Frenum Attachment and its applied Ascpect. Anatomy, Syndromes, Diagnosis and Treatment

INDEX

INTRODUCTION
SUPERIOR LABIAL FRENUM-Muscular Anatomy
DEVELOPMENT
ETIOLOGY

SYNDROMES
INFANTILE HYPERTROPHIC PYLORIC STENOSIS
HOLOPROSENCEPHALY
ELLIS-VAN CREVELD SYNDROME
EHLERDANLOS SYNDROME
PALLISTER –HALL SYNDROME
OPTIZ C SYNDROME
NONSYNDROMIC CONDITIONS

CLASSIFICATION

DIAGNOSIS

INDICATIONS

TREATMENT
Classical Frenectomy:2,28
2.Miller’s Technique 2,29
Z Plasty 30,31
V-Y Plasty 34
Electro Surgery 35,36
LASER

LINGUAL FRENECTOMY

FRENECTOMY PROCEDURES IN ORTHODONTIC PATIENTS BEFORE OR AFTER ?

REFERENCES

INTRODUCTION

The word” frenum” is derived from the latin word fraenum.

A frena are triangular shaped folds found in maxillary and mandibular alveolar mucosa, and are located between the central incisors, canine and premolar area.

A frenum is an anatomic structure formed by a membranous fold of mucous membrane and connective tissue, sometimes muscle fibres. There are several frena that are usually present in a normal oral cavity, most notably the maxillary labial frenum, the mandibular labial frenum, and the lingual frenum.1 (Fig:1)

Histologically , Knox and Young studied the frenulum, and they have reported both elastic and muscle fibres (Orbicularis oris - horizontal bands and oblique fibres). However, Henry, Levin and Tsaknis have found considerably dense collagenous tissue and elastic fibres but no muscle fibres in the frenulum.2

The primary function of frena is to provide stability to the upper and lower lips and the tongue.3

The frena may also jeopardize the gingival health by causing a gingival recession when they are attached too closely to the gingival margin, either because of an interference with the proper placement of a toothbrush or through the opening of the gingival crevice because of a muscle pull.1

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SUPERIOR LABIAL FRENUM-Muscular Anatomy

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Fig:8 Simple frenum with a nodule

r in shape,they are thin folds of mucous membrane with enclosed muscle fibres originating from orbicularis oris muscle of upper lip that attach at the lips to the alveolar mucosa and underlying periosteum.

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

This attachment generally changes as the alveolar process grows to assume the adult configuration.4

Taylor has observed that a midline diastema is normal in about 98% children between 6 and 7 years of age but the incidence decreases to only 7 % in persons 12-18 yrs old.5

DEVELOPMENT

Embryonically, the superior labial frenum appears to be developed from the frontonesal process 6, and it begins to take form in the fetus at a relatively early stage. Within the first few months of fetal life, it emerges as a part of the oral cavity, along with the lips and the cheeks.7

As growth and development progress, a prominence begins to appear in the middle part of the inner zone of the upper lip, and this becomes the tuberculum. About this time, an other prominence forms on the anterior part of the palate and develops into the palatine papilla. A continuous fold of tissue, the tectolabial frenum, connects the tuberculum with the palatine papilla. It is interesting at this time to note that the tectolabial frenum of the fetus simulates the abnormal frenum of postnatal life, in that it extends as a continuous band of tissue from the inner aspect of the upper lip, over and across the alveolar ridge , to be inserted in the palatine papilla.

Normally, however, the growing alveolar process causes a severance of the continuous fold of tissue, dividing it into a palatal and labial portion. The palatal part corresponds to the palatine papilla, and the labial tissue becomes the superior labial frenum, extending from the lip to the crest of the alveolar ridge.

Histologically, Noyes 9 studied newborn infants and found that the frenum is composed mostly of connective tissue, with a few striated muscle fibers which arise from the muscle bundles of the lip on either side of the midline and pass in a diagonal direction medially and posteriorly but do not reach the alveolar process. The loose character of the fibrous connective tissue becomes more regular in arrangement with strands lying in an anteroposterior direction as it nears the alveolar attachment.

