Original Article

Evaluating the Clinical Efficacy of Maxillary Labial Frenectomy

Procedure Using Diode Laser (980 nm) and Conventional Scalpel: An
Observational Study
Kiran Vincent1, Sachin Aslam2, Roshni Abida2, Tom Thomas2, Mathew Pynummoottil Cherian2, Sooraj Soman2
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1
Department of OMFS, Aim: This is an era of minimally invasive and least traumatic surgical interventions

Abstract
Malabar Dental College and
Research Center, Edappal,
Kerala, India, 2Department of
OMFS, MES Dental College,
Perinthalmanna, Kerala, India
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being focused on. The traditional scalpel frenectomy technique offers an increase
in post‑operative sequelae. To unravel this scenario a comparative evaluation is
carried out to find out the clinical outcomes and quality of life after maxillary
labial frenectomy using a conventional scalpel and diode laser frenectomy of
980 nm. Materials and Methods: Thirty‑six subjects age ranging between 18
and 45 years reported to the Department of Oral and Maxillofacial Surgery, MES
Dental College, Perinthalmanna with an aberrant frenal attachment of maxillary
labial frenum were randomly assigned into two groups. Group A underwent the
conventional scalpel technique and group B for the diode laser‑assisted (980 nm)
frenectomy technique. The post‑operative parameters of ooze from the surgical

site, pain, wound healing, and discomfort or acceptance of the procedure were
assessed on day 1, day 7, and day 14, respectively. Results: The diode laser group
exhibited statistically significant clinical and healing outcomes. Less pain, minimal
or absent ooze, increased healing, and better acceptance of the procedure with
diode laser at 1, 7, and 14 days recall visit. Conclusion: Surgical interventions
involving needle puncture and the associated post‑operative sequelae are the most
dreaded experiences that make patients indifferent toward surgical treatments.
Thus in terms of better clinical outcomes and improved quality of life diode laser
frenectomy is an excellent alternative wherein a needleless anesthetic success
followed by minimal surgical intervention and less post‑operative sequelae with
Submitted: 29-Jan-2023
fast recovery is possible.
Revised: 13-Feb-2023
Accepted: 14-Feb-2023
Keywords: Conventional technique, diode laser 980 nm, frenectomy, laser
Published: 05-Jul-2023 therapy, quality of life, scalpel

Introduction procedure that involves the complete removal of the

A berrant frenal attachment and its management is
a routine minor oral surgical procedure carried
out in maxillofacial surgery. An abnormal frenum
has hypertrophic, fibrotic, fan‑shaped, or bifid‑ending
construction.[1] Individuals with an abnormal frenulum
attachment can experience papilla loss, gingival
recession, difficulty in maintaining oral hygiene along
with diastema, and psychological discomfort.[2] Thus,
the treatment of this aberrant frenal attachment involves
complete excision of the frenum commonly known as
frenectomy. According to Archer, frenectomy is a surgical
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frenulum and its attachment to the underlying bone that
has been done with the conventional traditional technique
using a scalpel since 1961.[3] Surgical interventions are
accompanied by various post‑operative sequelae such as
pain, swelling, bleeding, and delay in wound healing.
Address for correspondence: Dr. Kiran Vincent,
Department of OMFS, Malabar Dental College and Research
Centre, Edappal ‑ 679582, Kerala, India.
E‑mail: kiranvincent5@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak,
and build upon the work non‑commercially, as long as the author is credited and the new
creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Vincent K, Aslam SA, A R, Thomas T, Cherian MP,
Soman S. Evaluating the clinical efficacy of maxillary labial frenectomy
DOI: 10.4103/jpbs.jpbs_85_23 procedure using diode laser (980 nm) and conventional scalpel: An
observational study. J Pharm Bioall Sci 2023;15:S688‑92.

