Frenotomy and Frenectomy

FRENOTOMY AND FRENECTOMYFRENOTOMY AND FRENECTOMY

By: Yogesh Goswami By: Yogesh Goswami

P.G. Student , P.G. Student ,

Department of Periodontology and Department of Periodontology and Implantology Implantology

HItkarini Dental College and Hospital.HItkarini Dental College and Hospital.

CONTENTSCONTENTS

IntroductionIntroductionClassification of frenum attachmentClassification of frenum attachmentClinical feature of abnormal Clinical feature of abnormal attachmentattachmentIndicationsIndicationsSurgical techniqueSurgical techniqueReferencesReferences

FRENUMFRENUM

Definition :Definition : A Frenum is a fold of mucous membrane, A Frenum is a fold of mucous membrane,

usually with enclosed fibers, that attaches the usually with enclosed fibers, that attaches the lips and cheeks to the alveolar mucosa and / or lips and cheeks to the alveolar mucosa and / or gingiva and underlying periosteum.gingiva and underlying periosteum.

Carranza 10th edition

Sickle shaped foldsSickle shaped folds

Found normally in maxillary and mandibular Found normally in maxillary and mandibular alveolar mucosa in canine premolar area, alveolar mucosa in canine premolar area, and between central incisors. and between central incisors.

Contain loose connective tissue with elastic Contain loose connective tissue with elastic and dense collagen fibers, fat cells & and dense collagen fibers, fat cells & occasionally acini of mucous producing occasionally acini of mucous producing salivary glands.salivary glands.

Occasionally, muscle fibers may be present.Occasionally, muscle fibers may be present.

CLASSIFICATION OF FRENUM CLASSIFICATION OF FRENUM ATTACHMENTATTACHMENT

Depending upon its morphology as: Long and thin Short and broad

BASED ON LOCATION OF ORIGIN OF FRENUM BASED ON LOCATION OF ORIGIN OF FRENUM (Placek (Placek et alet al 1974) 1974)

1. Mucosal Attachment - attachment to MG junction

2. Gingival attachment - to attached gingivato attached gingiva3. Papillary attachment - within papillawithin papilla4. Papilla-penetrating attachment – when when

fibres cross alveolar process and extend fibres cross alveolar process and extend

upto palatine papillaupto palatine papilla

Mucosal Attachment

Gingival attachment

Papillary attachment

Papilla-penetrating attachment

Pull syndromePull syndromeA detaching movement of the A detaching movement of the

marginal gingiva transferred from the marginal gingiva transferred from the lip by the frenum has been termed the lip by the frenum has been termed the pull syndrome. pull syndrome.

Placek et al 1974Placek et al 1974

Tension testTension testIt’s aIt’s a term used to describe the term used to describe the movement or displacement of movement or displacement of marginal gingiva when tension is marginal gingiva when tension is applied to the lip in an outward, applied to the lip in an outward, downward & lateral direction.downward & lateral direction.

Perecentage of Types of AttachmentPerecentage of Types of AttachmentMaxillary Maxillary Midline AreaMidline Area

Mandibular Mandibular Midline AreaMidline Area

Mucosal Mucosal AttachmentAttachment

46.546.5 92.192.1

Gingival Gingival AttachmentAttachment

34.334.3 6.56.5

Papillary Papillary AttachmentAttachment

3.13.1 0.70.7

Papillary- Papillary- Penetrating Penetrating AttachmentAttachment

16.116.1 1.21.2

Kaimenyi JT. Occurrence of midline diastema and frenum attachment among school children in Nairobi, Kenya.Indian J dent Research 1998;130:85-94.

Percentage of Pull SyndromePercentage of Pull SyndromeMaxillary Maxillary Midline AreaMidline Area

Mandibular Mandibular Midline AreaMidline Area

Mucosal Mucosal AttachmentAttachment

4.54.5 6.56.5

Gingival Gingival AttachmentAttachment

53.553.5 76.276.2

Papillary Papillary AttachmentAttachment

100100 100100

Papillary- Papillary- Penetrating Penetrating AttachmentAttachment

84 84 100100

Kaimenyi JT. Occurrence of midline diastema and frenum attachment among school children in Nairobi, Kenya.Indian J dent Research 1998;130:85-94.

