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“Other Procedures” For Which Your Soft Tissue Laser is Useful

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by Benjamin Lund, Editor, Orthotown Magazine

The use of a laser in an orthodontic office is no longer a “novelty.” Many orthodontists are taking advantage of the benefits of exposing teeth to allow earlier access or easier bonding and gingival recontouring to improve results. There have been a number of excellent articles written about these procedures. What is perhaps less known and certainly less mentioned in the orthodontic literature are the “other” laser procedures that are not only possible but advantageous as an adjunct to orthodontic treatment. Here, we’ll discuss these “other” procedures and the ways they can be performed using diode lasers.

Frenectomies/Frenotomies
A frenum is by definition “a narrow fold of mucous membrane connecting a moveable part to a fixed part.”¹ There are normally seven oral frena-upper and lower midline frena, upper and lower, right and left lateral frena and a lingual frenum at the base of the tongue.² When functioning normally, these frena “keep the lips and tongue in harmony with the growing bones during fetal development.”² Abnormally developing frena can cause developmental and orthodontic problems. Fortunately, abnormal frena can be easily corrected with a diode laser.

When a frenum is released without removal of tissue, it is called a frenotomy. When release includes removal of tissue, the proper term is frenectomy. Kotlow³ has proposed a classification system for labial frena.

Class I Normal Frenum
Class II Frenum inserts above the teeth
Class III Frenum inserts between centrals
Class IV Frenum inserts into palate

To determine the depth of insertion of a labial frenum, simply pull the lip away from the alveolus and observe where the tissue blanches. Blanching on the anterior aspect of the alveolus suggests local insertion of the frenal fibers (Class I or II), while blanching on the palatal aspect (incisive papilla area), indicates a palatal insertion (Class IV). Class I or II frena can usually be corrected with a superficial frenotomy, while Class IV frena will likely require a deep frenectomy. Class III frena may fall in either category.

Superficial Frenotomy
For Class I, Class II and some Class III frena, correction can be effected with a superficial frenotomy. Technique is straightforward. Set the laser to the normal settings used for gingivectomies (see section on laser settings below) and blacken only the very tip of the fiber. Anesthetize the area (a topical anesthetic is usually adequate), place tension on the associated lip and with the laser fiber parallel to the alveolar gingival, touch the tip of the laser against the frenum as close as possible to the alveolus. While lasing, assure everyone within the nominal hazard zone is wearing protective eyewear, make sure everyone in close proximity is wearing a protective mask (filtering to 0.1 microns) and have your assistant place high volume suction close to the lasing site to draw cool area across the site and suction away the “plume” (combination of water vapor, cell contents, odor given off when using a laser). With a brushing motion, separate the frenal tissues, keeping tension on the lip. Using only the tip of the laser fiber, continue separating the frenum until you are left with a symmetrical lesion (Figure 1B).

Give the patient normal home care instructions (see Patient Home Care Instructions below) and make sure they keep the lip moving to prevent relapse. One way to avoid reattachment of the frenum would be to suture it closed from lateral aspect to lateral aspect, but an easier solution is to simply have the patient to pull the lip out to look at the site at least once a day. Normal healing for a labial frenotomy is approximately one to two weeks.

One example of when a superficial fiberotomy is appropriate is shown in Figure 1, where the frenal attachment is close to the gingival crest. The pull of the lip has caused recession and chronic gingivitis on the lower left lateral incisor. Releasing the frenum reduces the pull and prevents further recession, allowing the inflamed tissues to heal. In some cases, it is possible to actually see regrowth of the gingival attachment.

To see a video representation of a superficial frenotomy, visit www.eggheadortho.com and see the “Training Movies” page.

Another scenario where a superficial frenotomy would be appropriate is in association with a gingivectomy. Even a frenum that appears to be a non-issue initially (Figure 2A), might become an issue after performing a gingivectomy to improve post-treatment aesthetics. In these cases, a superficial frenotomy avoids leaving a frenum close to the gingival margin and the possibility of future recession (Figure 2B).




Deep Frenectomy
When a Class III or Class IV frenum is associated with a midline diastema, a more involved approach is appropriate. To avoid relapse, it is necessary to remove the deep fibers attached to the bone and extending through the diastema. When performed with a scalpel, release involves laying a flap, removing all the fibers, including scaling away all the deep fibers attached to the bone, then suturing closed.

