FRENECTOMY

INTRODUCTION

A frenum is a fold of mucous membrane, usually with enclosed muscle fibers, that attaches the lips and cheeks to the alveolar mucosa and/or gingiva and underlying periosteum. Frenum problem most often occurs on the labial surface between the maxillary and mandibular central incisors and in canine and premolar areas. They occur less often on the lingual surface of the mandible.

The frena may also affect 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.

AETIOLOGY

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 gingiva.

CLASSIFICATION

Placek et al (1974) classified frenal attachment depending upon the extension of attachment of fibres, as:

• Mucosal: When the frenal fibers are attached up to mucogingival junction.

• Gingival: When fibers are inserted within attached gingiva.

• Papillary: When fibers are extending into interdental papilla.

• Papilla penetrating: When the frenal fibers cross the alveolar process and extends up to the palatine papilla.

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.

• 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 of the underlying bone.

Frenotomy is the incision and the relocation of the frenal attachment.

 TECHNIQUES FOR FRENECTOMY

 • Conventional (Classical) frenectomy

• Miller’s technique

• V-Y Plasty

• Z Plasty

• Frenectomy which was done by using electrocautery

CONVENTIONAL FRENECTOMY :

Ø Was introduced by Archer (1961) and Kruger (1964).

Ø 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 .

Ø This technique is an excision type frenectomy which includes the interdental tissues and the palatine papilla along with the frenulum.

Ø Anaesthetize  the area with a local infiltration by using 2% lignocaine with 1:80000 adrenaline.

Ø Engage the frenum  with a haemostat which was inserted into the depth of the vestibule and place the incisions on the upper and the undersurface of the haemostat until the haemostat was free.

Ø Remove the triangular resected portion of the frenum with the haemostat.

Ø Suture the edges of the diamond shaped wound by using 4-0 black silk with interrupted sutures.

MILLER’S TECHNIQUE :

Ø Was advocated by Miller PD in 1985.

Ø Technique was proposed for the post-orthodontic diastema cases.

Ø The ideal time for performing this surgery is after the orthodontic movement is complete and about 6 weeks before the appliances are removed.

Ø Anaesthetize the area with a local infiltration by using 2% lignocaine with 1:80000 adrenaline.

Ø Excision of the frenulum and exposure of the labial alveolar bone in the midline is done.

Ø A horizontal incision is made to separate the frenulum from the interdental papilla.

Ø A laterally positioned pedicle graft (split thickness) is obtained and  sutured across the midline.

Z PLASTY:

Ø This technique is indicated when there is hypertrophy of the frenum with a low insertion, also in cases of a short vestibule.

Ø Anaesthetize with a local infiltration by using 2 % lignocaine with 1:80000 adrenaline.

Ø The length of the frenum is incised with the scalpel and at each end, limbs at between 60º and 90º angulation, incisions were made in equal length to that of the band.

Ø Using fine tissue forceps, the submucosal tissues is dissected beyond the base of each flap, into the loose non-attached tissue planes.

Ø Resultant flaps is mobilized and transposed through 90º to close the vertical incisions horizontally.

Ø Sutures are placed.

V-Y PLASTY:

Ø V-Y plasty can be used for lengthening the localized area, like the broad frena in the premolar-molar area.

Ø Area is anaesthetized with a local infiltration by using 2 % lignocaine with 1:80000 adrenaline.

Ø Frenum is held with the haemostat.

Ø Incision is made in the form of V on the undersurface of the frenal attachment

Ø Frenum is relocated at an apical position and the V shaped incision is converted into a Y, and sutured with 4-0 silk sutures.

ELECTRO SURGERY:

Ø 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.

Ø Area is anaesthetized with local infiltration by using 2% lignocaine with 1:80000 adrenaline.

Ø Frenum is held with the haemostat and by using a loop electrode tip, it is excised.

Ø Electrocautery offers the advantage of minimal procedural bleeding and there is no need of sutures.

                                                                             DR. ANJUSHA SHARDA