Evaluation of Pain Perception and Wound Healing After Laser-Assisted Frenectomy in Pediatric Patients: A Retrospective Comparative Study

Abstract

Background:

The maxillary labial frenulum is an attachment that connects the upper lip to the gingival tissue, and when it is too closely attached to gingival margin due to inadequate plaque control, it may put gingival health at risk.

Objective:

This study aimed to assess postoperative pain perception and wound healing after laser-assisted frenectomy in a pediatric population retrospectively.

Methods:

This study is based on the clinical records of the patients who received laser-assisted frenectomy treatment due to mucogingival problems at the pediatric dentistry department. Twenty-two patients were treated with either 2780 nm Er,Cr:YSGG laser (Waterlase iPlus; Biolase Technology, Irvine, CA, USA) or 940 nm diode laser (Epic10; Biolase Technology). The analyzed data included age, gender, frenulum insertion type, type of dental laser, postoperative pain perception, and wound healing. Postoperative pain evaluation was performed using Wong–Baker Faces Pain Rating Scale after 3 h, 1 day, 1 week, and 2 weeks. Wound surface healing was assessed through photography. Images were uploaded to the software, and changes in the wound surface area were measured in square millimeters on the day of frenectomy and on postoperative first day, first week, and second week.

Results:

Er,Cr:YSGG group had statistically significant better wound healing results after 1 and 2 weeks, respectively (p < 0.05). No significant difference was found between 2780 nm Er,Cr:YSGG laser and 940 nm diode laser groups in terms of pain perception.

Conclusions:

It can be concluded that both laser wavelengths are a safe and useful tool for frenectomies in pediatric patients with less pain. Er,Cr:YSGG laser achieved faster healing than 940 nm diode laser.

Clinical Registration number: Clinical Trials gov ID NCT04368715.

Introduction

The frenulum is described as a fold attaching the lip and the cheek to the gingival tissues.¹ When frenulum attachment is too close to the gingival margin, it can act as a local anatomic factor that increases plaque accumulation.² An abnormal labial frenulum has also been associated with midline diastema.³ Regarding the functional aspect, the labial frenectomy can be performed when the presence of an abnormal frenulum negatively impacts a child's life.⁴

Labial frenectomy can be performed by different methods including conventional scalpel technique, electrosurgery, or laser surgery.⁵ Scalpel technique is surgical excision of frenulum using a scalpel followed by suturing the operation area that may sometimes result in postoperative complications such as bleeding, pain, or swelling. These disadvantages of the conventional technique can be overcome by laser surgery. Using lasers in soft tissue procedures enhances the prognosis due to the following advantages: precision excision of tissue, minimum injury to adjacent tissue, hemostatic effect, and less postoperative pain and swelling.^2,6

Dental lasers such as diode lasers, carbon dioxide (CO₂) laser, neodymium-doped yttrium aluminum garnet laser (Nd:YAG), erbium yttriumm-garnet YAG laser (Er:YAG), and erbium, chromium:yttrium-scandium-gallium-garnet laser (Er,Cr:YSGG) can be used for soft tissue procedures. Different laser–tissue interactions occur depending on characteristics (wavelength, power, frequency, etc.) of the dental laser.^7,8

Absorption is the most essential laser–tissue interaction. Each tissue has specific chromophores that absorb specific laser wavelengths.⁸ The amount of energy that is absorbed is based on the characteristics of tissue such as pigmentation, content of water as well as laser wavelength, and emission mode.⁹ Diode lasers have a relatively broad wavelength range that are highly absorbed in soft tissue chromophores such as melanin and hemoglobin.¹⁰ Laser energy is absorbed by the tissue and converted into thermal energy that results in a change in tissue structure. This allows diode lasers to act selectively and coagulate, ablate, or vaporize soft tissue with better hemostasis.¹¹ Therefore, diode lasers are generally well indicated for soft tissue procedures.¹²

The major chromophores absorbing erbium laser wavelengths are water and hydroxyapatite. As regards the Er,Cr:YSGG laser and its interaction with soft tissue, water present within the tissue is naturally the major chromophore wherein the laser–tissue interaction occurs.^13,14 Erbium lasers ablate soft tissues by a similar mechanism as it works on the hard tissue. The laser energy is converted to local and superficial thermal energy that creates a massive expansion of the water molecules. These microexplosions result in thin layers of tissue ablation.¹⁵ Er,Cr:YSGG laser has been proven to be a useful tool for soft tissue applications with minimal thermal damage to the tissues and rapid healing of the wounds due to its short pulse duration and limited depth of penetration.^15,16

In this study, clinical outcomes of pediatric patients treated for labial frenectomy with either 2780 nm Er,Cr:YSGG laser or 940 nm diode laser were compared retrospectively.

