Treatments for ankyloglossia and labial frenal restrictions include frenectomy; most up-to-date techniques involve lasers.4-6 With CO2 laser frenectomy, patients report less post-operative pain and discomfort than with the scalpel.5 CO2 laser ablates tissue while coagulating small blood and lymphatic vasculature; this creates clear surgical site and helps preventing post-surgical edema.
The presence of an aberrant frenum is often obvious on the initial examination and it is clear what tissue to ablate in order to remove the restriction. But sometimes restrictions are not always immediately noticeable. And to truly benefit the patient and specifically target areas that are interconnected to oral restrictions, frenectomy procedures are performed under the palpatory guidance of an osteopath who is trained in assessing the soft tissues and myofascial strains. The laser clinician uses a probe inside the patient’s mouth to find “tight places” or tension bands, while the osteopath provides constant feedback pointing out whether the spot that appears tight is, indeed, restrictive in the way it is connected to other structures. This approach makes the procedure most effective allowing the laser clinician remove only the true restrictions that need to be released.
The authors’ technique for the osteopathically guided Functional Frenectomy involves of the following phases:
- Pre-surgical osteopathic structural assessment and manipulative treatment, and myofunctional therapy exercises to prepare and re-pattern tongue function once the restriction is released;
- CO2 laser frenectomy, preferably under topical anesthesia and combined with real-time lingual and labial restriction assessment by palpatory guidance of an osteopath to achieve ideal release for the optimal function;
- Post-procedure osteopathic structural assessment and manipulative treatment, and myofunctional therapy exercise program to ensure long-lasting functional results.
The osteopathically guided Functional Frenectomy (for both labial and lingual restrictions) is illustrated by the clinical case shown in Figures 1-3. Note both the immediately improved mobility and lift of the tongue. The well controlled hemorrhage, sealed lymphatics and reduced zone of thermal impact result in less edema and discomfort to the patient. Magnification during the frenectomy is strongly encouraged due to the close proximity of large blood vessels to the surgical site. The authors prefer using topical anesthesia to increase the reliability of the functional assessment during the release. However, the patient in this case felt the laser at times and small amounts of local anesthetic were administered to the upper and lower frenectomy sites.
In order to achieve the proper myofascial release in adult patients, it is not sufficient to just remove the aberrant frena. Under the osteopathic guidance, the clinician should often re-access the effect of the restriction release on other myofascial structures. The clinician must take into account the jaw range of motion, the floor of the mouth flexibility, along with the tongue’s ability to elevate, protrude, and achieve lateral functions. The clinician should proceed slowly and cautiously. It is important to remember that full range of motion is not always possible due to other limitations, i.e., clinician needs to know when to stop to achieve the maximum benefit. Frenum that restricts proper lingual or labial motion feels tight to finger pressing in. Unrestricted tongue and lips feel soft. To feel for restrictions, one can grasp the tip of tongue or lip with gauze and gently pull the tongue upwards and the lip outwards. Finger pressure of the other hand could help reveal accessory restrictions as push back would be felt. In this case study, the clinician used the tongue director as a probe to apply pressure to the points that appeared restrictive, and removed those fibers, or not, depending on the real-time osteopathic feedback from Dr. Geis.
The patient normally returns to the dental office for healing assessment at varying intervals. The team then reviews and re-evaluates the benefits achieved. This is necessary for evaluation of the performance of the tongue and lips, the tone and function changes of the lingual muscles and the suppleness of the healing tissue at the surgical sites.
Figure 2. 2A: Pre-op aspect of the maxillary labial frenum. 2B: SuperPulse CO2 laser release in progress. Note complete lack of bleeding. 2C: Immediately after the laser release. Wound was left to heal by secondary intention. 2D: Healing two weeks following the laser frenectomy. Note lack of inflammation or swelling.