midline or the interdental papilla gets shifted when the frenulum is stretched (Miller). Such abnormal frenulum can pose several problems such as midline diastema, gingival recession, loss of papilla, interference in prosthesis (denture), and periodontal problems due to hindrance in oral hygiene practices.[4],[5],[6] Abnormal labial frenulum also causes the “pull-syndrome” in which free gingiva from the tooth surface is detached accompanied by the ischemia (blanching) of the gingival tissue (Bergstrom et al., 1973).

An abnormal frenulum can be corrected by frenectomy or frenotomy. The literature demonstrates that frenectomy procedures can be performed with a conventional scalpel surgical technique, electrosurgery, or using the soft-tissue laser.[5] Conventional frenectomy with a scalpel usually results in postsurgical pain which is aggravated when the suture come in contact with food bolus or materials.[7] Scalpels and sutures are considered the source of anxiety/fear, especially in pediatric patients. Infiltration anesthesia is also required during conventional surgery for an aberrant frenum.[4] Literature has demonstrated the advantages of laser-assisted frenectomy over conventional surgical modalities such as hemostasis effect, great visualization of the surgical field, decreased operating time, reduced need for local anesthesia, sterilization effect on the operative site and surgical wound, elimination of the need for suturing, minimal or no postoperative pain, edema, and reduced scar formation.[8]

There is a paucity of published literature regarding the diode laser of 808 nm wavelength in correcting abnormal labial frenulum in a pediatric patient.[4],[6],[9],[10] The present article describes the successful treatment of aberrant maxillary labial frenulum using the diode laser of wavelength 808 nm and 600 μm fiber tip without infiltrated anesthesia in a 10-year-old patient. The patient's anxiety was assessed with the help of the facial image scale (FIS) (Buchanan and Niven, 2002).

This clinical case report has been written according to the CARE case report guidelines.


  Clinical Case Presentation Top


A 10-year-old male patient presented with a chief complaint of spacing in the upper front teeth for 4 years. His medical history was not significant. Dental history revealed difficulty in brushing teeth due to abnormally high labial frenulum attachment.

General physical examination revealed normal systemic health. Extraoral examination showed no unusual findings. Intraoral examination revealed high frenal attachment with a wide and thick labial frenulum with midline diastema in maxillary dentition [Figure 1]. The positive findings of the blanch test confirmed the aberrant maxillary labial frenulum and its high attachment. After detailed history and clinical examination of the patient, the clinical diagnosis of high frenulum attachment of papillary type of maxillary labial frenulum with midline diastema was established.
Figure 1: Preoperative view showing aberrant labial frenulum with midline diastema

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All the available treatment options and their characteristics for the labial frenectomy were explained to the patient's parents. Considering the age of the pediatric patient and the advantages of soft-tissue lasers in frenectomy procedures, the suitable treatment plan consisted of diode laser-assisted maxillary labial frenectomy. After a detailed explanation of the laser-assisted frenectomy procedure, written informed consent was obtained from the patient's parents.

The Tell-Show-Do technique was adopted to have the cooperative behavior of the child patient during the procedure. The surgical field was sprayed with topical anesthesia. Necessary safety measures for laser use were followed during the entire laser procedure. The upper lip was retracted digitally. A diode laser with an emitted wavelength of 808 nm (class-4 GaAlAs diode) (Elexxion claros pico® Singen, Germany) was used in the present case to perform labial frenectomy. The laser parameters were used pulse power: 5 W; frequency 20 kHz; pulse length: 26 μs; average output: 5 W. A fiber tip of 600 μm was used in pulsed mode for ablating the frenulum in brushing strokes in contact mode from base to apex of the frenulum [Figure 2]. Adequate hemostasis was achieved intraoperatively using a diode laser. The tissue laser plume was cleaned with wet cotton soaked in normal saline solution. No infiltration anesthesia was needed in the patient as the patient was comfortable intraoperatively without any kind of pain. A rhomboidal-shaped surgical wound was formed following laser frenectomy [Figure 3]. Sutures were not required as hemostasis was achieved. The whole laser surgery was accomplished successfully within 4 min. The patient reported no pain intraoperatively and the procedure was well tolerated and comfortable for the patient.
Figure 2: Intraoperative view showing the diode laser application for labial frenectomy