In the labial portion there are mucous glands in the subcutaneous tissue on either side of a central artery and vein that lie near the muscle bundles of the lip.

This artery and vein have branches which are given to the frenum and these travel in an antero- posterior direction, providing the blood supply of the structure. Nerve filaments accompany the vessels.

The posterior fibers terminate by ramifying with the connective tissue of the alveolar crest and its anterior surface. Anderson10 and Dewel11 give very similar descriptions, except that Anderson makes no mention of muscle fibers, and Dewel says that there are none in the frenum.

ETIOLOGY

The maxillary labial frenum develops as a post-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 between the two central incisors and an abnormal frenum attachment results. The mandibular frenum is considered as aberrant when it is associated with a decreased vestibular depth and an inadequate width of the attached gingival.1,12

SYNDROMES

Syndromes associated with different frenal attachments:

Ehlers-Danlos syndrome

Infantile hypertrophic pyloric stenosis,

Holoprosencephaly,

Ellis-van Creveld syndrome, and

Oro-facial-digital syndrome.

Each syndrome exhibits relatively specific frenal

abnormalities, ranging from multiple, hyper

plastic, hypoplastic, or an absence of frena.

Each syndrome exhibits relatively specific frenal abnormalities ranging from multiple, hyper plastic, hypoplastic, or an absence of frena.

Oro-Facial-Digital Syndrome

Oro-facial-digital syndrome arises as the result of a single gene malformation showing X-linked dominant inheritance.18

Clinical features within the oral cavity:

The tongue is lobulated with hamartomata between lobules, hypertrophied lingual frenum which is incompletely differentiated from the floor of the mouth.

Gums are clefted by abnormal supernumerary frenula.

Cleft often in soft palate, might be bilateral or asymmetrical.

Teeth are malpositioned, often and may have enamel

Hypoplasia

Midline notch (pseudocleft) may be seen in the upper lip

INFANTILE HYPERTROPHIC PYLORIC STENOSIS

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

There is a disturbance in the frenum formation.

The absence or hypoplasia of mandibular frenum represents an important diagnostic tool in detection of this disease.19

HOLOPROSENCEPHALY

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

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

Absence of labial maxillary frenum is one of the characteristic features of this condition.20

ELLIS-VAN CREVELD SYNDROME

Ellis-van Creveld (EvC) syndrome is an autosomal recessive disorder, mainly affecting the ectodermal components such as enamel, nail, and hair.

Patients with EvC syndrome characteristically presents with congenitally missing teeth, abnormal frenal attachment, microdontia, and hexadactyly.21

Oral manifestations in the EvC syndrome are characteristic and Constant.

The most constant finding is fusion of the anterior portion of the upper lip to the maxillary gingival margin, as a result of which no mucobuccal fold exists,causing the upper lip to present a sligh V-shaped notch in the middle.

Changes in the upper lip can be addressed by various names such as partial hare-lip or lip tie. The anterior portion of the lower ridge is often serrated and presents with multiple small labial frenula.

The maxillary and mandibular alveolar process presents with notching or submucous clefts and continuous or broad labial frenula with dystrophic philtrum.21

EHLERDANLOS SYNDROME

It is a genetic disorder characterized by hyper extensive skin and hyper mobile joints with no gender predilection.

Absence of the inferior labial and lingual frena has been described in this disorder.22

PALLISTER –HALL SYNDROME

Inherited as an autosomal dominant pattern. The gene responsible for this disorder has been mapped to 7p13 and is identified as GL13.

Clinical features include short mid face and nose with a flat nasal bridge and anteverted nostrils.