S688 © 2023 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow
 Vincent, et al.: Frenectomy: Scalpel/ laser

In addition to the traditional conventional frenectomy,

modern technology like soft tissue lasers provides an
alternative treatment option. Various types of lasers
used in dentistry include neodymium‑doped yttrium
aluminum garnet (Nd: YAG), carbon dioxide, erbium
YAG (Er: YAG) and erbium, chromium: yttrium:
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scandium gallium‑garnet (Er, Cr: YSGG), and diode

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lasers.[4] The advantage of using laser during surgery

includes less discomfort, less bleeding, minimal to no
a b c
anesthesia, and less damage to the surrounding tissues.
Less scarring, quicker procedure recovery, minimal
post‑operative discomfort, and a lower risk of infection
are all benefits after surgery.[5]
In the present study, to find out better clinical outcomes,
an evaluation was conducted for frenectomies using a
conventional scalpel and diode laser of 980 nm. The aim
of this study is to find out the most clinically efficient
surgical technique with improved quality of life and
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faster recovery.
Materials and Methods
This study was conducted in the Department of Oral and
Maxillofacial Surgery, MES Dental College and Hospital
after obtaining approval from the institutional ethics
committee board and an informed consent was obtained
from each patient before enrolling into the study.
Study groups
American Society of Anesthesiologists (ASA 1) patients
with papillary and papilla penetrating type of frenal
attachment (according to Placek M et al. classification),[6]
aged between 18 and 45 years were included. A total of
36 patients of both males and females were 18 of who
underwent the conventional scalpel technique (Group A)
and the other 18 for diode laser‑assisted (980 nm)
maxillary labial frenectomy technique (Group B).
Patients with systemic illness and those who do not turn
up for the follow‑up were excluded from the study.
Surgical procedure
For the conventional frenectomy technique,
local anesthesia of 2% lignocaine with 1:80 000
adrenaline (LIGNOX 2%) infiltration was given. The lip
extended and the frenum engaged with a hemostat and
was inserted into the depth of the vestibule. Using the
No. 15 blade a triangular‑shaped incision was carried on
the upper and lower surface of the hemostat. Together
with the alveolar attachment the whole band of tissues
was excised. Fibrous attachments were then dissected
to the underlying periosteum. The wound edges were
approximated and sutured with interrupted sutures using
a non‑resorbable 3‑0 black braided silk suture (Ethicon,
Johnson and Johnson pvt. Ltd) [Figure 1].
d e f
Figure 1: Conventional scalpel frenectomy (a) Pre‑operative (b)
Surgical defect (c) Immediate post‑operative (d) Post‑operative day 1 (e)
Post‑operative day 7 (f) Post‑operative day 1
For the laser technique, topical spray (Lidayn surface
anesthetic, Lidocaine USP 15% w/w) was used to obtain
surface anesthesia. Evolution Med Medical Diode Laser
Systems with a power setting of 10W, laser wavelength
of 980 nm, an aiming beam of 635 nm, and 400 um
fiber tip was used. Mode of operation of the laser was
continuous with intermittent loading. The tip of the laser
was moved with a paintbrush technique from the base
to the apex of the frenum. The surgical site was neither
sutured nor wound dressings applied [Figure 2].
Post‑operative instructions were given and were
instructed to take analgesics in case of intolerable
pain. All patients were recalled on 1st, 7th, and 14th day
post‑operatively to assess post‑operative ooze or
bleeding from the surgical site, post‑operative pain,
wound healing, and post‑operative discomfort or
assessment of the procedure.
Outcome measurement
Patients who underwent the surgical procedure were
assessed for the post‑operative clinical and healing
outcomes, following that all the patients were recalled
on 1st, 7th, and 14th day post‑operatively. Post‑operative
ooze from the surgical site was noted as present or
absent.
Evaluation of post‑operative pain using visual analog
scale (VAS) in which the patients were instructed to
make a vertical mark on a horizontal line of 10 cm
in length attached by word descriptors at each point
for pain and discomfort during a speech at 1st, 7th, and

Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023 S689
 Vincent, et al.: Frenectomy: Scalpel/ laser
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c
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a
d
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b e
Figure 2: Diode laser frenectomy (a) Pre‑operative (b) Immediate
post‑operative (c) Post‑operative day 1 (d) Post‑operative day 7 (e)
Post‑operative day 14
14th day post‑operatively and were classified as Score
0–1 cm—no pain or distress, Score 2–3 cm—annoying,
Score 4–5 cm—uncomfortable, Score 6–7 cm—dreadful,
Score 8–9 cm—horrible, and Score 10 cm—agonizing
or unbearable distress.[7]
Progression of healing is assessed by the following
scoring criteria, 1: Complete epithelialization, 2:
Incomplete epithelialization, 3: Ulcer, and 4: Necrosis.[8]
Post‑operative discomfort or assessment of the procedure
by the patient is estimated by the post‑operative symptom
severity (PoSSe) scale on the 7th day post‑operatively.[9]
Statistical analysis
The data was analyzed using statistical package
Statistical Package for the Social Sciences 22.0 (SPSS
Inc., Chicago, IL), and level of significance was set
at P < 0.05. Descriptive statistics was performed to
assess the proportion of each category of the respective
groups. Normality of the data was assessed using
Shapiro Wilkinson test. Inferential statistics was done
using Chi‑square test for categorical data to find out
the association between the groups and independent
t‑test for the continuous data to find out the difference
between the groups.
Result
A total of 36 patients participated in this study of which
the mean age of the study population in the conventional
group was 20.22 (50% males and 50% females) and
that of the diode laser group was 22.11 (33.46% males
S690 Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023
and 66.6% females). On comparing post‑operative
ooze from the surgical site all the participants of the
conventional frenectomy group exhibited the presence
of post‑operative ooze on day 1, whereas only six
subjects (33.4%) exhibited the same of diode laser
group and evaluation on day 7 and day 14 exhibited an
absence of ooze among both the groups.
Mean VAS scores for pain in conventional and diode
groups on day 1, day 2, and day 14 were found to
be (2.55 ± 1.44, 1.36 ± 0.68, 0.25 ± 0.34) (0.66 ± 0.76,
0.38 ± 0.50, 0 ± 0), respectively. The analysis showed
that the VAS score for pain and speech discomfort was
significantly less for the test group than the control
group at 1st P = 0.0001, 7th P = 0.0001, and 14th day
P = 0.005.
Clinical evaluation wound healing in both groups
exhibited incomplete epithelialization on day 1 and
day 7. While on day 14, eight subjects exhibited
complete epithelialization (44.4%) and 10 (55.6%)
exhibited incomplete epithelialization among the
conventional group. Thirteen subjects (72.3%) presented
complete epithelialization whereas only five subjects
presented (27.7%) incomplete epithelialization in the
diode group and statistically significant difference
between the groups exhibited on day 14 (P = 0.0001).
Mean posse scale scores of both the conventional and
diode groups on day 7 were found to be 22.38 ± 6.32
and 3.69 ± 4.47, respectively (P = 0.0001)
Discussion
To achieve more functional and aesthetic results in oral
and maxillofacial surgery, the techniques adopted should
be more conservative and precise. Frenectomy can be
performed using a variety of techniques, including the
traditional scalpel technique, electrocautery, and lasers.
In soft tissue surgeries, laser is now a viable alternative
to the scalpel.
An aberrant frenum can be treated either by a frenectomy
or frenotomy procedure, wherein frenectomy aims at
complete removal of the frenum with its attachment with
the underlying bone and frenotomy points relocation of
the frenal attachment.[1] Various techniques proposed for
frenectomy include the classical frenectomy proposed
by Archer and Kruger, Millers technique, Schuchardt
Z‑plasty, V‑Y Plasty, Frenectomy using electrocautery,
lasers—diode, CO2, Nd: YAG, Er: YAG, and soft tissue
lasers.[10]
The basic concept in surgical laser is the photothermal
interaction with the tissues structure. Laser light within
the tissue is converted to thermal energy on contact with
the tissues and produces reactions ranging from incision,
 Vincent, et al.: Frenectomy: Scalpel/ laser
vaporization, and coagulation. The wavelength has an
affinity toward melanin, gets strongly absorbed by the
blood hemoglobin, and contributes to the thermal effect
and hence hemostasis.[11] Therefore, lasers offer a lot of
advantages such as a relatively bloodless surgical field
and post‑surgical events, precise cut and coagulation
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of the tissues, decreased post‑surgical pain, and high
