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INTRODUCTION In 1974, Mirko Placek et al. has introduced a upper labial frenum classification based on the adhesion position of upper labial frenum to help clinicians identify functional problems that need to be intervented. Position of upper labial frenum, with diverse subjects of race, age ...; such as the study of Janczuk and Banach in 1980 in adolescents, the study of Boutsi and Tatakis in 2011 in children ... However, in Vietnam today, studies of position of upper labial frenum attachment use this classification. on children is not much. At the same time, upper labial frenum is a small anatomical structure, but it has many different shapes that are easily overlooked clinically. Therefore we need to have research to help understand the diversity of labial frenum. Lasers have been known in the dental industry for over 25 years. However, for a long time, the laser generation was considered as a difficult device to use, the price was high, so it was less accepted by the patients and received less attention from practicing doctors. In the last few years, the introduction of compact, easy-to-use, light-weight, semiconductor lasers has changed the views of clinicians and has proven to be a effective treatment facility and likened to a "soft tissue driller" in dental treatment. The absorption of tissue on the light energy of Laser Diode determines the energy level used in surgical operations Laser Diode is widely used in surgery and treatment of soft tissue sinuses such as: gingival cutting, boss gingival, lip excision, fibrous tissue, periodontal treatment support, implant disclosure in second stage surgery ... The benefits of Laser Diode in soft tissue modalities include: precise surgery, without bleeding, minimally invasive surgery, swelling and minimal scarring, requiring little or no suture and painless surgery during and after surgery. From the above reasons, we implemented the research titled: “Studying the abnormal upper labial frenum attachment and the effectiveness of Laser Diode treatment in the pupils aged 7-11 years old”, with three objectives: 1. Determining the ratio of abnormal upper labial frenum attachment of 7 - 11 year-old pupils in two primary schools in Hanoi. 2. Describing the relationship of abnormal upper labial frenum attachment to teeth and periodontal contexture of the two maxillary central incisors in the above group. 3. Evaluating the effectiveness of treating abnormal upper labial frenum attachment by Laser Diode in the group of patients who are indicated for the treatment.
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY PHUNG THI THU HA STUDYING THE SUPERIOR LABIAL FRENULUM WITH ABNORMAL ATTACHMENT AND THE EFFECTIVENESS OF LASER DIODE TREATMENT IN THE PUPILS AGED 7-11 YEARS OLD Speciality: Odonto - Stomatology Code: 62720601 SUMMARY OF MEDICAL PhD THESIS HA NOI – 2020 INTRODUCTION In 1974, Mirko Placek et al has introduced a upper labial frenum classification based on the adhesion position of upper labial frenum to help clinicians identify functional problems that need to be intervented Position of upper labial frenum, with diverse subjects of race, age ; such as the study of Janczuk and Banach in 1980 in adolescents, the study of Boutsi and Tatakis in 2011 in children However, in Vietnam today, studies of position of upper labial frenum attachment use this classification on children is not much At the same time, upper labial frenum is a small anatomical structure, but it has many different shapes that are easily overlooked clinically Therefore we need to have research to help understand the diversity of labial frenum Lasers have been known in the dental industry for over 25 years However, for a long time, the laser generation was considered as a difficult device to use, the price was high, so it was less accepted by the patients and received less attention from practicing doctors In the last few years, the introduction of compact, easy-to-use, light-weight, semiconductor lasers has changed the views of clinicians and has proven to be a effective treatment facility and likened to a "soft tissue driller" in dental treatment The absorption of tissue on the light energy of Laser Diode determines the energy level used in surgical operations Laser Diode is widely used in surgery and treatment of soft tissue sinuses such as: gingival cutting, boss gingival, lip excision, fibrous tissue, periodontal treatment support, implant disclosure in second stage surgery The benefits of Laser Diode in soft tissue modalities include: precise surgery, without bleeding, minimally invasive surgery, swelling and minimal scarring, requiring little or no suture and painless surgery during and after surgery From the above reasons, we implemented the research titled: “Studying the abnormal upper labial frenum attachment and the effectiveness of Laser Diode treatment in the pupils aged 7-11 years old”, with three objectives: Determining the ratio of abnormal upper labial frenum attachment of - 11 year-old pupils in two primary schools in Hanoi Describing the relationship of abnormal upper labial