FRENUMFRENUM

Attachments And Attachments And ManagementManagement

ByBy

L.DevibalaL.Devibala

FrenumFrenum A fold of mucous membrane,usually with enclosed A fold of mucous membrane,usually with enclosed

muscle fibres,that attaches the lips and cheeks to the muscle fibres,that attaches the lips and cheeks to the alveolar mucosa and/or gingiva and underlying peiosteumalveolar mucosa and/or gingiva and underlying peiosteum..

Frena of the mouth:Frena of the mouth:

1.Labial frenum 1.Labial frenum

2.Buccal frenum2.Buccal frenum

3.Lingual frenum3.Lingual frenum

FRENAL ATTACHMENTSFRENAL ATTACHMENTSThe upper labial frenum is triangular in shape The upper labial frenum is triangular in shape

and attaches lip to alveolar mucosa and/or gingiva.It extends and attaches lip to alveolar mucosa and/or gingiva.It extends over the alveolar process in infants and forms raphe that over the alveolar process in infants and forms raphe that reaches the palatal papilla.Through the growth of alveolar reaches the palatal papilla.Through the growth of alveolar process as the teeth erupt,this attachment generally process as the teeth erupt,this attachment generally changes to assume the adult configuration.changes to assume the adult configuration.

Depending upon the extension of attachment of fibres,frena Depending upon the extension of attachment of fibres,frena have been classified as,have been classified as,

11..mucosalmucosal-when frena attached to mucogingival -when frena attached to mucogingival junctionjunction

2.2.gingivalgingival-when fibres inserted within attached -when fibres inserted within attached gingivagingiva

3.3.papillarypapillary-when fibres extending into interdental -when fibres extending into interdental papillapapilla

4.Papilla penetrating4.Papilla penetrating-when fibres cross alveolar -when fibres cross alveolar process and extend upto palatine papillaprocess and extend upto palatine papilla

Papillary and papilla penetrating types are clinically pathological Papillary and papilla penetrating types are clinically pathological

and found to be associated with and found to be associated with

Loss of papillaLoss of papilla RecessionRecession DiastemaDiastema Difficulty in brushing Difficulty in brushing Psychological disturbances to the individualPsychological disturbances to the individual

GINGIVAL RECESSION:GINGIVAL RECESSION: Frenal and muscle attachments that encroach Frenal and muscle attachments that encroach

on the marginal gingiva distend the gingival on the marginal gingiva distend the gingival sulcus,fostering plaque accumulation,increasing the sulcus,fostering plaque accumulation,increasing the rate of propogation of periodontal recession.rate of propogation of periodontal recession.

This problem is more common on facial This problem is more common on facial surfacessurfaces

GINGIVAL RECESSIONGINGIVAL RECESSION

DIASTEMA FORMATION: DIASTEMA FORMATION:

This is common with maxillary This is common with maxillary midline frenum.midline frenum.

The upper labial frenum The upper labial frenum may be broad and large and may be broad and large and separate the upper incisors.separate the upper incisors.

Frenectomy is not indicated Frenectomy is not indicated unless the frenum is still unless the frenum is still attached to the incisive attached to the incisive papilla by strong fibres papilla by strong fibres which prevent physiologic which prevent physiologic closure of the space closure of the space between the incisors and between the incisors and then not before the then not before the permanent cuspids have permanent cuspids have erupted.erupted.

ANKYLOGLOSSIAANKYLOGLOSSIA

It is a condition in which It is a condition in which lingual frenum is short, lingual frenum is short, tight or otherwise tight or otherwise restrictive, resulting in restrictive, resulting in reduced mobility of reduced mobility of tongue.tongue.

CONSEQUENCES:CONSEQUENCES: Interference with feedingInterference with feeding Difficulty with speechDifficulty with speech Unseen effects on Unseen effects on

personality developmentpersonality development Poor oral hygienePoor oral hygiene

Classification of AnkyloglossiaClassification of Ankyloglossia(as per Kotlow)(as per Kotlow)

Clinically acceptable, normal range of free tongue is Clinically acceptable, normal range of free tongue is

16mm16mm..

Class I Class I MildMild ankyloglossia ankyloglossia(12-16mm)(12-16mm)

Class II Class II ModerateModerate ankyloglossia ankyloglossia(8-(8-11mm)11mm)

Class III Class III SevereSevere ankyloglossia ankyloglossia(3-7mm)(3-7mm)

Class IV Class IV CompleteComplete ankyloglossiaankyloglossia(<3mm)(<3mm)

MANAGEMENT OF MANAGEMENT OF ABNORMAL FRENAL ABNORMAL FRENAL

ATTACHMENTSATTACHMENTSFRENOTOMY:FRENOTOMY:

Simple excisional release of frenum from Simple excisional release of frenum from the apex of its insertion to its base and down to the apex of its insertion to its base and down to the alveolar process.the alveolar process.

FRENECTOMY:FRENECTOMY:

Complete removal of the frenum,including Complete removal of the frenum,including its attachments to the underlying alveolar its attachments to the underlying alveolar processprocess..

