Case Report http://doi.org/10.18231/j.idjsr.2020.

006

Maxillary labial frenectomy by using conventional technique and laser –

Report of two cases
Archana N.V1*, Jose Paul2, Johnson Prakash D’Lima3, Senny Thomas parackal4, Deepak Thomas5, Akhil S6
1,6
Post Graduate student, 2Professor and Head, 3,4Professor, 5Reader, Dept. of Periodontics, Annoor Dental College and
Hospital, Muvattupuzha, Ernakulam, Kerala, India

Corresponding Author: Archana. N.V

Email: [email protected]

Abstract
Aberrant frenum causes a problem of midline diastema which leads to unaesthetic smile for the patient. Orthodontic
correction of midline diastema helps to create aesthetic smile but frenum attachment may interfere it. The labial frenectomy is
the procedure performed to remove aberrant frenum attachment. This article presents two case reports of maxillary labial
frenectomy by using conventional technique and Laser.

Keywords: Labial Frenectomy, Midline diastema, Aesthetic smile, Laser frenectomy.

Introduction fan-shaped or bifid ending construction are described

One of the more exciting but often misunderstood as an abnormal frenum whose development is not
anatomic structures in the oral cavity is the frenum. It dependent upon its point of insertion.3
is a mucous membrane fold that attaches the lip and Frenectomy or frenotomy procedures can be used
the cheek to the alveolar mucosa, the gingiva, and the to treat the abnormal frenum. Surgical removal of the
underlying periosteum. abnormal frenum is known as frenectomy that includes
A frenulum is a small frenum.1 In a normal oral its attachment to the underlying bone, whereas
cavity several frena are usually present, most frenotomy is the incision and the repositioning of the
specifically the maxillary labial frenum, the frenal attachment. Frenectomy can be done either by
mandibular labial frenum, and the lingual frenum. The the routine scalpel technique, electro surgery or via
main function of the frenum is to provide stability of lasers. The conventional technique involves using a
the upper and lower lip and the tongue. scalpel to excised the frenum. In fact, it holds the
Content of frenum is; routine risks of surgery such as bleeding and patient
1. Variable amount of loose connective tissue with compliance.4
elastic and dense collagen fibers The role of laser in dentistry has been well
2. Fat cells established in traditional oral disease management. 5 It
3. Occasionally acini of mucous producing salivary is a device that can attain maximum oral health in a
glands minimally invasive manner so far that laser technology
4. Muscle fibers is evolving very rapidly. 6 The leading laser
5. Mucogingival junction – closely associated. demonstrated by Robert N. Hall in 1962 remained a
diode laser that stands as a solid-state semiconductor
Classification of frenum by Placek et al 19742 laser that utilizes a combination of Gallium (Ga),
1. Mucosal: when the frenal fibres are attached up to Arsenide (Ar) and additional components, such as
mucogingival junction Aluminum (Al) and Indium (In), to convert electrical
2. Gingival: when fibres are inserted within attached energy into light energy. Usually it is operated in
gingiva contact mode through a flexible fiber optic delivery
3. Papillary: when fibres are extending into inter system that emits in continuous-wave or gated-pulsed
dental papilla modes.7
4. Papillary penetrating: when the frenal fibres cross
the alveolar process and extend up to palatine Case Report 1
papilla. A 17 year old male patient presented with the chief
Frenum is protected by stratified layered epithelium complaint of spacing between the upper anterior teeth
containing vascular structures with thin peripheral and the patient was referred from the department of
nervous ramifications. Hypertrophic, fibrotic, ample, orthodontics for frenectomy.

International Dental Journal of Student Research, January-March, 2020;8(1):27-32 27

Archana N.V et al. Maxillary labial frenectomy by using conventional technique and laser…