Materials and Methods

Study design and data collection

This study is based on the records of the patients treated for labial frenectomy using a dental laser at the department of pediatric dentistry between September 2016 and December 2017. This study was conducted retrospectively from data obtained for clinical purposes and was in accordance with the Declaration of Helsinki. The study protocol was approved by the Research Ethical Review Committee of Trakya University Faculty of Medicine (TUTF-BAEK no. 2019/48). All treatment procedures performed were part of the routine care, in which patients were verbally informed regarding the clinical procedure. Treatment was completed after the patient's legal representative had read and signed an informed consent form.

Study population

The clinical records of 22 patients who matched the described inclusion criteria were selected for the retrospective investigation. The analyzed data included age, gender, frenulum insertion type, type of dental laser, postoperative wound healing, and postoperative pain perception.

The following are the inclusion criteria:

Patients aged between 8 and 13 years

Patients without any systemic condition

Treatments performed and followed up by the same operator

Patients who were treated using 2780 nm Er,Cr:YSGG laser for labial frenectomy

Patients who were treated using 940 nm diode laser for labial frenectomy.

The study subjects who met the inclusion criteria were assigned to each group according to the laser wavelength used for frenectomy procedure as follows: Er,Cr:YSGG laser group (n = 11) and 940 nm diode laser group (n = 11).

Treatment protocol

The same surgical technique was performed for all patients by the same operator after topical lidocaine spray anesthesia, followed by 0.3 mL of 4% articaine hydrochloride with 1:100,000 epinephrine local anesthesia administration. The upper lip was held under tension using a piece of gauze. The tip of the laser was held perpendicular to the frenulum, and the laser incision was made following the vertical axis of the frenulum, releasing all the fiber attachments until the wound took a linear shape. Next, the laser irradiation was applied in a transverse direction until the wound presented a rhomboidal form. Any adhesions to the periosteum were also removed by laser irradiation. In some patients, the interdental papilla was removed in case of papillary and papilla penetrating frenal attachment. No sutures were placed.

A piece of gauze dipped in normal saline was used to clean the wound area to remove any debris from the wound edges that may interfere with tissue healing. All treatment procedures were performed following guidelines for laser safety. The operator, assistant, and patient wore protective eyewear supplied with the laser system during the treatment. Patients were instructed to maintain good oral hygiene throughout the postoperative period and were evaluated after 3 h, 1 day, 1 week, and 2 weeks, postoperatively. The same operator examined all the patients to assess pain, edema, infection, fibrin layer thickness and formation, functional complications (speaking, eating, and brushing), and the overall surgical wound healing progress.

The 940 nm diode laser treatment procedure

Frenectomy was performed using an InGaAsP semiconductor diode laser 940 nm wavelength (Epic 10; Biolase Technology, Irvine, CA, USA), operated at a power of 1.5 watts (W) in continuous wave mode with a 400 μm diameter optical fiber tip. The power density was calculated as 298.5 W/cm². Before laser irradiation, initiation of the optical fiber tip was performed, and the frenulum was removed in contact mode.

Er,Cr:YSGG laser 2780 nm laser procedure

Frenectomy procedures were performed using the Er,Cr:YSGG 2780 nm laser (Waterlase^®; Biolase Technology) and free-running pulsed laser system. The latter was with fiber optic trunk fiber delivery system using a gold hand piece with an MZ5 (500 μm) glass fiber tip. Calibration of laser was performed according to the calibration factor of laser tip. The following laser parameters were used: power, 2.75 W; frequency, 50 Hz; pulse duration, 60 μs; pulse energy, 55 mJ/pulse; energy density per pulse, 22 J/cm²; air/water spray (20% air, 40% water). Laser parameters for laser bandage were power, 0.5; frequency, 30 Hz; pulse duration, 700 μs; noncontact mode, air/water spray (20% air, 20% water).

