what does a healing frenectomy supposed to look like

• Periodical List
• J Clin Diagn Res
• 5.six(9); 2012 November
• PMC3527809

J Clin Diagn Res. 2012 November; half dozen(nine): 1587–1592.

Frenectomy: A Review with the Reports of Surgical Techniques

Devishree

^one Assistant Professor, Department of Periodontics, JSS Dental Higher & Hospital, Mysore-570015, Karnataka, India

Sheela Kumar Gujjari

² Professor, Department of Periodontics, JSS. Dental Higher & Hospital, Mysore-570015, Karnataka, India

P.V. Shubhashini

³ Ex-Post Graduate Student, Section of Periodontics, JSS. Dental College & Infirmary, Mysore-570015, Karnataka, India

Received 2012 Feb 2; Revisions requested 2012 Apr 17; Accepted 2012 Aug 6.

Abstract

The frenum is a mucous membrane fold that attaches the lip and the cheek to the alveolar mucosa, the gingiva, and the underlying periosteum. The frena may jeopardize the gingival wellness when they are attached too closely to the gingival margin, either due to an interference in the plaque control or due to a muscle pull. In add-on to this, the maxillary frenum may nowadays aesthetic problems or compromise the orthodontic result in the midline diastema cases, thus causing a recurrence after the treatment. The management of such an aberrant frenum is accomplished by performing a frenectomy.

The present article is a compilation of a brief overview nearly the frenum, with a focus on the indications, contraindications, advantages and the disadvantages of diverse frenectomy techniques, similar Miller's technique, Five-Y plasty, Z-plasty and frenectomy by using electrocautery. A series of clinical cases of frenectomy which were approached past diverse techniques accept likewise been reported.

Keywords: Frenum, Frenectomy, Mucogingival techniques

Introduction

Aesthetic concerns have led to an increasing importance in seeking dental treatment, with the purpose of achieving perfect smile. The continuing presence of a diastema between the maxillary central incisors in adults, has often been considered every bit an artful problem. The presence of an aberrant frenum being 1 of the aetiological factors for the persistence of a midline diastema, the focus on the frenum has become essential [1].

The frena may too jeopardize the gingival health by causing a gingival recession when they are fastened too closely to the gingival margin, either considering of an interference with the proper placement of a toothbrush or through the opening of the gingival crevice considering of a musculus pull [2].

The Muscular Anatomy of the Frenum

A frenum is a mucous membrane fold which contains muscle and connective tissue fibres that attach the lip and the cheek to the alveolar mucosa, the gingiva and the underlying periosteum [2].

Knox and Young histologically studied the frenulum, and they take reported both elastic and muscle fibres (Orbicularis oris – horizontal bands and oblique fibres). However, Henry, Levin and Tsaknis accept institute considerably dumbo collagenous tissue and rubberband fibres but no muscle fibres in the frenulum [2].

Aetiology

The maxillary labial frenum develops as a postal service-eruptive remnant of the ectolabial bands which connect the tubercle of the upper lip to the palatine papilla. When the 2 central incisors erupt widely separated, no bone is deposited inferior to the frenum. A V-shaped bony cleft betwixt the two central incisors and an abnormal frenum zipper results. The mandibular frenum is considered as aberrant when it is associated with a decreased vestibular depth and an inadequate width of the fastened gingiva [ane,ii].

Diagnosis

The aberrant frena are detected visually by applying tension over the frenum to come across the movement of the papillary tip or the blanch which is produced due to ischaemia in the region. The frenum is characterized equally pathogenic when information technology is unusually wide or when at that place is no apparent zone of the attached gingiva along the midline or the interdental papilla shifts when the frenum is extended.

Classification

The labial frenal attachments have been classified as mucosal, gingival, papillary and papilla penetrating, by Placek et al (1974) [3].

1. Mucosal – when the frenal fibres are attached upwardly to the mucogingival junction.

2. Gingival – when the fibres are inserted inside the attached gingiva.

3. Papillary – when the fibres are extending into the interdental papilla.

4. Papilla penetrating – when the frenal fibres cross the alveolar process and extend up to the palatine papilla.

Indications

The frenum is characterized as pathogenic and is indicated for removal when

1. An aberrant frenal attachment is present, which causes a midline diastema.

2. A flattened papilla with the frenum closely attached to the gingival margin is present, which causes a gingival recession and a hindrance in maintaining the oral hygiene.

