DTME1010

Trends & Applications DENTALTRIBUNE Middle East & Africa Edition4 _Introduction The word frenum is derived from the Latin word “fraenum”. Frena, are triangle-shaped folds found in the maxillary and mandibular alveolar mucosa, and arelocatedbetweenthecentralin- cisors and canine premolar area. Frenummaybeclassifieddepend- ing upon its morphology as: _Long and thin _Short and broad. Depending upon the attachment level, frenum has been classified as: (Placek et al. 1974) _Mucosal _Gingival _Papillary _Papillary penetrating. Whentheinsertionpointofthe frena is at the gingival margin it may pose a problem (Corn 1964). This kind of abnormal insertion of the frenum may cause marginal recessionofthegingiva.Abnormal frenal insertion can distend and retract the marginal gingiva or papilla away from the tooth when the lip is stretched. 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 sul- cus. This condition may be more conducivetoplaqueaccumulation and inhibit proper oral hygiene. Aberrantfrenumcanbetreatedby frenectomy or frenotomy proce- dures. The terms frenectomy and frenotomy signify operations that differ in degree of surgical ap- proach. Frenectomy is a complete removal of the frenum, including its attachment to the underlying bone,andmayberequiredforcor- rection of abnormal diastema be- tween maxillary central incisors (Friedman1957).Frenotomyisthe incision and relocation of the fre- nal attachment. Indications _The indications for frenectomy procedure include _Tension on the gingival margin (frenal-pullconcomitantwithor without gingival recession) _Facilitate orthodontic treatment _Facilitatehomecare.Techniques for frenectomy _Conventional technique _Using soft tissue lasers. Conventional tech- nique Conventional technique utilises traditional instruments like the scalpels and periodontal knives. Different procedures have been mentioned under the con- ventional frenectomy technique. These include Dieffenbach, Schuchardt, & Mathis. The most common being Dieffenbach V- plasty & Schuchardt Zplasty. _Armamentarium Bard-Parker handles no. 3, No. 15 blade, mosquito haemostat, su- ture material. _Procedure Dieffenbach V-plasty Surgical steps: The area is anesthetized by giving local anes- thetic injection (2 % lignocaine with 1:200,000 adrenaline). After anesthesiaisachieved,thefrenum is held with the mosquito haemo- stattoitsfulldepth.WiththeNo.15 blade mounted on a Bard-Parker handle, an incision is made along theuppersurfaceofthehaemostat till the entire depth of the frenum extending into the vestibule. A similar incision is repeated on the under-surface of the haemostat so that the haemostat is detached along with the frenal tissue within its beaks. Once this is achieved, a rhomboid area exposing the deeperconnectivetissuefibersbe- comesvisible.Withthehelpoffine scissors, the deeper fibers are de- tached from the underlying pe- riosteum. Periosteal scoring is done with the help of surgical bladesoastopreventthereattach- ment of fibers. The labial mucosa is undermined so as to permit the approximation of the edges. The bleeding is controlled by applying pressure packs. Suturing:Thediamondshaped wound is sutured using either a 4- 0 or 5-0 silk sutures in simple in- terrupted fashion. Proper approx- imation of the margins is ensured. A periodontal dressing is placed to cover the surgical area. Frenectomy by V-plasty may result in scar formation that could prevent the mesial movement of the central incisors (West 1968). However, it is typically a safe sur- gical procedure with no notable complications. Schuchardt Z-plasty The main advantage of this method over the Vplasty method was minimal scar tissue forma- tion.Themethodrequiresaskilled operatorasitistedioustoperform. _Frenectomy using soft tissue lasers LASER (Light Amplification by Stimulated Emission of Radiation) isbasedonAlbertEinstein’stheory of spontaneous and stimulated emission of radiation. It was Maiman in 1960 who gave the first laser prototype using ruby crystal. Shortlythereafter,in1961,Snitzer published the prototype for the Nd:YAG laser. The first application of a laser to dental tissue was reported by Goldmanetal.andSternandSogn- naes, each article describing the effects of the ruby laser on enamel and dentin. Lasers designed for surgery deliver concentrated and controllable energy to the tissue. For the laser to have effect the en- ergy must be absorbed. The de- gree of absorption in the tissue varies as a function of