Both the procedures are used,but frenotomy Both the procedures are used,but frenotomy generally suffices for periodontal purposes,that is generally suffices for periodontal purposes,that is relocating the frenal attachment so as to create a relocating the frenal attachment so as to create a zone of attached gingiva between the margin and the zone of attached gingiva between the margin and the frenum frenum

FRENECTOMYFRENECTOMY

LABIAL FRENECTOMYLABIAL FRENECTOMY LINGUAL RENECTOMYLINGUAL RENECTOMY

LABIAL FRENECTOMY LABIAL FRENECTOMY Types:Types:

1)1) Classical FrenectomyClassical Frenectomy2)2) Diamond techniqueDiamond technique3)3) V plasty techniqueV plasty technique4)4) Z plasty techniqueZ plasty technique5)5) V-Y plasty techniqueV-Y plasty technique6)6) Laser FrenectomyLaser Frenectomy

CLASSICAL CLASSICAL FRENECTOMYFRENECTOMY

Incision made at the base of frenum at its Incision made at the base of frenum at its attachment of incisive papillaattachment of incisive papilla

The dissection is carried down to the The dissection is carried down to the periosteum and incision is then extended along periosteum and incision is then extended along both the sides of frenum to its attachment on both the sides of frenum to its attachment on labial mucosalabial mucosa

The specimen is placed on traction and excised The specimen is placed on traction and excised from lip. Results in bell shaped defectfrom lip. Results in bell shaped defect

Relaxing incisions made at mucogingival lineRelaxing incisions made at mucogingival line Labial flaps advancedLabial flaps advanced This diamond shaped defect is allowed to healThis diamond shaped defect is allowed to heal

Classical frenectomyClassical frenectomy

DIAMOND TECHNIQUEDIAMOND TECHNIQUE

Using two hemostats, secure the frenum adjacent to the gingiva and adjacent to the vestibule

Cut on the outside of the hemostats to avoid leaving crushed tissue in place

The key to healing is to open up the submucosal tissue

If you close the wound in its present state, a scar will form, and you will lose what you have attempted to accomplish

Undermine the wound to prevent scar formation

This will ensure a tension-free wound

V-Plasty techniqueV-Plasty technique

It is the most oftenly used It is the most oftenly used techniquetechnique

After anaesthetizing the After anaesthetizing the

area, engage the frenum area, engage the frenum with the hemostat inserted with the hemostat inserted to the depth of the to the depth of the vestibulevestibule

Incise along the upper Incise along the upper surface of the hemostat, surface of the hemostat, extending beyond the tipextending beyond the tip

Make a similar incision Make a similar incision along the undersurface of along the undersurface of the hemostatthe hemostat

Remove the triangular resected Remove the triangular resected portion of the frenum with the portion of the frenum with the hemostat.This exposes the hemostat.This exposes the underlying brushlike fibrous underlying brushlike fibrous attachment to the bone.attachment to the bone.

Make a horizontal Make a horizontal incision,separating the incision,separating the fibres,and bluntly dissect the fibres,and bluntly dissect the bone.bone.

If necessary,extend the If necessary,extend the incisions laterally and suture incisions laterally and suture the labial mucosa to the apical the labial mucosa to the apical periosteum.periosteum.

Clean the surgical field and Clean the surgical field and pack with gauze sponges until pack with gauze sponges until bleeding stopsbleeding stops

Cover the area with aluminium Cover the area with aluminium foil and apply periodontal pack.foil and apply periodontal pack.

Z plasty techniqueZ plasty techniqueComparitively a difficult technique, but useful when frenum is Comparitively a difficult technique, but useful when frenum is

broad and vestibule short. It achieves 2 objectivesbroad and vestibule short. It achieves 2 objectives

1.1. Fibrous band excised Fibrous band excised

2.2. Vertical lengthening of vestibule achieved Vertical lengthening of vestibule achieved

Procedure:Procedure: Make an elliptical incisionMake an elliptical incision The central portion of the incision is placed over the fibrous The central portion of the incision is placed over the fibrous

band band Excise fibrous tissueExcise fibrous tissue Make 2 oblique incisions at 60 degrees of projection with Make 2 oblique incisions at 60 degrees of projection with

equal length to central incisorequal length to central incisor Undermine pointed flapsUndermine pointed flaps Rotate points to close vertical incisions horizontally. Closed Rotate points to close vertical incisions horizontally. Closed

with sutureswith sutures An effective superior to inferior lengthening of approximately An effective superior to inferior lengthening of approximately

75% occurs after closure. 75% occurs after closure.

Z plasty in lower labial FrenumZ plasty in lower labial Frenum

V –Y plasty techniqueV –Y plasty technique V-Y type of incision can be used for V-Y type of incision can be used for

lengthening localized arealengthening localized area Broad frena in premolar-molar area can be Broad frena in premolar-molar area can be

treated by taking semilunar incisions at the treated by taking semilunar incisions at the mucogingival junction and supra periosteal mucogingival junction and supra periosteal dissection is donedissection is done

The superior edge of the incision is sutured The superior edge of the incision is sutured at the depth of the vestibule to the at the depth of the vestibule to the periosteum and the rest of the raw area periosteum and the rest of the raw area below is allowed to heal by secondary below is allowed to heal by secondary epithelialization. epithelialization.

