|Year : 2012 | Volume
| Issue : 1 | Page : 33-37
Use of Nd: YAG laser in the treatment of ankyloglossia for pediatric patient
Prasad K Musale, Abhishek S Soni, Shoeb Mujawar, Iqbal Musani
Department of Pedodontics and Preventive Dentistry, M. A. Rangoonwala College of Dental Sciences and Research Centre, Pune, Maharashtra, India
|Date of Web Publication||15-Sep-2012|
Abhishek S Soni
Department of Pedodontics and Preventive Dentistry, M. A. Rangoonwala College of Dental Sciences and Research Centre, Azam Campus, Hidayatulla Road, Camp, Pune - 411 001
Source of Support: None, Conflict of Interest: None
The lingual frenum has been a topic of controversy for a long time. Ankyloglossia causes problems in eating, dyspnoea, and speech disturbances. Hence, it is necessary to perform a lingual frenectomy in cases where ankyloglossia is very severe. Various methods such as surgery, diathermy, and lasers have long been used. The following case report highlights and discusses lingual frenectomy using Nd:YAG laser over other methods in children.
Keywords: Frenectomy, Nd:YAG laser, pediatric patient
|How to cite this article:|
Musale PK, Soni AS, Mujawar S, Musani I. Use of Nd: YAG laser in the treatment of ankyloglossia for pediatric patient. J Dent Lasers 2012;6:33-7
| Introduction|| |
Etymologically, ''ankyloglossia''originates from the Greek words ''agkilos'' (curved) and ''glossa'' (tongue).  The English synonym is ''tongue-tie.'' The first use of the term ankyloglossia in the medical literature dates back to the 1960s, when Wallace defined tongue-tie as ''a condition in which the tip of the tongue cannot be protruded beyond the lower incisor teeth because of a short frenulum linguae, often containing scar tissue.''  The Academy of Breastfeeding Medicine Protocol defines partial ankyloglossia as "the presence of a sublingual frenulum which changes the appearance and/or function of the infant's tongue because of its decreased length, lack of elasticity or attachment too distal beneath the tongue or too close to or onto the gingival ridge". Complete ankyloglossia in which there is extensive fusion of the tongue to the floor of the mouth is extremely rare. 
The prevalence of ankyloglossia reported in the literature varies from 0.1 to 10.7%. ,, Ankyloglossia, or tongue-tie, can be observed in neonates, children, or adults. Many affected children or adults do not complain about their anatomic peculiarity, although anatomic or functional problems can be associated with tongue tie in different stages of life. About 3% of infants are born with a tongue-tie or partial Ankyloglossia. A specific screening tool, the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF), was developed to evaluate the severity of tongue-ties in newborns. It was recommended by the Academy of Breastfeeding Medicine as a method of assessing ankyloglossia.  Horton et al. proposed another classification and reviewed the surgical procedures used in 102 cases.  Several classifications have been proposed, but none has been universally accepted. ,,,
A tongue tie may cause multiple developmental problems.  These include from a younger age to an older age. ,,
- Poor breastfeeding leading to failure to thrive
- Sleep disturbances
- Unable to swallow normally leading to a swallowing pattern which creates orthodontic problems such as open bite and crowded teeth.
- Impaired speech- Some children can compensate well and have normal sounding speech, even those with a tongue tie attached very close to the front of the tongue tip. Unfortunately, many children may have imprecise articulation, especially when talking quickly.
- Dental health problems - Cavities can occur due to food debris not being removed by the tongue's action of sweeping the teeth and spreading saliva which may also result in gum disease.
- Poor self-esteem - Children with poor communication as a result of being tongue tied often show low self-esteem.
- Inadequate facial development including malocclusion
- an open bite situation (where the front teeth do not touch with each other when the child closes his/her mouth). This happens because during swallowing the tongue sits between the teeth in the front part not allowing the jaws to come together.
- maxillary hypo development and mandibular prognathism
- Gingival Recession
Frenectomy is the complete removal of the frenum, including its attachment to the underlying bone.  One technique for removal of a frenum is the conventional approach, using scalpels and periodontal incisions. Lasers, especially Nd: YAG lasers, have been used for a wide range of dental applications. 
The Nd:YAG LASER  has been used in dentistry since 1970. The active medium is a crystal of yttrium aluminum garnet in which some molecules are substituted with atoms of neodymium. Its wavelength (1064 nm) is well absorbed by chromophores melanin and hemoglobin and collagen. The interaction of laser wavelength and energy density with tissue at the tip of the fiberoptic contact delivery system allows simultaneous cutting and coagulation of tissue. The contact fiber laser hand piece is used much like an electrosurgical pencil and can be used in and around the dentition where access is difficult with the scalpel. In dentistry, soft tissue surgery using the Nd: YAG laser has been widely accepted, and its purported advantages versus scalpel surgery have been enumerated by various authors: ,,,,,,,
Thus, Lasers also make possible minimally- invasive dentistry for certain soft tissue procedures.
