management of aberrant frenum with case presentation"

1. By Sneha V.V.
Guided by : Dr.Sivaram MDS.,

2.  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

3.  What is a frenum?
Frenum is a thin fold of mucous
membrane with enclosed muscle fibers that attach the lips
to the alveolar mucosa and underlying periosteum.
A frenulum is a small frenum. 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.
Their primary function is to provide stability of the upper and
lower lip and the tongue.

4.  The maxillary labial frenum develops as a post
eruptive remnant of the ectolabial bands which
connects the tubercle of the upper lip into the
palatine papilla.
 It extends over the alveolar process in infants
and forms a raphe that reaches the palatal
papilla.
 Through the growth of alveolar process as the
teeth erupt, this attachment generally changes
to assume the adult configuration.

5. Picture Showing Maxillary Labial Frenum In An Infant

6. Depending upon the extent of attachment of fibres, frena have
been classified by (Placek et al. 1974) as:
 MUCOSAL- where the frenal fibres are attached up
to the mucogingival junction.
 GINGIVAL- where the fibres are inserted within
the attached gingiva.
 PAPILLARY- where the fibres extend into the
interdental papilla.
 PAPILLA PENETRATING- where the frenal fibres
cross the alveolar process and extend up to palatine
papilla.

7. 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

8.  Clinically, papillary and papilla penetrating
types are considered as pathological.
 Frenal problems occur most often on the
facial surface between the maxillary and
mandibular central incisors and in the canine
and premolar areas.
 They occur less often on the lingual surface
of the mandible.

9. Mucosal frenal attachment

10. Gingival frenal attachment

11. Papillary frenal attachment

12. Papilla penetrating frenal attachment

18.  Abnormal or aberrant frena are detected visually, by
applying tension over it to see the movement of
papillary tip or blanch produced due to ischemia of
the region.
 Miller(1985) has recommended that the frenum
should be characterised 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.

19.  Ankyloglossia or tongue-tie is an uncommon
congenital anomaly that occurs as a result of a
short, tight, lingual frenulum causing difficulty
in speech articulation due to limitation of
tongue movement.
WALLACE defined tongue-tie as
“a condition in which the tip of the tongue cannot be
protruded beyond the lower incisor teeth because of a
short frenulum linguae, often containing scar tissue.”

20. Ankyloglossia leads to :
 limited mobility of tongue.
 Swallowing dysfunction.
 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
insertion of 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.

21.  Ankyloglossia can be classified into 4 classes based
on Kotlow’s assessment (based on length of tongue from
insertion of lingual frenum at base of the tongue to the tip
of the tongue) as follows:
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)

23.  Ehlers-Danlos syndrome
 Infantile hypertrophic pyloric stenosis
 Holoprosencephaly
 Ellis-van Creveld syndrome
 Oro-facial-digital syndrome
Each syndrome exhibits relatively specific
frenal abnormalities, ranging from multiple,
hyper plastic, hypoplastic, or an absence of
frena.

24.  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
frenum has been described in this disorder.

26.  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 is seen in patients with this syndrome.

27.  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.

28. Picture showing patients affected with
holoprosencephaly in increasing order of severity

29.  It is an autosomal recessive disorder mainly affecting enamel,
hair and nails.
 Patients with this syndrome characteristically present with
congenitally missing teeth, abnormal frenal attachment,
microdontia and hexadactyly.
 Oral manifestations are characteristic and constant.
 The most common 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 slight V-shaped notch in the middle (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 processes presents with
notching or submucous clefts and continuous or broad labial
frenula with dystrophic philtrum.

30. Oral manifestations seen in Ellis-van Creveld
syndrome

31.  Oral manifestations include micrognathia,
macroglossia and abnormal supernumerary
frena extending from the buccal mucosa to the
alveolar ridge.
 OPITZ C SYNDROME exhibits similar frenal
abnormalities.

32.  Anomalous frena are also encountered without
other associated phenotypic features of
genetic or chromosomal states.
 For instance, ankylosis of superior labial frena
may show a familial pattern of occurrence.
 Aberrant frenal attachments may be seen
after orthognathic surgeries, due to errors in
surgical technique.

33. A frenum becomes a problem if the attachment is too close
to the marginal gingiva. Tension on the frenum may pull the
gingival margin away from the tooth. This condition may be
conducive to plaque accumulation and inhibit proper tooth
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.