With a “hard tissue laser” (i.e., Erbium), the approach is similar, but without laying a flap. Usually a frenotomy is performed first, with the same technique and recommendations as for a superficial frenotomy, to allow access. Then the laser is directed into the soft tissue until it touches bone and manipulated to remove the fibers that insert on the facial and extend to the palate.

Most orthodontists use diode lasers, which can damage bone if used improperly. With a diode, a deep frenectomy also involves first releasing superficial fibers. Then a wedge of tissue is removed to allow access (preferably without actually touching the bone). Once close to bone, a sharp scaler is used to release the deep fibers. Since there is no flap, this is done by feel. After the fibers are released all the way to the crest of the interproximal bone, the laser is used to stop any bleeding. In this way, the fibers are removed without damaging the bone from excess heat. Figure 3 shows results of a deep frenectomy.

Home care recommendations are the same as for a superficial frenotomy.

Lingual Frenum-Ankyloglossia-Tongue-Tied
A normal lingual frenum allows enough freedom to lick lips, annunciate properly, clean buccal surfaces of teeth and swallow with the tip of the tongue against the palate. Abnormally short lingual frena can occur in nearly five percent of all neonates and is often diagnosed early when there are difficulties breast feeding, where the incidence jumps to 12.8 percent.4-6 In older patients, ankyloglossia is associated with speech difficulties7,8 even significant orthodontic problems.2,9,10

Diagnosis of ankyloglossia has often been based on symptoms (i.e., difficulty breastfeeding) or appearance (a short, thick, muscular or fibrotic). Kotlow11 measured the distance from the tip of the tongue to the insertion of the frenal attachment for 322 consecutive patients in his pediatric dentistry practice and proposed a more objective diagnostic matrix:

Clinically acceptable, normal range of freedom:  >16 mm
Class I: Mild Ankyloglossia:  12-16 mm
Class II: Moderate Ankyloglossia (Figure 4):  8-11 mm
Class III: Severe Ankyloglossia:  3-7 mm
Class IV: Complete Ankyloglossia (Figures 5A&B):  < 3mm



Normal Range of motion:
  1. Tip of the tongue can protrude outside the mouth without clefting (Figure 4).
  2. Tip of the tongue can sweep upper and lower lips easily without straining (Figures 5B&C).
  3. When retruded, no blanching of tissue lingual to the lower anterior teeth.
  4. Tongue should not place excessive forces on the lower anteriors.
  5. The lingual frenum should allow a normal swallowing pattern.
  6. The lingual frenum should not create a diastema between the mandibular central incisors.
  7. In infants, the underside of the tongue should not exhibit abrasion.
  8. The frenum should not prevent an infant from attaching to the mother’s nipple during nursing.
  9. Children should not exhibit speech difficulties associated with limitations of the movement of the tongue.
Traditionally, lingual frena were released in newborns prior to leaving the hospital. Many medical practitioners now take a “wait and see” approach, delaying frenotomy until after development of the primary dentition11-13 or until “there are any problems.” Since the traditional “problems” are related to breastfeeding, once past the age of suckling, ankyloglossia is often left undiagnosed and untreated. For this reason, it is not uncommon to see patients with some degree of ankyloglossia in an orthodontic office.

It is therefore appropriate to include evaluation of tongue mobility as part of the routine orthodontic examination sequence. Have the patient raise their tongue toward the roof of the mouth and evaluate the shape, the distance from the tip to the frenal attachment and the mobility. While it is certainly not appropriate to release every Class II, III or IV lingual frenum, it is also important to realize that these patients do not necessarily have a frame of reference for what is normal. All they have ever known is what they’ve always had.

From an orthodontic perspective, there is a host of possible growth and development issues that might be related to ankyloglossia. For example, it is generally held that a normal swallow involves placing the tongue against the roof of the mouth and that an improper swallow (with the tongue not against the palate) can lead to a narrowing of the upper arch, crossbite or crossbite tendency, excessive vertical growth of the maxilla and an open bite tendency.14-16 With ankyloglossia, a patient’s tongue cannot touch the palate and these patients might develop any or all these symptoms. Northcutt2 reported 84 percent of patients with abnormal frena developed maxillary constriction and concomitant crowding (80 percent), while 52 percent developed an open bite.

Another possible consequence of being tongue-tied relates to airway. One diagnostic sign of sleep apnea is when the posterior aspect of the tongue occludes part of the airway (Malampati score). With Class IV ankyloglossia, any attempt to raise the tongue results in an appearance typical of that seen with sleep apnea sufferers.

