Evaluation of Patient Perceptions AfterFrenectomy Operations: A Comparisonof Carbon Dioxide Laser andScalpel TechniquesM. Cenk Haytac* and Onur Ozcelik*

Background: A frenum that encroaches on the margin ofthe gingiva may interfere with plaque removal and cause ten-sion. Frenectomy is the complete removal of the frenum thatcan be made by scalpels or with soft tissue lasers. The aimof this article was to compare the degree of postoperativepain, such as discomfort and functional complications (eatingand speech), experienced by patients after two frenectomyoperation techniques.

Methods: Forty patients requiring frenectomy were ran-domly assigned to have treatment either with a conventionaltechnique or with a carbon dioxide (CO2) laser. The postoper-ative pain and functional complication ratings of each patientwere 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 compli-cations (speaking and chewing) (P <0.0001 each) and re-quired fewer analgesics (P <0.001) compared to patientstreated with the conventional technique.

Conclusions: This clinical study indicates that CO2 lasertreatment used for frenectomy operations provides better pa-tient perception in terms of postoperative pain and functionthan that obtained by the scalpel technique. Considering theabove advantages, when used correctly, the CO2 laser offersa safe, effective, acceptable, and impressive alternative forfrenectomy operations. J Periodontol 2006;77:1815-1819.

KEY WORDS

Lasers; pain; periodontal diseases/surgery; postoperativecomplications; visual analog scale.

Afrenum is a fold of mucous

membrane, usually with en-closed muscle fibers, that atta-

ches the lips and cheeks to the alveolarmucosa and/or gingiva and underlyingperiosteum. A frenum that encroacheson the margin of the gingiva may inter-fere with plaque removal, and tension onthis frenum may tend to open the sulcus.This condition may be conducive toplaque accumulation and may inhibitproper toothbrushing. In these cases,surgical removal of the frenum is indi-cated. Frenal problems occur most oftenon the labial surface between the max-illary and mandibular central incisorsand in canine and premolar areas. Theyoccur less often on the lingual surface ofthe mandible.1

Frenectomy is the complete removalof the frenum, including its attachmentto underlying bone. There are two tech-niques for the removal of the frenum.One of these is the conventional tech-nique with scalpels and periodontalknives, and the other is using the softtissue laser.1-3 Lasers such as the neo-dymium-doped:yttrium, aluminum, andgarnet (Nd:YAG), carbon dioxide (CO2),and erbium-doped (Er):YAG lasers en-able minimally invasive dentistry for softtissue procedures.4-7 The CO2 laser hasbeen used for soft tissue surgery, includ-ing the oral tissues, since the early 1970sand received clearance by the United

* Department of Periodontology, Faculty of Dentistry, Cukurova University, Adana, Turkey.

doi: 10.1902/jop.2006.060043

J Periodontol • November 2006

1815

States Food and Drug Administrationfor this purpose in 1976.6-10 CO2 lasersurgery of the oral soft tissue is gener-ally performed with a power setting of5 to 15 W in either a pulse, superpulse,or continuous mode. It has been usedfor gingivectomy-gingivoplasty,11-14

frenectomy,2,3 adjunct to surgical andnon-surgical periodontal treatment,15-18

incisional and excisional biopsy, andvarious maxillofacial surgical treatmentapproaches.19-23

The aim of this study was to com-pare the effects of the CO2 laser and theconventional technique on the degreeof postoperative pain, discomfort, andfunctional complications (eating andspeech) experienced by patients afterfrenectomy operations.

MATERIALS AND METHODS

Subjects and Study DesignThe study sample was selected from pa-tients who had been referred to the Fac-ulty of Dentistry, Cukurova University,between May 2005 and January 2006.Forty patients requiring frenectomywere randomly assigned to have treat-ment either with conventional surgicalor with CO2 laser techniques. The study protocolwas reviewed and approved by the institutional reviewboard. Informed written consent was obtained from allpatients. All subjects were systemically healthy, didnot use medications, and had good oral hygiene atthe time of the surgery. Only maxillary and mandibu-lar anterior frena extending to the interdental papilla ofthe central incisors were included in this study, and thepatients were matched for age and gender and for thesize and location (maxillary or mandibular) of the fre-num to standardize the postoperative wound size.Twenty-four females and 16 males aged between18 and 26 years were included in the study, and thequalified patients were entered consecutively.

For the conventional technique, the frenum washeld with a pair of hemostats, and the whole band oftissue together with its alveolar attachment was ex-cised with a #15 blade. After freeing any fibrous adhe-sions to the underlying periosteum, the wound wasclosed with sutures (Figs. 1A through 1C).