34.  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 diastema
between maxillary central incisors (Friedman 1957).
Frenotomy: is the incision of the frenum.
It is usually done to relocate the frenal attachment
so as to create a zone of attached gingiva between
the gingival margin and the frenum.

35. INDICATIONS
1. Gingival or papillary frenal attachment: Where
frenal fibres radiate into marginal gingiva producing
gingival retraction and localized gingival recession.
2. High frenal attachment: Where oral hygiene is
hindered by shallow vestibule caused by high frenal
attachment.
3. Ankyloglossia: When lingual frenum interferes with
speech.

36.  Conventional (classical) frenectomy
 Miller’s technique
 V-Y plasty
 Z plasty
 Frenectomy by using electrocautery
 Laser frenectomy

37.  The classical technique was introduced by
Archer(1961) and Kruger(1964).
 This approach was advocated in midline diastema
cases with an aberrant frenum to ensure the
removal of muscle fibres which were supposedly
connecting the orbicularis oris with the palatine
papilla.
 This is an excision type of frenectomy which
includes the interdental tissues and palatine papilla
along with the frenulum.

38.  Mosquito forceps/hemostat
 Surgical handle Bard Parker no.3
 Surgical blades no. 15/11 (detachable and
replaceable).
 Gauze sponges
 4-0 black silk sutures
 Suture pliers
 Scissors
 Periodontal dressing (Coe-pak)

40.  ANESTHESIA:
 Local infiltration is given to anesthetize the selected site.
 The lip is extended and the frenum is gripped with mosquito
forceps/hemostat to the depth of the vestibule.
 INCISIONS:
 Incisions are made above and below the instrument, the triangular
frenum tissue is removed.
 Underlying fibrous attachment to the bone is exposed .
 Horizontal incision is given onto these fibers separating and dissecting
from the bone.
 SUTURING:
 The edges of the wound are undermined slightly and approximated
without creating tension.
 Only the mucosal extent of incision is sutured.
 The gingival extent is allowed to heal by secondary intention.
 The area is covered with dry aluminium foil and a periodontal pack is
placed.

41. Picture showing aberrant frenum

42. Incision made above the hemostat

43. Incision made below the hemostat

44. Underlying fibrous attachment to bone exposed

45. Sutures placed

46. One month post-operative view

47.  Causes un-aesthetic , labial tissue scarring.
 This may become a matter of concern in case
of high smile line exposing the anterior
gingiva.

48.  This technique was advocated by Miller PD in
1985.
 This was proposed for 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 allows healing and tissue maturation and also
permits the surgeon to use orthodontic appliances
as a means of retaining the periodontal dressing.

49.  Hemostat
 Scalpel blade no.15
 Gauze sponges
 5-0 black silk sutures
 Suture pliers
 Scissors
 Periodontal dressing( Coe- pak)

50.  The area is anesthetized with a local infiltration.
 The frenulum is excised and the labial alveolar bone in the
midline is exposed.
 A horizontal incision is made to separate the frenulum from
the interdental papilla. Care must be taken to extend
incisions into the lip as far as necessary, to assure that a
remnant of the frenulum is not left on the lip.
 A laterally positioned pedicle (split thickness graft) is placed
and sutured across the midline.
 Periodontal dressing is placed.

51. Pre-operative attached type of frenal
attachment

52. Frenum excised

53. Lateral pedicle graft obtained

54. Graft sutured across the midline

55. 2 weeks post-operative

56.  Post-operatively, on healing, there is a continuous
band of gingiva across the midline, that gives a
bracing effect than the “scar” tissue, thus
preventing orthodontic relapse.
 The transseptal fibres are not disrupted
surgically and so, there is no loss of interdental
papilla.
 Obtaining orthodontic stability without an
aesthetic sacrifice.

57.  This technique is indicated when:
a) there is hypertrophy of the frenum with a low
insertion, associated with an inter-incisor
distema.
b) lateral incisors have appeared without causing
the diastema to disappear
c) there is a short vestibule.

58.  Scalpel blade no.15
 Gauze sponges
 Tissue forceps
 5-0 vicryl sutures
 Suture pliers
 Scissors
 Periodontal dressing (coe-pak)

59.  The area is anesthetized with local infiltration.
 The frenum is held with a hemostat.
 The releasing incision is placed one on the superior border
of frenum and other on the inferior border in opposite
directions.
 The Z flaps are raised and then interchanged, so that the
length of the frenum is increased.
 Thus, double rotation flaps that are 1cm long are obtained.
 Sutures are placed first through the apices of the flaps
to ascertain the adequacy of the flap repositioning.
 The wound is then closed along the cut edges and a
periodontal dressing is placed.

