Laser Study by Aetna
Frenectomy or Frenotomy for Ankyloglossia
Policy
Aetna considers inferior lingual frenectomy or
lingual frenotomy for ankyloglossia medically necessary when newborn feeding
difficulties or childhood articulation problems exist.
Background
Ankyloglossia, or tongue-tie, exists when the
inferior lingual frenulum attaches to the bottom of the tongue and restricts its
movement. This condition can impair the normal mobility of the tongue and
interfere with speech or newborn feeding.
If the tongue can touch the anterior dentition,
mobility is adequate for the development of normal speech. However, in
situations where the inferior lingual frenulum significantly impedes tongue
excursion, a frenulectomy may be performed in order to free the tongue.
An assessment by the National Institute for Health
and Clinical Excellence (NICE, 2005) concluded that “current evidence suggests
that there are no major safety concerns about division of ankyloglossia
(tongue-tie) and limited evidence suggests that this procedure can improve
breastfeeding”.
Aras and colleagues (2010) compared the tolerance
of lingual frenectomy with regard to a local anesthesia requirement as well as
post-surgical discomfort experienced by patients operated on with diode laser
or erbium: yttrium-aluminum-garnet (Er:YAG) Laser. A total of 16
referred patients with tongue mobility complaints were included in this study.
A GaAiAs laser device with a continuous wavelength of 808 nm was used in the
diode group. Frenulums were incised by applying 2W of laser power. The Er:YAG
laser device with a continuous wavelength of 2,940 nm was used inEr:YAG group.
Frenulums were incised by applying 1W of laser power. The acceptability of the
lingual frenectomy without local anesthesia and the degree of the post-surgical
discomfort were evaluated. Although the majority of patients (n = 6) could be
operated on without local anesthesia in theEr:YAG group, all
patients could not be operated on without local anesthetic agent in the diode
group. There were no differences between the 2 groups with regard to pain,
chewing, and speaking on the 1st or 7th day
after surgery, whereas patients had more pain in the Er:YAG group
than in the diode group the first 3 hrs after the surgery. The authors
concluded that these findings indicate that only the Er:YAG laser can
be used for lingual frenectomy without local anesthesia, and there was no
difference between 2 groups regarding the degree of the post-surgical
discomfort except in the first 3 hrs. Thus, these results indicate that
the Er:YAG laser is more advantageous than the diode laser in minor soft-tissue
surgery because it can be performed without local anesthesia and with only
topical anesthesia.
Buryk et al (2011) noted that ankyloglossia has
been associated with a variety of infant-feeding problems and that frenotomy
commonly is performed for relief of ankyloglossia. The investigators conducted
a randomized, single-blinded, controlled trial to determine whether frenotomy
for infants with ankyloglossia improved maternal nipple pain and ability to
breastfeed. A secondary objective was to determine whether frenotomy
improved the length of breastfeeding. Over a 12-month period, neonates who had
difficulty breastfeeding and significant ankyloglossia were assigned to either
a frenotomy (30) infants or a sham procedure (28 infants) and breastfeeding was
assessed by a pre-intervention and post-intervention nipple-pain scale and the
Infant Breastfeeding Assessment Tool. Study subjects were followed two weeks
post-procedure and at regularly scheduled follow-ups over one year period. The
infants with the sham group were given a frenotomy before or at the 2-week
follow-up if it was desired. Both groups demonstrated statistically
significantly decreased pain scores after the intervention, but the frenotomy
group improved significantly more than the sham group (P < .001).
Breastfeeding scores significantly improved in the frenotomy group (P = .029)
without a significant change in the control group. All but 1 parent in the sham
group elected to have the procedure performed when their infant reached 2 weeks
of age, which prevented additional comparisons between the 2 groups. The
investigators demonstrated immediate improvement in nipple-pain, which they
state provides convincing evidence for those seeking a frenotomy for infants
with significant ankyloglossia.