Oral manifestations include micrognathia, microglossia and abnormal supernumerary frena extending from the buccal mucosa to the alveolar ridge.23

OPTIZ C SYNDROME

Exhibits similar frenal abnormalities as Pallister-Hall

syndrome.24

NONSYNDROMIC CONDITIONS

In addition to abnormal oral frena observed in syndromic conditions, anomalous frena are encountered without other associated phenotypic features of genetic or chromosomal states. For example ankylosis of superior labial frena may show a familiar pattern of occurrence.25

CLASSIFICATION

1. Depending upon its morphology:

Long and thin

Short and broad

2. Depending upon the attachment level by Placek et al (1974):13

Mucosal – when the frenal fibers are attached up to the mucogingival junction.(Fig:3)

Gingival – when the fibers are inserted within the attached gingiva.(Fig:4)

Papillary – when the fibers are extending into the interdental papilla.(Fig:5)

Papilla penetrating – when the frenal fibers cross the alveolar process and extend up to the palatine papilla.(Fig:6)

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Fig:3,Mucosal frenal attachment

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Fig:4,Gingival frenal attachment

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Fig:6,Papilla penetrating frenal attachment

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Fig:5,Papillary frenal attachment

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3.Sewerin has also classified the variations of frenum as:14

- Normal frenum(Fig:7)
- Normal frenum with a nodule(Fig:8)
- Normal frenum with appendix(Fig:9)
- Normal frenum with nichum (Fig:10)
- Bifid labial frenum (Fig:11)
- Persistent tectolabial frenum (Fig:12)
- Double frenum (Fig:13)
- Wider frenum (Fig:14)

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Fig:7 Normal frenum

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Fig:8 Simple frenum with a nodule

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Fig:9 Simple frenum with a appendix

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Fig:10 Simple frenum with nichum

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Fig:12 Persistent tectolabial frenum

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Fig:11 Bifid labial frenum

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Fig: 14 Wide frenum

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Fig:13 Double frenum

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Clinically, papillary and papilla penetrating frena are considered as pathological and have been found to be associated with loss of papilla, recession, diastema, difficulty in brushing, malalignment of teeth and it may also prejudice the denture fit or retention leading to psychological disturbances to the individual.15,16

Miller has recommended that the frenum should be characterized as pathogenic when it is unusually wide or there is no apparent zone of attached gingiva along the midline or the interdental papilla shifts when the frenum is extended.17

DIAGNOSIS

Tension test(Blanching test):

The abnormal frena are detected visually by applying tension over the frenum to see the movement of the papillary tip or the blanch which is produced due to ischaemia in the region.(Fig:2).

The frenum is characterized as pathogenic when it is unusually wide or when there is no apparent zone of the attached gingiva along the midline or the interdental papilla shifts when the frenum is extended.

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Fig:2 : Tension test

INDICATIONS

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

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

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.

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

TREATMENT

The aberrant frena can be treated by frenectomy or by frenotomy procedures.

Frenectomy is the complete removal of the frenum, including its attachment to the underlying bone, while Frenotomy is the incision and the relocation of the frenal attachment .24

Various Frenectomy techniques practiced are:

1. Classical frenectomy by Archer and Kruger
2. Millers technique (unilateral single pedicle flap)
3. Schuchardt Z-plasty
4. V-Y Plasty
5. Frenectomy using electrocautery.
6. Laser – Diode,CO2, Nd:YAG, Er:YAG and other soft tissue lasers.

Classical Frenectomy:2,28

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.

TECHNIQUE

Armamentarium - Haemostat, scalpel blade no.15, gauze sponges, 4-0 black silk sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

Procedure (Fig:15A&B) :

The area is anaesthetized with a local infiltration by using 2% lignocaine with 1:80000 adrenaline. The frenum is engaged with a haemostat which is inserted into the depth of the vestibule . Incisions are placed on the upper and the undersurface of the haemostat until the haemostat is free . The triangular resected portion of the frenum with the haemostat is removed. A blunt dissection is done on the bone to relieve the fibrous attachment.

The edges of the diamond shaped wound are sutured by using 4-0 black silk with interrupted sutures Placement of the first suture should be at the maximal depth of the vestibule and should include both edges of mucosa and underlying periosteum at the height of the vestibule beneath the anterior nasal spine.This technique reduces hematoma formation and allows for adaptation of the tissue to the maximal height of the vestibule.

