Using a Dental Laser for a Frenectomy
• "Straw Effect"
•Anesthetic Concerns
•Laser Settings
•Two is Better than One
One of the most important secrets I've found in performing frenectomies is that trying to accomplish the entire procedure with just a laser isn't the most effective or efficient approach. Like other laser dentists throughout the country, I've developed a technique that uses the laser in combination with conventional instruments.
My technique uses the Nd:YAG laser (either the l0-W PulseMaster or the 3-W ADT dLase 300, now upgraded to the 5-W dLase 300 Plus) in conjunction with sharp tissue scissors. Both lasers are manufactured by American Dental Technologies (Southfield, MI). The settings, which I'll discuss later, depend on the needs of the patient and your goals for that specific procedure. But no matter which laser or settings are used, the basic technique is the same.
The frenectomy procedure begins by bringing the fiber slightly out of contact or slightly in contact with the frenum. Clinicians may go back and forth between those levels of contact, depending on the patient's comfort level. Lase over the target tissue until the effects of tissue ablation can be seen. Soon, the fibrous tissue no longer has a pink color but takes on the appearance and color of strands of straw, also known as the "straw effect." The more fibrous the tissue, the longer it takes to achieve this tissue effect.
When the straw effect is achieved, you can be confident that the nerve endings and blood vessels in that tissue have been sealed off.
The next step is to use sharp tissue scissors to carefully dissect through those affected fibers. Take extreme care to snip only through the tissue altered with the laser. If you cut too deep, you'll reach nonlased tissue and create both bleeding and patient discomfort. However, because of the tissue's highly visual change, keeping the lased bands separate isn't difficult.
After you snip the first layer of fibrous tissue, go back with the laser and create the strawlike effect on the next layer, which should then be snipped away with tissue scissors. Go back and forth between the laser and the scissors in this manner until you've passed through that fibrous zone near the surface and have reached the softer tissue underneath. When finally in that softer layer, you'll find less need to use the tissue scissors because the laser alone can rapidly and comfortably ablate the tissue.
I perform frenectomies with or without anesthetic. If I'm not doing any other procedure,
I usually like to attempt the treatment without any anesthetic. Of course, if I have an apprehensive patient who won't tolerate discomfort very well, I don't fight the situation.
But if I have a patient who seems to tolerate things well and says he or she would rather feel some mild warmth or discomfort rather than have an injection with numbness afterward, then I feel very comfortable attempting the technique without any anesthetic.
It has been my experience that frenectomies and other soft tissue procedures can be performed with little or no anesthetic almost 80% of the time. I often believe dentists focus too much on speed. Performing a frenectomy or any soft tissue procedure without anesthetic means you'll have to work at lower energy settings and, therefore, the actual ablation will occur more slowly. But when considering the time it takes to administer anesthetic and "babysit" the patient through an uncomfortable injection, that "speed" may not be that much of an advantage.
In contrast, if I'm going to be performing multiple extractions on a denture patient, for example, and give anesthetic regardless in that area, then I inject and take advantage of the fact that I can use higher power settings without creating discomfort. This allows the procedure to be performed much more rapidly. Even when I use anesthesia, I use it conservatively. If I'm doing just soft tissue work, I'll often use a topical anesthetic and maybe just a few drops of local. I try to avoid uncomfortable injections as much as possible, especially when working in the maxillary anterior region.
Postoperative discomfort doesn't seem to vary much whether the patient has had the treatment done at lower energy levels without anesthesia or higher energy levels with anesthesia. Whether using the technique with or without the anesthesia, the laser provides clear advantages compared to performing the surgery with a scalpel, which will result in bleeding and require suturing and a postoperative visit to remove the sutures.
My settings vary according to which laser I use and whether I've administered anesthesia. With the ADT dLase 300 Plus, I use 5.0-W at 80-Hz pulses per second with anesthesia and 2.7-W at 80-Hz pulses per second without anesthesia. My experience is that if you go above 2.7-W at 80 Hz with the 300 laser, the patient starts to experience more discomfort.
With the PulseMaster, I use up to 4.8-W (60 mJ) at 80 Hz pulses per second with anesthesia. Without anesthesia, I use 2.7-W (30 mJ) at 90 Hz pulses per second.
My experience has been that raising the Hertz and lowering the watts or millijoules significantly increases cutting speed. It accomplishes that by giving you the option of combining a higher wattage with more pulses per second. With other wavelengths, especially those delivered through optical fibers (Argon, Diode, Erbium, or continuous wave Neodymium), using more than 5 W of energy is seldom necessary. The standard of care in laser dentistry is to use the minimum amount of energy necessary to accomplish the desired treatment.
With or without anesthesia, using this scissors/laser combination is a much faster technique than the laser alone. It enables you to rapidly dissect through a frenum with all of the advantages in patient comfort and homeostasis associated with dental lasers. Though you need to take care to avoid cutting into tissue that hasn't been altered by the laser, visual signs (the straw effect) serve as a dependable guide.