3. An aberrant frenum with an inadequately attached gingiva and a shallow vestibule is seen.

Treatment

The aberrant frena can be treated past frenectomy or by frenotomy procedures. Frenectomy is the complete removal of the frenum, including its zipper to the underlying bone, while frenotomy is the incision and the relocation of the frenal attachment [iii].

Frenectomy can exist accomplished either past the routine scalpel technique, electrosurgery or by using lasers. The conventional technique involves excision of the frenum by using a scalpel. However, it carries the routine risks of surgery like bleeding and patient compliance.

The use of electro surgery and lasers has also been proposed for frenectomy [four–9]. Researchers have advocated the use of an electrocautery probe due to its efficacy and due to the safety of the procedure, the balmy bleeding and the absenteeism of postoperative complications. Notwithstanding, it is associated with certain complications which include burns, the adventure of an explosion if combustible gases are used, interference with pacemakers and the production of surgical fume. These complications have not been reported with the new comeback in the electro surgical techniques, like the Argon Axle Coagulation (ABC) [4,5].

Recently, the use of a COii laser in lingual frenectomies has been reported equally a safe and effective procedure with the advantages of a shorter duration of the surgery, simplicity of the procedure, the absence of postoperative infections, bottom pain, swelling and the presence of a small or no scar [4]. A delayed healing every bit compared to that in the conventional scalpel techniques, a reduced surgical precision which results in an inadvertent laser-induced thermal necrosis and/or a photo acoustic injury, are some of the complications which are associated with lasers. The awarding of diode and Er:YAG lasers [6] in labial frenectomies in infants and Er,Cr:YSGG lasers [7] in labial frenectomies in the adolescent and the pre-pubescent populations have also been reported.

Since the conventional procedure of frenectomy was first prop-osed, a number of modifications [10–12] of the diverse surgical techniques like the Miller'south technique, V-Y plasty and Z-plasty have been developed to solve the problems which are caused past an aberrant labial frenum.

The present article is a compilation of a series of clinical cases of an aberrant frenum which were approached by various surgical techniques which were employed for frenectomy, with an added note on the merits and the demerits of each procedure.

The techniques which were employed were:

• Conventional (Classical) frenectomy

• Miller's technique

• V-Y Plasty

• Z Plasty

• Frenectomy which was done past using electrocautery

Clinical Cases

Classical Frenectomy [2,13]

The classical technique was introduced by Archer (1961) and Kruger (1964). This approach was advocated in the midline diastema cases with an aberrant frenum to ensure the removal of the muscle fibres which were supposedly connecting the orbicularis oris with the palatine papilla [2]. This technique is an excision type frenectomy which includes the interdental tissues and the palatine papilla along with the frenulum.

Armamentarium – Haemostat, scalpel blade no.xv, gauze sponges, 4-0 blackness silk sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

The nowadays example was a papilla type of frenal attachment [Table/Fig-1]. The area was anaesthetized with a local infiltration by using ii% lignocaine with 1:80000 adrenaline. The frenum was engaged with a haemostat which was inserted into the depth of the vestibule [Table/Fig-2] and incisions were placed on the upper and the undersurface of the haemostat until the haemostat was free [Table/Fig-3]. The triangular resected portion of the frenum with the haemostat was removed. A edgeless autopsy was washed on the bone to relieve the fibrous zipper. The edges of the diamond shaped wound were sutured by using four-0 black silk with interrupted sutures [Table/Fig-4]. The surface area was covered with a periodontal pack. The pack and the sutures were removed i week postal service-operatively.

Pre-operative papilla type of frenal zipper

Frenum held with hemostat

The post-operative sequelae at one month of follow-upward included un-aesthetic or labial tissue scarring [Tabular array/Fig-5].