Beyond that, it is not uncommon for teenagers to have suffered from speech issues or difficulty swallowing and not realize it isn’t normal. The 19-year-old patient in Figure 4 presented for orthodontic treatment. When made aware of her Class II ankyloglossia, her mom immediately asked whether that could be related to her lisp and pointed out that no one had ever mentioned this before. Correcting this problem is relatively easy with a diode laser and is very similar to a superficial frenotomy.

Lingual Frenotomy Technique
First, anesthetize the frenum. This can be done with a topical anesthetic, but take care to assure none of the topical is swallowed, as this can cause an uncomfortable inability to swallow and can cause a nervous patient to become even more apprehensive. An injection just below the lingual frenum is also effective without danger of swallowing anesthetic.

Once numb, set the laser to the normal settings used for gingivectomies (see section on laser settings below), blacken only the very tip of the laser fiber and place tension on the lingual frenum. While this can be done by wrapping a cotton 2x2 around the tip of the tongue, a very effective tool is the grooved director probe (Figure 6B). Simply have the patient lift the tongue and bring it slightly forward, then place the director probe to keep tension on the frenum. While lasing, assure everyone within the nominal hazard zone is wearing protective eyewear and a 0.1 micron protective mask and have your assistant place high volume evacuation in close proximity to the lasing site to draw cool area across the site and suction away the “plume.”

In order to avoid deep tissues, large vessels and nerves, and the ducts of the sublingual salivary glands, it is best to stay within the fibrous portions of the frenum. This can be done effectively by holding the laser fiber perpendicular to the inferior border of the tongue and, using the tip of the laser and a brushing motion, separate the frenal tissues, keeping tension on the tongue (Figure 6). Continue separating the frenum until you are left with a symmetrical lesion (Figures 6C, 7B).




If this technique does not allow adequate mobility, additional release can be obtained by releasing the frenum as close as possible to the alveolus (Figure 7). Limit the amount of release in this area to the fibrous tissues to avoid severing the submandibular saliva gland ducts.

Give the patient normal patient home care instructions (see below), but with the additional recommendation to make sure and keep the tongue moving as much as possible to avoid reattachment of the frenum. As was the case with labial frenectomies and frenotomies, suturing is an option, but by having the patient open wide and stretch their tongue toward the roof of the mouth several times a day, relapse can be avoided. It is also important to explain that after about one week, the patient should expect to see a white plaque form (Figure 8). This is normal and should resolve to look more normal at two weeks, but if the patient is not informed, they might mistakenly assume there is an infection.

To see a video representation of a lingual frenotomy, please go to www.eggheadortho.com and see the “Training Movies” page.

Laser Settings for Frenectomies/ Frenotomies
Each diode uses different settings for different procedures and the settings for a particular diode can vary dependant on many factors, including the thickness and type of tissue being lased (since a diode is absorbed in keratin and hemoglobin, tissue with less circulation might require a slightly higher setting), length and age of the fiber (when there is a cleavable fiber, instead of one-use tips, the effective power at the end of the fiber tends to degrade as the laser is used, requiring a higher power for the same procedure when approaching the end of the fiber), and the technique used. In general, it is best to use the lowest power necessary to accomplish a task. This reduces the risk of tissue charring, leaves a more natural looking immediate result (pinker, healthier looking tissue) and usually results in less soreness and more rapid healing.

For most frenectomies, excellent results can generally be obtained using the same settings as used for gingivectomies. As a general guideline, the author uses approximately 0.9W CW (Continuous Wave) or 3.2W pulsed at 20ms on/20ms off with an 810nm laser for the initial setting. Longer pulse lengths seem to approximate the results of continuous wave, so when the pulse lengths are long (>40 ms), it might be just as advantageous to use a continuous wave mode.

Just as on gingivectomies, patience is important. A common issue for new laser users is to use more power than is necessary, which produces desiccated, charred tissue that increases the patients discomfort during healing and takes longer to completely heal. The first pass with the laser will not produce the total desired effect and might seem like it’s not doing anything at all. With repeated passes, however, it is possible to get excellent results at these lower settings.

Patient Home Care Instructions
Recommend that the patient avoid salty or spicy foods for a few days. Give them several Vitamin E tablets with instructions to cut open the tabs and rub the oil into the affected area once a day to keep it moist and promote healing. Let them know that there might be minor soreness that is usually relieved with a mild analgesic and that they should use warm salt water rinses after the first few days. Mobility to avoid relapse is also appropriate.

