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

  • 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

  • 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

Pre-operative Planning

Consent

Risks

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

Alternatives

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

Surgical Instruments

Anaesthesia, positioning and draping

Skin Marking

Surgical Steps

Post-operative care

Follow-up

Complications

References