frenum attachment to teeth and periodontal contexture of the two maxillary central incisors in the above group Evaluating the effectiveness of treating abnormal upper labial frenum attachment by Laser Diode in the group of patients who are indicated for the treatment NEW CONTRIBUTIONS OF THE THESIS Upper labial frenum is an anatomical structure with many variations depending on the individual, there have been many types of classification of shapes, the classification of the location of sticking given Although the function of upper labial frenum has not been clearly stated, the effect of its position on the development of the arch and periodontal contexture has been mentioned by many reports Abnormal upper labial frenum attachment such as interdental papillae attachment or excessive interdental papillae attachment may cause diastema between the upper middle incisors, the rotating incisors, affecting crossbite, overbite, overjet, gum recession, gingivitis, etc full of upper labial frenum anatomical shape, the effect of abnormal upper labial frenum attachment on dental arch and periodontal is very necessary, with scientific significance The author has boldly selected this thesis topic to help clinicians better understand abnormal upper labial frenum attachment and appropriate intervention solutions Regarding the anatomical characteristics of upper labial frenum, the thesis has obtained very detailed and meticulous results, such as 57% of normal upper labial frenum attachment to the mucosa, 47% abnormal attachment, of which 38.6% attach to the gingival, rate of papillae and papillae are very rare Most labial frenum have a normal shape, 10.4% have a residue, 9.1% has a nodule, 2.8% has a depression, and 2.4% has a domed shape, very rare labial frenum bifurcate These results clearly illustrate the other classifications of other authors, contributing to theoretical insights Regarding the relationship of abnormal upper labial frenum attachment to the teeth and periodontal of the two maxillary central incisor, from the results, the author found that the risk of crossbite is 2.66 times higher in the group of pupils having abnormal upper labial frenum attachment compared to children with upper labial frenum with normal attachment, the risk of diastema was 3.1 times higher, or as the incisor risk between abnormal teething was 1.71 to 2.23 times These are the new findings of the author and meaningful contributions both theory and practice The abnormal attachment location of upper labial frenum was also discovered by the author to have a certain percentage affecting the incisor upper periodontal state Regarding the effectiveness of using Laser Diode to cut upper labial frenum, the author also saw 80% of cases without bleeding after surgery The rate of using painkillers is very low, only about 17% and after days almost no patients have to take pain reduce medicine The healing rate increased gradually from 61.3% after days, then after week was 72.5% and after weeks was completely cured This shows that Laser Diode is a desirable means for labial frenum excision surgery, which is not only convenient for doctors but also beneficial for patients The advantage of the dissertation is that it has studied in depth the upper labial frenum on a large research population, although it is a very small detail in oral cavity but has been clearly and highlighted by the author effects of anatomical abnormalities Besides, the author has also contributed to further proof along with other works on the advantages of Laser Diode, a method chosen by dentists more and more in the modern dental period The layout of the thesis includes 125 pages: Introduction (2 pages), Literature overview (37 pages); Research subjects and methods (27 pages); Research results (28 pages); Discussion (25 pages); Conclusion (2 pages); Recommendations (1 page); In the thesis, there are 28 tables, 16 diagrams, 24 figures and 112 references Chapter 1: LITERATURE OVERVIEW 1.1 Characteristics of Upper labial frenum: 1.1.1 Anatomy, physiology, histology of upper labial frenum Refers to anatomical, physiological, histological, and taxonomic characteristics Upper labial frenum 1.1.2 Classifying the attachment of upper labial frenum by Mirko Placke et al (1974) divided into four categories: Normally the upper labial frenum attaches to the location of the buccal-buccal mucosal boundary a few millimeters (about I) from the gumline When upper labial frenum attached to gingiva (degree II), interdental papillae attachment (degree II) and excessive interdental papillae attachment (degree III) are considered abnormal upper labial frenum attachment 1.1.3 Classification according to the labial frenum according to Sewerin (1971) divided into eight categories: Simple upper labial frenum; Continuous palate shape; With excessive pieces; With nodes; Double labial frenum; With recessions; Bifurcate; Combined the above types 1.2 The relationship of abnormal upper labial frenum attachment on the teeth and periodontal of two maxillary central incisors 1.2.1 The relationship between abnormal upper labial frenum attachment to diastema of the two