J Periodontol â€˘ November 2006
Evaluation of Patient Perceptions After Frenectomy Operations: A Comparison of Carbon Dioxide Laser and Scalpel Techniques M. Cenk Haytac* and Onur Ozcelik*
Background: A frenum that encroaches on the margin of the gingiva may interfere with plaque removal and cause tension. Frenectomy is the complete removal of the frenum that can be made by scalpels or with soft tissue lasers. The aim of this article was to compare the degree of postoperative pain, such as discomfort and functional complications (eating and speech), experienced by patients after two frenectomy operation techniques. Methods: Forty patients requiring frenectomy were randomly assigned to have treatment either with a conventional technique or with a carbon dioxide (CO2) laser. The postoperative pain and functional complication ratings of each patient were recorded using a visual analog scale on days 1 and 7. Results: The results indicated patients treated with the CO2 laser had less postoperative pain and fewer functional complications (speaking and chewing) (P <0.0001 each) and required fewer analgesics (P <0.001) compared to patients treated with the conventional technique. Conclusions: This clinical study indicates that CO2 laser treatment used for frenectomy operations provides better patient perception in terms of postoperative pain and function than that obtained by the scalpel technique. Considering the above advantages, when used correctly, the CO2 laser offers a safe, effective, acceptable, and impressive alternative for frenectomy operations. J Periodontol 2006;77:1815-1819. KEY WORDS Lasers; pain; periodontal diseases/surgery; postoperative complications; visual analog scale.
* Department of Periodontology, Faculty of Dentistry, Cukurova University, Adana, Turkey.
frenum is a fold of mucous membrane, usually with enclosed muscle fibers, that attaches the lips and cheeks to the alveolar mucosa and/or gingiva and underlying periosteum. A 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. This condition may be conducive to plaque accumulation and may inhibit proper toothbrushing. In these cases, surgical removal of the frenum is indicated. Frenal problems occur most often on the labial surface between the maxillary and mandibular central incisors and in canine and premolar areas. They occur less often on the lingual surface of the mandible.1 Frenectomy is the complete removal of the frenum, including its attachment to underlying bone. There are two techniques for the removal of the frenum. One of these is the conventional technique with scalpels and periodontal knives, and the other is using the soft tissue laser.1-3 Lasers such as the neodymium-doped:yttrium, aluminum, and garnet (Nd:YAG), carbon dioxide (CO2), and erbium-doped (Er):YAG lasers enable minimally invasive dentistry for soft tissue procedures.4-7 The CO2 laser has been used for soft tissue surgery, including the oral tissues, since the early 1970s and received clearance by the United
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States Food and Drug Administration for this purpose in 1976.6-10 CO2 laser surgery of the oral soft tissue is generally performed with a power setting of 5 to 15 W in either a pulse, superpulse, or continuous mode. It has been used for gingivectomy-gingivoplasty,11-14 frenectomy,2,3 adjunct to surgical and non-surgical periodontal treatment,15-18 incisional and excisional biopsy, and various maxillofacial surgical treatment approaches.19-23 The aim of this study was to compare the effects of the CO2 laser and the conventional technique on the degree of postoperative pain, discomfort, and functional complications (eating and speech) experienced by patients after frenectomy operations. MATERIALS AND METHODS Subjects and Study Design The study sample was selected from paFigure 1. tients who had been referred to the FacPatient presenting with a maxillary midline frenum causing pull on the marginal and ulty of Dentistry, Cukurova University, interdental papilla (A) and immediately after a frenectomy operation performed using between May 2005 and January 2006. scalpel technique with sutures in place (B). Healing 3 months after surgery (C). Another patient presenting with a maxillary midline frenum (D) and immediately after Forty patients requiring frenectomy CO2 lasing of the frenum (E). Healing 3 months after laser surgery (F). were randomly assigned to have treatment either with conventional surgical or with CO2 laser techniques. The study protocol was also used to remove any adhesions to the perioswas reviewed and approved by the institutional review teum, and the remnants of the ablated tissue were reboard. Informed written consent was obtained from all moved using sterile gauze dampened with saline. No patients. All subjects were systemically healthy, did sutures were placed after CO2 laser treatment (Figs. not use medications, and had good oral hygiene at 1D through 1F). the time of the surgery. Only maxillary and mandibuBoth groups received postoperative instructions, lar anterior frena extending to the interdental papilla of and they were told to use an analgesic if needed. the central incisors were included in this study, and the Method of Scoring patients were matched for age and gender and for the The patients were asked to separately rate the degree size and location (maxillary or mandibular) of the freof pain and postoperative functional complications, num to standardize the postoperative wound size. which included discomfort during eating and speech, Twenty-four females and 16 males aged between on a 10-cm horizontal visual analog scale (VAS) by 18 and 26 years were included in the study, and the placing a vertical mark to assess position between qualified patients were entered consecutively. the two endpoints. The left endpoint of the pain scale For the conventional technique, the frenum was was designated as ‘‘no pain,’’ and the right endpoint held with a pair of hemostats, and the whole band of was marked as ‘‘worst pain imaginable.’’ The endtissue together with its alveolar attachment was expoints of the scales for the degree of discomfort during cised with a #15 blade. After freeing any fibrous adheeating and speech were marked as ‘‘no discomfort’’ on sions to the underlying periosteum, the wound was the left side and ‘‘extreme discomfort’’ on the right closed with sutures (Figs. 1A through 1C). side. The patients were asked to mark the position beA CO2 surgical laser unit† with a flexible hollowtween the two endpoints that best described their perfiber delivery system and a non-contact, air-cooling sonal perception of the degree of pain and the hand-piece was used as the alternative frenectomy discomfort during eating and speech they had experioperation. Again the frenum was held with hemostats, enced on postoperative days 1 and 7. The hatch mark and the non-contact focused beam at repeated superplaced by the patient was measured to the nearest pulse mode (7 W, 0.8-mm spot size, 20 Hz, and 10 milliseconds) was applied for excision. The beam † Luxar Nova Pulse LX-20 SP, Bothell, WA. 1816
J Periodontol • November 2006
millimeter; thus, the scores for pain and functional complications degree were between 0.0 and 10.0.24 A single operator recorded these scores at postoperative days 1 and 7. After completion, all recordings were analyzed, which included comparison of postoperative pain and the degree of functional complications after the two periodontal treatment techniques. All patients were instructed to use the same analgesic containing paracetomol if needed, and they were also compared for their need of analgesics after the two techniques. Statistical Method Non-parametric tests were chosen for continuous variables because the data were not distributed normally. Comparisons between groups were applied using the Mann-Whitney U test. Time-dependent intragroup data were analyzed using the Wilcoxon rank sum test. The categorical variables between the groups were analyzed using the x2 test or Fisher exact test. Results were represented as mean – SD and median (minimum-maximum). A P value <0.05 was considered significant. Statistical analyses were performed using a statistical program.‡ RESULTS Results of the study are summarized in Table 1 and Figure 2. The VAS scores of pain on days 1 and 7 were significantly lower in the laser group compared to the conventional technique (P <0.0001). In addition, postoperative functional complications assessed by the chewing and speaking VAS scores were also significantly lower in the laser group (P <0.0001). Although 17 patients (85%) of the conventional technique used analgesics during the first postoperative week, only seven patients (33.3%) used them in the laser group. Table 1.
Comparison of the VAS Scores of Postoperative Patient Perceptions After Conventional and CO2 Laser Techniques Technique Conventional (mean – SD)
CO2 Laser (mean – SD)
Pain at 1 day
6.2 – 1.8
3.4 – 1.1
Pain at 7 days
3.3 – 1.5
0.1 – 0.3
Chewing at 1 day
5.2 – 1.4
1.7 – 0.9
Chewing at 7 days
2.4 – 1.0
0.1 – 0.3
Speaking at 1 day
4.0 – 1.4
0.8 – 0.7
Speaking at 7 days
1.6 – 0.9
0.1 – 0.2
Figure 2. VAS scores of patient perceptions after conventional and laser techniques.
DISCUSSION The aim of this study was to compare the postoperative subjective effects of CO2 laser and conventional techniques after frenectomy surgery. The CO2 laser is now a viable alternative to the scalpel in soft tissue surgery. Because oral tissues are composed of >90% water, and considering the affinity of the CO2 laser for wet tissue, it is readily applicable for most intraoral soft tissue surgery, including frenectomies.2-4,6-8,11-14, 21,23,25 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.7,25-29 Anecdotal reports claiming that incising oral soft tissue with a laser is less painful than using a scalpel and therefore requires less local anesthesia have no scientific confirmation to date. In our study, patients treated with the CO2 laser had significantly less postoperative pain and functional complications compared to scalpel surgery. Classically, a frenectomy procedure involves grasping the frenum with hemostats, incising above and below the hemostats, creating a large triangular-shaped wound, often with copious bleeding, and placing sutures. Patients often experience post-surgical bleeding and pain, and sutures can further increase bleeding and pain when they come into contact with food. The unpleasant taste of blood and unaesthetic appearance of sutures may result in a loss of the sense of well-being during the postoperative period. In addition, suture removal from gingival and labial tissues after 1 week can be painful because the sutures may be buried in the mucosa.1-3 To overcome these disadvantages, some clinicians use bioabsorbable sutures after oral surgery. On the other hand, the laser technique offers some advantages, such as a relatively bloodless surgical and post-surgical event; the ability to precisely coagulate, vaporize, or cut tissue; sterilization of the wound site; minimal swelling ‡ SPSS version 10.0, SPSS, Chicago, IL.
