Title	Lasers Are More Effective Than Scalpels for Labial Frenectomies When Considering Clinical and Patient Outcomes
Clinical Question	For a patient with an abnormal labial frenum, is a laser more effective than conventional scalpel methods in performing a frenectomy?
Clinical Bottom Line	For patients with an abnormal labial frenum, a laser frenectomy is more effective than a conventional scalpel frenectomy. This is supported by a meta-analysis including four randomized controlled trials, and a more recent well-done randomized controlled trial. With benefits of the laser frenectomy including shorter surgical times, less bleeding, and less overall discomfort, it is a procedure that would likely be accepted by a patient. Purchasing a laser may be cost prohibitive for the clinician; however, the skills needed to perform the procedure are easily learned and can be added to a general or specialty practice.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 31624426 Protásio / 2019 239 patients needing frenectomy in 6 included studies Meta-Analysis Key results This meta-analysis showed that patients who had the laser frenectomy experienced significantly faster average surgical times, less pain, less speech discomfort, and less chewing discomfort on the first and seventh days post-operatively when compared to those who had the conventional scalpel technique. Analgesic use, although lower in the laser groups, was not found to be significant. Post-operative bleeding occurred in all scalpel frenectomy groups, and no sutures were needed in the laser frenectomy groups. However, intra-operative time and fear were not able to be assessed in the meta-analysis due to significant heterogeneity in the studies. A high risk of bias was found in this meta-analysis, so results should be viewed with caution. 33369213 Sarmadi / 2020 40 patients ages 7-19 needing frenectomy Randomized Controlled Trial Key results This randomized controlled trial found average surgical time (54% longer) and bleeding (three times higher) in the scalpel groups to be significant when compared to the laser groups. Neither group had significant pain levels immediately post-operative or at follow-up. For wound healing, the wounds following laser frenectomy were significantly larger post-operatively, but there was not statistical difference at the 5-day follow-up.
Evidence Search	(((laser) AND (frenum or frenulum)) AND (frenectomy)) AND (scalpel)
Comments on The Evidence	The Protásio et al. systematic review was conducted according to PRISMA guidelines. The meta-analysis included four randomized controlled trials and two intervention studies with no mention of randomization. Three studies used a Nd:YAG laser, two used a diode laser, and one used a CO2 laser. Due to inadequate sample sizes, further analysis comparing the different laser types could not be done. The statistically significant results of surgical time, pain, chewing discomfort, and speech discomfort from each study were fairly similar. The risk for bias was characterized for five criteria (concealment of treatment allocation, double-blind, attrition bias, reporting bias, and ethical criteria) for each study, and the results showed unclear risk in 40%, low in 40%, and high in 20% of the criteria. When looking specifically at risk of bias for blindness, the analysis showed high risk at 40%. Confidence in the results is diminished by the small number of RCTs, small sample sizes, variation of laser used, and high risk of bias. The Sarmadi et al. study was a single-blind, prospective, randomized controlled trial. As the patient and clinician performing the procedures were unable to be blinded, the single blind portion of the study was achieved by the examiner at the 3-month follow-up not knowing which treatment the patient received. The laser used in this study was the Er:YAG. The exclusion criteria included severe disease, need for general anesthesia, and smoking. With the age range of 7-19 years old, those exclusion criteria should have minimal impact on generalizing the results to the general pediatric and young adult populations who frequently require frenectomy. A strength of this study was that 39/40 patients completed all follow-ups, with only one patient missing the 5-day follow-up due to illness. Although the researchers concluded minimal pain with both procedures, which does not align with the Protasio et al. results, it is interesting to note that initial assessment would have occurred while patients were still anesthetized and that around 50% of patients were taking some type of pain control medication at the 5 and 12-day follow-up appointments. Therefore, the pain outcomes in this study may be skewed by the effects of local anesthesia and pain medications. The surgical time and bleeding assessments were well designed, and the results should be applicable to clinicians who use an Er:YAG laser.
Applicability	The limited amount of high-level literature and lack of larger sample sizes in the available literature hampers the ability to extrapolate these results to the larger general population. However, because a large percentage of frenectomies occur in pediatric and young adult populations, the possibility of decreasing surgical time, bleeding amount, and overall discomfort by using a laser for the frenectomy in that population would be of great benefit. The larger wound resulting post-operatively from a laser frenectomy is the most significant downside to the procedure, but with similar results at five days post-operatively, the other benefits may outweigh this disadvantage in both the patient and clinician perspective. Although the Samardi article did not show significant differences in pain, the meta-analysis by Protásio et al. did, and could be motivation for clinicians who frequently do frenectomies to incorporate a laser in their practice.
Specialty	(General Dentistry) (Oral Surgery) (Orthodontics) (Pediatric Dentistry) (Periodontics)
Keywords	Frenectomy, laser, scalpel
ID#	3474
Date of submission	11/23/2021
E-mail	shieldsa1@uthscsa.edu
Author	Ashley I. Shields, DMD
Co-author(s)	Se’quon M. H. Scott, DDS, MHS
Co-author(s) e-mail	scotts6@uthscsa.edu
Faculty mentor	Brian L. Mealey, DDS, MS
Faculty mentor e-mail	mealey@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available