maxillary central incisors 1.2.2 Relationship between abnormal upper labial frenum attachment to gingival recession, plaque and gingivitis of two maxillary central incisors The gingival recession is identified by the tooth root's exposure as the gingival margin moves towards cementum through the cement-enamel boundary (CEJ) Due to the tension in the movement, the labial frenum causes an ischemia of the surrounding tissue and traction can cause gum contouring pain of gingival margin 1.2.3 The relationship of abnormal upper labial frenum attachment with the two maxillary central incisors The abnormal upper labial frenum attachment can lead to some undesirable clinical conditions such as: rotating teeth, complications on the growth of lateral and canine incisor, crossbite of lateral incisor 1.3 Treatment methods for the abnormal upper labial frenum attachment 1.3.1 Indication for surgery of the abnormal upper labial frenum attachment: when upper labial frenum cling to Level II, III, IV and/or accompanied by the following signs: - Abnormal upper labial frenum attachment causes gingival margin phenomenon (positive labial frenum tension test), long-term gums, gingivitis, gingival margin shrinkage, causing limited lip movement, hindering dental hygiene causes early tooth decay in children, causing distortion, diastema between two maxillary central incisors, cutting labial frenum then orthodontic closure of diastema Abnormal upper labial frenum attachment surgery after the canines have erupted and orthodontic treatment is involved affects the denture retention 1.3.2 Surgical methods of treating abnormal upper labial frenum attachment 1.3.2.1 Conventional techniques The commonly used techniques are: Classic techniques; Parallel engineering; Miller's technique; Plasty V-Y Technique; Plasty Z technique 1.3.2.2 Electrocautery technique 1.3.2.3 Recestion of abnormal upper labial frenum attachment Laser Types of lasers commonly used in dentistry are Laser CO2, Neodymium: YAG Laser, Erbium: YAG Laser, Erbium: YSGG, Bipolar laser, Argon Laser,… 1.3.2.3.1 Surgery of abnormal upper labial frenum attachment with Bipolar laser (Diode) Bipolar laser (A.R.C Fox) 810 nm wavelength selected Proceed until all the underlying muscle fibers are removed 1.3.2.3.2 Advantages of Laser surgery compared to traditional techniques - No need for injection anesthesia, no pain, patients are less afraid, without bleeding so they can see better No need to use periodontal surgical tape so patients not feel uncomfortable Better healing with less scarring Less time consuming 1.4 The situation of researches in the world and in Vietnam on abnormal upper labial frenum attachment by Laser Dioide 1.4.1 In the world: Studies have demonstrated and clarified the effectiveness of abnormal upper labial frenum attachment by Laser Diode and the limited aspects such as cost and recurrence rate due to the removal of collagen fibers close to the periosteum 1.4.2 In Vietnam: The author Do Hoang Viet also studied the effectiveness of Laser Diode treatment but on a smaller sample size Chapter RESEARCH SUBJECTS AND METHODS 2.1 Cross-sectional descriptive study 2.1.1 Location and time The study was conducted at two elementary schools in Hanoi city from May 2016 to March 2017 2.1.2 Research subjects Selection criteria: Pupils whose parents are Vietnamese; No previous intervention of upper labial frenum shaping before; Never had orthodontic treatment; No history of upper lip injury, upper labial frenum; There were no birth defects in the maxillofacial region; Normal health status and family agree Exclusion criteria: Those who not meet the above standards; Taking medications that affect benefits like phynantoin 2.1.3 Sample size: p(1-p) n = Z2(1-α/2) x DE d2 In which: + n: sample size in the community + Z2(1-α/2): reliability coefficient, with α = 0,05 => Z2 (1-α/2) = 1,962 + p: percentage of children with abnormal upper labial frenum attachment in the population + p = – the percentage of children having upper labial frenum attachment (mucosal attachment) in the population According to the research of Impellizzeri A, Tenore G, Palaia G, et al In 2013, the percentage of labial frenum was abnormally attached, ranging from 88% for 7-year-olds and 48% for 10-11-year-olds In our study of 5-year-olds, we calculated the sample size for an age group with the lowest labial frenum cling rate was the 11-year-old group with p = 40% = 0.4 + d: the absolute precision desired; choose d =10% = 0,1 + DE: design coefficients: DE=2 p(1-p) Sample size for age group = Z2(1-α/2) x DE =184,36 d2 with α = 0,05 Thus, the sample size needed for an age group is 200, in the study there are age groups, the minimum sample size needed for the descriptive study is N = 1000 with α = 0.05 In fact, we conducted surveys at two primary schools with a total of 1,600 children 2.1.4 Research sample selection techniques Intentional sampling of patients in accordance with selection and exclusion criteria 2.1.5 Process of conducting the research 2.1.5.1 Making the form to collect information - Designed in the form of research papers 2.1.5.2 Collecting the research