Nghiên cứu phanh môi trên bám bất thường và hiệu quả điều trị bằng Laser Diode ở học sinh 7 - 11 tuổi ( TT ANH)

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


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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.
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


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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 3 days almost no
patients have to take pain reduce medicine. The healing rate increased
gradually from 61.3% after 3 days, then after 1 week was 72.5% and after 3
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


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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: 1. Simple upper labial frenum; 2.
Continuous palate shape; 3. With excessive pieces; 4. With nodes; 5. Double
labial frenum; 6. With recessions; 7. Bifurcate; 8. 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.

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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 bằng 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 do 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.


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Chapter 2
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 do 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 = 1 – 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 1 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 5 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.


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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 8 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.


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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 7 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 = 1 – 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

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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, 1 hour after surgery and 6
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 3 days, after 7 days and after 21 days after
surgery. The patient will select a number between 0 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 3 days, after 7 days and after 21 days of
surgery.
- The healing of postoperative gums through Landry, Turnbull, Howley indexes
at the time after intervention, 3 days, 7 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


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- 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 3
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.


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3.1.2. Characteristics of upper labial frenum
3.1.2.1.Position characteristics of of upper labial frenum attachment.

Chart 3.1. Position rate of upper labial frenum attachment (n=1600)
Comments: More than half of the pupils had a position of normal upper labial
frenum attachment at the mucosal position, accounting for 57.0%. The ratio of
abnormal upper labial frenum attachment accounted for 43.0%.
3.1.2.2. Characteristics of shape of upper labial frenum

Chart 3.2. Characteristics of shape of upper labial frenum (n=1600)
Comments: The majority of pupils participating in the study had a simple,
simple labial frenum (74.3%). 25.7% of pupils had abnormal labial frenum
shape, of which 10.4% with excessive pieces, 9.1% with nodes, 2.8% had
dimples, 2.4% had upper labial frenum with continuous palate shape. The
incidence of abnormalities such as upper labial frenum double, bifurcate and
combination of many low forms, less than 1%.


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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**
11
9.8 ± 3.5
Total
9.6 ± 3.4
*T test
**Kwallis test
Comments: The average height of the pupil's upper labial frenum was 9.6 mm,
higher for boys (9.7 mm) than for girls for 9.5 mm, with no statistically
significant difference in average height of upper labial frenum by gender (p>
0.05). In the age group 7-8 years and 11 years, the average height of upper labial
frenum is 9.8 higher than that in the age group 9-10 years old is 9.2. The difference is
statistically significant with p <0.05.
3.2. The relationship between abnormal upper labial frenum attachment to
teething and periodontal condition of two maxillary central incisors
3.2.1 The relationship between abnormal upper labial frenum attachment to
overbite/overjet, diastema, teething types of the two maxillary central incisors

2 test: p>0,05
Chart 3.3. Rate of the pupils with overbite, overjet based on the position of
upper labial frenum attachment (n=1600)
Comments: The highest rate of abnormal overbite, overjet among pupils was
highest in position of upper labial frenum attached to excessive interdental
papilla, accounting for 14.3%, followed by upper labial frenum attached to
interdental papillae (4.8%). The lower was in upper labial frenum cling to

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gingival was 3.2% and upper labial frenum clung to the mucosa (3.0%). The
difference is not statistically significant with p> 0.05.
Table 3.2. The relationship between abnormal upper labial frenum
attachment over crossbite, overbite/overjet, diastema (n=1600)
Position of upper labial
Yes
No
OR
95% CI
frenum
Crossbite(n=1600)
Yes
No
Abnormal attachment (n=688)
23
665
1.23 0.66-2.27
Normal attachment (n=912)
25
887
Overbite/overjet (n=1600)
Abnormal
Normal
Abnormal attachment (n=688)
24
664
1.18 0.65 – 2.15

