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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 31-34

Bilateral pedicle flap: A novel technique for functional and esthetic management of aberrant labial frenum


Department of Periodontology and Implantology, M. P. Dental College and Hospital, Vadodara, Gujarat, India

Date of Web Publication18-Feb-2019

Correspondence Address:
Isha Agrawal
15, Sakar Bunglows, Nr Ward Office 6, Vadodara, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_44_17

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   Abstract 


An aberrant maxillary labial frenum can lead to diastema and gingival recession creating functional and esthetic problems. Archer's classical frenectomy technique is an extensive procedure and has led to scarring and loss of interdental papilla. Conservative approaches such as Edward's frenectomy, frenum relocation by Z-plasty, and free gingival graft showed limitations in terms of esthetics. This case report describes a novel technique of bilateral pedicle flap for frenectomy which gives good esthetic results, color match, gain in attached gingiva, and no unaesthetic scar formation as healing takes place by primary intention.

Keywords: Aberrant frenum, bilateral pedicle flap, esthetics, frenectomy


How to cite this article:
Agrawal I, Nadig P, Chandran S. Bilateral pedicle flap: A novel technique for functional and esthetic management of aberrant labial frenum. J Interdiscip Dentistry 2019;9:31-4

How to cite this URL:
Agrawal I, Nadig P, Chandran S. Bilateral pedicle flap: A novel technique for functional and esthetic management of aberrant labial frenum. J Interdiscip Dentistry [serial online] 2019 [cited 2019 Jul 15];9:31-4. Available from: http://www.jidonline.com/text.asp?2019/9/1/31/252525




   Clinical Relevance to Interdisciplinary Dentistry Top


  • The present novel technique of bilateral pedicle flap for the management of abnormal frenum has advantages such as:
  • Healing takes place by primary intention
  • A zone of attached gingiva matching with adjacent tissue forms
  • No unaesthetic scar formation
  • No recession of interdental papilla occurs as transseptal fibers are not severed out.



   Introduction Top


Afrenum is an anatomic structure formed by a fold of mucous membrane, connective tissue, and sometimes, muscle fibers. Maxillary labial frenum is triangular in shape and attaches lip-to-alveolar mucosa and/or gingiva.[1] Depending on the extension of attachment of fibers, frenula have been classified as:[2]

  1. Mucosal – When the frenal fibers are attached up to mucogingival junction
  2. Gingival – When fibers are inserted within attached gingiva
  3. Papillary – When fibers are extending into interdental papilla
  4. Papilla penetrating – When the frenal fibers across the alveolar process and extend up to palatine papilla.


Clinically, papillary and papilla-penetrating frenula have been mostly found to be associated with loss of papilla, recession, diastema, difficulty in brushing leading to plaque accumulation, misalignment of teeth, and psychological disturbances to individual.[3],[4] When the frenum is unusually wide or there is no apparent zone of attached gingiva along the midline, it is characterized as pathogenic.[5] Abnormal frenum is detected by applying tension to see the movement of papillary tip or blanch produced due to ischemia of the region.[6] In such cases of pathognomonic labial frenum, it is necessary to perform frenectomy for functional and esthetic correction.

Numerous surgical techniques are advocated for the removal of labial frenum. In the classical frenectomy technique by Archer,[7],[8] the frenum, interdental tissue, and palatine papilla are completely excised leading to the exposure of underlying alveolar bone and thus leading to scarring in midline. Edward[9] advocated a conventional procedure, by apically repositioning of the frenum, splitting of transseptal fibers between two central incisors followed by gingivoplasty of excess labial/palatal tissue in the interdental area. However, the healed scar in the midline appeared unaesthetic to the subjects.[9] Various modifications were then suggested such as free gingival graft[5],[10] to avoid scar formation but led to mismatch color gingiva in midline. To overcome color mismatch and scar formation, Miller[5] advocated a surgical technique combining frenectomy and laterally positioned pedicle graft. The advantages of this technique are as follows: it healed through primary intention, no scar formation, and esthetically acceptable attached gingiva in midline.[5] However, it showed a slight lateral shift of frenum from midline in cases with broad, thick, and hypertrophied frenum.[11]

Thus, this case report describes the novel technique of bilateral pedicle flap for the management of aberrant frenum in the maxillary anterior region which led to 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.


   Case Report Top


A 28-year-old male patient was referred to the Department of Periodontics, M. P. Dental College, Vadodara, for the correction of abnormal maxillary labial frenum. The patient was well aware and concerned about the abnormal attachment of the frenum. Medical history was noncontributory. Clinical examination revealed a hypertrophied, broad, and thick labial frenum of papillary penetrating-type attachment [Figure 1]. The “tension test” presented positive when force was applied to the upper lip in outward, downward, and lateral direction. A full complement of teeth was present with adequate buccal vestibular depth except in the frenal area. An adequate amount of attached gingiva was present at the maxillary anterior region without any mucogingival problems. As conventional frenectomy would lead to scar formation due to a wide surgical wound after frenum excision, the novel technique of frenectomy was planned which 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: Papillary penetrating frenum