A CO2 surgical laser unit† with a flexible hollow-fiber delivery system and a non-contact, air-coolinghand-piece was used as the alternative frenectomyoperation. Again the frenum was held with hemostats,and the non-contact focused beam at repeated super-pulse mode (7 W, 0.8-mm spot size, 20 Hz, and 10milliseconds) was applied for excision. The beam

was also used to remove any adhesions to the perios-teum, and the remnants of the ablated tissue were re-moved using sterile gauze dampened with saline. Nosutures were placed after CO2 laser treatment (Figs.1D through 1F).

Both groups received postoperative instructions,and they were told to use an analgesic if needed.

Method of ScoringThe patients were asked to separately rate the degreeof pain and postoperative functional complications,which included discomfort during eating and speech,on a 10-cm horizontal visual analog scale (VAS) byplacing a vertical mark to assess position betweenthe two endpoints. The left endpoint of the pain scalewas designated as ‘‘no pain,’’ and the right endpointwas marked as ‘‘worst pain imaginable.’’ The end-points of the scales for the degree of discomfort duringeating and speech were marked as ‘‘no discomfort’’ onthe left side and ‘‘extreme discomfort’’ on the rightside. The patients were asked to mark the position be-tween the two endpoints that best described their per-sonal perception of the degree of pain and thediscomfort during eating and speech they had experi-enced on postoperative days 1 and 7. The hatch markplaced by the patient was measured to the nearest

Figure 1.Patient presenting with a maxillary midline frenum causing pull on the marginal andinterdental papilla (A) and immediately after a frenectomy operation performed usingscalpel technique with sutures in place (B). Healing 3 months after surgery (C).Another patient presenting with a maxillary midline frenum (D) and immediately afterCO2 lasing of the frenum (E). Healing 3 months after laser surgery (F).

† Luxar Nova Pulse LX-20 SP, Bothell, WA.

Patient Perceptions After CO2 Laser Volume 77 • Number 11

1816

millimeter; thus, the scores for pain and functionalcomplications degree were between 0.0 and 10.0.24

A single operator recorded these scores at postoper-ative days 1 and 7. After completion, all recordingswere analyzed, which included comparison of postop-erative pain and the degree of functional complica-tions after the two periodontal treatment techniques.All patients were instructed to use the same analgesiccontaining paracetomol if needed, and they were alsocompared for their need of analgesics after the twotechniques.

Statistical MethodNon-parametric tests were chosen for continuous var-iables because the data were not distributed normally.Comparisons between groups were applied using theMann-Whitney U test. Time-dependent intragroupdata were analyzed using the Wilcoxon rank sum test.The categorical variables between the groups wereanalyzed using the x2 test or Fisher exact test. Resultswere represented as mean – SD and median (mini-mum-maximum). A P value <0.05 was consideredsignificant. Statistical analyses were performed usinga statistical program.‡

RESULTS

Resultsof thestudyaresummarized inTable1andFig-ure 2. The VAS scores of pain on days 1 and 7 were sig-nificantly lower in the laser group compared to theconventional technique (P <0.0001). In addition,post-operative functional complications assessed by thechewing and speaking VAS scores were also signifi-cantly lower in the laser group (P <0.0001). Although17 patients (85%) of the conventional technique usedanalgesics during the first postoperative week, onlyseven patients (33.3%) used them in the laser group.

DISCUSSION

The aim of this study was to compare the postopera-tive subjective effects of CO2 laser and conventionaltechniques after frenectomy surgery. The CO2 laseris now a viable alternative to the scalpel in soft tissuesurgery. Because oral tissues are composed of >90%water, and considering the affinity of the CO2 laser forwet tissue, it is readily applicable for most intraoralsoft tissue surgery, including frenectomies.2-4,6-8,11-14,

21,23,25 However, there are very few studies compar-ing the postoperative effects of laser and conven-tional techniques, which can justify the use of lasersfor intraoral soft tissue surgery.7,25-29 Anecdotal re-ports claiming that incising oral soft tissue with a laseris less painful than using a scalpel and therefore re-quires less local anesthesia have no scientific confir-mation to date.

In our study, patients treated with the CO2 laser hadsignificantly less postoperative pain and functionalcomplications compared to scalpel surgery. Classi-cally, a frenectomy procedure involves grasping thefrenum with hemostats, incising above and belowthe hemostats, creating a large triangular-shapedwound, often with copious bleeding, and placingsutures. Patients often experience post-surgicalbleeding and pain, and sutures can further increasebleeding and pain when they come into contact withfood. The unpleasant taste of blood and unaestheticappearance of sutures may result in a loss of the senseof well-being during the postoperative period. In addi-tion, suture removal from gingival and labial tissuesafter 1 week can be painful because the suturesmay be buried in the mucosa.1-3 To overcome thesedisadvantages, some clinicians use bioabsorbablesutures after oral surgery. On the other hand, thelaser technique offers some advantages, such as arelatively bloodless surgical and post-surgical event;the ability to precisely coagulate, vaporize, or cut tis-sue; sterilization of the wound site; minimal swelling

Figure 2.VAS scores of patient perceptions after conventional and lasertechniques.