Clinical features of Abnormal frenumClinical features of Abnormal frenum

Midline DiastemaMidline Diastema

Accumulation of debris by Accumulation of debris by reflection & opening of sulcusreflection & opening of sulcus

Difficult oral hygiene maintenanceDifficult oral hygiene maintenance

Gingival RecessionGingival Recession

Frenotomy : Frenotomy :

It is a procedure that is relocating the It is a procedure that is relocating the

frenal attachment so as to create a zone of frenal attachment so as to create a zone of

attached gingiva between the gingival margin and attached gingiva between the gingival margin and

the frenum.the frenum.

Frenectomy :Frenectomy :

It is the complete excision of the frenum, It is the complete excision of the frenum,

including its attachment to underlying bone. including its attachment to underlying bone.

IndicationsIndications

1) 1)     To eliminate tension on & retraction of To eliminate tension on & retraction of the gingival margin that has been caused by the gingival margin that has been caused by the frenum during lip movements. If left the frenum during lip movements. If left untreated, it may cause.untreated, it may cause.

a) Distention of the orifice of the sulcus or a) Distention of the orifice of the sulcus or pocket, leading to debris accumulation.pocket, leading to debris accumulation.

b) An increase in the severity of the pocket, b) An increase in the severity of the pocket, impairing healing. impairing healing.

2) To eliminate a well developed frenum that 2) To eliminate a well developed frenum that penetrates the gingival papilla to its origin on penetrates the gingival papilla to its origin on the incisive papilla. The coronally attached the incisive papilla. The coronally attached frenum may lead to a midline diastema & frenum may lead to a midline diastema & prevent mesial drift, which usually closes this prevent mesial drift, which usually closes this space.space.

3) To facilitate orthodontic treatment, A thick 3) To facilitate orthodontic treatment, A thick frenum resists orthodontic forces & its wedging frenum resists orthodontic forces & its wedging area can be responsible for slight spacing of the area can be responsible for slight spacing of the maxillary Central Incisors following orthodontic maxillary Central Incisors following orthodontic treatment.treatment.

4) To eliminate a frenum that makes it difficult 4) To eliminate a frenum that makes it difficult or impossible to use a Tooth Brush effectively or impossible to use a Tooth Brush effectively in the area.in the area.

5) When combined with more sophisticated 5) When combined with more sophisticated periodontal surgery, e.g.. to eliminate periodontal surgery, e.g.. to eliminate periodontal pockets & increase Attached periodontal pockets & increase Attached Gingiva & depth of vestibular trough. Gingiva & depth of vestibular trough.

Surgical TechniquesSurgical Techniques Simple excision Simple excision Z-PlastyZ-Plasty Vestibuloplasty with Secondary Vestibuloplasty with Secondary EpithelializationEpithelialization V-Rhomboid plastyV-Rhomboid plasty Modification of V-Rhomboid plastyModification of V-Rhomboid plasty V-Y plastyV-Y plasty Simple IncisionSimple Incision Submucosal frenotomy Submucosal frenotomy Lingual frenectomyLingual frenectomy

Simple ExcisionSimple Excision

Abnormal FrenumAbnormal Frenum

A narrow elliptic incision around the frenal area A narrow elliptic incision around the frenal area down on the periosteum is completed.down on the periosteum is completed.

The fibrous frenum is then sharply dissected from The fibrous frenum is then sharply dissected from the underlying periosteum and soft tissue and the underlying periosteum and soft tissue and the margins of the wound are gently undermined the margins of the wound are gently undermined and reapproximated.and reapproximated.

Excised Wound (elliptical)

Placement of the first suture at the maximal depth of the vestibule.

The remainder of the incision should be than closed with interrupted sutures.

