By Sneha V.V.

Guided by : Dr.Sivaram MDS.,

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

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.

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.

Picture Showing Maxillary Labial Frenum In An Infant

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.

Other variations of normal frenal attachmentInclude:• Simple frenum with a nodule • Simple frenum with appendix • Simple frenum with nichum • Bifid labial frenum• Persistent tectolabial frenum• Double frenum• Wider frenum

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.

Mucosal frenal attachment

Gingival frenal attachment

Papillary frenal attachment

Papilla penetrating frenal attachment

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.

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.”

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.

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)

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.

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.

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.

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.

Picture showing patients affected with holoprosencephaly in increasing order of severity

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.

Oral manifestations seen in Ellis-van Creveld syndrome

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.

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.

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.

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.

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.

Conventional (classical) frenectomy

Miller’s technique

V-Y plasty

Z plasty

Frenectomy by using electrocautery

Laser frenectomy

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.

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)

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.

Picture showing aberrant frenum

Incision made above the hemostat

Incision made below the hemostat

Underlying fibrous attachment to bone exposed

Sutures placed

One month post-operative view

Causes un-aesthetic , labial tissue scarring.

This may become a matter of concern in case of high smile line exposing the anterior gingiva.

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.

Hemostat

Scalpel blade no.15

Gauze sponges

5-0 black silk sutures

Suture pliers

Scissors

Periodontal dressing( Coe- pak)

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.

Pre-operative attached type of frenal attachment

Frenum excised

Lateral pedicle graft obtained

Graft sutured across the midline

2 weeks post-operative

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.

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.

Scalpel blade no.15

Gauze sponges

Tissue forceps

5-0 vicryl sutures

Suture pliers

Scissors

Periodontal dressing (coe-pak)

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.

Pre-operative attached type of frenal attachment

Incision given through the frenum

Outline for z- plasty

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

Flaps transposed across the midline sutured in the form of Z

one month post-operative view

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.

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)

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.

Pre-operative papilla type of frenal attachment

Frenum held with hemostat

Frenum incised by V-shaped incision

V-shaped incision sutured in the form of Y

1 month post operative view

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

ARMAMENTARIUM:

An electrocautery unit with the loop electrode. Hemostat.

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.

Pre-operative attached type of frenal attachment

Frenum held with hemostat and excised with a loop electrode

Excision of frenum completed with no requirement for suture placement

1 month post operative view

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.

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.

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 theperiosteum.

6 If necessary “score” the periosteum horizontally with a scalpel blade orperiosteal elevator.

7 Hydrogen Peroxide or wet cotton pellet to remove tissue tags.

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.

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.

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