The area is covered with a periodontal pack. The pack and the sutures are removed 1 week post-operatively.

DRAWBACK

The classical technique leaves a longitudinal surgical incision and scarring, which may lead to periodontal problems and an unaesthetic appearance

Also patient experiences post-surgical bleeding and pain mainly because of the open area at the base of the frenectomy site

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(Fig:15A)

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(fig:15B)

2.Miller’s Technique 2,29

The Miller’s technique was advocated by Miller PD in 1985.

This technique was proposed for the post-orthodontic diastema cases.

The ideal time for performing this surgery is after the orthodontic movement is complete and about 6 weeks before the appliances are removed. This not only allows healing and tissue maturation, but it also permits the surgeon to use orthodontic appliances as a means of retaining a periodontal dressing.

TECHNIQUE 37

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

Procedure (Fig:16):

The area is anaesthetized with a local infiltration by using 2% lignocaine with 1:80000 adrenaline. A horizontal incision is made to separate the frenulum from the interdental papilla.This incision is extended apically up to the vestibular depth to completely separate the frenum from the alveolar mucosa.(Any remnant of frenum tissue in the mid line and on the under surface of lip is excised ).

A vertical parallel incision was taken on the mesial side of lateral incisor, 2-3 mm apical to margina gingiva, up to vestibular depth. The gingiva and alveolar mucosa in between these two incisions were undermined by partial dissection to raise the flap.

A horizontal incision was then given 1-2 mm apical to gingival sulcus in the attached gingiva, connecting the coronal ends of the two vertical incisions.

Flap is raised, mobilised mesially and sutured to obtain primary closure across the midline. The surgical area is dressed with periodontal pack. Dressing and the sutures are removed 1 week later.

Advantages

1. Healing takes place by primary intention.
2. A zone of attached gingiva, matching with adjacent tissue, forms in midline which is pleasing to the individual.
3. No unesthetic scar formation.
4. No recession of interdental papilla occurs because the transseptal fibers are not severed out.
5. On healing, a greater width of attached gingiva with its collagenous content is obtained in the midline may have a bracing effect which helps in prevention of orthodontic relapse(reopening of th diastema) .

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Fig:16 Preoperative view

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Fig:16 Resected frenum site.

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Fig:16 Displacement and suturing of the pedicle.

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Fig:16 Vertical incision mesial to lateral incisor and undermining of the pedicle.

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Fig:16 Postoperative healing after 1 month.

Z Plasty 30,31

The technique Z plasty was given by Schuchardt.

Indicated where there is hypertrophy of the frenum with a low insertion , which is associated with an midline diastema and also in cases of short vestibule .

TECHNIQUE

Armamentarium - Scalpel blade no.15, gauze sponges, tissue forceps, 5-0 vicryl sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

Procedure:

The area is anaesthetized with a local infiltration by using 2 % lignocaine with 1:80000 adrenaline.The length of the frenum is incised with the scalpel and at each end, limbs at between 60º and 90º angulation, incisions are made in equal length to that of the band. By using fine tissue forceps, with care not to damage the apices of the flaps, the submucosal tissues were dissected beyond the base of each flap, into the loose non-attached tissue planes. Thus, double rotation flaps which are at least 1 cm long were obtained.

The resultant flaps which are created were mobilized and transposed through 90º to close the vertical incisions horizontally. Absorbable 5-0 vicryl sutures are placed, first through the apices of the flaps, to ascertain the adequacy of the flap repositioning and then they are evenly spaced along the edges of the flaps, to close the wound along the cut edges of the attached mucoperiosteum and the labial mucosa .

A periodontal dressing is placed.

Advantages :

It facilitates re-distribution of tension on the skin and the wound and helps in healing along the skin lines

It minimizes scar formation and has got a camouflaging effect.