Pre-operative fastened type of frenal attachment

Lateral pedicle graft obtained

Graft sutured across the midline

Miller's Technique [2,14]

The Miller'due south technique was advocated by Miller PD in 1985. This technique was proposed for the post-orthodontic diastema cases. The ideal fourth dimension for performing this surgery is after the orthodontic movement is complete and almost half dozen weeks earlier the appliances are removed. This not simply allows healing and tissue maturation, but it also permits the surgeon to utilize orthodontic appliances as a ways of retaining a periodontal dressing.

Armamentarium – Haemostat, scalpel blade no.15, gauze sponges, 5-0 black silk sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

An attached blazon of frenal zipper was treated with the post-obit surgical process later on the area was anaesthetized with a local infiltration by using 2% lignocaine with 1:80000 adrenaline: [Table/Fig-1-10]:

• Excision of the frenulum and exposure of the labial alveolar bone in the midline.

• A horizontal incision was made to divide the frenulum from the interdental papilla.

• A laterally positioned pedicle graft (dissever thickness) was obtained and it was sutured beyond the midline.

• A periodontal dressing was placed.

Care must be taken to extend the incisions into the lip every bit far as necessary, to assure that a remnant of the frenulum is non left on the lip. Later on one calendar week, the periodontal dressing was removed, while the remnants of the sutures were left, equally resorbable sutures were used. At 1 calendar month of follow-up, there was a gingiva across the midline and the interdental papilla was maintained.

Z Plasty [fifteen–17]

This technique is indicated when there is hypertrophy of the frenum with a low insertion, which is associated with an inter-incisor diastema, and when the lateral incisors have appeared without causing the diastema to disappear and also in cases of a brusk vestibule.

Armamentarium – Scalpel blade no.fifteen, gauze sponges, tissue forceps, v-0 vicryl sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

A case of a hypertrophic attached type of frenal attachment [Table/Fig-eleven] was operated by using the Z-plasty technique. The expanse was anaesthetized with a local infiltration by using two % lignocaine with 1:80000 adrenaline. The length of the frenum was incised with the scalpel [Table/Fig-12] and at each end, limbs at between 60° and 90° angulation, incisions were fabricated in equal length to that of the band. Past using fine tissue forceps, with care not to damage the apices of the flaps, the submucosal tissues were dissected beyond the base of operations of each flap, into the loose non-fastened tissue planes. Thus, double rotation flaps which were at to the lowest degree ane cm long were obtained. The resultant flaps which were created were mobilized and transposed through 90° to close the vertical incisions horizontally [Table/Fig-thirteen]. Absorbable v-0 vicryl sutures were placed, first through the apices of the flaps, to ascertain the adequacy of the flap repositioning and so they were evenly spaced along the edges of the flaps, to close the wound along the cutting edges of the attached mucoperiosteum and the labial mucosa [Table/Fig-xiv]. A periodontal dressing was placed. After 1 week, the dressing was removed, while the remnants of the sutures were left, as resorbable sutures were used.

Pre-operative fastened type of frenal attachment

Incision given through the frenum

Incision given at both ends of the frenum to obtain ii triangular flaps

Flaps transposed across the midline sutured in the grade of Z

At 1 month of follow-upward [Table/Fig-xv], the healing was found to be uneventful, with no hypertrophic scar formation and tension at the frenum area.

V-Y Plasty [18]

V-Y plasty can be used for lengthening the localized area, like the wide frena in the premolar-molar expanse.

Armamentarium: Haemostat, scalpel blade no.fifteen, gauze sponges, four-0 blackness silk sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

This technique was employed in a instance of a papilla type of frenal attachment [Table/Fig-16]. After the area was anaesthetized with a local infiltration past using two % lignocaine with 1:80000 adrenaline, the frenum was held with the haemostat [Table/Fig-17] and an incision was made in the form of 5 on the undersurface of the frenal attachment [Tabular array/Fig-18]. The frenum was relocated at an apical position and the V shaped incision was converted into a Y, while it was sutured with iv-0 silk sutures [Table/Fig-xix]. A periodontal pack was placed. The periodontal pack and the sutures were removed at 1 calendar week of follow-up. At one month of follow-upwards [Table/Fig-20] the frenal attachment was found to exist relocated at an apical position, with an uneventful healing.

