FRENUM ATTACHMENT

AND IT’S MANAGEMENT.

DR BHAUMIK THAKKAR.

PART II P.G. DEPT OF PERIODONTOLOGY.

CONTENTS

INTRODUCTION

DEVELOPMENT

TYPES OF FRENAL ATTACHMENT

VARIATIONS

DIAGNOSIS

ANKYLOGLOSSIA

COMPLICATIONS OF ANKYLOGLOSSIA

CLASSIFICATION

SYNDROMES ASSOCIATED WITH ABNORMAL FRENUM

COMPLICATIONS OF ABNORMAL FRENUM

TREATMENT

CONCLUSION

REFERENCES

INTRODUCTION

What is a frenum?

Frenum is a thin fold of mucous membrane with enclosed musclefibers that attach the lips to the alveolar mucosa and underlyingperiosteum. ( Carranza 10th edition)

A frenulum is a small frenum. There are several frena that are usuallypresent in a normal oral cavity, most notably the maxillary labialfrenum, the mandibular labial frenum, and the lingual frenum.

Their primary function is to provide stability of the upper and lower lipand the tongue.

DEVELOPMENT

The maxillary labial frenum develops as a post eruptiveremnant of the ectolabial bands which connects the tubercleof the upper lip into the palatine papilla.

It extends over the alveolar process in infants and forms araphe that reaches the palatal papilla.

Through the growth of alveolar process as the teeth erupt,this attachment generally changes to assume the adultconfiguration.

TYPES OF FRENAL ATTACHMENT

Depending upon the extent of attachment of fibres, frena have beenclassified by Placek et al. 1974 as:

MUCOSAL- The frenal fibres are attached up to themucogingival junction.

GINGIVAL- The fibres are inserted within the attachedgingiva.

PAPILLARY- The fibres extend into the interdental papilla.

PAPILLA PENETRATING- The frenal fibres cross the alveolarprocess and extend up to palatine papilla.

VARIATIONS

Other variations of normal frenal attachment

Include:

• Simple frenum with a nodule

• Simple frenum with appendix

• Simple frenum with nichum

• Bifid labial frenum

• Persistent tectolabial frenum

• Double frenum

• Wider frenum

Mucosal frenal attachment

Gingival frenal attachment

Papillary frenal attachment

Papilla penetrating frenal attachment

Simple frenum with a nodule

Simple frenum with appendix

Wider frenal attachment

Simple frenum with nichum

DIAGNOSIS

Tests for frenal attachment:

1. Tension Test.

2. Blanch Test.

Miller et al(1985) recommended that the frenum should becharacterised as pathogenic when it is unusually wide orthere is no apparent zone of attached gingiva along themidline or the interdental papilla shift when the frenum isextended.

ANKYLOGLOSSIA (TONGUE

TIE)

ANKYLOGLOSSIA

Ankyloglossia or tongue-tie is an uncommon congenitalanomaly that occurs as a result of a short, tight, lingualfrenulum causing difficulty in speech articulation due tolimitation of tongue movement.

WALLACE et al 1963 defined tongue-tie as

“a condition in which the tip of the tongue cannot be protrudedbeyond the lower incisor teeth because of a short frenulumlinguae, often containing scar tissue.”

CLINICAL FEATURES OF ANKYLOGLOSSIA

Ankyloglossia leads to :

Limited mobility of tongue.

Difficulty in swallowing.

Difficulty in speech articulation which is evident for consonants like “s, z, t,d, l, j, zh, ch, th, dg” and it is especially difficult to roll an “r”.

Notched or “heart-shaped” tongue when it is protruded.

FREE-TONGUE:

The term free-tongue is defined as the length of tongue from the insertionof lingual frenum from the base of the tongue to the tip of the tongue.

Clinically acceptable, normal range of free-tongue is greater than 16 mm.