wavelength andcharacteristicsoftargettissue. As the temperature increases at surgical site, the soft tissues are subjected to: _Warming (37 °C to 60 °C) _Welding (60 °C to 65 °C) _Coagulation (65 °C to 90 °C) _Protein denaturisation (90 °C to 100 °C) _Drying (100 °C) _Carbonization (above 100 °C) _Carbon dioxide laser Thecarbondioxidelasershave a wavelength of 10,600 nm. The beam of this laser falls in the in- frared range and is thus invisible. This made the use of CO2 lasers awkward. Thus later on a quartz fiberincorporatinga630nmcoax- ialHe-Nelaserwasusedasanaim- ing beam in the handpiece. The CO2 laser received safety clear- ance from FDA in 1976 for use in soft tissue surgery. With the CO2 laser there is rapid intracellular rise of temperature and pressure leading to cellular rupture and re- lease of ‘laser plume’ (vapour and cellular debris). The CO2 laser is readily ab- sorbed by water. Soft tissue con- sists of 75 % to 90 % water, 98 % of the incident energy is converted intoheatandabsorbedatthetissue surface with very little scatter or penetration. Thus moist surface is essential for maximal effect. With CO2 laser no contact is made with the tissue, and no tactile feedback occurs. _Neodymium:YAG laser The Nd:YAG laser has a wave- length of 1,064 nm and lies in the infrared zone like the CO2 laser. The Nd:YAG laser penetrates wa- ter upto 60 mm after which it is at- tenuated 10 % of its original strength. Thus energy is scattered in soft tissue rather than being ab- sorbed onto the surface. The wavelength of Nd:YAG laser is at- tractedtocoloursandasaresultits scattering in heavily pigmented soft tissues like skin is almost dou- ble its absorption. This heating effect of the Nd:YAG laser is ideal for the abla- tion of potentially haemorrhagic abnormal tissue and for haemostasis of small capillaries and venules. In 1990, the FDA ap- proved soft tissue removal by meansofapulsedNd:YAGlaser.In 1997, the FDA approved sulcular debridement by means of a pulsed Nd:YAG laser. _Erbium:YAG laser The Er:YAG laser was intro- duced in 1974 by Zharikov et al. as a solid-state laser that generates a light with a wavelength of 2,940 nm. Of all lasers emitting in the near- and mid-infrared spectral range, the absorption of the Er:YAG laser in water is the great- est because its 2,940 nm wave- lengthcoincideswiththelargeab- sorption band for water. The absorption coefficient of water of the Er:YAG laser is theo- retically 10,000 and 15,000–20,000 times higher than that of the CO2 and the Nd:YAG lasers, respec- tively. Since the Er:YAG laser is well absorbed by all biological tis- suesthatcontainwatermolecules, this laser is indicated not only for the treatment of soft tissues but also for ablation of hard tissues. The FDA approved the pulsed Er:YAG laser for hard tissue treat- ment such as caries removal and cavity preparation in 1997, un- changedforsofttissuesurgeryand sulcular debridement in 1999 and for osseous surgery in 2004. Frenectomy review: Comparison of conventional techniques with diode laser Authors_Dr M.L.V. Prabhuji, Prof Dr S.S. Madhu Preetha, Dr Ameya G. Moghe, India Fig. 14 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 15 Fig. 16 Fig. 11 Fig. 12 Fig. 13 Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 10Fig. 9 Fig. 5_Papillary frenal attachment. Fig. 6_Horizontal incision made. Fig. 7_Outline for Z-plasty. Fig. 8_Sutures placed. Fig. 11_Papillary penetrating frenum. Fig. 12_Diode laser applied. Fig. 13_Immediate Post-operative view. Fig. 14_Post-op 2 days. Fig. 15_Post-op 1 week. Fig. 16_Post-op 2 months. Fig. 1_Abnormal frenal attachment. Fig. 2_Haemostat in place & incision made. Fig. 3_Sutures placed. Fig. 4_Post-op two months. Laser Type Wavelength Colour Excimer laser Argon fluoride (ArF) Xenon chloride (XeCl) 193 nm 308 nm Ultraviolet Ultraviolet Gas laser Argon Helium-Neon (HeNe) Carbon dioxide (CO2) 488 nm 514 nm 637 nm 10,600 nm Blue Blue green Red Infrared Diode laser Indium GalliumArsenide Phosphorus (InGaAsP) GalliumAluminiumArsenide (GaAlAs) GaliumArsenide (GaAs) Indium GaliumArsenide (InGaAs) 655 nm 677–830 nm 840 nm 980 nm Red Red-Infrared Infrared Infrared Solid state Frequency doubledAlexandrite PotassiumTitanyl Phosphate (KTP) 337 nm 532 nm Ultraviolet Green Lasers Neodymium:YAG (Nd:YAG) Holmium:YAG (Ho:YAG) Erbium,Chromium (Er,Cr:YSGG) Erbium:YSGG (Er:YSGG) Erbium:YAG (Er:YAG) 1,064 nm 2,100 nm 2,780 nm 2,790 nm 2,940 nm Infrared Infrared Infrared Infrared Infrared