Disadvantages :

It is technique sensitive

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Fig:17a Schematic Diagram of Z-plasty technique

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Fig:17b Incision given through the frenum

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Fig: 17b Pre-operative attached type of frenal attachment

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Fig:17b 1 month post-operative

V-Y Plasty 34

The technique V-Y plasty is given by Dieffenbach .

It is used for lengthening the localized area , like the broad frena in the premolar-molar area.

It is employed for papilla type of frenal attachment.

TECHNIQUE

Armamentarium: Haemostat, scalpel blade no.15, gauze sponges, 4-0 black silk sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

Procedure:

The area is anaesthetized with a local infiltration by using 2 % lignocaine with 1:80000 adrenalin.The frenum held with a hemostat. Incision is made in the form of V on the undersurface of the frenal attachment. The frenum relocated at an apical position and the V shaped incision is converted into a Y , while it is sutured. A periodontal pack is placed.

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Fig:18a Schematic Diagram of V-Y plasty technique

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Fig:18b Preoperative

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Fig:18b Engagement with haemostat

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Fig:18b V shaped incision given

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Fig:18b Incision extended

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Fig:18b 1 month postoperative view

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Fig:18b Sutures placed

Electro Surgery 35,36

Electrosurgery (diathermy) is the delivery of radio frequency (RF) energy to tissue for a desired clinical effect, such as cutting and coagulation [Pearce 1986].

Indications :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.

TECHNIQUE

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

Procedure:

The area is anaesthetized with a local infiltration by using 2 % lignocaine with 1:80000 adrenaline. The frenum is held with the haemostat and by using a loop electrode tip, it is excised. Electrocautery offered the advantage of minimal procedural bleeding and there was no need of sutures.

Advantages:

Minimal procedural bleeding

No need of sutures

Minimal time consumption.

Drawback :

Healing by secondary intention, as the wound edges were not aprroximated by sutures.

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LASER

INTRODUCTION

LASER (LIGHT AMPLIFICATION BY STIMULATED EMISSION OF RADIATION) is based on Albert Einstein’s theory of spontaneous and stimulated emission of radiation. It was Maiman in 1960 who gave the first laser prototype using ruby crystal.Shortly there after, in 1961, Snitzer published the prototype for the Nd:YAG laser.

The first application of a laser to dental tissue was reported by Goldman et al. and Stern and Sognnaes, each article describing the effects of the ruby laser on enamel and dentin. Lasers designed for surgery deliver concentrated and controllable energy to the tissue.

For the laser to have effect the energy must be absorbed. The degree of absorption in the tissue varies as a function of wavelength and characteristics of target tissue.

As the temperature increases at surgical site, the soft tissues are subjected:

Warming (37 °C to 60 °C)

Welding (60 °C to 65 °C)

Coagulation (65 °C to 90 °C)

Protein denaturisation (90 °C to 100 °C)

Drying (100 °C)

Carbonization (above 100 °C)

Frenectomy procedure using diode lasers

Diode laser (A.R.C. Fox™) with wavelength of 810 nm is selected for the procedure. No local anaesthesia is given to the patient. The frenum is stretched to visualize its extent.The diode laser is applied in a contact mode with focused beam for excision of the tissue. The ablated tissue is continuously mopped using wet gauze piece. This takes care of the charred tissue and prevents excessive thermal damage to underlying soft tissue. The tissue is lased until all the underlying muscle fibers were dissected. No sutures were placed at the end of this procedure.Patients were asked to take analgesics only if needed.

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Advantages of Laser over Conventional technique:

No need of local anaesthesia. Hence it’s a painless

procedure. As a result there is less patient apprehension.

Bloodless operative field, thus better visibility.

No need of periodontal dressing, therefore no patient

discomfort as a result of irritation from the dressing.

Better healing and less scarring.

Less time consuming.

Disadvantages

Burns

delayed healing as compared to that in the conventional scalpel techniques

reduced surgical precision which results in an inadvertent laser-induced thermal necrosis and/or a photo acoustic injury,

the risk of an explosion if combustible gases are used,

interference with pacemakers and the production of surgical smoke.

