|Year : 2015 | Volume
| Issue : 1 | Page : 27-30
Bilateral pedicle approach for esthetic management of upper labial frenum
Ankit Jivan Desai1, Subani Bedi2, Triveni M Gowda2, Raison Thomas2, DS Mehta2
1 Department of Periodontics and Oral Implantology, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India
2 Department of Periodontics and Oral Implantology, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Web Publication||12-Aug-2015|
Ankit Jivan Desai
Department of Periodontics and Oral Implantology, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
An abnormal upper labial frenum is one of the most common mucogingival problems that can lead to formation of diastema, limit the lip movement, and may affect the esthetics in case of a high smile line. Frenectomy is a common restorative surgical procedure in the field of dentistry and is the treatment of choice to correct the atypical frenum. Over the last century, this technique has been modified in many ways. This case report highlights a technique of frenectomy that resulted in good esthetics, color match, and patient comfort for treatment of an abnormal frenum.
Clinical Relevance to Interdisciplinary Dentistry
Present technique was carried out as a preventive measure to avoid post-orthodontic relapse due to existing tension by the labial frenum. Specifically before orthodontic intervention, presented technique also displayed its significance because of the achieved gain in attached gingiva; healing by primary intention and acceptable color match in the esthetic zone.
Keywords: Bilateral pedicle, esthetics, frenectomy, frenum
|How to cite this article:|
Desai AJ, Bedi S, Gowda TM, Thomas R, Mehta D S. Bilateral pedicle approach for esthetic management of upper labial frenum. J Interdiscip Dentistry 2015;5:27-30
|How to cite this URL:|
Desai AJ, Bedi S, Gowda TM, Thomas R, Mehta D S. Bilateral pedicle approach for esthetic management of upper labial frenum. J Interdiscip Dentistry [serial online] 2015 [cited 2019 Jun 17];5:27-30. Available from: http://www.jidonline.com/text.asp?2015/5/1/27/162741
| Introduction|| |
Afrenum is an anatomic structure which is formed by the folding of mucous membrane and connective tissue; at times muscle fibers may be present. Frenum may be present at variable locations in the anterior maxilla. An abnormally placed frenum may influence the growth and development of the anterior maxillary region which can lead to development of midline diastema and may interfere with lip function and compromise esthetics. It may jeopardize the gingival health, either due to interference in the plaque control or due to a muscle pull. Furthermore, sometimes it is responsible for the relapse after orthodontic therapy.  A frenum can be considered as "abnormal" if it is unusually broad without apparent attached gingiva in the midline and the interdental papilla can be moved by stretching the frenum. 
Broadbent  outlined the developmental stages of tooth eruption, and suggested to avoid the surgical removal of frenula to allow normal tooth eruption; as in majority of cases, the problem will be self-correcting. Taylor  while examining 6-year-old children, found 98% of them with a midline diastema. By the age of 12, only 7% still had persistent diastema, thus confirming the findings of Broadbent. However, in cases of persistent aberrant frenum, surgical excision is considered the preferable treatment.
Since the procedure of frenectomy was first proposed, a number of modifications ,, have been developed to solve the problems caused by an abnormal labial frenum. However, in most of these procedures, the esthetic outcome in terms of gain in attached gingiva with color matching was not favorable. The present article reports a technique of frenectomy  aimed to preserve attached gingiva with a good color match in the maxillary anterior region.
| Case report|| |
A 21-year-old male reported to the Department of Periodontology after being referred from the Department of Orthodontics, Bapuji Dental College and Hospital of Davangere for the management of high frenal attachment. Medical history was noncontributory. Clinical examination revealed a thick, broad, dense labial frenum of gingival type attachment  [Figure 1]. The "tension test" presented positive when force was applied to upper lip in outward, downward, and lateral direction.  A full complement set of teeth was present with adequate buccal vestibular depth. As conventional frenectomy would lead to a wide surgical wound after excision, the treatment plan consisted of two pedicle preparations from either side of the excised frenum to fulfill patient's concern for esthetics. The procedure was explained to the patient and informed consent was obtained. Routine hematologic investigations were within normal limits.
|Figure 1: Thick labial frenum of gingival type attachment with positive tension test|
Click here to view
Local infiltration was given on buccal and palatal aspects of a maxillary anterior region using 1:200,000 lidocaine hydrochloride with adrenaline. A V-shaped full-thickness external bevel incision was given using Bard Parker knife [Osung, Korea] with no. 15 blade at the base of the gingival frenal attachment [Figure 2]a and the tissue along with periosteum was elevated from underlying bone. It resulted in a V-shaped defect in the gingival region [Figure 2]b. Fibrous tissue attached to the lip was dissected with scissors, and undermining of the labial mucosa was done. An oblique partial-thickness incision was given on the attached gingiva on either side of frenum, beginning 3 mm apical to the free gingival margin of maxillary central incisors and extending beyond the mucogingival junction. Partial-thickness dissection from the medial margin was carried out in an apico-coronal direction to create a triangular pedicle of attached gingiva with its free end as the apex and its base continuous with the alveolar mucosa [Figure 3]. Alveolar mucosa at the base was undermined to facilitate repositioning of the pedicle without tension. The resultant 2 pedicles were sutured to each other at the medial aspect [Figure 4] and laterally to the adjacent intact periosteum of the donor site [Figure 5] by 4-0 silk suture. Analgesics (combination of diclofenac sodium 50 mg + paracetamol 500 mg) and 0.2% chlorhexidine gluconate mouthwash were prescribed for next 5 days.