Patient Perceptions After CO2 Laser
and scarring; no suturing in most cases; little mechanical trauma; reduction of surgical time; decreased post-surgical pain; and high patient acceptance.6,7,15,26-31 There is abundant evidence confirming markedly less bleeding,11,29,30 particularly of highly vascular oral tissues, with laser surgery.27 Some reports suggest that laser-created wounds heal more quickly and produce less scar tissue than conventional scalpel surgery,28 although contrary evidence also exists.31-33 Postoperative pain from oral and otolaryngological surgical procedures has been claimed to be reduced in laser surgery.10,29 It is theorized that this 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.10,28 On the other hand, the superpulse mode, which was used in this study, releases bursts of higher peak powers and shorter pulse durations in the microsecond range. This mode allows the surgeon to deposit pulses of higher peak power into tissue with control, to confine the exposure to pulses that are within the thermal relaxation time of the tissue (which is the time needed by the tissue to release the absorbed heat via conduction or circulation), and to use pulse repetition rates that allow cooling between individual pulses to reduce heat accumulation.14,30 The use of this mode may have beneficial effects on the control of post-surgical complications by preventing carbonization or charring, which may interfere with wound healing. Although it has many advantages, the laser technique requires some precautions. The CO2 laser beam may be reflected from shiny metal surfaces, such as retractors or mouth mirrors, and cause eye injury. Protective eyewear must be worn by the operator and assistants. The patient’s eyes, throat, and delicate oral tissues outside the surgical site must be protected from accidental beam impact through use of safety glasses and wet towels or gauze packs. Clinicians experienced in CO2 laser surgery have emphasized the need for an adequate shield, such as a flat-bladed instrument or silver foil, between the gingiva and teeth. Finally, an important part of laser safety is a properly trained staff.4,6 ACKNOWLEDGMENT The authors thank Dr. Roland Blankenstein, London, United Kingdom, for his valuable assistance. REFERENCES 1. Takei HH, Azzi RA. Periodontal plastic and esthetic surgery. In: Newman MG, Takei HH, Carranza FA, eds. Carranza’s Clinical Periodontology. London: W.B. Saunders; 2002:870-871. 2. Fiorotti RC, Bertolini MM, Nicola JH, Nicola EM. Early lingual frenectomy assisted by CO2 laser helps prevention and treatment of functional alterations caused 1818
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treatment: A comparison of surgical and non-surgical therapy. J Periodontol 1993;64:990-997. Gaspar L, Szabo G. Manifestations of the advantages and disadvantages of using the CO2 laser in oral surgery. J Clin Laser Med Surg 1990;8:39-43. Pogrel MA, McCracken KJ, Daniels TE. Histologic evaluation of the width of soft tissue necrosis adjacent to carbon dioxide laser incisions. Oral Surg Oral Med Oral Pathol 1990;70:564-568. Kaplan L, Raif J. The Sharplan carbon dioxide laser in clinical surgery: 7 years experience. In: Goldman L, ed. The Biomedical Laser. New York: Springer-Verlag; 1981:89-97. Fisher SE, Frame JW, Browne RM, Tranter RMD. A comparative histological study of wound healing following CO2 laser and conventional surgical excision of canine buccal mucosa. Arch Oral Biol 1983;28:287-291. Abt E. CO2 laser treatment for gingivectomies reduces hemorrhaging, post-op pain. Clin Laser Mon 1992;10: 8-12.
30. Hobbs ER, Bailin PL, Wheeland RG, Ratz JL. Superpulsed lasers: Minimizing thermal damage with short duration, high irradiance pulses. J Dermatol Surg Oncol 1987;13:955-964. 31. Buell BR, Schuller DE. Comparison of tensile strength in CO2 laser and scalpel skin incisions. Arch Otolaryngol 1983;109:465-467. 32. White JM, Goodis HE, Rose CL. Use of the pulsed Nd:YAG laser for intraoral soft tissue surgery. Lasers Surg Med 1991;11:455-461. 33. Frame JW. Removal of oral soft tissue pathology with the CO2 laser. J Oral Maxillofac Surg 1985;43: 850-855. Correspondence: Dr. Onur Ozcelik, Department of Periodontology, Faculty of Dentistry, Cukurova University, Balcali 01330, Adana, Turkey. Fax: 90-322-3387331; e-mail: email@example.com. Accepted for publication June 6, 2006.