Assessment of pain

Postoperative pain was measured subjectively through children's evaluations at postoperative 3 h, 1 day, 1 week, and 2 weeks. Patients were asked to report their pain levels by using the Wong–Baker Faces Pain Rating Scale,¹⁷ which contains different facial expressions. Each child indicated the facial expression that most described their pain. On the Wong–Baker Faces Pain Rating Scale, the first expression is a happy face, and the other faces express rising degrees of pain until the last face is very unhappy. This method was previously validated for the determination of pain and discomfort in children.¹⁷

Assessment of wound healing

All patients were examined on 1 day, 1 week, and 2 weeks after the laser surgery to assess the surgical wound healing. Standardized photographs were taken using a scale (periodontal probe) that was used as a reference for the wound area measurements immediately after laser surgery and at postsurgical follow-up periods. The photographs were exported to an image software program (Image J—NIH, Bethesda, MD, USA), and the wound surface area was calculated in square millimeters.^18,19 An examiner who was blind to the treatment groups performed the measurements. Before the analysis, the examiner calibration was performed by using the wound area measurements of 10 patients who received laser-assisted frenectomy and were not involved in the study. Calibration was completed when the measures were similar to the square millimeter at the 90% level on these two previous assessments.

For each patient, the intraoral size of the upper right central incisor (mesial to distal) was measured and then correlated with the dimension of the incisor on the image. The proportion between the actual and image size was used to calibrate the photographs. Baseline wound surface area was calculated from the photographs taken immediately after surgery and compared with postoperative day 1, 1 week, and 2 weeks measurements of wound surface area.

Statistical analysis

Statistical analysis was performed using NCSS (Number Cruncher Statistical System) 2007 Statistical Software (Utah). Along with descriptive statistical analysis (mean, standard deviation, median, and interquartile range), independent t-test was used for comparison of pairs with normal distribution, Friedman test for time comparisons of non-normal distribution, and Dunn's multiple comparison test for subgroup comparisons. Mann–Whitney U test and chi-square test were used to compare qualitative data. Statistical significance level was set to p < 0.05. The effect size of the study was calculated.

Results

A total of 22 [16 girls (72.7%) and 6 boys (27.3%)] children between 8 and 13 years old were included in the study. All permanent maxillary incisors had fully erupted when frenectomy procedure was performed. Distribution of age, gender, and frenulum insertion type in relation to the laser treatment group is given in Table 1. No significant difference was found between study groups regarding the frenulum insertion type, age, and gender (p > 0.05). Er,Cr,YSGG laser group and 940 nm diode group were compared in terms of pain perception given in Table 2 and Fig. 1. No statistically significant difference was observed between groups regarding the pain rating scale scores (p > 0.05). The mean pain rating scale score at postoperative day 1 was found as 2 ± 1.27 for Er,Cr:YSGG laser-treated group and 2.36 ± 1.21 for 940 nm diode laser-treated group. There were statistically significant differences at subgroup comparison of pain rating scale scores for both laser groups given in Table 2 (p = 0.0001). The comparison of wound surface area measurements between groups and subgroup comparison are given in Table 2. No statistically significant difference was observed between wound surface measurements immediately after the operation and on postoperative day 1 between Er,Cr:YSGG and 940 nm diode groups (p > 0.05), whereas wound surface area measurements of Er,Cr:YSGG group were found significantly lower than the measurements of 940 nm diode group on postoperative 1 week and 2 weeks shown in Fig. 2 (p = 0.002, p = 0.023).

FIG. 1.

Changes in pain rating scores of children according to laser groups.

FIG. 2.

Changes in the wound surface area measurements according to laser groups.

Table 1.

Distribution of Age, Gender, and Frenulum Insertion Type Between Groups

	Er,Cr:YSGG	940 nm diode	p
Age (years)
Mean ± SD	9.91 ± 2.071	10.64 ± 2.80	0.618^a
Median (IQR)	10 (8–12)	9 (8–13)	0.618^a
Gender, n (%)
Female	6 (54.55)	10 (90.91)	0.056^b
Male	5 (45.45)	1 (9.09)	0.056^b
Frenulum insertion type, n (%)
Gingival	2 (18.18)	3 (27.27)	0.856^b
Papillary	4 (36.36)	4 (36.36)
Transpapillary	5 (45.45)	4 (36.369

p < 0.05.