Normal attachment (n=912)
27
885
Diastema (n=1600)
Yes
No
Abnormal attachment (n=688)
257
431
1.45 1.17-1.80
Normal attachment (n=912)
266
646
Comments: Pupils with abnormal upper labial frenum attachment are 1.45
times more likely to have diastema compared to upper labial frenum with
normal attachment (OR = 1.45, 95% CI: 1.17-1.80).
No relationship was found between position of upper labial frenum attachment
and abnormal overbite/overjet status, crossbite in pupils.
Table 3.3. The relationship between abnormal labial frenum attachment to
teething types of the two central incisors (n=1600)
Abnormal Vertical
Position of upper labial frenum
OR
95% CI
teething teething
Teething types R11 (n=1600)
Abnormal attachment (n=688)
182
164
1.64 1.28 – 2.10

Normal attachment (n=912)
506
748
Teething types R21 (n=1600)
Abnormal attachment (n=688)
187
176
1.56 1.23 – 1.99
Normal attachment (n=912)
501
736
Comments: Pupils with upper labial frenum attached to a normal attachment are at
risk of maxillary central incisor on the right - R11 and maxillary central incisor on
the left - R21 abnormal teething is 1.64 times higher and 1.56 times higher than
pupils with upper labial frenum with normal attachment (OR = 1.64, 95% CI: 1.282.10 and OR = 1.56, 95% CI: 1.23-1.99).
3.2.2. The relationship between abnormal upper labial frenum attachment to
gum recession, gingivitis of two maxillary central incisors
Comments: Gum recession was most common in pupils with upper labial
frenum attached to interdental papillae (14.3%), followed by upper labial


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frenum attached to excessive interdental papilla (11.1%). Only 3.2% of pupils
had gum recession in upper labial frenum attached to gingiva and 0.9% in the
upper labial frenum attached to mucosa. The difference was statistically
significant (p <0.05).
Table 3.4. The relationship between attachment location and gum recession
(n=1600)
Gum recession
Position of

Yes
No
OR
95% CI
Upper labial frenum
Abnormal attachment (n=688)
30
658
5.15 2.29 – 13.08
Normal attachment (n=912)
8
904
Comments: The risk of gum recession was higher in pupils with abnormal
upper labial frenum attachment 5.15 times higher than pupils with normal
upper labial frenum attachment (OR = 5.15, 95% CI: 2.29 - 13.08).
Table 3.5. The state of gingivitis R11, R21 based on the position of upper
labial frenum attachment (n=1600)
Attachment position Without gingivitis
With gingivitis
p (2
of upper labial
n
%
n
%
test)
frenum
1262
R11
338

Mucosal attachment
708
77.6
204
22.4
Gum attachment
502
81.2
116
18.8
Interdental papillae
47
74.6
16
25.4
>0,05
attachment
Excessive interdental
5
71.4
2
28.6
papillae attachment
1265
R21
335
Mucosal attachment
709
77.7
203

22.3
Gum attachment
502
81.2
116
18.8
Interdental papillae
49
77.8
14
22.2
>0,05
attachment
Excessive interdental
5
71.4
2
28.6
papillae attachment
Comments: The percentage of pupils with gingivitis R11, R21 was highest in
the upper labial frenum attached to excessive interdental papilla (28.6%) and
upper labial frenum attached to interdental papillae (25.4% and 22.2%), lower
in the upper labial frenum attached to mucosa and upper labial frenum attached
to gingiva. However, the difference is not statistically significant with p> 0.05.


14
3.3. Assessing the effectiveness of Laser Diode treatment in patients with
abnormal upper labial frenum attachment.
3.3.1. Characteristics of research subjects to treat abnormal upper labial

frenum attachment:
The total number of patients participating in Laser Diode treatment was 80, the
number of male patients was higher than the number of female patients (51.3%
and 48.7%)..
3.3.2. Assessing the the effectiveness of near treatment