Table 1.

Comparison of the VAS Scores ofPostoperative Patient Perceptions AfterConventional and CO2 Laser Techniques

Technique

Conventional

(mean – SD)

CO2 Laser

(mean – SD) P Value

Pain at 1 day 6.2 – 1.8 3.4 – 1.1 0.0001

Pain at 7 days 3.3 – 1.5 0.1 – 0.3 0.0001

Chewing at 1 day 5.2 – 1.4 1.7 – 0.9 0.0001

Chewing at 7 days 2.4 – 1.0 0.1 – 0.3 0.0001

Speaking at 1 day 4.0 – 1.4 0.8 – 0.7 0.0001

Speaking at 7 days 1.6 – 0.9 0.1 – 0.2 0.0001‡ SPSS version 10.0, SPSS, Chicago, IL.

J Periodontol • November 2006 Haytac, Ozcelik

1817

and scarring; no suturing in most cases; little me-chanical trauma; reduction of surgical time; de-creased post-surgical pain; and high patientacceptance.6,7,15,26-31 There is abundant evidenceconfirming markedly less bleeding,11,29,30 particu-larly of highly vascular oral tissues, with laser sur-gery.27 Some reports suggest that laser-createdwounds heal more quickly and produce less scar tis-sue than conventional scalpel surgery,28 althoughcontrary evidence also exists.31-33 Postoperative painfrom oral and otolaryngological surgical procedureshas been claimed to be reduced in laser surgery.10,29

It is theorized that this may be due to the protein co-agulum that is formed on the wound surface, therebyacting as a biologic dressing and sealing the ends ofthe sensory nerves.10,28 On the other hand, the super-pulse mode, which was used in this study, releasesbursts of higher peak powers and shorter pulse dura-tions in the microsecond range. This mode allows thesurgeon to deposit pulses of higher peak power intotissue with control, to confine the exposure to pulsesthat are within the thermal relaxation time of the tissue(which is the time needed by the tissue to release theabsorbed heat via conduction or circulation), and touse pulse repetition rates that allow cooling betweenindividual pulses to reduce heat accumulation.14,30

The use of this mode may have beneficial effects onthe control of post-surgical complications by prevent-ing carbonization or charring, which may interferewith wound healing.

Although it has many advantages, the laser tech-nique requires some precautions. The CO2 laser beammay be reflected from shiny metal surfaces, such asretractors or mouth mirrors, and cause eye injury. Pro-tective eyewear must be worn by the operator and as-sistants. The patient’s eyes, throat, and delicate oraltissues outside the surgical site must be protectedfrom accidental beam impact through use of safetyglasses and wet towels or gauze packs. Clinicians ex-perienced in CO2 laser surgery have emphasized theneed for an adequate shield, such as a flat-bladed in-strument or silver foil, between the gingiva and teeth.Finally, an important part of laser safety is a properlytrained staff.4,6

ACKNOWLEDGMENT

The authors thank Dr. Roland Blankenstein, London,United Kingdom, for his valuable assistance.

REFERENCES1. 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. Earlylingual frenectomy assisted by CO2 laser helps pre-vention and treatment of functional alterations caused

by ankyloglossia. Int J Orofacial Myology 2004;30:64-71.

3. Bullock N Jr. The use of the CO2 laser for lingualfrenectomy and excisional biopsy. Compend ContinEduc Dent 1995;16:1118-1123.

4. Pick RM, Colvard MD. Current status of lasers in softtissue dental surgery. J Periodontol 1993;64:589-602.

5. Midda M, Renton-Harper P. Lasers in dentistry. Br DentJ 1991;170:343-346.

6. American Academy of Periodontology. Lasers in peri-odontics (position paper). J Periodontol 2002;73:1231-1239.

7. Schuller DE. Use of the laser in the oral cavity.Otolaryngol Clin North Am 1990;23:31-42.

8. Pick RM, Pogrel MA, Loh HS. Clinical applications ofthe CO2 laser. In: Miserendino LJ, Pick RM, eds. Lasersin Dentistry. Chicago: Quintessence; 1995:145-160.

9. Carruth JAS. Resection of the tongue with the carbondioxide laser. J Laryngol Otol 1982;96:529-543.

10. Guerry TL, Silverman S, Dedo HH. Carbon dioxidelaser resection of superficial oral carcinoma: Indica-tions, technique and results. Ann Otol Rhinol Laryngol1986;95:547-555.

11. Pick RM, Pecaro BC, Silberman CJ. The laser gingivec-tomy. The use of the CO2 laser for the removal ofphenytoin hyperplasia. J Periodontol 1985;56:492-496.