Patient’s medical history was not significant. Local anesthesia was administered and laser fiber
Intraoral examination showed papilla penetrating was applied vertically and laterally to the frenum,
type hypertrophic labial frenum and midline diastema which initially disrupted the continuity of the mucosa.
between maxillary central incisors. (Fig. 8)
After taking patient’s consent it was decided to do This made it easy to access in performing a deeper
frenectomy with classical technique by Archer (1961) cut of the frenum in a horizontal dimension. (Fig. 9)
and Kruger (1964). Wave length Specific goggles were worn by the
patient and all the staffs throughout the procedure.
Armamentarium And high speed evacuation was used to reduce the
Scalpel blade no.15, Gauze pieces, Tissue forceps, Silk slight charred odor and to remove the laser plume.
sutures, Hemostat, Scissors Hemostasis was achieved without suturing
The area was anesthetized with a local infiltration According to the report of the patient there was no
by using 2% lignocaine with 1:200000 adrenaline post-operative complications
Fig. 1: Maxillary labial frenum (Papilla New insertion of labial frenum was observed at the
penetrating type) with diastema between maxillary mucogingival junction after 2months post operatively.
central incisors. (Fig. 10)
Step 1: The frenum was engaged with a haemostat Also improved oral hygiene with easy access to
which was inserted into the depth of the vestibule and the cervical region was claimed by the patient.
the incision with the 15 no scalpel blade was placed on
the upper and the lower surface of the haemostat until
the haemostat was free. The triangular resected portion
of the frenum with the haemostat was removed, which
leaves a rhomboid area exposing the deeper connective
tissue fibers. (Fig. 2)
Step 2: Dissection of muscle fibers was done on
the bone. (Fig. 3)
Step 3: The edges of the diamond shaped wound
were sutured by using 3-0 black silk with simple
interrupted sutures. (Fig. 4)
Fig..5: Showed postoperative view after one week.

Case Report 2
A 14 year old female patient presents with chief
complaint of mild spacing between the upper front Fig. 1: Preoperative
teeth and the patient was referred from the department
of orthodontics for frenectomy.
No significant medical history reported
The clinical examination revealed the presence of
papilla penetrating type hypertrophic labial frenum
and midline diastema between the central maxillary
incisors (Fig. 6)
The treatment of choice was to perform laser
frenectomy after complete evaluation and detailed
history.
Informed consent was obtained from the patient to
perform frenectomy after explaining the intra and post-
operative aspects.
The frenectomy performed with a wavelength of Fig. 2: Appearance after the initial incision and
980 nm with photon plus diode laser manufactured by frenum removal
Zolar Tech technology. (Fig. 7)
The laser was operated at a power of 3.0 watt in
continuous wave mode with 400 µm optical fiber.

International Dental Journal of Student Research, January-March, 2020;8(1):27-32 28

Archana N.V et al. Maxillary labial frenectomy by using conventional technique and laser…

Fig. 6: Preoperative

Fig. 3: Appearance after the dissection of muscle

fibers

Fig. 4: Simple interrupted sutures given Fig. 7: Zolar Photon plus diode laser

Fig. 8: Laser was applied

Fig. 5: one week post operative

International Dental Journal of Student Research, January-March, 2020;8(1):27-32 29

Archana N.V et al. Maxillary labial frenectomy by using conventional technique and laser…

lead to various periodontal problems and an unesthetic

appearance, thus mandating further modifications.11
The laser is a viable alternative for conventional
techniques for many intraoral soft tissue surgical
interventions. The commercially available dental
instruments have wavelengths varying from 488 nm to
10,600 nm and are completely non-ionizing radiations
to avoid any mutations in cellular DNA parts that are
known to cause ionizing radiation. One of the main
advantages of using diode lasers is the ability to
interact with diseased tissues selectively and precisely.
Lasers enables the clinician to decrease the quantity of
bacteria and other pathogens in the surgical area and in
the case of soft tissue measures, attain excellent
haemostasis with the decreased precondition for
Fig. 9: Dissection done
sutures.