Apthous Ulcers
Another lesser-known service possible with a diode laser is to help relieve the pain of apthous ulcers or herpetic lesions. The technique used for these procedures if very different than that used for most other laser procedures:
  1. No anesthesia: These procedures are performed without anesthesia. In fact, it is important that the patient have sensation to let you know when to alter your technique.
  2. Unactivated tip: While most laser procedures with a diode laser involve “activating” the tip of the fiber by placing it against articulating paper or articulating film, treatment of apthous ulcers and/or herpetic lesions is performed with an unactivated tip.
  3. Non-contact: While the technique used for gingivectomies, exposures, frenectomies and frenotomies involves light contact, treatment for apthous ulcers is performed without touching the tissues.
Lingual Frenotomy Technique & Settings
With no anesthesia and no tip activation, prepare the patient by explaining that you will be using the laser to reduce the pain of the apthous ulcer or herpetic lesion. There are two recommended settings to help with these procedures, both on continuous wave:
  1. Set the power at 2.0W and direct the laser fiber perpendicular to the surface of the lesion, starting approximately an inch from the lesion. Slowly bring the fiber closer to the lesion until the patient just begins to feel warmth. If it becomes uncomfortable, move the laser back a bit, then forward and keep the laser energy over the lesion for a total of approximately one minute.
  2. Set the power to 0.6W and direct the laser fiber perpendicular to the surface of the lesion. With the fiber approximately 1mm from the lesion, systematically “cover” the lesion, first going left to right, then top to bottom, extending approximately 1mm beyond the edges of the lesion and keeping the laser moving to avoid excessive heat buildup in any one area. Continue for approximately one minute.
While protective equipment should always be worn while lasing, it is of particular importance when using a laser on herpetic lesions. Because lasing basically involves vaporizing cells, all the contents of the cells become part of the plume. Therefore, when lasing herpetic lesions, it is known that there are herpetic viruses in the plume. Therefore, make sure everyone within the nominal hazard zone is wearing protective eyewear, a protective 0.1 micron mask and have your assistant use high volume evacuation to draw cool air across the site and suction away the “plume.”

It is expected that the patient experience immediate pain relief and it has been suggested that both apthous ulcers and herpetic lesions heal more quickly (Figure 9).17-19 It has also been suggested that herpetic lesions usually do not return to the same areas after lasing and that those that do return, they are less severe than the previous lesion.17-19

Other Possible Procedures
In addition to the procedures detailed above, there are a number of other procedures for which a soft tissue laser is potentially useful:
  1. Fibroma removal: During orthodontic treatment, when the cheeks rub against the braces, occasionally a fibroma forms. These can become a source of irritation to the patient and may become large enough to interfere with proper biting. A soft tissue laser can be used to remove the fibroma. Note that when performing such a procedure, the removed portion should be evaluated by a qualified pathologist to rule out cancer and that it should be noted on the referral that the biopsy was taken with a laser to avoid improper diagnosis.
  2. Venous Lakes: Although rare in orthodontics, as patients age, venous lakes sometimes form on the lips. In actuality, these lesions are perhaps best treated with a diode laser, as the depth of penetration and relatively high absorption in hemoglobin and melanin can provide effective non-invasive reduction or elimination of the venous lake.20,21
  3. Tissue Welding: While most laser procedures occur at 100-150 degrees Fahrenheit (boiling point of water), tissue welding occurs at approximately 70-90 degrees. Numerous reports of effective tissue welding are available in the medical literature22,23 and it is possible to use a diode laser, at a lower setting (approximately 80 percent) of that for a gingivectomy or frenectomy to weld tissue together without sutures. In an orthodontic office, this could potentially be useful in the northern states in the winter, when patients come in with split lips.
Summary
While the use of soft tissue lasers is becoming more and more commonplace in orthodontic offices, primarily for gingivectomies and exposure of teeth, they can also be used for a variety of additional procedures appropriate to orthodontics.
Author’s Bio
Dr. Lou Chmura graduated from Michigan State University in 1978. After working for three years as an engineer, he became convinced he could better serve people in health care. Dr. Chmura completed his Master’s degree in Orthodontics from the University of Michigan in 1987 and has had specialized training in biomechanics and aesthetics. His research project was selected for first place at the University of Michigan and he was selected to present his findings at the Association of Dental Research meeting at Denver University. Dr. Chmura is member of the American Dental Association, Michigan Dental Association, the American Association of Orthodontics, the American Board of Orthodontics, the Academy of Laser Dentistry, and the American Academy of Dental Sleep Medicine. In 2006, Dr. Chmura was invited to write a chapter on the innovative uses of a Diode laser in an orthodontic office. Dr. Chmura has lectured nationally on “Uses of a Soft Tissue Laser in Orthodontics” and “Treatment Planning in an Era of Innovative Technology.”