DC

BA Frenum attachment

Incision

Suturing

Post-operative 1 mths

Incision

Fiber attachment removal

FE

Procedure –Removal of frenumProcedure –Removal of frenum

Two Haemostats TechniqueTwo Haemostats Technique Local anaesthesiaLocal anaesthesia Raise the lip, put a hemostat parralel to the Raise the lip, put a hemostat parralel to the

alveolar ridge.alveolar ridge. Another hemostat parallel to the lip at right angle Another hemostat parallel to the lip at right angle

to the first.to the first. With no. 11 or 15 blade , labial frenum is excised With no. 11 or 15 blade , labial frenum is excised

by cutting around the outside surfaces of the by cutting around the outside surfaces of the two hemostat leaving behind a diamond shaped two hemostat leaving behind a diamond shaped cut.cut.

Hemostats and incision

Excised Wound (Diamond shaped)

Placement of the first suture at the maximal depth of the vestibule.

The remainder of the incision should be than closed with interrupted sutures.

Z-Plasty TechniqueZ-Plasty Technique For a narrow band of frenumFor a narrow band of frenum Excision of fibrous connectve tissue is done Excision of fibrous connectve tissue is done

similar to simple excisionsimilar to simple excision

Two Oblique incisions are made in Z fashion, one Two Oblique incisions are made in Z fashion, one at each end of excisionat each end of excision

Flaps reflectedFlaps reflected

Vertical flaps positioned HorizontallyVertical flaps positioned Horizontally and sutured and sutured

VESTIBULOPLASTY WITH VESTIBULOPLASTY WITH SECONDARY EPITHELIZATIONSECONDARY EPITHELIZATION

For extremely wide base of frenal attachment.For extremely wide base of frenal attachment.

Incision is made through mucosal tissue and Incision is made through mucosal tissue and underlying submucosal tissue, without underlying submucosal tissue, without perforating the periosteum.perforating the periosteum.

Supraperiosteal dissection is completed by Supraperiosteal dissection is completed by undermining the mucosal and submucosal tissue undermining the mucosal and submucosal tissue with scissors.with scissors.

Incision starting from apex to baseIncision starting from apex to base

Mucosal flap sutured in the most depth of Mucosal flap sutured in the most depth of vestibule and the exposed periosteum is vestibule and the exposed periosteum is allowed to heal by secondary epithelization.allowed to heal by secondary epithelization.

V-Rhomboid PlastyV-Rhomboid Plasty

Engage frenum in a hemostat.Engage frenum in a hemostat.

Excise frenum coronal & apical to hemostat Excise frenum coronal & apical to hemostat with a blade.with a blade.

Circumferential submucosal tissue is Circumferential submucosal tissue is dissected.dissected.

Excised frenum is removed.Excised frenum is removed.

Rhomboid wound closed with suturesRhomboid wound closed with sutures

Modification of V-rhomboid plastyModification of V-rhomboid plasty In v- rhomboidplasty , vestibule may become In v- rhomboidplasty , vestibule may become

shallow and the band of attached gingiva is shallow and the band of attached gingiva is narrowed after completion of sutures. narrowed after completion of sutures.

Triangular wound is left open in the attached Triangular wound is left open in the attached gingiva.gingiva.

Sutures are placed at the alveolar mucosa.Sutures are placed at the alveolar mucosa.

Open wound surface is created in the attached Open wound surface is created in the attached gingiva.gingiva.

V-Y PlastyV-Y Plasty

Indicated in reducing height of attachment Indicated in reducing height of attachment of frenum.of frenum.

V shaped incision is made in the V shaped incision is made in the Attachment of frenum.Attachment of frenum.

Underlying fibrous tissue is removed.Underlying fibrous tissue is removed.