Postoperative instructions were given. Sutures were removed on the 7 th day and healing of the surgical site was satisfactory [Figure 6]a. Patient was scheduled for follow-up recall visits at 2 weeks, 1 and 3 months. At 3 months postsurgical evaluation, sufficient width of attached gingiva, and good color match was observed with negative tension test [Figure 6]b.
| Discussion|| |
Mirko et al.  classified frenum attachment into mucosal, gingival, papillary, and papilla penetrating type depending upon the extension of the fiber attachment. Clinically, papillary and papilla penetrating frenums are considered as pathological and have been found to be associated with loss of papilla, recession, midline diastema, difficulty in brushing, malalignment of teeth, and psychological disturbances to the individual. , Other preventive indications of frenectomy include positive tension test and also after orthodontic corrections.
Some of the frenectomy techniques produce unsatisfactory and unaesthetic results. ,,, Simple frenectomy that is done with a V-shaped incision also known as the Archer incision,  causes scarring due to healing by secondary intention, which may lead to periodontal problems and an unaesthetic appearance. Free gingival graft from the palate  has also been used as a treatment modality for aberrant frenum as it covers the wound area completely, however, it still does not completely address the esthetic concern as it can lead to improper color match by producing a "tattoo-like"  or "tire-patch"  appearance at the recipient site.
The technique described in this case report uses bilateral pedicles as a means to maintain the width of attached gingiva without compromising the color match because of resulting scar formation. Furthermore, covering the V-shaped defect by pedicles not only helps to attain healing by primary intention, it also avoids the formation of an unaesthetic scar. The patient's discomfort is also minimized as compared to conventional frenectomy procedures where the defects are left essentially open. It also preserves and/or enhances the attached gingiva at the site previously occupied by the labial frenum and hence, helps to maintain periodontal health of involved teeth postoperatively.
Usually, it is preferred to do surgical removal of frenum after final orthodontic corrections as the developing scar, due to secondary intention healing, may affect the cosmetic outcome of the orthodontic therapy. However, in the present case, though diastema was absent, the muscle pull of the thick labial frenum could cause relapse of the orthodontic treatment. Thus, as a preventive tactic to avoid scar formation and relapse, bilateral pedicle approach frenectomy was carried out before starting the orthodontic therapy.
Hence, the presented method can be considered as one of the suitable techniques of choice in situations where anterior esthetics is of significance. However, proper case selection with the presence of an adequate zone of attached gingiva is vital for the success of the present frenectomy technique.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kahnberg KE. Frenum surgery. I. A comparison of three surgical methods. Int J Oral Surg 1977;6:328-33.
Miller PD Jr. The frenectomy combined with a laterally positioned pedicle graft. Functional and esthetic considerations. J Periodontol 1985;56:102-6.
Broadbent BH. Odontogenic development of occlusion. Angle Orthod 1941;11:223-41.
Taylor JE. Clinical observation relating to the normal and abnormal frenum labii superioris. Am J Orthod 1939;25:646-50.
Coleton SH. Mucogingival surgical procedures employed in re-establishing the integrity of the gingival unit (III). The frenectomy and the free mucosal graft. Quintessence Int Dent Dig 1977;8:53-61.
Bagga S, Bhat KM, Bhat GS, Thomas BS. Esthetic management of the upper labial frenum: A novel frenectomy technique. Quintessence Int 2006;37:819-23.
Mirko P, Miroslav S, Lubor M. Significance of the labial frenum attachment in periodontal disease in man. Part I. Classification and epidemiology of the labial frenum attachment. J Periodontol 1974;45:891-4.
Priyanka M, Sruthi R, Ramakrishnan T, Emmadi P, Ambalavanan N. An overview of frenal attachments. J Indian Soc Periodontol 2013;17:12-5.
Dewel BF. The labial frenum, midline diastema, and palatine papilla: A clinical analysis. Dent Clin North Am 1966;4:175-84.
Díaz-Pizán ME, Lagravère MO, Villena R. Midline diastema and frenum morphology in the primary dentition. J Dent Child (Chic) 2006;73:11-4.
Archer WH. Oral surgery for dental prosthesis. In: Archer WH, editor. Oral and Maxillofacial Surgery. Philadelphia: Saunders; 1975. p. 135-210.
Breault LG, Fowler EB, Moore EA, Murray DJ. The free gingival graft combined with the frenectomy: A clinical review. Gen Dent 1999;47:514-8.
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.
Cohen ES. Cosmetic root coverage: Gingival augmentation. In: Cohen ES, editor. Atlas of Cosmetic and Reconstructive Periodontal Surgery. Philadelphia: Lea and Febiger; 1989. p. 189-232.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]