Labial Frenectomy: Difference between revisions
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** Infant diastema is common irrespective of frenular attachment (normal in primary dentition and mixed dentition until the eruption of upper canines) | ** Infant diastema is common irrespective of frenular attachment (normal in primary dentition and mixed dentition until the eruption of upper canines) | ||
* Classifications: | * Classifications: | ||
*# Kotlow Classification: | *# Kotlow Classification<ref>[https://doi.org/10.1177/0890334413491325 Kotlow LA. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. Journal of Human Lactation. 2013 Nov;29(4):458-64.]</ref>: | ||
*#* Grade 1 - minimal alveolar mucosa and minimal attachment | *#* 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 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 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 | *#* Grade 4 - the frenulum attaches just into the anterior papilla and extends into the hard palate | ||
*# Stanford Classification: | *# Stanford Classification<ref name = "newborn"></ref>: ← shown to have better intra- and interrater reliability | ||
*#* Type 1 - insertion of the frenulum is near the mucogingival junction | *#* Type 1 - insertion of the frenulum is near the mucogingival junction | ||
*#* Type 2 - insertion is along the mid attached gingiva | *#* 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 | *#* Type 3 - insertion is along inferior margin at the alveolar papilla, and can continue to the posterior surface | ||
[[File:Labial frenum.gif|frame|center|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.<ref name = "newborn"></ref>]] | |||
* 83% of newborn children have Stanford type 2 frenular attachment | |||
==Decision Making== | ==Decision Making== | ||
* 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== | ==Consent== | ||
===Risks=== | ===Risks=== | ||
Pain, infection, bleeding, bruising, swelling, altered sensation, scar tissue (can potentially impede subsequent tooth movement), recurrence | |||
===Alternatives=== | ===Alternatives=== | ||
* Nothing | |||
* Important to discuss alternative techniques available for procedure (cold steel vs electrosurgery vs laser) | |||
==Surgical Instruments== | ==Surgical Instruments== | ||
* Haemostat | |||
* Scalpel blade no.15 | |||
* Needle holders | |||
* Scissors | |||
==Anaesthesia, positioning and draping== | ==Anaesthesia, positioning and draping== | ||
Suitable for local anaesthetic procedure in an outpatient/clinic setting | |||
==Surgical Steps== | ==Surgical Steps== | ||
== | ===Classical Frenectomy=== | ||
This technique is an excisional frenectomy which aims to remove the interdental tissues and the palatine papilla along with the frenulum | |||
# Anaesthetise the area with local infiltration | |||
# Engage the frenum with a haemostat/clip - attached at the deepest point in the vestibule | |||
# Excise a diamond shape above and below the clip and deliver the excised tissue on the clip | |||
# Blunt dissect down to bone to remove any fibrous tissue/bands | |||
# Close with 4-0 vicryl rapide | |||
<gallery mode="slideshow"> | |||
File:Fren1.jpg | Images from Devishree et al. 2012<ref name = "Devi">[https://doi.org/10.7860/jcdr/2012/4089.2572 Devishree SK, Shubhashini PV. Frenectomy: a review with the reports of surgical techniques. Journal of clinical and diagnostic research: JCDR. 2012 Nov;6(9):1587.]</ref> | |||
File:Fren2.jpg | Images from Devishree et al. 2012<ref name = "Devi"></ref> | |||
File:Fren3.jpg | Images from Devishree et al. 2012<ref name = "Devi"></ref> | |||
File:Fren4.jpg | Images from Devishree et al. 2012<ref name = "Devi"></ref> | |||
</gallery> | |||
===Z-Plasty=== | |||
Helpful for hypertrophic frenula and in cases where vestibular lengthening is needed | |||
# Anaesthetise the area with local infiltration | |||
# Incise through the length of the frenum | |||
# Extend the incision at each end to create limbs at an angle of 60<sup>o</sup> to 90<sup>o</sup> | |||
# Mobilise the flaps and transpose them to complete the Z-plasty | |||
# Close with 4-0 vicryl rapide | |||
=== | <gallery mode="slideshow"> | ||
File:Fren5.jpg | Images from Devishree et al. 2012<ref name = "Devi"></ref> | |||
File:Fren6.jpg | Images from Devishree et al. 2012<ref name = "Devi"></ref> | |||
File:Fren7.jpg | Images from Devishree et al. 2012<ref name = "Devi"></ref> | |||
</gallery> | |||
==References== | ==References== | ||
Line 63: | Line 109: | ||
<references /> | <references /> | ||
[[Category:]] | [[Category:Oral Surgery Procedures]] |
Latest revision as of 21:11, 19 November 2021
- 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 | edit source]
- 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:
- 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
- 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
- Kotlow Classification[2]:
- 83% of newborn children have Stanford type 2 frenular attachment
Decision Making[edit | edit source]
- 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 | edit source]
Risks[edit | edit source]
Pain, infection, bleeding, bruising, swelling, altered sensation, scar tissue (can potentially impede subsequent tooth movement), recurrence
Alternatives[edit | edit source]
- Nothing
- Important to discuss alternative techniques available for procedure (cold steel vs electrosurgery vs laser)
Surgical Instruments[edit | edit source]
- Haemostat
- Scalpel blade no.15
- Needle holders
- Scissors
Anaesthesia, positioning and draping[edit | edit source]
Suitable for local anaesthetic procedure in an outpatient/clinic setting
Surgical Steps[edit | edit source]
Classical Frenectomy[edit | edit source]
This technique is an excisional frenectomy which aims to remove the interdental tissues and the palatine papilla along with the frenulum
- Anaesthetise the area with local infiltration
- Engage the frenum with a haemostat/clip - attached at the deepest point in the vestibule
- Excise a diamond shape above and below the clip and deliver the excised tissue on the clip
- Blunt dissect down to bone to remove any fibrous tissue/bands
- Close with 4-0 vicryl rapide
Z-Plasty[edit | edit source]
Helpful for hypertrophic frenula and in cases where vestibular lengthening is needed
- Anaesthetise the area with local infiltration
- Incise through the length of the frenum
- Extend the incision at each end to create limbs at an angle of 60o to 90o
- Mobilise the flaps and transpose them to complete the Z-plasty
- Close with 4-0 vicryl rapide
References[edit | edit source]
- ↑ 1.0 1.1 1.2 Santa Maria C, Aby J, Truong MT, Thakur Y, Rea S, Messner A. The superior labial frenulum in newborns: what is normal?. Global pediatric health. 2017 Jul 10;4:2333794X17718896.
- ↑ Kotlow LA. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. Journal of Human Lactation. 2013 Nov;29(4):458-64.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Devishree SK, Shubhashini PV. Frenectomy: a review with the reports of surgical techniques. Journal of clinical and diagnostic research: JCDR. 2012 Nov;6(9):1587.