These complications have not been reported with the new improvement in the electro surgical techniques, like the Argon Beam Coagulation (ABC).

LINGUAL FRENECTOMY

Lingual frenum is attached to the crest of the alveolar ridge and it connects to the tongue ,below the tip of the tongue in the edentulous patient .In dentulous patient,it is attached to the lingual gingival,behind the mandibular incisor. This condition is also known as tongue tie or ankyloglossia.

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In dentulous

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In edentulous

AIM OF THE SURGERY

To correct speech

Prior to denture construction

To improve the tongue mobility

TECHNIQUE

Armamentarium - Haemostat, scalpel blade no.15, gauze sponges, 4-0 black silk sutures, suture pliers, scissors, and a periodontal dressing (Coe-pak).

Procedure:

The area is anaesthetized with a local infiltration by using 2 % lignocaine with 1:80000 adrenaline.The tongue is retracted and held with a traction suture, this makes the frenum taut and easily visible for surgical release. Surgical release of the lingual frenum requires incising the attachment of the fibrous connective tisuue at the base of the tongue in a transverse manner and closure of wound in a linear fashion.

Placement of a hemostat across the frenal attachment at the base of the tongue for approximately 3 minutes provides vasoconstriction .The tongue is retracted superiorly, and the margins of the wound are carefully undermined and closed parallel to the mid-line of the tongue.

Careful attention must be given to blood vessels at the inferior aspect of the tongue and floor of the mouth and to the submandibular duct openings .Soft tissue closure is done with interrupted sutures.

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INTRAOPERATIVE POSSIBLE COMPLICATION:

Injuiry to superior lingual vessels

Injuiry to the whartons duct/papilla

POSTOPERATIVE COMPLICATION

Hematoma in the floor of the mouth.

Pain, restricted tongue movement.

Partial dysphagia.

FRENECTOMY PROCEDURES IN ORTHODONTIC PATIENTS BEFORE OR AFTER ?

Currently, surgical correction is not generally considered until after the eruption of the permanent maxillary anterior teeth. Difficulty in moving teeth through scar tissue,10 and the self-correcting nature of the problem3 are cited as the most common reasons for delaying surgical treatment.Recent research has centered on surgical treatment to prevent relapse following orthodontic closure of the diastema.

Edwards13 in a definitive study evaluated 308 patients who, prior to orthodontic treatment, demonstrated either a diastema, or an "abnormal frenulum," or a combination of both. Seventy per cent had a combination of an abnormal frenulum and a diastema. He found a strong correlation between a pretreatment, clinically determined, abnormal frenulum and the relapse tendency (63.4%). However, in cases treated with a "conservative surgical procedure," relapse was reduced to 6.4%. Edwards also pointed out that it was not always possible to determine that a frenulum was abnormal prior to orthodontic treatment. He advocated delaying surgery until after the diastema was closed, and his method consisted of three separate procedures:

(1) apically repositioning of the frenulum (with denu-dation of alveolar bone).
(2) destruction of the transeptal fibers between the approximated central incisors.
(3) gingivoplasty of any excess labial and/or palatal tissue in the interdental area.

One of the salient aspects of Edwards's technique was the esthetic maintenance of the interdental papilla between the central incisors. In 45 of 47 patients, no loss of interdental papilla was noted. Thus both stabilization of the orthodontic result and esthetic maintenance were achieved.

Often there is reluctance by the orthodontist to subject a patient to a surgical procedure that produces an unesthetic result although the surgery may prevent some degree of orthodontic relapse. Whether the interdental papilla between the approximated central incisors is collagen-rich and elastic fiber poor or vice versa, apparently is of no clinical significance. Furthermore,the presence or absence of muscle fibers is not significant. The significant factors appear to be the ultimate size of the interdental papilla, and the fact there is contiguous collagenous band of tissue across the midline.