Wound margins closely adapted like Wound margins closely adapted like the letter Y and suturedthe letter Y and sutured

Simple IncisionSimple Incision For a frenum attached too closely to gingival For a frenum attached too closely to gingival

margin.margin. Incision made into the attachment of the frenum Incision made into the attachment of the frenum

along the base . along the base . Frenum is raised up apically as a full thickness or Frenum is raised up apically as a full thickness or

split thickness flap.split thickness flap. In split thicness , dissection is carried out , the In split thicness , dissection is carried out , the

underlying fibrous tissue should be removed underlying fibrous tissue should be removed

enough not to relapse.enough not to relapse.

Dissected frenum raised till MGJ & an open wound Dissected frenum raised till MGJ & an open wound surface is left & pack is givensurface is left & pack is given

Submucosal FrenotomySubmucosal Frenotomy

Indicated in a frenum with a wide base.Indicated in a frenum with a wide base. A vertical incision along the ridge & two A vertical incision along the ridge & two

incisions bilaterally to the attachment.incisions bilaterally to the attachment. Surgical scissors inserted through the incised Surgical scissors inserted through the incised

margin to dissect submucosal tissue bluntly.margin to dissect submucosal tissue bluntly. Traversing muscle fibres are cut.Traversing muscle fibres are cut. Periosteum is revealed following cutting of Periosteum is revealed following cutting of

the muscle fibres.the muscle fibres. Suturing done.Suturing done.

Healing After Frenectomy / FrenotomyHealing After Frenectomy / Frenotomy

The wound is triangular in shape.The wound is triangular in shape.

It is bound on the two sides by attached gingiva It is bound on the two sides by attached gingiva (fixed tissue). It provides one source of (fixed tissue). It provides one source of granulation tissue.granulation tissue.

The other source of tissue is the exposed bone The other source of tissue is the exposed bone that occurs as all the tissue is removed. that occurs as all the tissue is removed.

When the bone is not exposed by the removal of When the bone is not exposed by the removal of periosteum , gingiva will also regenerate.periosteum , gingiva will also regenerate.

However, all the loose C.T , elastic fibres and fatty However, all the loose C.T , elastic fibres and fatty

tissue elements must be removed, leaving the tissue elements must be removed, leaving the dense fibrous collagen fibres over the dense fibrous collagen fibres over the periosteum.periosteum.

The immovable base upto which newer The immovable base upto which newer granulation tissue can form results in new granulation tissue can form results in new attached gingiva.attached gingiva.

References :References : Michael G. Newman , Henry H. Takei , Perry R. Klokkevold , Fermin Michael G. Newman , Henry H. Takei , Perry R. Klokkevold , Fermin

A. Carranza : Carranza's Clinical Periodontology 10A. Carranza : Carranza's Clinical Periodontology 10 thth edition. edition. Periodontal Therapy – Goldman 6Periodontal Therapy – Goldman 6thth ed ed Oral & Maxillofacial Surgery – Peterson Oral & Maxillofacial Surgery – Peterson Oral & Maxillofacial Surgery – ArcherOral & Maxillofacial Surgery – Archer Oral & Maxillofacial Surgery – LaskinOral & Maxillofacial Surgery – Laskin Gottsegen R. Frenum position and vestibule depth in relation to Gottsegen R. Frenum position and vestibule depth in relation to

gingival health. Oral Surg 1954;7:1069-72.gingival health. Oral Surg 1954;7:1069-72. Placek M, Miroslavs, Mrklas L. Significance of the labial frenal Placek M, Miroslavs, Mrklas L. Significance of the labial frenal

attachment in periodontal disease in man. Part 1; Classification and attachment in periodontal disease in man. Part 1; Classification and epidemiology of the labial frenum attachment. J Periodontol epidemiology of the labial frenum attachment. J Periodontol 1974;45:891-94.1974;45:891-94.

Kaimenyi JT. Occurrence of midline diastema and frenum attachment Kaimenyi JT. Occurrence of midline diastema and frenum attachment among school children in Nairobi, Kenya.Indian J dent Research among school children in Nairobi, Kenya.Indian J dent Research 1998;130:85-94.1998;130:85-94.