60. Pre-operative attached type of frenal
attachment

61. Incision given through the frenum

62. Outline for z- plasty

63. Incision given at both ends of the frenum to
obtain 2 triangular flaps

64. Flaps transposed across the midline sutured in
the form of Z

65. one month post-operative view

67.  Ideal for broad , thick , hypertrophic frenum
associated with inter-incisor distema and short
vestibule.
 This technique achieved both removal of
fibrous band and vertical lengthening of
vestibule.

68. This technique can be used for lengthening the
localized area, like a broad frena in the
premolar- molar area.
ARMAMENTARIUM:
 Hemostat
 Scalpel blade no.15
 Gauze sponges
 4-0 black silk sutures
 Suture pliers
 Scissors
 Periodontal dressing (Coe-pak)

69.  This technique was employed in a case of a papilla type of
frenal attachment.
 The area was anesthetized with a local infiltration.
 The frenum was held with a hemostat.
 Incision was made in the form of “V” at the undersurface
of the frenal attachment.
 The frenum was relocated at an apical position and the V
shape was converted into a Y.
 The wound was closed with sutures and a periodontal pack
was placed.

70. Pre-operative papilla type of frenal attachment

71. Frenum held with hemostat

72. Frenum incised by V-shaped incision

73. V-shaped incision sutured in the form of Y

74. 1 month post operative view

75.  This technique is recommended for patients
with bleeding disorders and non-compliant
patients.
ARMAMENTARIUM:
 An electrocautery unit with the loop electrode.
 Hemostat.

76.  A case of an attached type of frenal
attachment was approached with
electrocautery.
 The area was anesthetized with local
infiltration.
 The frenum was held with a hemostat.
 By using the loop electrode tip, it was excised.

77. Pre-operative attached type of frenal
attachment

78. Frenum held with hemostat and excised with a
loop electrode

79. Excision of frenum completed with no
requirement for suture placement

80. 1 month post operative view

81. 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.

82. The benefits of a laser frenectomy are greater as
compared to traditional 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 anesthetics and sutures, as well
as improved postoperative comfort and healing, make
this technique particularly useful for very young
patients.

83. STEP PROCEDURE
1 Properly strip, cleave and initiate well the disposable fiber tip.
2 Place topical (small) or a few drops of anesthetic (large) on
either side of the frenum attachment.
3 Use 0.8 - 1.4 watts Continous wave ( Less energy without
anesthetic).
4 Start ablation at the attachment and pull the lip outwards
“releasing “ attachment resulting in a “diamond” shaped wound.
5 Continue until all vertical fibers are removed and you are at the
periosteum.
6 If necessary “score” the periosteum horizontally with a scalpel
blade or
periosteal elevator.
7 Hydrogen Peroxide or wet cotton pellet to remove tissue tags.

87. The patient should be instructed –
 NOT to eat anything until the anesthesia wears off, as there are chances
of biting the lips, cheek or tongue.
 Avoid extremely hot foods for the rest of the day and do NOT rinse out
your mouth, as these will often prolong the bleeding. If bleeding
continues, apply light pressure to the area with a moistened gauze for
20-30 minutes.
 Follow a soft food diet, taking care to avoid the surgical area when
chewing. Chew on the opposite side and do NOT bite into food. Be sure to
maintain adequate nutrition and drink plenty of fluids. Do NOT use a
drinking straw, as the suction may dislodge the blood clot.
 Avoid alcohol and smoking until after your post-operative
appointment. Smoking is not advised during the 7-14 days following
surgery.
 Maintain normal oral hygiene measures in the areas of mouth not affected
by the surgery. In areas where there is dressing, lightly brush only the
biting surfaces of the teeth. Vigorous rinsing should be avoided!
 Do NOT pull down the lip or cheek.

88. Frenum may not regularly draw close scrutiny on
routine dental examination.
While an aberrant frenum can be removed by any
of the modification techniques that have been
proposed, a functional and an aesthetic outcome
can be achieved by a proper technique selection,
based on the type of frenal attachment.

89.  Frenectomy – a review with reports of surgical
techniques (Journal of clinical and diagnostic
research)
 An overview of frenal attachments( Indian society of
Periodontology)
 Ankyloglossia (tongue-tie):A diagnostic and
treatment quandary Lawrence A. Kotlow, DDS