Unpaired t test.

Chi square test.

IQR, interquartile range; SD, standard deviation.

Table 2.

Comparison and Subgroup Comparison of Pain Rating Scores and Wound Surface Area Measurements Between Groups

	Er,Cr:YSGG	940 nm diode	p ^a
Pain
Postoperative third hour
Mean ± SD	2 ± 1.27	2.36 ± 1.21	0.489
Median (IQR)	2 (2–2)	2 (2–4)	0.489
Postoperative first day
Mean ± SD	1.09 ± 1.04	0.73 ± 1.01	0.403
Median (IQR)	2 (0–2)	0 (0–2)	0.403
Postoperative first week
Mean ± SD	0 ± 0	0 ± 0	1
Median (IQR)	0 (0–0)	0 (0–0)	1
Postoperative second week
Mean ± SD	0 ± 0	0 ± 0	1
Median (IQR)	0 (0–0)	0 (0–0)	1
p ^b	0.0001	0.0001
Wound surface area
Immediately after operation
Mean ± SD	76.01 ± 28.98	72.63 ± 24.40	0.818
Median (IQR)	76.44 (47.24–105.63)	71.456 (54.32–92.98)	0.818
Postoperative first day
Mean ± SD	61.68 ± 25.57	73.13 ± 25.76	0.309
Median (IQR)	52.75 (43.37–79.68)	71.19 (55.2–79.81)	0.309
Postoperative first week
Mean ± SD	23.42 ± 15.56	50.70 ± 14.91	0.002
Median (IQR)	18.62 (13.42–37.79)	50.68 (39.02–68.58)	0.002
Postoperative second week
Mean ± SD	10.85 ± 8.03	20.91 ± 11.89	0.023
Median (IQR)	7.70 (5.08–16.04)	18.81 (12.35–24.63)	0.023
p ^b	0.0001	0.0001

p < 0.05, statistical significance.

Mann–Whitney U test.

Friedman test.

Discussion

Recent advances in laser technology enable optimal preventive and minimally invasive interventions for therapeutic procedures in pediatric dentistry. Many clinical applications can be performed on both soft and hard tissues using different laser wavelengths.²⁰ Lasers are useful tools for surgical procedures in pediatric dentistry as they reduce the amount of local analgesia required and the duration of intervention. In addition, lasers have a hemostatic effect that improves visibility of the operating area, which is considered a substantial advantage when treating pediatric patients.^21,22 This study retrospectively evaluated the postoperative clinical outcomes such as pain perception and wound healing after laser-assisted frenectomy in a pediatric population.

Surgical treatment using a diode laser requires anesthesia since thermal energy applied generates pain. Therefore, patients whose laser frenectomy was performed after local anesthesia administration were included in the study for bias reduction. The pain was evaluated using the Wong–Baker Faces Pain Rating Scale, which is a self-reported pain scale recommended for use in children aged 3 years and older.^17,23 Our findings indicated that there was no statistically significant difference between pain rating scores, during and after frenectomy procedure performed using Er,Cr:YSGG laser and 940 nm diode laser. Children mostly reported “Face 2” that indicates “hurts a little bit” from Wong–Baker Faces Pain Rating Scale 3 h after laser surgery.

Previous studies evaluated postoperative clinical outcomes of different dental lasers for oral surgical procedures. In most of the studies, laser-assisted frenectomy was compared with the conventional scalpel technique.^2,5,16,18,19 According to results of these previous studies, less postoperative pain and discomfort were reported when diode, Nd:YAG, Er:YAG, Er,Cr:YSGG, and CO₂ lasers were used for frenectomy, compared with the traditional scalpel technique.^6,7,24 Luchian et al.²⁵ evaluated 940 nm diode laser versus conventional technique for the frenectomy procedure in orthodontic patients. According to their study results, the healing process was faster in the laser surgery group than in the scalpel technique group. It was also concluded that the laser surgery group presented significantly reduced postoperative pain.²⁵

In another study, it was reported that frenectomy performed using Er,Cr:YSGG (2780 nm) laser significantly reduced postoperative pain compared with frenectomy performed with the scalpel technique. Moreover, healing time was significantly lower in Er,Cr:YSGG laser-assisted frenectomy compared with frenectomy performed using scalpel technique.²⁶

In this study, there was no scalpel group due to difficulties in operating children using the conventional technique, which is one of the limitations of this study. Lasers are mostly preferred for treating pediatric patients for frenectomy procedure in the department of pediatric dentistry.