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Figure 3: Immediate postoperative view of the rhomboidal-shaped surgical wound after laser-assisted labial frenectomy

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Postoperative instructions were given to the parents for optimum surgical wound care at home. Antibiotics were not prescribed; only analgesics were advised to take if needed. Meticulous oral hygiene was instructed to follow. Hot, spicy, and hard food items were not advised postoperatively for the initial few days; only a soft diet was advised.

The patient was advised to periodic follow-up evaluations. On follow-up visits after 1 week [Figure 4] and 1 month [Figure 5], the patient was found asymptomatic and oral examination revealed an optimum healing process without any complications. The laser surgical wound was optimally healed with the secondary intention process. Parents and patient were reported satisfaction with the favorable results of the laser-assisted labial frenectomy.
Figure 4: Follow-up view after 1 week showing optimum healing process without any complications

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Figure 5: Follow-up view after 1 month of laser surgery showing the excellent results of the diode laser-assisted frenectomy procedure without any scar

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  Discussion Top


The predisposing factor such as aberrant labial frenulum should be corrected as a part of the interceptive approach for managing the midline diastema in a pediatric patient. Various conventional surgical approaches have been described in the literature, i.e., Z-plasty frenectomy[4] and V-shaped incision frenotomy (Edwards, 1977). However, such conventional surgical approaches have several demerits.[5] Lasers have been becoming more popular in oral surgical procedures due to several evidence-based advantages reported in the literature. For soft-tissue surgeries, Lasers such as Nd: YAG, CO2, and Er: YAG lasers can be used with a minimally invasive dentistry approach.[7] Photothermal interaction with tissue by absorption is the fundamental laser–tissue interaction or concept for laser surgeries, where the emitted laser beam is absorbed by the tissue and transformed/converted into heat (thermal) energy changing the tissue structure.[11] Such photothermal interaction with operated tissue results in ablation, incision, vaporization, or coagulation during laser surgery.[11]

One of the important aspects of laser application is minimal or no pain perception postoperatively without using anesthesia or analgesia because laser light causes the sealing of sensory nerve endings which results in reduced pain response.[7],[11] The formation of a protein coagulum layer over the surgical wound surface due to laser application acts as a biologic dressing and also protects the wound from external irritation, causing less minimal postoperative pain and avoiding the use of analgesic drugs.[7],[11]

In recent years, diode lasers have been reported in the literature to use in oral soft-tissue surgeries. Diode lasers are made of semiconductors and they are mainly used for soft-tissue surgical procedures because their wavelengths interact with soft tissue as its absorption coefficient has affinity for pigmented tissues containing chromophores such as hemoglobin, melanin, and collagen.[7] Diode lasers have wavelengths ranging from 808 to 980 nm.[5] The diode laser has been reported as an excellent soft-tissue laser as it does not interact with adjacent dental hard tissues (enamel or cementum) because its wavelength is poorly absorbed in water but highly absorbed by hemoglobin and other pigments of soft tissues.[4],[7] Furthermore, it improves surgical precision, improves the operator's view of the surgical field due to the hemostatic effect, eliminates the need for postoperative sutures, and shortens operation time.[5]

In the present case also, the application of a diode laser of 810 nm wavelength demonstrated the excellent intraoperative and postoperative aspects in treating the abnormal labial frenum along with high satisfaction and cooperation from the patient and parents. The patient was comfortable without any anxiety as the laser surgery was painless without using infiltration anesthesia and sutures. The patient showed favorable cooperative behavior intraoperatively and in follow-up visits as assessed by the anxiety scale FIS. In the follow-ups, healing process was found faster without any complications. The patient and parents displayed high cooperation and satisfaction with the diode laser-assisted labial frenectomy.

