Exploring Effective Frenectomy Methods for Enhanced Oral Health

Frenotomies performed using a scalpel or scissors may result in significant bleeding, which can obscure the surgical field and make it challenging to determine if the restriction has been fully removed. Due to the increased risk of early primary closure of the site, postoperative active wound care is crucial to minimize the risk of potential scarring. To restore and maintain optimal function, active wound care should begin as soon as possible. However, if sutures are placed, active wound care might be delayed to avoid early tearing of tissue. The contact nature of conventional procedures carries a certain infection risk, and higher levels of postoperative pain and discomfort have been reported. Electrocautery and the hot glass tip of dental diodes can leave a substantial thermal tissue change zone, potentially delaying healing. Erbium lasers produce excellent incisions but are not efficient for coagulation, so clinicians using an erbium wavelength for frenectomy may need to manage intra-operative bleeding. The 10,600-nm CO2 laser has been shown to accurately incise soft tissue while efficiently coagulating. The photo-thermal coagulation depth of this wavelength closely matches the diameters of small oral soft tissue blood and lymphatic vasculature, helping to maintain a clear surgical site and reduce the risk of postoperative edema.

Frenectomy and Role of OMT

Improperly formed orofacial structures and deviant swallowing, chewing, speaking, and breathing patterns can result from incorrect oral posture and oral restrictions. Therefore, the authors believe that removing oral restrictions is necessary to achieve optimal orofacial function, and this must be combined with regular pre- and post-frenectomy orofacial myofunctional therapy (OMT). OMT helps re-educate the tongue and orofacial muscles during movement and at rest to establish new neuromuscular patterns for proper oral function, including chewing, swallowing, speaking, and breathing. Camacho et al. demonstrated a reduction in the apnea-hypopnea index in children and adults following myofunctional therapy. Without such re-education therapy, deviant oral and breathing habits may persist, eventually leading to the recurrence of airway and sleep issues that existed before the frenectomy.

Case Example

A 29-year-old Caucasian female (an orofacial myologist) visited a dental sleep office for labial and lingual laser frenectomy. The patient was unable to progress efficiently through myofunctional therapy due to tethered oral tissues. She had always struggled to maintain a proper lip seal due to a restricted labial frenum and exhibited a short upper lip from mouth breathing. While treating her clients, she was unable to demonstrate certain myofunctional therapy exercises that required elevation of the middle and posterior portions of the tongue. The patient hoped the frenectomy procedures would help her create a lip seal, correct her tongue rest posture, and establish a proper swallowing pattern.

Childhood History of Symptoms

The patient was bottle-fed during infancy and had a history of thumb-sucking and pacifier use until the age of four. At seven, she underwent adenoidectomy and tonsillectomy. She had a deviated septum after breaking her nose at nine (which has not been corrected) and reported frequent mouth breathing. The patient had orthodontic treatment from age twelve to fourteen, which included rapid palatal expansion and retractive headgear. Due to orthodontic relapse, she also underwent orthodontic treatment at age twenty and again at age twenty-five.

Figure 2: A. Pre-frenectomy / OMT: Long, narrow face and low facial muscle tone, a short upper lip (philtrum length: 14 mm), open mouth resting posture with 7 mm interlabial gap; B. 3 weeks post-frenectomy/OMT: Improvement in overall facial tone, philtrum length: 18 mm, relaxed closed mouth resting posture with 0mm interlabial gap.

Figure 1: A.-B. Pre-frenectomy: note jaw deviation, facial asymmetry, bulbous tongue tip, and inability to lateralize without downward pull from lingual restriction; C.-D. 3 weeks post-frenectomy/OMT: note improved facial symmetry, unrestricted and controlled tongue lateralization, and less jaw deviation.

Clinical Exam and Symptoms

The following TMD symptoms were observed: jaw deviation to the right along with clicking/popping/crepitus on the right side. The patient reported neck pain and frequent headaches.

Figure 3: A. Posture pre-frenectomy/OMT: forward head/neck, forward rolled shoulders; patient reported tension in neck and shoulders B. Posture 3 weeks post-frenectomy w/ OMT: forward head/neck, forward rolled shoulders is considerably reduced; patient reports neck and shoulder tension has decreased significantly, and she is able to maintain better posture for a longer time.

Figure 4: A. Pre-Frenectomy: 28 mm ROM with tongue tip to incisive papilla; functional ROM 60.8% B. 10.5 months Post-Frenectomy: 47mm ROM with tongue tip to incisive papilla; functional ROM: 94%.

