LASERfocus The Importance of Orofacial Myofunctional Therapy Before and After CO2 Laser Frenectomy in Achieving Optimal Orofacial Function by Karen M. Wuertz, DDS, ABCDSM, DABLS, FOM, and Brooke Pettus, RDH, BSDH, COMS Frenectomy Methods ing, speaking, and breathing patterns may be Frenotomies performed with a scalpel or scissors can be accompanied by caused by incorrect oral posture and oral re- significant bleeding, obscuring the surgical field making it difficult to ensure strictions. Therefore, in the authors’ opinion, if the restriction has been completely removed. Because of the increased risk the removal of oral restrictions is necessary to of early primary closure of the site, postoperative active wound care is es- attain optimal orofacial function, and must be sential to reduce the risk of potential scarring. To properly restore and main- combined with regular pre- and post-frenecto- tain optimum function, active wound care should be implemented as soon my orofacial myofunctional therapy (OMT).1,4 as possible. However, if sutures are placed, the active wound care may be OMT helps re-educate the tongue and orofa- delayed so as not to cause early tearing of tissue. Due to the contact nature of cial muscles during movement and at rest to conventional procedure, there is a certain potential for infection; in addition, create new neuromuscular patterns for proper higher levels of postoperative pain and discomfort have been reported.1,2 Elec- oral function, including chewing, swallowing, trocautery and a hot glass tip of dental diodes may leave a fairly substantial speaking, and breathing.5,6 Camacho et al.7 zone of thermal tissue change3 and may result in delayed healing. Erbium la- demonstrated the reduction of apnea-hypo- sers produce excellent incisions, but are not efficient for coagulation.3 There- pnea index in children and adults following fore, the clinician utilizing an erbium wavelength for frenectomy may need to myofunctional therapy. In the absence of such re-education therapy, deviant oral and breath- control intra-operative bleeding. The 10,600-nm CO2 laser has been shown to accurately incise soft tissue, with simultaneous efficient coagulation. The ing habits may continue to exist, eventually photo-thermal coagulation depth of this wavelength closely matches the di- ameters of small oral soft tissue blood and lymphatic vasculature.1,3 This helps maintain a clear surgical site and reduces the risk of postoperative edema. Frenectomy and role of OFMT Improperly formed orofacial structures and deviant swallowing, chew- A. C. B. D. A. B. A. B. Figure 1: A.-B. Pre-frenectomy: note jaw de- Figure 2: A. Pre-frenectomy/OMT: Long, narrow face Figure 3: A. Posture pre-frenectomy/OMT: forward head/ viation, facial asymmetry, bulbous tongue tip, and low facial muscle tone, a short upper lip (phil- neck, forward rolled shoulders; patient reported tension in and inability to lateralize without downward trum length: 14 mm), open mouth resting posture neck and shoulders B. Posture 3 weeks post-frenectomy pull from lingual restriction; C.-D. 3 weeks with 7 mm interlabial gap; B. 3 weeks post-frenec- w/ OMT: forward head/neck and forward rolled shoulders post-frenectomy/OMT: note improved facial tomy/OMT: Improvement in overall facial tone, phil- posture is considerably reduced; patient reports neck and symmetry, unrestricted and controlled tongue trum length: 18 mm, relaxed closed mouth resting shoulder tension has decreased significantly, and she is lateralization, and less jaw deviation. posture with 0 mm interlabial gap. able to maintain better posture for a longer time. Reprint from Dental Sleep Practice Fall 2018 DentalSleepPractice.com 1 LASERfocus leading to the return of airway and sleep is- was 14 mm long), and open mouth resting posture with the 7 mm interlabial gap sues that preceded frenectomy.1,5 (Figure 2A). The patient reported mouth breathing all night, regular night time drooling, restless sleep, and frequent waking. She complained of daytime fatigue Case Example and never waking well rested. Her left nostril “whistled” during nasal breathing, A 29 year old Caucasian female (an oro- and she was frequently congested. Moreover, the patient had a forward head/ facial myologist) presented to a dental sleep neck and forward rolled shoulder posture; she reported significant tension in office for labial and lingual laser frenectomy. the neck and shoulders and was concerned about Dowager’s hump formation The patient was unable to efficiently prog- (Figures 2A and 3A). She had a bilateral tongue thrust during swallowing and low ress through myofunctional therapy due to tongue resting posture (tongue tip resting against lower incisors). The patient re- tethered oral tissues. She had always strug- ported