It is widely accepted that when choosing a service for division of tethered oral tissues the number one consideration is the experience of the provider.
However, do babies, infants and adults not deserve an experienced provider AND the optimal tool?
Given that advanced technology is available to us we should embrace it. Move forwards and always strive to achieve better.
When looking at surgery we want a tool that offers the following;
- Precision of surgical technique
- Post-operative comfort
- Optimal outcome
Following release of a tongue tie the most important immediate effect we need is best function. Keeping the tongue moving, and with the greatest range of movement, is imperative.
The number one inhibitor of free movement is pain.
The greatest cause of pain post surgery is inflammation.
Therefore the tool which causes the least inflammation is the obvious choice.
We give analgesia to all patients however young, both before the procedure (topically) and in the days following surgery (orally or rectally), but not because using a laser causes more pain than scissors. We prescribe analgesia because all surgery causes post-operative discomfort at some level. CO2 laser causes the least(1,3) but we don’t want our patients experiencing any discomfort. This is the kindest approach and the one which impedes function the least. Therefore outcome will be better.
Other advantages that the CO2 laser offers is a bloodless field during surgery. This allows excellent vision throughout the procedure. It is this as well as the facility to alter the settings on the laser that allows precision both in terms of the width and the depth of the release down to the appropriate fascial layer.
When the wound heals there is less myofibroblast activity and less collagen(2,4) laid down in CO2 wounds compared to traditional scissors or scalpel wounds which is important when considering the pathophysiology of reattachment (this will be expanded on in a future post).
As we have made the progression, over the years, scissors → diode laser → CO2 laser, our clinic has become a progressively calmer environment. We now bring back a calmer baby as CO2 laser gives 2-6 hours of pain relief and, as there is no bleeding, parents and the baby are not traumatised. If baby and mother would like a cuddle for a while that is no problem as there is no time pressure for the baby to feed straight away to settle bleeding. When the baby does choose to feed it’s then a more positive experience as they don’t have the taste of blood in their mouth and are not crying. This is important to allow the baby to organise how they feed to facilitate transition of sucking technique. Less stressed parents are also more able to absorb the information and post-op care we give them.
No-one deciding on surgery should have to compromise. Patients deserve the best care available.
If you’re interested in some of the finer details of laser physics keep reading;
NOT ALL LASERS ARE CREATED EQUAL
Whilst most people would regard all lasers as the one in the same there are many differences between the different frequency of lasers and how they interact with the tissues of the body. It is this tissue interaction that determines which is the best laser to use for any given application.
The lasers typically used for tongue tie divisions are either diode, erbium or CO2 lasers.
- DIODE lasers are relatively cheap and are portable with many fitting into a briefcase and some just a little larger than a pen. Their interaction is with soft tissue only (gums and skin). However, their absorption in the tissues is low, unless highly pigmented, so the laser energy travels far into the tissue. To make a diode laser able to cut the tissue it is necessary to trap the laser energy in the tip of the fibre by ‘blackening’ the tip. This causes the tip of the fibre to heat up and it is this heat that cuts the tissue. As a result of this there is very little difference between one diode laser frequency and another.
- ERBIUM lasers have excellent cutting properties in both soft tissue and hard tissue (teeth). This makes this laser frequency attractive to dentists as the can use it instead of a drill for some procedures. As the laser energy at this frequency is very well absorbed in the soft tissue they don’t coagulate the blood vessels as well so it is possible for there to be some bleeding during procedures. There is usually also water sprayed into the site during procedures to help with cooling of the tissue.
- CO2 lasers come in two frequencies 9300nm and 10600nm. The 9300nm frequency has an action on both soft and hard tissue. At present this can only be used with an articulating arm. The 10600nm frequency is absorbed in soft tissue only and has a coagulation depth just slightly deeper than the cutting depth. This makes it both efficient at cutting whilst making the surgery bloodless. Using a superpulse mode means that there is no charring as the tissue can cool down between pulses. The disadvantage of the CO2 laser is that it is only transportable within a facility due to its’ size and the cost which is significantly higher than a diode laser.
1. Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques. J Periodontol. 2006;77(11):1815-1819.
2. Ben-Baruch G, et al. Comparison of wound healing between chopped mode – superpulse mode CO2 laser and steel knife incision. Laser Surg Med. 1988;8(6):596-9.
3. Chiniforush N, et al. Treatment of Ankyloglossia with Carbon Dioxide (CO2) Laser in a Paediatric Patient. Journal of Lasers in Medical Sciences. Vol 4. Num 1. Winter 2013
4. Hendrick DA, Meyers A. Wound Healing after Laser Surgery. Otolaryngol Clin North Am. 1995 Oct;28(5):969-86
For a video of a tongue tie division with a CO2 laser please click here