FRENOTOMY AND FRENECTOMY

By: Yogesh Goswami P.G. Student ,

Department of Periodontology and Implantology

HItkarini Dental College and Hospital.

CONTENTS

Introduction Classification of frenum attachment Clinical feature of abnormal attachment Indications Surgical technique References

FRENUM
Definition :
A Frenum is a fold of mucous membrane, usually with enclosed fibers, that attaches the lips and cheeks to the alveolar mucosa and / or gingiva and underlying periosteum.

Carranza 10th edition

Sickle shaped folds

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

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

CLASSIFICATION OF FRENUM ATTACHMENT

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

BASED ON LOCATION OF ORIGIN OF FRENUM (Placek et al 1974) 1.

2. 3. 4.

Mucosal Attachment - attachment to MG junction Gingival attachment - to attached gingiva Papillary attachment - within papilla Papilla-penetrating attachment when fibres cross alveolar process and extend upto palatine papilla

Mucosal Attachment

Gingival attachment

Papillary attachment

Papillapenetrating attachment

Pull syndrome
A detaching movement of the marginal gingiva transferred from the lip by the frenum has been termed the pull syndrome.

Tension test

Placek et al 1974

Its a term used to describe the movement or displacement of marginal gingiva when tension is applied to the lip in an outward, downward & lateral direction.

Perecentage of Types of Attachment

Mucosal Attachment Gingival Attachment Papillary Attachment PapillaryPenetrating Attachment Maxillary Midline Area 46.5 34.3 3.1 16.1 Mandibular Midline Area 92.1 6.5 0.7 1.2

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 Syndrome

Mucosal Attachment Gingival Attachment Papillary Attachment PapillaryPenetrating Attachment Maxillary Midline Area 4.5 53.5 100 84 Mandibular Midline Area 6.5 76.2 100 100

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 frenum

Midline Diastema Accumulation of debris by reflection & opening of sulcus Difficult oral hygiene maintenance Gingival Recession

Frenotomy :
It is a procedure that is relocating the

frenal attachment so as to create a zone of

attached gingiva between the gingival margin and

the frenum.

Frenectomy :
It is the complete excision of the frenum,
including its attachment to underlying bone.

Indications

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

a) Distention of the orifice of the sulcus or pocket, leading to debris accumulation. b) An increase in the severity of the pocket, impairing healing.

2) To eliminate a well developed frenum that penetrates the gingival papilla to its origin on the incisive papilla. The coronally attached frenum may lead to a midline diastema & prevent mesial drift, which usually closes this space.
3) To facilitate orthodontic treatment, A thick frenum resists orthodontic forces & its wedging area can be responsible for slight spacing of the maxillary Central Incisors following orthodontic treatment.

4)

To eliminate a frenum that makes it difficult or impossible to use a Tooth Brush effectively in the area. When combined with more sophisticated periodontal surgery, e.g.. to eliminate periodontal pockets & increase Attached Gingiva & depth of vestibular trough.

5)

Surgical Techniques

Simple excision Z-Plasty Vestibuloplasty with Secondary Epithelialization V-Rhomboid plasty Modification of V-Rhomboid plasty V-Y plasty Simple Incision Submucosal frenotomy Lingual frenectomy

Simple Excision
Abnormal Frenum

A narrow elliptic incision around the frenal area down on the periosteum is completed. The fibrous frenum is then sharply dissected from the underlying periosteum and soft tissue and the margins of the wound are gently undermined 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.

A Frenum attachment

Procedure Removal of frenum

B
Incision

Incision

Fiber attachment removal

Suturing

Post-operative 1 mths

Two Haemostats Technique

Local anaesthesia Raise the lip, put a hemostat parralel to the alveolar ridge. Another hemostat parallel to the lip at right angle to the first. With no. 11 or 15 blade , labial frenum is excised by cutting around the outside surfaces of the two hemostat leaving behind a diamond shaped 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 Technique

For a narrow band of frenum Excision of fibrous connectve tissue is done similar to simple excision

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

Flaps reflected

Vertical flaps positioned Horizontally and sutured

VESTIBULOPLASTY WITH SECONDARY EPITHELIZATION

For extremely wide base of frenal attachment. Incision is made through mucosal tissue and underlying submucosal tissue, without perforating the periosteum. Supraperiosteal dissection is completed by undermining the mucosal and submucosal tissue with scissors.

Incision starting from apex to base

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

V-Rhomboid Plasty

Engage frenum in a hemostat. Excise frenum coronal & apical to hemostat with a blade. Circumferential submucosal tissue is dissected. Excised frenum is removed.

Rhomboid wound closed with sutures

Modification of V-rhomboid plasty

In v- rhomboidplasty , vestibule may become shallow and the band of attached gingiva is narrowed after completion of sutures. Triangular wound is left open in the attached gingiva. Sutures are placed at the alveolar mucosa. Open wound surface is created in the attached gingiva.

V-Y Plasty

Indicated in reducing height of attachment of frenum. V shaped incision is made in the Attachment of frenum. Underlying fibrous tissue is removed.

Wound margins closely adapted like the letter Y and sutured

Simple Incision

For a frenum attached too closely to gingival margin. Incision made into the attachment of the frenum along the base .

Frenum is raised up apically as a full thickness or split thickness flap. In split thicness , dissection is carried out , the underlying fibrous tissue should be removed enough not to relapse.

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

Submucosal Frenotomy

Indicated in a frenum with a wide base.

A vertical incision along the ridge & two incisions bilaterally to the attachment.
Surgical scissors inserted through the incised margin to dissect submucosal tissue bluntly. Traversing muscle fibres are cut.

Periosteum is revealed following cutting of the muscle fibres.

Suturing done.

Healing After Frenectomy / Frenotomy

The wound is triangular in shape. It is bound on the two sides by attached gingiva (fixed tissue). It provides one source of granulation tissue. The other source of tissue is the exposed bone that occurs as all the tissue is removed.

When the bone is not exposed by the removal of periosteum , gingiva will also regenerate. However, all the loose C.T , elastic fibres and fatty tissue elements must be removed, leaving the dense fibrous collagen fibres over the periosteum.
The immovable base upto which newer granulation tissue can form results in new attached gingiva.

References :

Michael G. Newman , Henry H. Takei , Perry R. Klokkevold , Fermin A. Carranza : Carranza's Clinical Periodontology 10th edition. Periodontal Therapy Goldman 6th ed Oral & Maxillofacial Surgery Peterson Oral & Maxillofacial Surgery Archer Oral & Maxillofacial Surgery Laskin Gottsegen R. Frenum position and vestibule depth in relation to gingival health. Oral Surg 1954;7:1069-72. Placek M, Miroslavs, Mrklas L. Significance of the labial frenal attachment in periodontal disease in man. Part 1; Classification and epidemiology of the labial frenum attachment. J Periodontol 1974;45:891-94. Kaimenyi JT. Occurrence of midline diastema and frenum attachment among school children in Nairobi, Kenya.Indian J dent Research 1998;130:85-94.