Fisher’s exact test: p>0,05
Chart 3.4. The ratio of using surface anesthetics and injectable anesthetics
according to the position of upper labial frenum (n = 80)
Comments: Most patients use surface anesthetics (70%) and 30% use injectable
anesthetics. There was no difference according to labial frenum, p> 0.05.
Table 3.6. Time of bleeding and level of bleeding after surgery
(n = 80)
Time
After 30
After 1
After 6
Level
minutes
hour
hours
n (%)
n (%)
n (%)
Degree 0 (Without bleeding)
8 (10.0)
75 (93.7) 80 (100.0)
Degree 1 (Bleeding)
46 (57.5)
2 (2.5)

0 (0)
Degree 2 (Mild bleeding)
26 (32.5)
3 (3.8)
0 (0)
Degree 3 (Severe bleeding)
0 (0)
0 (0)
0 (0)
Degree 4 (Very bad bleeding)
0 (0)
0 (0)
0 (0)
Comments: A study of 80 patients after intervention upper labial frenum
degree II and III showed that after 30 minutes of surgery there were 8 patients
without bleeding accounting for 10.0%, 46 hemorrhagic patients accounting for
57.5% and 26 patients flowing mild blood accounts for 32.5%. After 1 hour,


15
the number of patients without bleeding was 75, accounting for 93.7%; only 2
patients with hemorrhage accounted for 2.5% and 3 patients with mild bleeding
accounted for 3.8%.
Table 3.7. Distribution of postoperative pain level over time (n=80)
Time
1st day
3rd day
7th day
21st day
Pain level

(n=80)
(n=80)
(n=80)
(n=80)
Level 0 -No pain
34 (42.5)
53 (66.3) 75 (93.8) 80 (100.0)
Level 1 - Mild pain
16 (19.6)
9 (11.2)
5 (6.2)
0 (0)
Level 2 - Moderate pain
30 (37.5)
18 (22.5)
0 (0)
0 (0)
Level 3 - Severe pain
0 (0)
0 (0)
0 (0)
0 (0)
Comments: Immediately after the surgery, 42.5% of patients had no pain,
19.6% of patients had mild pain, 37.5% of patients had moderate pain and none
of them had very much pain (severe pain). By day 3, 11.2% of patients had
pain and by day 7 was only 6.2%. The percentage of patients with pain
gradually decreased over time after 3 days of surgery was 66.3%, increasing to
93.8% after 7 days and 100% after 21 days..
Table 3.8. Distribution of analgesic use rates by gender after treatment period
(n=80)

After 1
After 3
After 7
After 21
Time
day
days
days
days
n
Gender
n (%)
n (%)
n (%)
n (%)
Male
41
7 (14.3)
0 (0.0)
0 (0.0)
0 (0.0)
Female
39
10 (29.6)
0 (0.0)
0 (0.0)
0 (0.0)
Common
80
17 (21.2)

0 (0.0)
0 (0.0)
0 (0.0)
p
>0,05
Comments: The rate of use of painkillers on the first day after the study was
17.5%, higher among women than men (20.5% and 14.6%). After 3 days, 7
days and 21 days, no patients used pain medication. The rate of analgesic use
does not differ by gender, p> 0.05.
Table 3.9. Distribution of the degree of swelling after surgery over time
(n=80)
Time of swelling after surgery
1st
3rd
7th
21st
day
day
day
day
The degree of swelling
Degree 0 (No swelling)
80
80
55 (68.8) 73 (91.2)
(100.0) (100.0)
Degree 1 (Moderate swelling)
18 (22.5) 7 (8.8)
0 (0)
0 (0)

Degree 2 (Severe swelling)
6 (7.5)
0 (0)
0 (0)
0 (0)
Degree 3 (Very bad swelling)
1 (1.2)
0 (0)
0 (0)
0 (0)


16
Comments: The degree of swelling of the patient after surgery decreases. The
proportion of patients without swelling after one day after surgery is 68.8%;
After three days, 91.2% and after 7 days and 21 days were 100%. No patients
had swelling
Table 3.10. Time allocation of oral hygiene capabilities after Laser Diode
surgery (n=80)
After 1
After 3
After 7
After 21
Time
day
days
days
days
Degree
n