Use of prefabricated stent is necessary. Use of prefabricated stent is necessary.

Frenectomy with a Lateral Pedicle Frenectomy with a Lateral Pedicle graft graft

An esthetic frenectomy proposed by An esthetic frenectomy proposed by MillerMiller..

Healing takes place by primary intention.Healing takes place by primary intention. A zone of attached gingiva that is A zone of attached gingiva that is

esthetic.esthetic. No unaesthetic scar formation.No unaesthetic scar formation. No recession of interdental papilla as theNo recession of interdental papilla as the

transseptal fibres are not severed.transseptal fibres are not severed. The attached gingiva in the midline may The attached gingiva in the midline may

have a bracing effect which helps in have a bracing effect which helps in

prevention of orthodontic relapse.prevention of orthodontic relapse.

Laser frenectomyLaser frenectomy Diode laser with wavelength of 810nm is selected Diode laser with wavelength of 810nm is selected

for the procedure.No local anaesthesia given.for the procedure.No local anaesthesia given. The frenum is stretched to visualize its extent.The The frenum is stretched to visualize its extent.The

diode laser is applied in a contact mode with diode laser is applied in a contact mode with focussed beam for excision of the tissue.focussed beam for excision of the tissue.

The ablated tissue is continuously mopped using The ablated tissue is continuously mopped using wet gauze piece.This takes care of the charred wet gauze piece.This takes care of the charred tissue and prevents excessive thermal damage to tissue and prevents excessive thermal damage to the underlying soft tissue.the underlying soft tissue.

The tissue is lased until all the underlying muscle The tissue is lased until all the underlying muscle fibres are dissected.fibres are dissected.

No sutures are placed.No sutures are placed.

Advantages Of Laser frenectomy Advantages Of Laser frenectomy over Conventional frenectomyover Conventional frenectomy

1.1. No need of local anaesthesia.Hence it’s No need of local anaesthesia.Hence it’s a a painlesspainless procedureprocedure.As a result, there .As a result, there is less patient apprehension.is less patient apprehension.

2.2. BloodlessBloodless operative field, thus better operative field, thus better visibility.visibility.

3.3. No need of periodontal dressing.No need of periodontal dressing.

4.4. Better healing and Better healing and less scarringless scarring..

5.5. Less time consumingLess time consuming

6.6. Minimal post operative complications.Minimal post operative complications.

Management Of AnkyloglossiaManagement Of Ankyloglossia

Conventional surgery often Conventional surgery often performed at 6 months of age under performed at 6 months of age under GA. This is done mainly to enable GA. This is done mainly to enable them to latch and suckle.them to latch and suckle.

Laser frenectomy.Laser frenectomy. Lingual frenectomy can be Lingual frenectomy can be

performed in adults in cases where performed in adults in cases where the high frenal pull causes gingival the high frenal pull causes gingival recession, spacing etc.recession, spacing etc.

Lingual FrenectomyLingual Frenectomy

High Lingual frenal High Lingual frenal attachments may attachments may consist of different consist of different tissue types including tissue types including mucosa, connective mucosa, connective tissue and superficial tissue and superficial genioglossus muscle genioglossus muscle fibres.fibres.

Bilateral lingual blocks Bilateral lingual blocks and local infiltration in and local infiltration in anterior mandible given. anterior mandible given.

Surgical release of Surgical release of lingual frenum requires lingual frenum requires dividing the attachment dividing the attachment of fibrous connective of fibrous connective tissue at the base of the tissue at the base of the tongue in a transverse tongue in a transverse fashion, followed by a fashion, followed by a closure in a linear closure in a linear dissection, which dissection, which completely releases the completely releases the ventral aspect of ventral aspect of tongue from alveolar tongue from alveolar mucosamucosa..

Electrocautery or Electrocautery or hemostat is used to hemostat is used to control bleeding and for control bleeding and for visibility. visibility.

After the removal of After the removal of hemostat, an incision is hemostat, an incision is made through the area made through the area previously closed with previously closed with hemostat. hemostat.

The edges of incision are The edges of incision are undermined and the undermined and the wound edges are wound edges are approximated and closed approximated and closed with sutures. with sutures.

Reference :Reference :

1.1. Oral and maxillofacial surgery-Oral and maxillofacial surgery-Neelima Anil MalikNeelima Anil Malik

2.2. Clinical Periodontology-CarranzaClinical Periodontology-Carranza

3.3. Practical Pediatrics-Maxwell James Practical Pediatrics-Maxwell James RobinsonRobinson

4.4. Atlas of Cosmetic and Atlas of Cosmetic and Reconstructive Periodontal Reconstructive Periodontal Surgery-Edward S.CohenSurgery-Edward S.Cohen

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