In contrast to conventional surgery, the claimed

benefits of lasers include
1. Increased coagulation yielding a dry surgical field
and improved visualization
2. The ability to negotiate curvatures and folds
within tissue contours;
3. Tissue surface disinfection and consequently,
decrease in bacteraemia;
4. Reduced distension, edema, and scarring;
5. Decreased pain;
6. Faster healing response; and
7. Increased patient appreciation.
Once laser cutting is in progress, small blood and
lymphatic vessels are impassable owing to the heat
Fig. 10: Two months post operative produced, thus decreasing or eliminating blood flow
and edema.The denatured proteins restrained tissue
Discussion and plasma are the source of "coagulum" layer, that is
There has been much controversy over the relationship formed by laser action and protects the wound from
between the maxillary midline diastema and the labial bacterial or frictional properties. The diode laser, does
frenulum. Before 1940, Frenectomy was considered not cause any harmful effects on the root
prior to orthodontic treatment.8 The primary cause of surface.Therefore it can be performed safely close to
the diastema was regarded as Frenulum. Broadbent 9 dental hard tissue. 12
later showed that after teeth eruption the problem is There was definitely no bleeding at all during the
self-correcting. In his examination of 6-year-olds, procedure. Similarly, the patient experienced no
Taylor10 found that 98% had a midline diastema. By discomfort after surgery and no swelling or other signs
age 12, only 7 percent had a persistent diastema, of infection were noticed, however other alternative
thereby confirming Broadbent's findings. procedures must be accompanied by antibiotic and
Surgical correction is currently recommended after analgesic administration to minimize postoperative
orthodontic treatment and eruption of permanent infection and pain.
anterior maxillary teeth. It may be due to the difficulty The superiority of laser over conventional scalpel
of moving teeth through scar tissue and the problem's method has been suggested in many studies, including
self-correcting nature. Instead of various hemostasis effect, excellent visualization of the
modifications, a classical frenectomy is widely operating field, reduce2d operating time, less need for
followed. The classical technique results in a local anesthesia, sterilization of wound site,
longitudinal surgical incision and scarring, that can elimination of suturing, reduction of post-operative
edema, pain and minimum scarring. 13
International Dental Journal of Student Research, January-March, 2020;8(1):27-32 30
Archana N.V et al. Maxillary labial frenectomy by using conventional technique and laser…

A 2008 article by Kara compared an Nd: YAG wound that can show some hemorrhage, so it may be
laser to conventional scalpel surgery and reported that necessary to seal the wound with the laser bandage
laser-treated patients reported greater rates of approach.
satisfaction, less postoperative pain, and fewer The other drawbacks of diode lasers are that
functional problems that impacted chewing or 1. They are expensive
speech.14 Haytac and Ozcelik compared 20 frenectomy 2. Special equipment required
procedures conducted with a CO2 laser to 20 with 3. Requires additional skills for operation and
standard scalpel surgery and reported less pain after limited use.
one day and seven days in patients treated with the 4. During operation while performing the incision
laser.15 some fumes were released from vaporization of
Awooda et al.16 performed frenectomy in eight epithelium with a burning smell, which can
patients with diode laser and showed dry and bloodless provoke stress and hurt in the patient, to relieve
field during surgery, no post-operative swelling, no this complication, it is necessary to operate with a
pain or discomfort, with normal healing process. Due powerful air evacuator.
to its time saving, patient convenience and simple 5. The time required for frenum excision by using
manipulation, the authors recommend the use of laser diode laser is more than other techniques
for soft tissue surgery. 6. We can’t dissect the entire muscle fibers from the
Although emerging research reveals benefits from periosteum by using laser so reattachment of
the use of laser energy, some precautions are required frenum may occur. But in conventional scalpel
for the laser technique. technique we can dissect the entire fibers from the
1. Practitioners must understand the type of laser periosteum. So that the chances of reattachment of
being used and the appropriate laser settings and frenum is very less.
techniques because multiple types of lasers Two months post-operative view (Figure 10) of our
(carbon dioxide, Nd: YAG, diode, etc.) are case done with laser also shows the reattachment of
available. frenum at the level of mucogingival junction. But not
2. In addition, the clinician and staff should be occurred in the case done with conventional technique.
properly trained for themselves and the patient. in Though the laser frenectomy technique has more
laser safety. advantages over the conventional technique, the
Laser frenectomy procedures are predictably conventional technique offers the complete dissection
successful, provided the following steps are of muscle fibers of frenum with less chances of
implemented: reattachment.
a. Creating a periosteal fenestration at the base of
the frenectomy to prevent reattachment of Conclusion
fibers. Frenectomy is a removal of frenum should be
b. Removal of all impeding muscle fibers considered for potential complications associated with
All laser wavelengths can be used to successfully it. Various techniques can be employed for the same
perform a frenectomy; however, penetration depth for but selection of it according to the type of attachment
diode and Nd: YAG lasers is much higher (500 μm) is important for the achievement of proper functional
than for erbium or CO2 lasers (5 to 40 μm), so the and aesthetic result. Conventional technique and laser
settings need to be closely monitored to prevent have its merits and demerits over other technique but
thermal damage to the underlying periosteum and cost-effectiveness also considered before treatment
bone. planning.
With use of the right parameters (spot size, power,
hand speed), one pass of the laser should be sufficient Source of funding
to severe all of the fibers. If multiple passes are None.
needed, care must be taken to prevent excessive lateral
thermal necrosis from re-exposure of the already Conflict of interest
treated tissue. The laser incision is continued to None.
undermine the muscle attachment until the periosteum
is reached. All lasers are effective for a frenectomy References
with settings that the manufacturer suggests. Care 1. Mintz SM, Siegel MA, Seider PJ. An overview of oral
should be taken not to char the tissue, with consequent frena and their association with multiple syndromes and
thermal tissue damage. The erbium laser creates a
International Dental Journal of Student Research, January-March, 2020;8(1):27-32 31
Archana N.V et al. Maxillary labial frenectomy by using conventional technique and laser…