%
n
%
n
%
n
%
73 91.3 77 96.3 80
100
80
100
Not difficult
7
8.7
3
3.7
0
0.00
0
0.00
Less difficult
Comments: No patient had no oral hygiene after 1 day. The rate of having
problems with oral hygiene after the first and third day of surgery was 8.7%
and 3.7% respectively.
Table 3.11. Distribution of wound healing after Laser Diode surgery (n=80)
After 3
After 7
After 21
The level of healing
days

days
days
n (%)
n (%)
n (%)
Red ≥50%
67 (83.8)
15 (18.8)
0 (0)
The color of gum Red ≥ 25% and
13 (16.2)
54 (67.5)
16 (20.0)
tissue
< 50%
Red < 25%
0 (0)
11 (13.7)
64 (80.0)
Yes
0 (0)
0 (0)
0 (0)
Bleeding during
examination
No
80 (100)
80 (100)
80 (100)
Yes

14 (17.5)
2 (2.5)
0 (0)
Presence of
granulation tissue No
66 (82.5)
78 (97.5)
80 (100)
The presence of
Yes
80 (100)
44 (55.0)
4 (5.0)
incision
No
0 (0)
36 (45.0)
76 (95.0)
connective tissue
Yes
0 (0)
0 (0)
0 (0)
Pus
No
80 (100)
80 (100)
80 (100)
Poor
19 (23.8)

6 (7.5)
0 (0)
The level of
Good
49 (61.3)
16 (20.0)
0 (0)
healing
Very good
12 (15.0)
58 (72.5)
80 (100)
Comments: The level of healing after intervention increased in all criteria such
as the color of gingival tissue, the presence of granulation tissue and the
connective tissue of the incision. Particularly, signs such as bleeding and pus
did not appear during the postoperative follow-up from day 3. Evaluation of the
healing level showed that 3 days after surgery, 61.3% of patients were healed.


17
Good and 15.0% of patients were well healed. After 7 days after surgery,
20.0% of patients healed well and 72.5% of patients healed very well. After 21
days after surgery, 100% of the patients were well healed.
3.3.3. Assessing the effectiveness of remote intervention
Table 3.12. Scarring rate after 3 months, 6 months and 9 months according
to the position of Upper labial frenum (n=80)
Level Scar after 3 months
Scar after 9
months
Blurr Cle

Blur Cle
p
p
No
No
ed
ar (Fisher’
red
ar (Fisher’
s exact
s exact
Position of
test)
test)
n
n
Upper
n (%) n (%) n (%)
n (%)
(%)
(%)
labial
frenum
24
5
0
26
3
0
Degree II

Degree III
General

(82.8)
43
(84.3)
67
(83.8)

(17.2)
8
(15.7)
13
(16.2)

(0)
0
(0)
0
(0)

>0,05

(89.7)
46
(90.2)
72
(90.0)

(10.3)

5
(9.8)
8
(10.0)

(0)
0
(0)
0
(0)

>0,05

Comments: No patients had significant scarring after surgery. Only 16.2% had
faded scars after 3 months and decreased to 10% after 9 months. There was no
difference in scarring level according to Upper labial frenum position (p>
0.05).

Chart 3.5. Height characteristics according to attachment of upper labial
frenum before and after surgery (n=80)


18
ANOVA repeated test: p<0,001
Comments: Height of upper labial frenum before surgery at the position of
upper labial frenum attachment are all high, respectively: 11.12 ± 2.12 mm in
position of upper labial frenum attached to gingiva (degree II), 12.95 ± 2 , 81
mm at position of upper labial frenum attached to interdental papillae (degree
III) and markedly decreased after 3, 7 and 21 days after surgery. The height at
these positions after 21 days is 3.60 ± 1.06 mm and 4.33 ± 0.58 mm,

respectively.