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Surgical procedure

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 at the base of the gingival frenal attachment [Figure 2]a and [Figure 2]b. Tissue along with periosteum was separated from underlying bone which resulted in a V-shaped defect on the gingival side [Figure 2]c. Fibrous tissue attached to the lip was dissected with scissors, and undermining of the labial mucosa was done. A second oblique partial-thickness incision was placed on the adjacent 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 [Figure 3]. 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 4]a. 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 two triangular pedicles [Figure 4]b of attached gingiva. These two pedicles were sutured with each other at the medial side [Figure 4]c and laterally [Figure 4]d with the adjacent intact periosteum of the donor site by 4-0 vicryl sutures. Analgesics (ketorolac 10 mg) and 0.2% chlorhexidine gluconate mouthwash were prescribed for the next 5 days. Postoperative instructions were given. After 1 week, healing of surgical site was satisfactory [Figure 5]a, and sutures were removed [Figure 5]b. The 6-month follow-up revealed a zone of attached gingiva with esthetic color match in the area previously covered by the abnormal frenum. Normal healing was seen without any visible scarring and no lateral shift of frenum from midline was detected [Figure 5]c.
Figure 2: (a) A V-shaped external bevel incision, (b) after V-shaped incision, (c) V-shaped defect on the gingival side

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Figure 3: Oblique partial-thickness incision for pedicle flap

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Figure 4: (a) Triangular pedicles, (b) approximation of pedicles in the center, (c) pedicle flap stabilized with suture, (d) complete suturing of pedicles on the lateral aspect

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Figure 5: (a) Healing after 1 week, (b) suture removal after 1 week, (c) healing after 6 months

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   Discussion Top


In the era of periodontal plastic surgery, more conservative and precise techniques are being adopted to create more functional and esthetic results. The management of aberrant frenum has traveled a long journey from Archer's[7] and Kruger's[8] “classical techniques” of total frenectomy to Edward's[9] more conservative approaches. Recent techniques added frenal relocation by Z-plasty[12] frenectomy with soft-tissue graft[13] and laser[14] applications to avoid typical diamond-shaped scar and facilitate healing. Each method has its own advantages and disadvantages, for example, frenectomy followed by free gingival graft taken from the palate (keratinized gingiva) covers the wound area completely but creates an esthetic concern of unsatisfactory color match by producing a “keloid,” “tattoo-like,” or “tire patch” appearance at the grafted area.[11],[13] The lateral pedicle graft technique positions the unilateral pedicle at the midline but causes a slight shift in frenum position in broad, thick, and hypertrophied frenum as seen in our case.[11]

In the technique presented, i.e., bilateral pedicle flap, two triangular pedicles, when sutured together medially, completely cover the V-shaped defect on the gingiva and act as a tissue dressing, thus facilitating healing by primary intention and minimizing any chance of scar formation. Furthermore, an external bevel in the initial V-shaped incision helps to achieve better marginal adaptation of the pedicles. The clinician can more predictably reposition the maxillary labial frenum by preventing coronal regrowth of fibers. This technique also helps in maintaining the width of attached gingiva without compromising the color match which ultimately helps to maintain the periodontal health of involved teeth postoperatively. The patient's discomfort is also minimized as compared with conventional frenectomy procedures, where the defects are left essentially open.[11]

Hence, the present technique may be suitable in situ ations where anterior esthetics is of primary importance. The 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.


   Conclusion Top


The present case describes the novel surgical technique combining frenectomy with bilateral pedicle flap. This technique has certain distinct advantages such as:

  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 without shift of frenum from midline
  3. No unaesthetic scar formation
  4. No recession of interdental papilla occurs as transseptal fibers are not severed out
  5. The attached gingiva in midline may have a bracing effect which helps in the prevention of orthodontic relapse.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Henry SW, Levin MP, Tsaknis PJ. Histologic features of the superior labial frenum. J Periodontol 1976;47:25-8.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
Dewel BF. The labial frenum, midline diastema, and palatine papilla: A clinical analysis. Dent Clin North Am 1966;10:175-84.  Back to cited text no. 3
    
4.
Díaz-Pizán ME, Lagravère MO, Villena R. Midline diastema and frenum morphology in the primary dentition. J Dent Child (Chic) 2006;73:11-4.  Back to cited text no. 4
    
5.
Miller PD Jr. The frenectomy combined with a laterally positioned pedicle graft. Functional and esthetic considerations. J Periodontol 1985;56:102-6.  Back to cited text no. 5
    
6.
Gottsegen R. Frenum position and vestibule depth in relation to gingival health. Oral Surg 1954;7:1069-72.  Back to cited text no. 6
    
7.
Archer WH, editor. Oral Surgery: A Step by Step Atlas of Operative Techniques. 3rd ed. Philadelphia: W B Saunders Co.; 1961. p. 192-6.  Back to cited text no. 7
    
8.
Kruger GO, editor. Oral surgery. 2nd ed. St. Louis: The C.V. Mosby Co.; 1964. p. 146-9.  Back to cited text no. 8
    
9.
Edwards JG. The diastema, the frenum, the frenectomy: A clinical study. Am J Orthod 1977;71:489-508.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
Hungund S, Dodani K, Kambalyal P, Kambalyal P. Comparative results of frenectomy by three surgical techniques – Conventional, unilateral displaced pedicle flap and bilateral displaced pedicle flap. Dentistry 2013;4:183.  Back to cited text no. 11
    
12.
Ito T, Johnson JD. Frenectomy and frenotomy. In: Ito T, Johnson JD, editors. Color Atlas of Periodontal Surgery. London: Mosby Wolfe; 1994. p. 225-39.  Back to cited text no. 12
    
13.
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.  Back to cited text no. 13
    
14.
Gontijo I, Navarro RS, Haypek P, Ciamponi AL, Haddad AE. The applications of diode and Er:YAG lasers in labial frenectomy in infant patients. J Dent Child (Chic) 2005;72:10-5.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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