nonsyndromic conditions. Oral Surg Oral Med Oral Pathol 10. Taylor J.E. Clinical observation relating to the normal and
Oral Radiol Endod 2005;99:321-4. abnormal frenum labii superiors. Am J Orthod Oral Surg
2. Mirko P, Miroslav S, Lubor M. Significance of the labial 1939; 25: 646.
frenum attachment in periodontal disease in man. Part I. 11. Devishree, Frenectomy: A Review of the Reports of
Classification and epidemiology of the labial frenum Surgical Techniques. J Clin Diagn Res 2012;6(9):1587-92.
attachment. J Periodontol 1974;45:891‑4. 12. Mangalekar SB, Kaushal L, Johnson L, Soni A, Thakur P.
3. Olivi G, Chaumanet G, Genovese MD, Beneduce C, Maxillary labial frenectomy using diode laser and classical
Andreana S. Er, Cr: YSGG laser labial frenectomy: A technique: A case report. Int J Oral Health Med Res
clinical retrospective evaluation of 156 consecutive cases, 2015;2:48-50.
Laser Therapy. General Dent 2010. 13. Kotlow L. Diagnosis and treatment of ankyloglossia and
4. Kaur P, Dev YP, Kaushal S, Bhatia A, Vaid R, Sharma R et tied maxillary frenum in infants using Er.YAG and 1064
al. Management Of The Upper Labial Frenum: A diode lasers. Eur Arch Paediatr Dent 2011;12:106-12.
Comparison Of Conventional Surgical And Lasers On The 14. Kara C. Evaluation of patient perceptions of frenectomy: A
Basis Of Visual Analogue Scale On Patients Perception. J comparison of Nd: YAG laser and conventional techniques.
Periodontal J Periodontal Med Clin Pract 2014;1(1). Photomed Laser Surg 2008:26(2):147-52.
5. Khalid W, Sheeja VS, Sankari M, Jayakumar. The 15. Haytac MC, Ozcelik O. Evaluation of patient perceptions
lightsaber is mightier than the sword!-a case of frenectomy after frenectomy operations: A comparison of carbon die
using diode laser. Unique J Med Dent Sci 2015;03(01):22- oxide laser and scalpel techniques. J Periodontol
4. 2006;77(11):1815-19.
6. Gargari M, Autili N, Petrone A, Prete V. Using the diode 16. Awooda EM,Osman B,Nadia A Yahia.Use of Diode Laser
laser in the lower labial frenum removal. Oral Implantol - (810)nm in frenectomy. Sudan JMS 2007:2(1)
Anno V- N 2-3/2012.
7. Kafas P, Stavrianos C, Jerjes W, Upile T, Vourvachis M,
How to cite: Archana N.V*, Paul J, D’Lima JP,
Theodoridis M et al, Upper-lip laser frenectomy without
infiltrated anaesthesia in a paediatric patient: a case report.
parackal ST, Thomas D, Akhil S. Maxillary labial
Cases J 2009;2:7138. 1-3. frenectomy by using conventional technique and laser –
8. Tait C. H. Median fraenum of the upper lip and its Report of two cases. Int Dent J Student Res
influence on the spacing of upper central incisor teeth. Dent 2020;8(1):27-32.
J 1929; 25: 116.
9. Broadbent, H. Ontogenic development of occlusion. Angle
Orthodll 223:1941.

International Dental Journal of Student Research, January-March, 2020;8(1):27-32 32