Chart 3.6. So Comparing the thickness of upper labial frenum before surgery
and postoperative thickness (n=80)
ANOVA repeated test: p12,13,14<0,001, p23,24,34>0,05
Comments: After 3 months, 6 months, and 9 months after surgery, the average
value of the thickness of upper labial frenum by gum attachment position,
upper labial frenum attached to interdental papillae were reduced compared to
before the surgery, the difference was statistically significant. (p <0.001).
Chapter 4
DISCUSSION
4.1. General characteristics of the studied subjects
Our studied group consists of 1600 children aged 7-11 years old who are
studying at two primary schools in Hanoi City: 43.8% in the age group of 7-8,
32.7 % in the age group 9-10 years and 23.5% in the 11-year-old group.


19
4.2. The ratio of abnormal upper labial frenum attachment of 7 -11 yearold pupils
4.2.1. Position characteristics of upper labial frenum attachment
* Distribution of position of upper labial frenum
The percentage of pupils having upper labial frenum clinging to normal
position in the mucosa accounted for more than half of pupils (57.0%) (Chart
3.1) similar to Vu Duy Tung's study of position of upper labial frenum
attachment in 196 pupils 8-10 years old. Research by Jonathan PT et al. also
gave the results of position of Upper labial frenum attachment in 1200 children
aged 3-12 in India: the highest percentage of upper labial frenum attached to
mucosa, accounting for 47.5%, followed by upper labial frenum attached to
gingiva. (38.1%) and the lowest were upper labial frenum attached to
interdental papillae and Upper labial frenum attached to excessive interdental

papilla (14.2%).
4.2.2. Physical characteristics of upper labial frenum
* Form ration of upper labial frenum
The results (Chart 3.2) are similar to the results of Tran Huong Lam's
study on 241 pupils of mixed teeth group of 8-10 years old: the most popular
upper labial frenum is simple upper labial frenum 72.6%, continued followed
by upper labial frenum with nodes and upper labial frenum with excessive
pieces, upper labial frenum with domes and upper labial frenum with low
percentage. Other types of upper labial frenum are rare (<1%). Many studies
were conducted in many countries and races but the results were quite similar to
our research.
4.2.3. Height of upper labial frenum
The results of Table 3.1 are similar to those of Tran Huong Lam,
suggesting that upper labial frenum attached to excessive interdental papilla is
greater than upper labial frenum cling to other places with statistical
significance (p <0.05).
4.3. Relationship between abnormal upper labial frenum attachment to
teething types and periodontal of two maxillary central incisors in pupils
aged 7-11 years
4.3.1. Relationship of abnormal upper labial frenum attachment to the two
maxillary central incisors


20
Our study (Chart 3.2) is similar to that of Tran Thi Thao (2017). (20.0%),
the lowest in upper labial frenum attached to mucosa (3.9%) and this difference
is not statistically significant..
Table 3.2 shows that pupils with abnormal upper labial frenum attachment
have a risk of diastema between two maxillary central incisors 1.45 times
higher than normal upper labial frenum attachment (OR = 1.45, 95% CI: 1,171,80). In addition, Dewell admits that upper labial frenum is only an

influencing factor, not the cause of the upper midline diastema. Results from
table 3.3 show that pupils with low labial frenum have low risk of R11 teeth,
R21 abnormal teething is 1.64 times and 1.56 times higher than pupils with
normal upper labial frenum attachment (OR = 1 , 64, 95% CI: 1.28-2.10 and
OR = 1.56, 95% CI: 1.23-1.99).
4.3.2. The relationship of abnormal upper labial frenum attachment to the
periodontal condition of two maxillary central incisors
Yuri Castro's study reported that there was no association between
attachment of labial frenum and gum recession. This difference may be due to
the difference in sample size and subjects between the two studies. The gum
recession risk of two maxillary central incisors was encountered in pupils with
abnormal upper labial frenum attachment (table 3.5) in our study on children
aged 7-11 years, with mixed teeth is still in the process of development and
tooth replacement leading to upper labial frenum can also change the grip
position. Meanwhile, Yuri's research was conducted on adults aged 18 to 60
years (average age 28.6 ± 6), owning permanent teeth, so there is stability in
the position of upper labial frenum attachment.
4.4. Assessing the effectiveness of Laser Diode treatment in patients with
abnormal upper labial frenum attachment
4.4.1. Assessing the effectiveness of near treatment
* The rate of using surface anesthetics, injectable anesthetics and the level of
pain in surgery
Research results (Chart 3.3) on 80 patients participating in surgery showed
that one of the important advantages of Laser is to limit the use of injectable
anesthetics in surgery. In surgery when not using injectable anesthetics will
increase the ability of patients to cooperate, especially children.