References
  1. Summer, A: Ankyloglossia-To Clip or Not to Clip? That’s the Question. The ASHA Leader, 10(17), 6-7, 30.
  2. Northcutt, ME: The Lingual Frenum. JCO, 43(9), 557-565.
  3. Kotlow, LA: Oral Diagnosis of Abnormal Frenum Attachments in Neonates and Infants: Evaluation and Treatment of the Maxillary and Lingual Frenum using the Erbium: YAG Laser. J Pediatric Dental Care, 2004, 10(3).
  4. Marmet C,Shell, Marment R. Neonatal frenotomy may be necessary to correctbreastfeeding problems. J.Human Lact, 1990;6:117-120
  5. Messner, AH, Lalakea, ML: The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg, 2002, Dec; 127(6): 539-45.
  6. Ballard JL, Auer CE, Khoury JC: Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002, 110:e63.
  7. Messner AH, Lalakea, ML, Aby, J, Macmahon, J, Bair, E: Ankyloglossia: incidence and associated feeding difficulties, Arch Otolaryngol Neck Surg 2000, 126(1):36-9.
  8. Lalakea, ML, Messner, AH: Ankyloglossia: does it matter? Pediatr Clin North Am, 2003, Apr; 50(2); 381-97.
  9. Defabianis P. Ankyloglossia and its influence on maxillary and mandibular development. (A seven year follow-up case report). Funct Orthod, 2000, 17:25–33.
  10. Palmer, B: Frenums, tongue-tie, ankyloglossia. www.brianpalmerdds.com/frenum.htm. 2001
  11. Kotlow, LA: Ankyloglossia (tongue-tie):A diagnostic and treatment quandary. Quintessence International 1999, 30(4), 259-262.
  12. Ketty, N, Sciullo, P. Ankyloglossia with psychological implications. J Dent Dhild, 1974. Jan-Feb, 43-46.
  13. Warden, P. Ankyloglossia: A review of the literature. Gen Dent. 1991 July-August, 252- 253
  14. Linder-Aronsen, S. Adenoids: their effect on the mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the dentition. Acta Oto-laryng Suppl, 1970, 265:5-132.
  15. Lessa, F, Enoki, C, Feres, M, Valera, F, Lima, W, Matsumoto, M. Breathing mode influence in craniofacial development. Rev Bras Otorrinolaringol. 2005, 71(2): 1-8.
  16. Mattar, SE, Anselmo-Lima, WT, Valera, FCP, Matsumoto, Man. Skeletal and occlusal characteristics in mouth-breathing pre-school children. Journal Clin Ped Dent, 2004, 28(4): 315-318.
  17. Colvard, M, Kuo, P. Managing aphthous ulcers: laser treatment applied. J Am Dent Assoc, 1991, 122: 51-2.
  18. Convissar, RA, Massoumi-Sourey, M. Recurrent apthous ulcers, etiology and laser ablation. Gen Dent 1992, 40:512-515.
  19. Pekins, D, O’Toole, T, Yancy, J. Laser treatments of aphthous and herpetic lesions. J Dent Res 1994, 73:190.
  20. Bekhor, PS, Long-Pulsed Nd:YAG Laser Treatment of Venous Lakes: Report of a Series of 34 Cases. FACD Dermatologic Surgery. 2006, 32(9):1151 - 1154
  21. Wall TL, Grassi AM, Avram MM. Clearance of multiple venous lakes with an 800-nm diode laser: a novel approach. Dermatol Surg. 2007 Jan;33(1):100-3.
  22. Foyt, D, Johnson, J, Kirsch, R, Bruce, J, Wazen, J. Dural closure with laser tissue welding. Otolaryngology - Head and Neck Surgery, 1996. 115(6), 513-518.
  23. Ott, B, Züger, BJ, Erni, D, Banic, A, Schaffner, T, Weber, HP, and Frenz, M. Comparative In Vitro Study of Tissue Welding Using a 808nm Diode Laser and a Ho:YAG Laser. Lasers in Medical Science. 2001, 16(4), 260-266.
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