Whether it is necessary to destroy transseptal fibers remains a question. Although these fibers reform following pressure ischemia in orthodontic therapy, Edwards13 feels the pressure used in approximating central incisors is not adequate to produce transseptal fiber destruction, and these fibers remained convoluted and compressed in a coiled-up manner. Edwards, thus felt the transseptal fibers should be destroyed.

The nature of the orthodontic closure is equally important. If the central incisors have simply been tipped mesially to close the diastema without properly aligning the roots, removal of the frenulum or increasing attached gingiva across the midline will have no effect on prevention of relapse.

Timing of the procedure could be helpful in reducing the time of orthodontic retention. The ideal time for performing this surgery is after orthodontic movement is complete and about 6 weeks before appliances are Removed. This not only allows for healing and tissue maturation, but also permits the surgeon to use orthodontic appliances as a means of retaining a periodontal dressing (Coe-Pak® fortified with Ward's Wonder- Pak®) Newer techniques

Since the procedure of frenectomy was first proposed, a number of modifications2–4 have been developed to solve the problem caused by an abnormal labial frenum.

MODIFIED DOUBLE PEDICLE FLAP

This was given by Bagga et al.

Technique:

Maxillary anterior region was anesthetized with 1:200,000 lidocaine hydrochloride with adrenaline (Xylocaine 2% Adrenaline, Astra Zeneca) by local infiltration on the buccal and palatal aspects.

A V-shaped full-thickness incision was placed at the gingival base of the frenal attachment with an external bevel (Figs 2a and 2b). Tissue along with periosteum was separated from underlying bone. The initial incision resulted in a V-shaped defect on the gingival side (Figs 3a and 3b). Fibrous tissue attached to the lip was dissected with scissors, and undermining of the labial mucosa was done.

An oblique partial-thickness incision was placed on the adjacent attached gingiva (Figs 4a and 4b), beginning 1 mm apical to the free gingival groove and extending beyond the mucogingival junction. Partial-thickness dissection from the medial margin was carried out in an apicocoronal direction (Fig 5) to create a triangular pedicle of attached gingiva with its free end as the apex and its base continuous with the alveolar mucosa (Figs 6a and 6b). Alveolar mucosa at the base was undermined to facilitate repositioning of the pedicle without tension.

A similar procedure was repeated on the contralateral side of the V-shaped defect, resulting in 2 triangular pedicles of attached gingiva. These 2 pedicles were sutured with each other at the medial side and laterally with the adjacent intact periosteum of the donor site (Figs 7a and 7b) by 4-0 silk suture( Mersilk, Ethicon, Johnson & Johnson), completely covering the underlying defect created by the initial frenal excision.

Periodontal dressing (Coe-Pak, GC America) was used to cover the surgical site. Analgesics and 0.2% chlorhexidine mouthwash (Hexidine, ICPA Health Products) were prescribed for 5 days during the postoperative period. Postoperative instructions were given.

Sutures were removed on the 10th day, and the patient was scheduled for follow-up recall visits at 2 weeks and 1, 2, and 3 months. The 3-month follow-up revealed a zone of attached gingiva with esthetic color match in the area previously covered by the abnormal frenum (Fig 8). Normal healing was seen without any visible scarring or complication.

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Fig 5 Partial-thickness dissection of attached gingiva in an apicocoronal direction.

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Figs 6a and 6b Triangular pedicle of attached gingiva with the free end as apex and the base continuous with the alveolar mucosa.

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Figs 7a and 7b Bilateral triangular pedicle sutured at the center, covering the underlying defect.

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Fig 8 New zone of attached gingiva at the previous frenal site, with excellent color match, 3 months postoperatively.

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ADVANTAGES

The technique presented here provides many advantages, such as gain in attached gingiva in the region previously covered by the frenum, excellent color match, healing by primary intention, minimal scar formation, and prevention of coronal reformation. This technique may be suitable in situations where anterior esthetics is of primary importance. Presence of an adequate zone of attached gingiva is an important parameter during consideration of this technique. The technique is reliable and easy to perform and provides excellent esthetic results.

REFERENCES

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