21
* Level of bleeding during and after surgery

Table 3.6 shows that the advantage of hemostasis of Laser Diode is not
only better than the methods such as scalpel, electric knife but also better
hemostasis than some other types of laser such as Er: YAG Laser. Samo
Pirnat's research in 2007 showed that: Laser Diode is ideal for the treatment of
soft tissues due to its focus on Hemoglobin, helping to reduce blood loss and
reduce vascular damage. Diode Lasers are highly absorbed by pigments, upper
labial frenum is a thicker, less pigmented fibrous tissue, which requires a
higher energy level for tissue excision.
* The degree of pain and the rate of use painkillers after surgery
Our results (Table 3.7) show different results than Patel et al. (2015) using
Laser Diode and abnormal upper labial frenum attachment surgical for 20
subjects with moderate pain average first day postoperative was 2.25 ± 1.035
larger than our study. This difference can be thought of due to the Laser Diode
power used in the study, the two studies use 7W and 10W respectively for
surgery, in our study we use 0.8W of power. for surgery.
Thanks to the preeminent characteristics of Laser Diode in reducing pain,
our research results (Table 3.8) are quite similar to those of Do Hoang Viet,
with the daily rate of analgesic use. The most after research is 16.67%. After 3
days and 7 days, no patients used pain medication
* The degree of swelling and the ability to oral hygiene after surgery
The degree of swelling (Table 3.9) reduces postoperative swelling which
is characteristic of Laser surgery. The improvement of healthy tissue and
limited scar formation is due to a combination of reduced surgical tissue
damage, less thermal tissue damage, and the doctor being able to accurately
control the depth of damage, and reducing fibrous fibers in the tissue due to
cutting by Laser. Besides, our research results also showed that no patient did
not have oral hygiene after 1 day (Table 3.10). The problems that make it
difficult for patients with oral hygiene are those patients who feel pain when
hygiene or being entangled due to the swollen surgical area..
* Healing wounds after Laser Diode surgery

Assessing the healing level showed that, in 3 days after surgery, 61.3% of
patients were well healed and 15.0% of patients were well healed. After 7 days
after surgery, 20.0% of patients healed well and 72.5% of patients healed very


22
well. After 21 days after surgery, 100% of the patients were well healed (Table
3.11). Although the healing speed is slower than that of a conventional scalpel,
all of the above studies confirm the advantages of Laser Diode: patients have
little pain, no or very little swelling after surgery and patients. reduce
discomfort because there are no sutures that make it difficult for upper lip
movements.
4.4.2. Assessing the effectiveness of distant treatment
* Scars after surgery
Our research results show that no patients with obvious scarring after
surgery. (Table 3.12). Postoperative injury Upper labial frenum with no laser
Diode or minimal scars is thought to be due to less surgical tissue contraction.
Histological research shows that there are few fiber cells, and the pulling force
of the surgical tissue area by Laser Diode so after healing, scars due to Laser
Diode leave very little or at least.
* Characteristics of upper labial frenum after surgery
After the surgery, 100% of the patients who participated in the study had a
position of normal upper labial frenum attachment. Height of upper labial
frenum decreased completely compared to before surgery (Chart 3.5). After 3
months, 6 months and 9 months after surgery, the average value of the
thickness of upper labial frenum according to the position of upper labial
frenum attached to gingiva, upper labial frenum attached to interdental papillae
all decreased compared to before surgery (Chart 3.6). Pham Hoang Tuan's
study in 2014 showed that the group upper labial frenum level I has an average
height of 9.7 ± 1.9 mm. As such, the goal of treatment is to shorten upper labial

frenum achieved shortly after surgery.

