Labial Frenectomy

• 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

• 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
• 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:
     • 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:
     • 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.

Decision Making

Breastfeeding

Primarily, controversy stems from an emergence of interventions being performed on superior labial frenula, such as surgical or laser removal, despite limited knowledge of what is “normal” or “abnormal” in relation to this frenulum. The primary justification for these procedures is to facilitate and improve breastfeeding; however, there is little evidence that certain appearances of the labial frenula have any bearing on latching or feeding. While ankyloglossia, a tight lingual frenulum, has been shown to affect breastfeeding, and improvement in latching onto the breast can be achieved with its release,3,4 there is no similar evidence for the superior labial frenula.

The author of this classification system proposes that the higher the grade, the higher the “severity” of “lip-tie,” and the greater the association with breastfeeding problems

References

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