Use of different types of dental lasers for soft tissue procedures on pediatric patients has been mostly reported as case studies. In the literature, there are a few clinical studies that compared the clinical outcomes of different laser types.^7,22,27 Pie-Sanchez et al.⁷ investigated the clinical effects of laser frenectomy performed using a CO₂ laser (power: 5 W, power density: 1000 W/cm²) versus Er,Cr:YSGG laser (power: 1.5 W, energy density: 26.54 J/cm², 12% water, 8% air). According to their study results, lower postoperative pain and discomfort along with fast wound healing time was reported for Er,Cr:YSGG laser-treated group. It was also concluded that laser surgery was well accepted by all patients, without any complications during and after treatment.

In another study, Olivi et al.²⁷ retrospectively investigated the clinical outcomes of labial frenectomies performed by Er:YAG laser in a pediatric population. In this study, patients reported no pain or little discomfort after laser surgery.

Aras et al.²⁸ compared 16 patients treated using 808 nm diode laser and Er:YAG laser for ankyloglossia. According to their results, only patients assigned to the Er:YAG laser group could be operated without local anesthesia administration for lingual frenectomy procedure, whereas patients in the 808 nm diode laser group required local anesthesia infiltration. It was also reported that there was no significant difference between the two groups regarding the degree of surgical discomfort except for the postoperative first 3 h.

Kumar et al.²⁹ evaluated series of six cases who were operated using Er,Cr:YSGG laser for surgical soft tissue procedures. They reported no discomfort of the patients during and after laser procedure. Minimal bleeding, no edema, and good wound healing were observed without any need for suture placement and postoperative medication.

In this study, patients reported little discomfort after labial frenectomy for both laser groups. However, improved wound healing was observed in the Er,Cr:YSGG laser group compared with the 940 nm diode laser group. Pain reduction with laser-assisted frenectomy can be related to the protein coagulum developed on the wound surface, therefore, acting as a biological dressing and sealing the sensory nerve endings.³⁰ Further, laser-assisted frenectomy eliminates the need for sutures that may be one of the reasons for less pain perception after laser irradiation.

Erbium lasers in surgical procedures on soft tissues are associated with lower surface temperature rise and with fewer epithelization changes. Thus, Er,Cr:YSGG laser produces a comparably thin coagulation layer on the surface of the wound as a result of less penetration and decreased thermal changes. Irradiation with Erbium lasers can also form reactive oxygen species that result with sterilization effect, and fibroblast, collagen, and extracellular matrix formation is stimulated in the tissue.³¹ Further, there is the biostimulation effect that boosts the activity of macrophages for the removal of the fibrin layer and accelerates the epithelization processes.³² The fast and improved healing of the wound area after laser-assisted frenectomy using the Er,Cr:YSGG laser can be explained by all these effects.

Limitations

To the best of our knowledge, this is the first study comparing 940 nm diode laser versus Er,Cr:YSGG laser for frenectomy in a pediatric population, which makes it difficult to compare results of this study with those of previous studies. The retrospective nature of this comparative study and the small sample size were the limitations of this study. Therefore, further clinical trials with a larger sample size are required to demonstrate the efficiency of laser irradiation and to assess clinical outcomes of different laser wavelengths used for surgical procedures in pediatric dentistry.

Conclusions

In this study, the pain perception was low for both laser groups. However, the Er,Cr:YSGG laser-treated group had improved wound healing when compared with 940 nm diode laser-treated group. Laser-assisted frenectomy procedures were well tolerated by all patients without any postoperative complications. Within the limitations of this study, it is concluded that both types of lasers are safe and effective tools for treating pediatric patients for the frenectomy procedure.

Footnotes

Author's Contributions

S.G.O. conceived the ideas, collected the data, analyzed the data, and wrote the article.

Acknowledgments

I thank Dr. Nafi Onur an experienced specialist in periodontology for performing the measurements of the wound surface area.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was provided for this article.

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