- Minimal involvement of the other tissues during surgery
- Less need for sutures or periodontal pack
- Minimal postoperative pain and swelling
- The ability to negotiate curvatures and folds within tissue contours
- Tissue surface sterilization
- Lasers have the added advantage of maintaining a uniform depth in the surgical site thereby reducing unnecessary damage to muscle
- Increased coagulation i.e. excellent hemostasis, which yields a dry surgical field and better visualization
- Increased patient acceptance. ,,,,,,,
The purpose of this article is to increase awareness amongst clinicians about laser frenectomy and its advantages in pediatric dentistry.
| Case Report|| |
A seven year old girl reported to the department of Pedodontics and Preventive Dentistry M.A Rangoonwala College of Dental Sciences and Research Center, Pune with severe ankyloglossia. Unable to complete speech therapy, and tongue mobility complaints, this patient was referred to the dental clinic. Oral examination revealed severe or class IV ankyloglossia. A bifid or W shape of the anterior tip of the tongue was seen upon attempted extension [Figure 1]a-b. The patient's family and medical history were non-contributory. Her height and weight were appropriate for her age. ENT and general physical examination revealed insignificant findings. Hematologic examination of the patient revealed normal findings. After informed consent, lingual frenectomy using Nd:YAG laser (Fotona Fidelis III, Slovenia) was decided.
|Figure 1: (a) A clinical case of severe ankyloglossia in an eight year old child (b) Characteristic W shaped tongue clefting of severe ankyloglossia before surgery (c) Laser Frenectomy immediate postoperative view (d) Healing after two weeks and tongue movements are free (e) Protrusion of tongue improves three months postoperatively|
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Topical anesthesia was administered and the two ends of the frenulum were clamped using hemostat mosquito artery forceps. On clamping the two ends the patient exhibited mild discomfort and hence few drops of Xylocaine were injected into the frenum. A horizontal releasing incision was made and/or ablation conducted with pulsed wave mode of the Nd:YAG laser in a contact mode at 200 mJ pulse energy and 5 W output power with 20 Hz (55.6 J/cm 2 ), using an initiated tip of 320 μm flexible fiber.
The Frenum was ablated; the tip was moved from the apex of frenum to the base in a brushing stroke, cutting the frenum resulting in a "diamond" shaped wound. High vacuum suction was used continuously to evacuate saliva and tissue plume was removed using wet cotton pellet. After excision, the area was cleaned. Tongue movement was checked by protrusion to assess complete elimination of the frenum. No suturing was done; the patient was prescribed only analgesics and was recalled after 1 week [Figure 1]c-d.
The patient was instructed to use cold application for 24 hrs to minimize swelling, to avoid spicy, acidic (citrus fluids, wine) or sharp foods or liquids for the first 72 hrs, use of mild analgesic as and when required and use of soft tooth brush carefully around the wound. The patient was also told regarding the formation of a "white soft scab" (7-10 days) is not an infection and is covering the soft tissue forming and chlorhexdine rinse (0.12%) could be used or dabbed onto area. Patient was recalled in 7-10 days to evaluate healing.
The procedure was completed within 10 minutes and caused no discomfort to the patient. The surgical field was clear and dry without bleeding and caused no pain to the patient. No suturing was required for the patient. The postoperative area was left to heal by secondary intention. Healing was uneventful and no scarring was seen at two weeks.
| Discussion|| |
Laser-supported pediatric dentistry is one of the most promising fields in modern minimally invasive dentistry. Previous studies have reported several frenectomy techniques, such as surgical excision with a scalpel and laser excision.
Although the surgical technique described by Hall gives predictable results, it has a few drawbacks compared to laser-assisted frenectomy. ,
A laser is a device that emits light (electromagnetic radiation) through a process of optical amplification based on the stimulated emission of photons. The term "laser" was first introduced to the public in Gould's 1959 conference paper "The LASER, Light Amplification by Stimulated Emission of Radiation". 
- The suturing on the ventral surface can at times lead to blockage of Wharton's duct, causing submandibular swelling.
- Surgical manipulations in the ventral tongue region may also damage the lingual nerve and result in numbness of the tongue tip.
- Suturing can also cause contamination by a "wicking effect", causing secondary infection. This makes it necessary to prescribe postoperative antibiotics.