Similarly, Kafas et al. reported the successful management of aberrant maxillary labial frenulum without infiltration anesthesia using the diode laser with wavelength 808 nm in a pediatric patient with optimum healing outcomes.[10] The diode laser has been used successfully and effectively in frenectomy procedures as reported in previously published articles.[4],[6],[10],[12]


  Conclusion Top


This clinical case report demonstrated the successful and effective treatment of aberrant labial frenum by 808 nm wavelength diode laser with optimum healing outcomes without any complications in follow-up. The child patient demonstrated cooperation and satisfaction with the diode laser procedure. The findings of this case report suggest that a diode laser of 808 nm wavelength can be used safely and successfully as an alternative tool for labial frenectomy in pediatric patients with a minimal-invasive dentistry approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dutra SR, Pretti H, Martins MT, Bendo CB, Vale MP. Impact of malocclusion on the quality of life of children aged 8 to 10 years. Dental Press J Orthod 2018;23:46-53.  Back to cited text no. 1
    
2.
Keerthana SV, Gnanashanmugam, Kannan MS. Interceptive orthodontics – A review. Eur J Mol Clin Med 2020;7:1757-61.  Back to cited text no. 2
    
3.
Kumar S, Nagmode P, Tambe V, Gonmode S, Ali F. Midline diastema: Treatment options. J Evol Med Dent Sci 2012;1:126772.  Back to cited text no. 3
    
4.
Viet DH, Ngoc VT, Anh LQ, Son LH, Chu DT, Ha PT, et al. Reduced need of infiltration anesthesia accompanied with other positive outcomes in diode laser application for frenectomy in children. J Lasers Med Sci 2019;10:92-6.  Back to cited text no. 4
    
5.
Sobouti F, Dadgar S, Salehabadi N, Moallem Savasari A. Diode laser chairside frenectomy in orthodontics: A case series (Diode Laser Frenectomy: Case Series). Clin Case Rep 2021;9:e04632.  Back to cited text no. 5
    
6.
Aldelaimi TN, Mahmood AS. Laser-assisted frenectomy using 980nm diode laser. J Dent Oral Disord Ther 2014;2:1-6.  Back to cited text no. 6
    
7.
Patel RM, Varma S, Suragimath G, Abbayya K, Zope SA, Kale V. Comparison of labial frenectomy procedure with conventional surgical technique and diode laser. J Dent Lasers 2015;9:94-9.  Back to cited text no. 7
  [Full text]  
8.
Kotlow L. Diagnosis and treatment ofankyloglossia and tied maxillary frenum ininfants using Er: YAG and 1064 diodelasers. Eur Arch Paediatr Dent 2011;12:106-12.  Back to cited text no. 8
    
9.
Kamble A, Shah P, Velani PR, Jadhav G. Laser-assisted multidisciplinary approach for closure and prevention of relapse of midline diastema. Indian J Dent Res 2017;28:461-4.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Kafas P, Stavrianos C, Jerjes W, Upile T, Vourvachis M, Theodoridis M, et al. Upper-lip laser frenectomy without infiltrated anaesthesia in a paediatric patient: A case report. Cases J 2009;2:7138.  Back to cited text no. 10
    
11.
Patil P, Kabbur KJ, Madaiah H, Satyanarayana S. Diode laser frenectomy: A case report with review of literature. J Dent Lasers 2019;13:19-22.  Back to cited text no. 11
  [Full text]  
12.
Bianchi N, Lorenzi C, Pinto A, Laureti A, Carosi P. Upper-lip laser frenectomy with a diode laser in a pediatric patient: A case report. J Biol Regul Homeost Agents 2021;35:29-35.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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