The patient had a long, narrow face, low facial muscle tone, a short upper lip (philtrum was 14 mm long), and open mouth resting posture with a 7 mm interlabial gap. The patient reported mouth breathing all night, regular nighttime drooling, restless sleep, and frequent waking. She complained of daytime fatigue and never waking well-rested. Her left nostril “whistled” during nasal breathing, and she was frequently congested. Moreover, the patient had a forward head/neck and forward rolled shoulder posture; she reported significant tension in the neck and shoulders and was concerned about Dowager’s hump formation. She had a bilateral tongue thrust during swallowing and low tongue resting posture (tongue tip resting against lower incisors). The patient reported dry, chapped lips and the habits of lip licking, cheek biting, and clenching.

Figure 5: A. Mallampati score IV with tongue scalloping and limited opening due to TMD symptoms pre-frenectomy; B. Mallampati score I three weeks post-frenectomy w/ OMT.

Intraoral examination revealed a narrow, high palatal vault with pronounced rugae, and narrow soft palate. The tight upper labial frenum and attached gingiva blanched when extending the upper lip. The tongue appeared short and wide with a tight, restrictive lingual frenum. The functional range of motion (ROM) was 60.8%: the full ROM was 46 mm, and the ROM with tongue tip to incisive papilla was 28 mm. The patient’s Mallampati score was IV.

Medical History

At the time of the visit, no medications were taken; no known drug allergies, recent illnesses, or hospitalizations were reported.

Laser Surgery

After local anesthetic (Articaine hydrochloride 4% with 1:100,000 epinephrine) was administered by infiltration, the LightScalpel laser frenectomy was performed to release both the maxillary labial and lingual restrictions. LightScalpel^® CO₂ laser (LightScalpel, LLC, Bothell, WA) with 0.25 mm focal spot size laser handpiece was utilized, delivering 2 watts SuperPulse laser beam gated at 70% duty cycle at 20 Hz (average power to the tissue was 1.4 watts). For efficient incision, gentle traction tension was applied to the tongue and the lip during lingual and labial procedures, respectively. The laser nozzle was held 1-3 mm away from the target tissue and moved in zigzagging fashion until the tension was released. As frenectomy progressed, the dentist stopped several times to evaluate the extent of release and the function of the lip and the tongue. Minor bleeding was encountered during the labial procedure, but was quickly resolved by switching to the non-SuperPulse mode and increasing the distance between the nozzle and target tissue (i.e., defocusing the laser beam).

After the tension was released, the patient was asked to lift, extend, and lateralize the tongue, with the chin stabilized. This allows the dentist to see if lingual mandibular differentiation can be observed. The upper lip was retracted and a finger dissection of the remaining frenal fibers completed the procedure. After the surgery, the patient gained 19 mm in the ROM with tongue tip to incisive papilla – from 28 mm to 47 mm.

Figure 6: A. Pre-frenectomy; B. Immediately after laser frenectomy; C. 24 hours post-frenectomy w/ OMT; D. 48 hours post-frenectomy w/ OMT; E. 2 weeks post-frenectomy w/OMT; F. 10.5 months post-frenectomy w/ OMT.

Postoperative Care and Healing

Almost immediately after the CO₂ laser frenectomies, the patient reported less neck and shoulder tension, felt she could stand up straighter, and that her “airway feels more open” when breathing. She was able to close her mouth comfortably and without strain on her upper lip. She was able to elevate the middle and posterior portions of the tongue to the palate, and complete previously difficult myofunctional exercises with ease. 800 mg Ibuprofen was taken twice the day of and once the day after the procedure for minor postoperative soreness, and a soft, bland diet was maintained for 48 hours.

As an orofacial myologist, the patient was diligent with her active wound management and strictly followed her customized, progressive OMT regimen in order to achieve optimal healing of frenectomy sites, maximum ROM, and optimal oral function. Healing progressed with no complications (Figure 6 demonstrates lingual healing). At 10.5 months post frenectomy, the patient’s functional range of motion (ROM) was 94%: the full ROM was 50 mm, and the ROM with tongue tip to incisive papilla was 47 mm.

OMT helped the patient retrain and re-pattern neuromuscular movements that had been foreign to her and helped her integrate them into her everyday life. The establishment of proper oral rest posture (tongue to palate, instead of in the floor of the mouth), lip competence (no open mouth posture at rest – nasal breathing (this got increasingly easier aided with Buteyko breathing techniques, even with a deviated septum), and correct chewing and swallowing patterns has made a profound difference in her life. She has better posture, more energy, eats less, feels rested in the morning, and sleeps through the night. Her bilateral tongue thrust has been eliminated and night time drooling has been resolved. The patient reports a decrease in clenching and biting the sides of her tongue at night. As a long term goal, the patient intends to continue working on oral habituation and improving/maintaining better posture. The patient was informed that if symptoms of sleep disordered breathing returned, she would be referred to a sleep medicine physician for further evaluation.