information - General information: Pupil's name, age, gender, address for contact - Information gathering examination: *Attachment position of upper labial frenum; * Height of upper labial frenum (in mm): Attachment position of upper labial frenum is always examined with the upper lip pulled gently away from the alveolar bone Classify attachment of upper labial frenum according to Mirko Plake et al (1974) into four categories How to determine the boundary of the oral mucosa - gum sticking is determined by Lugol's Iodine 3% solution * Upper labial frenum shapes: Classification of upper labial frenum according to the classification of Sewerin (1971) with categories * Overbite: Overbite was evaluated by measuring (in mm) the vertical difference between the incisal edges of maxillary and mandibular central incisors, ideally overlap of 1/3 over mandibular incisor * Overjet: Overjet was measured with a probe from the buccal surface of the mandibular central incisors to incisal border of the most projected maxillary central incisor Normally, overjet range from 2mm to 4mm * Crossbite: When the edge of upper inscisors is in backward of lingual surface of lower inscisors * Diatema: Measuring the distance from the face near tooth 11 to the face near tooth 21 at the same position as the edge of tooth bite 11 and tooth 21 This seam must be parallel to the upper chewing plane with periodontal sonde * Teething types of the two maxillary central incisors: vertical teething, outer deviated teething, inner deviated teething, * Shrinkage level of gingival margin R11.21: The gingival recession is identified by the tooth root's exposure as the gingival margin moves towards cementum through the cement-enamel boundary (CEJ) Measure the length of the root tooth 11, 21 exposed from the enamel boundary line - tusks toward the tooth root with periodontal sonde * Gingivitis: is one of periodontal conditions such as gingivitis, alveolar bone resorption maybe due to bad oral hygiene or secondary by abnormal labial frenum attachment that causing food deposition difficult to clean teeth difficulty in oral hygiene leads to gingivitis, receding gums 2.1.5.3 Materials and tools of collecting information: - Designing community examination cards - Tray for examination, dental pick, dental mirror - There are many types of probes around the teeth Using a standard probe with a 0.5 mm-spherical tip, insert it gently into the gum pocket without pain The scale lines from the beginning end are 1, 2, 3, 5, 7, 8, 9, and 10mm respectively 2.2 Open clinical intervention studies with control groups 2.2.1 Location and time - Location: at Department of Odontology, Vietnam-Cuba Friendship Hospital - Time: from January 2016 to January 2019 2.2.2 Research subjects Selection criteria: are patients aged from to 11 years old; abnormal upper labial frenum attachment degree II, III according to Mirko Placek classification in 1974; Positive labial frenum tensile test positive; There are no contraindications related to systemic disease; Voluntarily participate in the study and obtain the consent of a parent or guardian Exclusion criteria: Those who were not voluntarily participating in the research; Incomplete information collection form; abnormal upper labial frenum attachment level IV and too thick; Patients with indications for bone grafting; Patients with abnormal X-ray abnormalities: residual teeth, underground teeth, root tooth follicles, tumors caused by incisor upper teeth … 2.2.3 Research Methods 2.2.3.1 Research design Open clinical intervention studies with control groups were conducted in 7-11 year-old patients who were school-age pupils to evaluate the effectiveness of Upper labial frenum with abnormal attachment by Laser Diode 2.2.3.2 Sample size: p(1-p) N = Z2(1-α/2) x DE d2 In which: + N: Patient sample size needed for the study + Z2(1-α/2): reliability coefficient, with α = 0.05 => Z2(1-α/2) = 1.962 + p: The success rate of abnormal upper labial frenum attachment surgery is usually by Laser Diode + p = – failure rate of abnormal upper labial frenum attachment with Laser Diode According to the research on the success rate of abnormal upper labial frenum treatment attachment by Laser Diode of Giovanni O., Gilles C., Maria D 2010: p = 80% = 0.8 + d: the absolute precision desired; choose d = 10% = 0.1 + DE: design coefficient:DE = 1.2 The required sample size is: p(1-p) N = Z2(1-α/2) x DE =73.7 với α = 0.05 d2 Thus, the minimum sample size needed for the study is 80 patients with Laser Diode surgery In fact, we have treated 93 patients but during treatment there were 13 patients did not visit again so the number of patients eligible for research was 80 patients 2.2.4 Process of conducting the research 2.2.4.1 Making the form to collect information - Designed in the form of clinical examination form 2.2.4.2 Steps to proceed collecting the research information - Organizing the clinical examination, to assess and select patients with abnormal upper labial frenum attachment degree II, level III and collect information about upper labial frenum attachment shape, clinging position, height of upper labial frenum - Upper