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patient’s acceptance.[10]
The aim of the study is to compare and evaluate the
clinical outcomes of maxillary labial frenectomy using
a diode laser and conventional scalpel. Heat produced
by the laser makes small blood vessels and lymphatic
vessels impassable thus reducing or eliminating blood
flow and edema.[12] Thus controlled bleeding enables the
surgeon to perform the operative procedure with ease and
better visibility. The heat generated from the laser beam
seals the sensory nerve endings which are responsible for
the decreased or an absent post‑operative pain.[13] Thus
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reduction in pain perception following laser application
is due to the nerve endings becoming unable to form
anastomosis with one another.[14] Diode laser frenectomy
offers a sutureless surgical field and leaves the area raw.
Comparative analysis on day 14 showed better wound
healing and absence of scar with the diode laser group.
Healing process with soft tissue lasers begins with
the formation of clots on the wound sides and the
formation of epidermal layers in 72 hours after injury.
This stimulation continues for the first 4 days. On day
2, inflammatory cells began to infiltrate the wound
edges. Re‑epithelialization and epidermal formation
undertook on day 3. On day 5, partial epithelialization
can be observed and within 8–10 days, the wound
heals completely, with the formation of a continuous
layer of epidermis and skin appendages.[15] Traditional
scalpel procedure leaves a longitudinal surgical incision
and scarring, whereas laser induced wounds heal with
secondary intention and no scar formation because
of the defined, clean wound and low level of wound
contraction caused by laser irradiation.[13]
The findings of our study revealed that a diode laser
is superior to a conventional scalpel in terms of
minimal or absent post‑operative ooze (P = 0.0001),
reduced post‑operative pain (P = 0.0001), better wound
healing (P = 0.0001) as well as improved patient
acceptance (P = 0.0001).
In 2019, Singh and Nath compared the clinical and
healing effects of frenectomy using a diode laser with
a traditional approach. When compared to the control
group, the VAS score for pain and speech discomfort
was shown to be lower in the test group with improved
wound healing.[13]
Journal of Pharmacy and Bioallied Sciences ¦ Volume 15 ¦ Supplement 1 ¦ July 2023
In 2020, Archana NV, et al. used a standard scalpel
approach and a diode laser to conduct maxillary
labial frenectomy and compared intra‑operative and
post‑operative outcomes. They concluded that the
diode laser demonstrated negligible bleeding and a
precise incision, lowered edema and scarring, reduced
pain, faster healing response, and enhanced patient
appreciation after analyzing both procedures.[12]
Drawback of diode lasers comprised of expensive and
requirement of special equipments along with the skill
of the operator. Diode lasers during operation, while
performing the incision, some fumes get released from
vaporization of epithelium with a burning smell, which
can arise stress in the patient, and it is necessary to
operate with a powerful air evacuator to alleviate this
complication is another disadvantage dealt with.[13]
With the use of lasers, dissection of the entire muscle
fibers from the periosteum is not possible thus, making
possibilities of reattachment of the frenum.[12]
Lack of long‑term follow‑up results, limited sample size,
unicentric study, and its scrutiny confined to a single surgical
procedure and assessment of acceptance of the procedure
among various age groups from pediatrics to geriatrics were
the limitations of this study. Within the limitations of this
study, it can be formulated that diode lasers offer a safer and
better alternative to the conventional scalpel technique.
Conclusion
The field of surgery and its surgical interventions is
redecorating and the future depends on minimally
invasive interventions offering fast recovery with less
post‑operative morbidity and enhanced quality of life.
While the traditional conventional frenectomies offered
pain, swelling as well as discomfort from sutures
diode lasers on the other hand provides better patient
perception in terms of reduced operative time, pain, and
discomfort. Thus it may be concluded that diode lasers
may be advocated in the field of oral and maxillofacial
surgery for minor procedures like frenectomy. However
further studies with multicentric trials, larger sample size
and different clinical situations should be considered
to authenticate the clinical efficacy of the diode laser
technique over the conventional scalpel technique.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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