CONCLUSION
1. Anatomy characteristics of upper labial frenum
The ratio of abnormal upper labial frenum attachment is 43%, of which
upper labial frenum attached to gingiva (38.6%) is predominant, the ratio of
upper labial frenum attached to interdental papillae and upper labial frenum
attached to excessive interdental papilla is low. 25.7% of pupils had abnormal


23
upper labial frenum attachment shape, of which 10.4% upper labial frenum with
excessive pieces, 9.1% upper labial frenum with nodes, 2.8% upper labial
frenum has dimples, 2.4% have upper labial frenum with continuous palate
shape. The pupil's average upper labial frenum height is 9.6 mm. The lower the
position of abnormal upper labial frenum attachment, the higher the height of
upper labial frenum will increase.
2. Relationship of abnormal upper labial frenum attachment on dental and
periodontal condition of two maxillary central incisors
2.1. The relationship of abnormal upper labial frenum attachment to two
maxillary central incisors
The pupils with abnormal upper labial frenum attachment are 1.45 times
more likely to have diastema between two maxillary central incisors, R11, R21
abnormal teething risk is 1.64 times higher and 1.56 times higher than pupils
have normal upper labial frenum attachment. The larger the distance between
teeth R11 and R21, the higher the percentage of upper labial frenum with gum
attachment, interdental papillae attachment and excessive interdental papillae
attachment. The incidence of severe gingivitis of two maxillary central incisors
is over 17%. The highest percentage of pupils with gingivitis R11, R21 in
upper labial frenum attached to excessive interdental papilla and papillae

2.2. The relationship of position of upper labial frenum attachment to the
periodontal condition of two maxillary central incisors
Gum recession was most common in pupils with upper labial frenum
attached to interdental papillae (14.3%), excessive interdental papillae
attachment (11.1%). The risk of gum recession of two maxillary central
incisors was 5.15 times higher among pupils with abnormal upper labial
frenum attachment compared to pupils with upper labial frenum with normal
attachment. Nearly 80% of pupils participated in the study. with gingivitis in
the region of two maxillary central incisors. The incidence of severe gingivitis
is over 17%.
3. Effiency of Laser Diode in the treatment of abnormal upper labial
frenum attachment
The rate of patients causing surface anesthetics is 2 times higher than the
rate of patients causing injectable anesthetics during surgery. 80% of patients
without bleeding (degree 0), 20% of hemorrhage (degree 1), no patients had


24
small, severe or very heavy bleeding (degree 2, 3 and 4). The rate of use of
painkillers on the first day after the study was 21.2%, higher among women
than men (19.6% and 14.3%). The level of swelling of patients after surgery
decreases rapidly after surgery. 3 days after surgery, 61.3% of patients healed
well and 15.0% of patients healed very well. After 7 days after surgery, 20.0%
of patients healed well and 72.5% of patients healed very well. After 21 days
after surgery, 100% of the patients were well healed. No patients had
significant scarring after surgery. Only 16.2% had faded scars after 3 months
and decreased to 10% after 3 months. The height and thickness of upper labial
frenum decreased significantly after surgery over a period of 3, 6 and 9 months.
RECOMMENDATIONS
1. It is required to have the studies on upper labial frenum with large sample

sizes, across different regions and ethnicities.
2. It is required to implement the longitudinal studies to accurately assess the
relationship of upper labial frenum to age, and the relationship of abnormal
upper labial frenum attachment to the teeth and periodontal condition of
two maxillary central incisors.
3. Prophylaxis for patients with cases of upper labial frenum cling too
protruding, need early intervention so that when the canine teeth erupt can
close the diastema caused by abnormal upper labial frenum attachment
ABREVIATION

Sort Order

Word Abreviated

Meaning in English

1

R11

Upper right central inscisor

2

R21

Upper left central inscisor