12. Barak S, Kaplan I. The CO2 laser in the excision of gin-gival hyperplasia caused by nifedipine. J Clin Peri-odontol 1988;15:633-635.

13. Roed-Petersen B. The potential use of CO2 lasergingivectomy for phenytoin-induced gingival hyper-plasia in mentally retarded patients. J Clin Periodontol1993;20:729-731.

14. Esen E, Haytac MC, Oz A. Gingival melanin pigmen-tation and its treatment with the CO2 laser. Oral SurgOral Med Oral Pathol Oral Radiol Endod 2004;98:522-527.

15. Misra V, Mehrotra KK, Dixit J, Maitra SC. Effect of acarbon dioxide laser on periodontally involved rootsurfaces. J Periodontol 1999;70:1046-1052.

16. Crespi R, Barone A, Covani U, Ciaglia RN, RomanosGE. Effects of CO2 laser treatment on fibroblast attach-ment to root surfaces. A scanning electron micros-copy analysis. J Periodontol 2002;73:1308-1312.

17. Miyazaki A, Yamaguchi T, Nishikata J, et al. Effects ofNd:YAG and CO2 laser treatment and ultrasonic scal-ing on periodontal pockets of chronic periodontitispatients. J Periodontol 2003;74:175-180.

18. Gopin BW, Cobb CM, Rapley JW, Killoy WJ. Histologicevaluation of soft tissue attachment to CO2 laser-treated root surfaces: An in vivo study. Int J Periodon-tics Restorative Dent 1997;17:316-325.

19. Pecaro BC, Garehime WJ. The CO2 laser in oral andmaxillofacial surgery. J Oral Maxillofac Surg 1983;41:725-728.

20. Apfelberg DB, Master MR, Lash H, White DN. Benefitsof the CO2 laser in oral hemangioma excision. PlastReconstr Surg 1985;75:46-50.

21. Pick RM, Pecaro BC. Use of the CO2 laser in soft tissuedental surgery. Lasers Surg Med 1987;7:207-213.

22. Pick RM, Colvard MD. Current status of lasers in softtissue dental surgery. J Periodontal 1993;64:589-602.

23. Barak S, Kaplan I, Rosenblum I. The use of the CO2

laser in oral and maxillofacial surgery. J Clin LaserMed Surg 1990;8:69-70.

24. Matthews DC, McCulloch CAG. Evaluating patientperceptions as short-term outcomes of periodontal

Patient Perceptions After CO2 Laser Volume 77 • Number 11

1818

treatment: A comparison of surgical and non-surgicaltherapy. J Periodontol 1993;64:990-997.

25. Gaspar L, Szabo G. Manifestations of the advantagesand disadvantages of using the CO2 laser in oralsurgery. J Clin Laser Med Surg 1990;8:39-43.

26. Pogrel MA, McCracken KJ, Daniels TE. Histologicevaluation of the width of soft tissue necrosis adjacentto carbon dioxide laser incisions. Oral Surg Oral MedOral Pathol 1990;70:564-568.

27. Kaplan L, Raif J. The Sharplan carbon dioxide laser inclinical surgery: 7 years experience. In: Goldman L,ed. The Biomedical Laser. New York: Springer-Verlag;1981:89-97.

28. FisherSE,FrameJW,BrowneRM,TranterRMD.Acom-parative histological study of wound healing followingCO2 laser and conventional surgical excision of caninebuccal mucosa. Arch Oral Biol 1983;28:287-291.

29. Abt E. CO2 laser treatment for gingivectomies reduceshemorrhaging, post-op pain. Clin Laser Mon 1992;10:8-12.

30. Hobbs ER, Bailin PL, Wheeland RG, Ratz JL. Super-pulsed lasers: Minimizing thermal damage with shortduration, high irradiance pulses. J Dermatol SurgOncol 1987;13:955-964.

31. Buell BR, Schuller DE. Comparison of tensile strengthin CO2 laser and scalpel skin incisions. Arch Otolar-yngol 1983;109:465-467.

32. White JM, Goodis HE, Rose CL. Use of the pulsedNd:YAG laser for intraoral soft tissue surgery. LasersSurg Med 1991;11:455-461.

33. Frame JW. Removal of oral soft tissue pathologywith the CO2 laser. J Oral Maxillofac Surg 1985;43:850-855.

Correspondence: Dr. Onur Ozcelik, Department of Peri-odontology, Faculty of Dentistry, Cukurova University,Balcali 01330, Adana, Turkey. Fax: 90-322-3387331;e-mail: oozcelik@cu.edu.tr.

Accepted for publication June 6, 2006.

J Periodontol • November 2006 Haytac, Ozcelik

1819