(Kotlow et al 1999)

CLASSIFICATION

Ankyloglossia can be classified into 4 classes based on Kotlow’sassessment in 1999 (based on length of tongue from insertion oflingual frenum at base of the tongue to the tip of the tongue) asfollows:

CLASS I: MILD ANKYLOGLOSSIA (12 to 16 mm)

CLASS II: MODERATE ANKYLOGLOSSIA (8 to 11mm)

CLASS III: SEVERE ANKYLOGLOSSIA (3 to 7 mm)

CLASS IV: COMPLETE ANKYLOGLOSSIA (< 3mm)

SYNDROMES ASSOCIATED WITH ABNORMAL FRENUM

Ehlers-Danlos syndrome

Infantile hypertrophic pyloric stenosis

Holoprosencephaly

Ellis-van Creveld syndrome

Oro-facial-digital syndrome

EHLERS-DANLOS SYNDROME

It is a genetic disorder characterized by hyperextensive skin and hyper mobile joints with nogender predilection.

Hypermobile joint and hyper extensive skin seen in a patient with Ehlers- danlos syndrome

EHLER DANLOS SYNDROME ORAL MANIFESTATION

DE FELICE ET AL 2001

INFANTILE HYPERTROPHIC PYLORIC STENOSIS

Occurs commonly in males at a ratio of 4.5 to 1with an unknown etiology.

The absence or hypoplasia of mandibular frenum isseen in patients with this syndrome.

INFANTILE HYPERTROPHIC PYLORIC STENOSIS

DE FELICE ET AL 2000

HOLOPROSENCEPHALY

It is an autosomal dominant condition characterized by abrain malformation due to defects in prosencephalon.

It is characterized by defects including cyclopia, singlenostril, single central incisor and premaxillary agenesis.

Absence of labial maxillary frenum is one of thecharacteristic features of this condition.

HOLOPROSENCEPHALY

ELLIS-VAN CREVELD SYNDROME

It is an autosomal recessive disorder mainly affecting enamel, hair andnails.

Patients with this syndrome characteristically present withcongenitally missing teeth, abnormal frenal attachment, microdontiaand hexadactyly.

The most common finding is fusion of the anterior portion of the upperlip to the maxillary gingival margin, as a result of which no mucobuccalfold exists, causing the upper lip to present a slight V-shaped notch inthe middle (partial hare lip or lip-tie).

The anterior portion of the lower ridge is often serrated and presentswith multiple small labial frenula.

Oral manifestations seen in Ellis-van Creveld syndrome

COMPLICATIONS OF ABNORMAL FRENUM

A frenum becomes a problem if the attachment is too close to the marginalgingiva.

Tension on the frenum may pull the gingival margin away from the tooth.

This condition may be conducive to plaque accumulation and inhibit propertooth brushing.

Abnormal frenum has been found to be associated with:

• Loss of papilla.

• Recession.

• Persistence of midline diastema.

• Difficulty in brushing.

• Malalignment of teeth .

• Compromised denture fit or retention.

TREATMENT

Techniques for removal of aberrant frenum are : Frenotomy Frenectomy

Frenectomy : Refers to the complete removal of frenum,including its attachment to the underlying bone.It is required in the correction of abnormal diastemabetween maxillary central incisors (Friedman 1957).

Frenotomy: Is the incision of the frenum.It is usually done to relocate the frenal attachment so as tocreate a zone of attached gingiva between the gingivalmargin and the frenum.

FRENECTOMY

INDICATIONS

1. Gingival or papillary frenal attachment: Where frenal fibresradiate into marginal gingiva producing gingival retraction andlocalized gingival recession.

2. High frenal attachment: Where oral hygiene is hindered byshallow vestibule caused by high frenal attachment.

3. Ankyloglossia: When lingual frenum interferes with speech.

TECHNIQUES OF FRENECTOMY

Conventional (classical) frenectomy

Miller’s technique

V-Y plasty

Z plasty

Frenectomy by using electrocautery

Laser frenectomy

CLASSICAL FRENECTOMY

The classical technique was introduced by Archeret al 1961 and Kruger et al 1964.