Pre-operative papilla blazon of frenal attachment

Frenum held with hemostat

Frenum incised by V-shaped incision

5-shaped incision sutured in the form of Y

Electro Surgery [4,v]

Electrosurgery is recommended in cases of patients with bleeding disorders, where the conventional scalpel technique carries a higher risk which is associated with problems in achieving a haemostasis and also in non-compliant patients.

Armamentarium: An electrocautery unit with the loop electrode and a haemostat.

The conventional approaches with the scalpel exercise offering some dis-advantages. To overcome these, a case of an attached type of frenal zipper [Tabular array/Fig-21] was approached with electrocautery. Subsequently the expanse was anaesthetized with local infiltration by using 2% lignocaine with ane:80000 adrenaline, the frenum was held with the haemostat and past using a loop electrode tip, information technology was excised [Table/Fig-22]. Electrocautery offered the reward of minimal procedural haemorrhage and there was no need of sutures [Tabular array/Fig-23]. The healing was past secondary intention, as the wound edges were not approximated with sutures [Tabular array/Fig-24].

Pre-operative fastened type of frenal attachment

Frenum held with hemostat and excised with a loop electrode

Excision of frenum completed with no requirement for suture placement

Discussion

Nevertheless, inspite of the various modifications which accept been proposed for frenectomy, the widely followed procedure which remains is the classical technique. The classical technique leaves a longitudinal surgical incision and scarring, which may atomic number 82 to periodontal problems and an unaesthetic advent, thereby necessitating other modifications.

Among all the approaches for frenectomy which were employed in the present case serial, the electrocautery procedure offered the advantage of minimal time consumption and a anemic field during the surgical procedure, with no requirement of sutures. The techniques like simple excision and a modification of V-rhomboplasty fail to provide satisfactory artful results in the case of a broad, thick hypertrophied frenum. This may be due to the inability to accomplish a main closure at the middle, consequently leading to a secondary intention healing at the wide exposed wound. It may become a matter of business organisation in the case of a high smile line exposing anterior gingiva. The Miller's technique offers the following advantages:[ii,fourteen,nineteen–21]

• Post-operatively, on healing, there is a continuous collagenous ring of gingiva beyond the midline, that gives a bracing effect than the "scar" tissue, thus preventing an orthodontic relapse.

• The transseptal fibres are not disrupted surgically and and then, in that location is no loss of the interdental papilla.

• Obtaining an orthodontic stability without an aesthetic sacrifice.

Thus, the Miller's technique results in no loss of the interdental papilla and no scar tissue. Thereby, it is best suited to forbid an orthodontic relapse.

The Z-plasty technique was plant to be ideal for a broad, thick hypertrophic frenum with a depression insertion, which was associated with an inter-incisor diastema and a short vestibule. It achieved both the removal of the fibrous band and the vertical lengthening of the vestibule [Table/Fig-25].

[Table/Fig-25]

Diverse Treatment Modalities

Treatment Modality	Clinical Enquiry	References
Electrosurgery	Instance study and clinical technique: argon beam electrosurgery for tongue ties and maxillary frenectomies in infants and children	v
Lasers	Application of diode and Er:YAG lasers in labial frenectomy in infants	6
	Er,Cr:YSGG laser (1.5 W and 20 to 30 pulses per second) labial frenectomy: a clinical retrospective evaluation of 156 frenectomies on 143 children	vii
	A instance written report of maxillary frenectomy using a carbon dioxide laser in a pediatric patient	8
	A instance report of upper-lip laser frenectomy without infiltrated anaesthesia in a pediatric patient	9
Miller's Technique	frenectomy combined with a laterally positioned pedicle graft-functional and esthetic considerations	14
Z-plasty Technique	Z-plasty technique, practical in instance of hypertrophy of the upper labial frenum	16

Conclusion

While an aberrant frenum can be removed past any of the modification techniques that accept been proposed, a functional and an aesthetic outcome can be achieved by a proper technique option, based on the type of the frenal zipper. Though the approaches to the trouble of not using the traditional scalpel, similar electro surgery and lasers take claim, farther improvements tin still exist attempted.

Notes

Fiscal or Other Competing Interests

None.

Acknowledgement

The authors express their gratitude to Dr. Shabana Anjum for her assistance in the clinical piece of work. The authors report no conflicts of interest which are related to this work.

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