labial frenum tension/blanching test to select patients for treatment when the labial frenum tensile test is positive, i.e when the gingival margin and papillae of the two maxillary central incisors become white when recession the upper labial frenum forward due to the lack of phenomenon blood appears in the mucosa located between or behind the two incisors when recession upper labial frenum - Level of bleeding during and after surgery: Use classification of bleeding level (WHO) in surgery, 30 minutes after surgery, hour after surgery and hours after surgery - Pain level after surgery: Use the VAS scale (Visual Analog Scale) to assess pain The numerical scale is an 11-point scale for patients to self-assess their pain level based on their ability to perform activities of daily life Research subjects will be asked to select the most appropriate score on VAS to best describe their pain status when being intervened by Laser Diode during surgery, on the first day, after days, after days and after 21 days after surgery The patient will select a number between and 10 that best describes pain Evaluate the results by VAS scale with the corresponding - Swelling degree examination: Using VAS to assess swelling, "0" means 'No swelling' and "10" means 'The most swollen' Researchers will choose the most appropriate score on VAS to best describe the swelling of the subject when visiting patients on the first day, after days, after days and after 21 days of surgery - The healing of postoperative gums through Landry, Turnbull, Howley indexes at the time after intervention, days, days, 21 days 2.2.4.3 Materials and tools for the information collection: - Laser Diode ADM Picasso Lite 2.5W by Densply, 810 nm wavelength - VAS scale measures the degree of swelling after surgery 2.2.4.4 Steps to conduct the recestion of labial frenum by Laser Diode: * The surgical process: - Preparing the patient: explaining, familiarizing and comforting the patient - Explain to the patient's parents and sign the surgical commitment - Prepare aseptic tools: examination kits, examination trays, mirrors, grippers, detectors Diode laser machine, laser head, set the mode recommended by the manufacturer Bipolar laser (Laser Diode) with the wavelength of 810 nm selected - Disinfect patient's mouth - Give patients gargle antiseptic solution Betadine - Conducting insensitivity: numbing with Cetacaine, TAC 20, Tricaine Blue/injectable anesthetics about 0.2ml 2% Lignocaine with 1: 80,000 adrenaline *Upper labial frenum cutting process by Laser Diode: (1) Activate the tip (2) Topical anesthetic (small labial frenum) or a few drops of local anesthetic injection of about 0.2ml 2% Lignocaine with 1: 80,000 adrenaline (large labial frenum) on both sides of the labial frenum (3) Use energy level of 0.8 - 1.4 Watt, continuous wavelength (without anesthesia requires less energy) (4) Start by cutting off the clipped part of the labial frenum and then pulling the lip forward to release the clipping that shows the diamond cut (5) Continue until you cut the entire warp tissue until it reaches the periosteum (6) If necessary, use a tapered tree or scalpel "cut" on the periosteum horizontally (7) Use a damp cotton ball or soaked with hydrogen peroxide to clean the tip 2.3 Errors and limiting the errors in the study Measures are applied to limit errors from sample selection, measurement errors until data processing Training for enumerators, standardizing data collection techniques, closely monitoring and coding when data entry 2.4 Data processing Collected data is cleaned, closely checked and entered using Epi data 3.1 Analyze and process data using SPSS 20.0 software by the method of medical statistics 2.5 Ethics in research The study was approved by the ethics jury of Hanoi Medical University in accordance with the Decision No.187/HDĐĐĐHYHN on February 20, 2016 and complies with the procedures and regulations issued Chapter RESEARCH RESULTS 3.1 The ratio of abnormal upper labial frenum attachment of the pupils aged 7-11 years old 3.1.1 General characteristics of the studied subjects The distribution of research subjects by age and gender is quite uniform, 43.8% in the age group 7-8 years, 32.7% in the age group 9-10 years and 23.5% in the 11-year-old group 54.51% of the study participants were female and 45.19% were male 11 3.1.2.3 Height of upper labial frenum Table 3.1 Average height of the upper labial frenum by gender and age group (n = 1600) Characteristics Height of upper labial frenum P (Mean ± SD) (mm) Male 9.7 ± 3.5 Gender >0,05* Female 9.5 ± 3.4 7-8 9.8 ± 3.3 Age group 9-10 9.2 ± 3.5 0,05 (8 9 .7) 46 (9 0.2) 72 (9 0.0) (1 0.3) (9 .8) (1 0.0) (0 ) (0 ) (0 ) >0,05 Comments: No patients had... 14 ( 17. 5) (2 .5) (0 ) Presence of granulation tissue No 66 (8 2.5) 78 ( 97. 5) 80 (1 00) The presence of Yes 80 (1 00) 44 (5 5.0) (5 .0) incision No (0 ) 36 (4 5.0) 76 (9 5.0) connective tissue Yes (0 ) (0 )... 15 (1 8.8) (0 ) The color of gum Red ≥ 25% and 13 (1 6.2) 54 ( 67. 5) 16 (2 0.0) tissue < 50% Red < 25% (0 ) 11 (1 3 .7) 64 (8 0.0) Yes (0 ) (0 ) (0 ) Bleeding during examination No 80 (1 00) 80 (1 00) 80 (1 00)