Laser-assisted lingual frenectomy is very easy to perform. The power output for dental laser use is generally around 2 to 10 watts.  Tissues can respond to laser light in four different ways: scatter, transmit, reflect, and absorb. Absorption is the most desired laser/tissue interaction in dental use which in turn depends on three factors i.e. wavelength, tissue composition and tissue's water content. Laser-tissue interaction is the use of light energy that is absorbed by the tissue to produce a photobiological effect which can be manifested as photodisruption, plasma induced-ablation, photoablation, thermal, and photochemical.
For many intraoral soft tissue surgical procedures, the laser is a viable alternative to the conventional techniques. The commercially available dental instruments have emission wavelengths ranging from 488 to 10,600 nm and are all nonionizing radiation. This is to avoid any mutations in the cellular DNA components which ionizing radiations are known to cause. Different wavelengths have different absorption coefficients based on the varied composition of human tissue. In order to maximize the thermal reaction, there should be a close match between the laser wavelength and the chromophore(s) present in the target tissue. During the thermal ablation as the temperature increases at the surgical site, the soft tissues are subjected to warming n g (37 to 60 °C) , protein denaturization, coagulation (> 60°C), welding (70 to 90°C), vaporization (100 to 150°C), and carbonization (> 200°C). The primary chromophores for intraoral soft tissue ablation are hemoglobin, water, and melanin. Lasers (810-980 nm range) emit laser light in the near infra-red spectrum of the electromagnetic radiation which are highly absorbed in hemoglobin and other pigments. ,
Nd:YAG lasers, which we used are, high-power lasers that show excellent soft tissue ablation capability, accompanied by an adequate hemostatic effect.  The Nd:YAG laser has been described for use in many soft tissue operations. 
In routine clinical dental treatments, pain control is important for the patient's physical and dental well-being and for the effectiveness of the therapy. In the present study, functional complications were not observed in the laser groups on postoperative day. The distinct advantages of Nd:YAG laser surgical treatment were that the laser cut was more precise in tissue removal, with greater visibility because of the lack of bleeding during and after surgery; the laser sterilized as it cut, which reduced the risk of the blood-borne transmission of disease because the wound was sealed with a biological dressing; there was minimal pain and swelling after surgery; no suturing was needed; surgical time was shorter; and no damage occurred to the adjacent normal tissue.
The Nd:YAG laser is a source of cold (athermic) energy that can aid healing, reduce inflammation and edema, and reduce pain. Because the pulse duration of this laser is shorter than the time required to initiate a nerve action potential, many procedures can be performed without the use of local anesthesia. 
The patient hardly noticed any discomfort and there was absolutely no bleeding. We used pulsed mode, as continuous wave mode causes a rapid rise in temperature in the target tissue. Pulsed mode provides time for the tissues to cool down and prevents the collateral tissue damage incident to excessive heat production. The frenum was completely eliminated and the patient could protrude her tongue up to 10 to 12 mm [Figure 1]e. The excellent hemostasis and absence of postoperative swelling was attributed to increased platelet activation  by lasers and sealing of lymphatic vessels.  Furthermore, by using near-infrared lasers on soft tissue, there is minimal or no bleeding due to a combination of sealing of small vessels through tissue protein denaturation and stimulation of factor VII production in clotting. Denatured proteins within tissue and plasma are the source of the layer termed "coagulum", which is formed because of laser action and serves to protect the wound from bacterial or frictional action.
The heat buildup also allows for the sealing of small lymphatic and blood vessels, which results in reduced postoperative bleeding and edema.  There was no need to suture, as there is complete hemostasis and improved wound healing. In addition, the laser's sterilization of the surgical wound reduces the need for postoperative care and antibiotics. The patient who underwent laser frenectomy reported that she did not need analgesics beyond 24 hr postoperatively. Although the lingual frenum was completely eliminated after one week, postoperative notching was seen at the tip of tongue, suggesting a permanent deformity of the tongue.
The patient was advised to undergo speech therapy for correction and improvement of their speech
Thus the soft tissue procedure described in the current article validates the advantages associated with Nd:YAG laser. The risk of eye injury is minimal but must be considered, especially for high-output lasers in the invisible range. Protective goggles, specific for the wavelength, must be used for the patient and the therapist. The future of Nd:YAG as soft tissue laser is promising and can be successfully integrated into the everyday dental practice.
| Conclusion|| |
The presence of tongue clefting suggests that lingual frenum interventions should be performed at a very young age to prevent tongue deformity and speech problems. This case report clearly shows that Nd:YAG laser definitely has an advantage over conventional methods of lingual frenectomy, as it prevents bleeding and swelling, and is associated with minimal or no postoperative pain. Thus, practitioners should consider integrating Nd:YAG laser in soft tissue surgical procedures for the benefit and comfort of the patient.
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