This approach was advocated in midline diastemacases with an aberrant frenum to ensure theremoval of muscle fibres which were supposedlyconnecting the orbicularis oris with the palatinepapilla.

One month post-operative view

DISADVANTAGES

Causes un-aesthetic labial tissue scarring.

This may become a matter of concern in case

of high smile line exposing the anterior gingiva.

MILLER’S TECHNIQUE

This technique was advocated by Miller PD et al in 1985.

This was proposed for post-orthodontic diastema cases.

The ideal time for performing this surgery is after theorthodontic movement is complete and about 6 weeksbefore the appliances are removed.

This allows healing and tissue maturation.

2 weeks post-operative

ADVANTAGES OF MILLER’S TECHNIQUE

Post-operatively, on healing, there is a continuous bandof gingiva across the midline, that gives a bracing effectthan the scar tissue, thus preventing orthodonticrelapse.

The transseptal fibres are not disrupted surgically and so,there is no loss of interdental papilla.

Z- PLASTY TECHNIQUE

This technique is indicated when:

a) There is hypertrophy of the frenum with a lowinsertion, associated with distema.

b) There is a short vestibule.

one month post-operative view

V-Y PLASTY TECHNIQUE

This technique can be used for lengthening thelocalized area, like a broad frena.

This technique is mostly employed in a case of apapilla type of frenal attachment.

ELECTROSURGERY

This technique is recommended for patients withbleeding disorders and non-compliant patients.

ADVANTAGES

This technique offers the advantages of:

Minimal time consumption.

Minimal procedural bleeding.

No need of sutures.

Healing is by secondary intention as the wound edges are not approximated with sutures.

LASER FRENECTOMY

The benefits of a laser frenectomy are greater as compared totraditional techniques .

These include :

Reduced bleeding during surgery.

Reduced operating time and rapid postoperative hemostasis,thus eliminating the need for sutures.

The lack of need for sutures, as well as improvedpostoperative comfort and healing, make this techniqueparticularly useful for very young patients.

DIODE LASER UNITS

POST OPERATIVE INSTRUCTIONS

NOT to eat anything until the anesthesia wears off, as there are chances of biting thelips, cheek or tongue.

Avoid extremely hot foods for the rest of the day and do NOT rinse out your mouth, asthese will often prolong the bleeding. If bleeding continues, apply light pressure to thearea with a moistened gauze for 20-30 minutes.

Follow a soft food diet, taking care to avoid the surgical area when chewing. Chew onthe opposite side and do NOT bite into food. Be sure to maintain adequate nutrition anddrink plenty of fluids. Do NOT use a drinking straw, as the suction may dislodge theblood clot.

Avoid alcohol and smoking until after your post-operative appointment.

Maintain normal oral hygiene measures in the areas of mouth not affected by thesurgery. In areas where there is dressing, lightly brush only the biting surfaces of theteeth. Vigorous rinsing should be avoided!

Do NOT pull down the lip or cheek.

CONCLUSION

Frenum may not regularly draw close scrutiny on routinedental examination.

While an aberrant frenum can be removed by any of themodification techniques that have been proposed, afunctional and an aesthetic outcome can be achieved by aproper technique selection, based on the type of frenalattachment.

References.

Carranza 10th and 12th edition.

Priyanka M, Sruthi R, Ramakrishnan T, Emmadi P, Ambalavanan N.An overview of frenal attachments. J Indian Soc Periodontol 2013

Mirko P, Miroslav S, Lubor M. Significance of the labial frenumattachment in periodontal disease in man. Part I. Classification andepidemiology of the labial frenum attachment. J Periodontol 1974

Devishree et al. Journal of Clinical and Diagnostic Research. 2012November.

Kotlow LA. Oral diagnosis of abnormal frenum attachments inneonates and infants: Evaluation and treatment of maxillaryfrenum using the Erbium YAG Laser. J Pediatr Dent Care 2004.

De Felice C, Toti P, Di Maggio G, Parinni S, Bagnoli F. Absence of theinferior labial and lingual frenula in Ehlers-Danlos syndrome. Lancet2001