Labial Frenectomy

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  • The frenulum (or frenum) is is a mucous membrane fold that attaches the lip to the alveolar mucosa, the gingiva, and the underlying periosteum
  • There are some indications for a frenectomy but in the majority of situations patient/parent reassurance and education is all that is needed

Anatomy[edit]

  • Superior labial frenulum (or maxillary labial frenulum) is a fold of connective tissue that attaches the upper lip to the anterior surface of the maxillary gingiva
  • It is made up of alveolar mucosa and arises embryologically as a posteruptive remnant of tectolabial bands[1]
  • There is disagreement as to what constitutes normal anatomy and when the presence of a frenulum is a "lip-tie"
  • There is also controversy as to whether there is any functional consequences relating to it attachment or appearance
  • Attachment of frenulum appears to vary with age:
    • Newborn and young infants → tend to have more prominent frenula with insertion onto the palatal surface of the papilla
    • Older children → less prominent frenula with insertion onto, or above, the mucogingival junction
    • Adults → predominance of frenula with the mucosal-type attachment
  • In children and adults a prominent frenulum may contribute to a diastema
    • Infant diastema is common irrespective of frenular attachment (normal in primary dentition and mixed dentition until the eruption of upper canines)
  • Classifications:
    1. Kotlow Classification[2]:
      • Grade 1 - minimal alveolar mucosa and minimal attachment
      • Grade 2 - frenulum attaches primarily into gingival tissue, at the junction point of the free and attached gingival margins
      • Grade 3 - the frenulum inserts just in front of the anterior papilla
      • Grade 4 - the frenulum attaches just into the anterior papilla and extends into the hard palate
    2. Stanford Classification[1]: ← shown to have better intra- and interrater reliability
      • Type 1 - insertion of the frenulum is near the mucogingival junction
      • Type 2 - insertion is along the mid attached gingiva
      • Type 3 - insertion is along inferior margin at the alveolar papilla, and can continue to the posterior surface
Stanford superior labial frenulum classification. Type 1: Insertion of the frenulum is near the mucogingival junction. Type 2: Insertion is along the mid attached gingiva. Type 3: Insertion is along inferior margin at the alveolar papilla, and can continue to the posterior surface.[1]
  • 83% of newborn children have Stanford type 2 frenular attachment

Decision Making[edit]

  • No absolute indications for the procedure
  • Some indications are below
  • Breastfeeding
    • Commonest indication for superior labial frenectomy in newborn
    • Kotlow suggested that the higher the grade (of his classification), the higher the “severity” of “lip-tie,” and the greater the association with breastfeeding problems
    • Currently, there is little evidence that certain appearances of the labial frenula have any bearing on latching or feeding
    • There is a similar lack of evidence that a frenectomy improves feeding for babies post-procedure
  • Diastema
    • Presence of a diastema (≤2mm) is normal in primary and mixed dentition → usually closes with eruption of maxillary canines
    • An early frenectomy may lead to scar formation that can impede diastema closure
    • If a frenectomy is indication is should always be preceded by orthodontic therapy and the timing should be coordinated between orthodontist and surgeon (usually carried out during orthodontic treatment)
    • Theoretically, the subsequent scar tissue formation may help to keep the diastema closed - but normal forms of retention are still essential
  • Oral hygiene
    • A flattened papilla with the frenum closely attached to the gingival margin may cause a gingival recession and a hindrance in maintaining the oral hygiene
  • Shallow vestibule
    • Another indication is an aberrant frenum with an inadequately attached gingiva and a shallow vestibule is seen
    • Shallow vestibule may affect denture stability

Consent[edit]

Risks[edit]

Pain, infection, bleeding, bruising, swelling, altered sensation, scar tissue (can potentially impede subsequent tooth movement), recurrence

Alternatives[edit]

  • Nothing
  • Important to discuss alternative techniques available for procedure (cold steel vs electrosurgery vs laser)

Surgical Instruments[edit]

  • Haemostat
  • Scalpel blade no.15
  • Needle holders
  • Scissors

Anaesthesia, positioning and draping[edit]

Suitable for local anaesthetic procedure in an outpatient/clinic setting

Surgical Steps[edit]

Classical Frenectomy[edit]

This technique is an excisional frenectomy which aims to remove the interdental tissues and the palatine papilla along with the frenulum

  1. Anaesthetise the area with local infiltration
  2. Engage the frenum with a haemostat/clip - attached at the deepest point in the vestibule
  3. Excise a diamond shape above and below the clip and deliver the excised tissue on the clip
  4. Blunt dissect down to bone to remove any fibrous tissue/bands
  5. Close with 4-0 vicryl rapide

Z-Plasty[edit]

Helpful for hypertrophic frenula and in cases where vestibular lengthening is needed

  1. Anaesthetise the area with local infiltration
  2. Incise through the length of the frenum
  3. Extend the incision at each end to create limbs at an angle of 60o to 90o
  4. Mobilise the flaps and transpose them to complete the Z-plasty
  5. Close with 4-0 vicryl rapide

References[edit]