dry, chapped lips and the habits of lip licking, cheek biting and clenching. gled to maintain a proper lip seal due to a Intraoral examination revealed a narrow, high palatal vault with pro- restricted labial frenum and demonstrated a nounced rugae, and narrow soft palate. The tight upper labial frenum and at- short upper lip from mouth breathing. While tached gingiva blanched when extending the upper lip. The tongue appeared treating her own clients, she was unable to short and wide with a tight, restrictive lingual frenum. The functional range demonstrate certain myofunctional therapy of motion (ROM) was 60.8%: the full ROM was 46 mm, and the ROM with exercises that were required elevation of the tongue tip to incisive papilla was 28 mm (Figure 4A). The patient’s Mallampati middle and posterior portions of the tongue. score was IV (Figure 5A). The patient hoped the frenectomy procedures Medical history: At the time of the visit, no medications were taken; no would aide in her ability to create a lip seal, known drug allergies, recent illnesses, or hospitalizations were reported. correct her tongue rest posture, and establish Laser surgery: After local anesthetic (Articaine hydrochloride 4% with a proper swallowing pattern. 1:100,000 epinephrine) was administered by infiltration, the LightScalpel laser Childhood history of symptoms: The frenectomy was performed to release both the maxillary labial and lingual patient was bottle fed during infancy. A his- ® restrictions. LightScalpel CO2 laser (LightScalpel, LLC, Bothell, WA) with 0.25 tory of thumb-sucking and pacifier use until mm focal spot size laser handpiece was utilized, delivering 2 watts SuperPulse the age of four were reported. At the age of laser beam gated at 70% duty cycle at 20 Hz (average power to the tissue was seven, the patient underwent adenoidectomy 1.4 watts). For efficient incision, gentle traction tension was applied to the and tonsillectomy. She had a deviated sep- tongue and the lip during lingual and labial procedures, respectively. The laser tum after breaking her nose at the age of nine nozzle was held 1-3 mm away from the target tissue and moved in zigzag- (this has not been corrected), and reported frequent mouth breathing. The patient had or- thodontic treatment from age twelve to four- Karen Wuertz, DDS, has been recently awarded the first ever teen that included rapid palatal expansion Fellowship of Orofacial Myology by the International Associa- and retractive headgear. Due to orthodontic tion of Orofacial Myology; is a Diplomate, American Board of relapse, she also had orthodontic treatment Craniofacial Dental Sleep Medicine; a Fellow, American Acad- at age twenty and again at age twenty five. emy of Craniofacial Pain; and a Diplomate, American Board of Clinical exam and symptoms: The fol- Laser Surgery. She is an Assistant Adjunct Professor, UNC Dental lowing TMD symptoms were observed: jaw School, Chapel Hill, and maintains membership in the Texas Dental Society, deviation to the right along with clicking/ American Dental Association, American Academy of Dental Sleep Medicine, popping/crepitus on the right side (Figures American Academy of Craniofacial Pain, and serves as the credentialing Chair 1A and 1B). The patient reported neck pain for the American Board of Craniofacial Dental Sleep Medicine. and frequent headaches. The patient had a long, narrow face, low Brooke Pettus, RDH, BSDH, COMS, is the owner of Myofunc- facial muscle tone, a short upper lip (philtrum tion Junction in Richmond, VA, where she works full time help- ing children overcome oral habits and myofunctional needs. She has trained through the Academy of Orofacial Myofunc- tional Therapy, the International Association of Orofacial Myol- ogy, MyoMentor, and is a certified orofacial myology specialist through the Graduate School of Behavioral Health Sciences. Brooke has spent hundreds of hours studying with, learning from, and partnering alongside pe- diatric and airway-focused dentists and orthodontists, speech language pathol- ogists, ENTs, occupational therapists, and lactation consultants. She strongly A. B. believes a team approach is necessary for optimal oromyofunctional outcomes. Figure 4: A. Pre-Frenectomy: 28 mm ROM with tongue Brooke graduated from Virginia Commonwealth University in 2009. She has tip to incisive papilla; functional ROM 60.8% B. 10.5 spoken nationally and internationally on a variety of oral health topics. months post-frenectomy: 47 mm ROM with tongue tip to incisive papilla; functional ROM: 94%. 2 DSP | Fall 2018 LASERfocus ging fashion until the tension was released. mm in the ROM with tongue tip to incisive papilla – from 28 mm to 47 mm As frenectomy progressed, the dentist stopped (Figure 4B). several times to evaluate the extent