DOI: JCDR/2012/4089:0000

Case Report

Frenectomy: A Review with the Reports

Pathology Section

of Surgical Techniques

Devishree, Sheela Kumar Gujjari, Shubhashini P.V.

ABSTRACT The management of such an aberrant frenum is accomplished

The frenum is a mucous membrane fold that attaches the lip and by performing a frenectomy.
the cheek to the alveolar mucosa, the gingiva, and the underlying The present article is a compilation of a brief overview about
periosteum. The frena may jeopardize the gingival health when the frenum, with a focus on the indications, contraindications,
they are attached too closely to the gingival margin, either due advantages and the disadvantages of various frenectomy
to an interference in the plaque control or due to a muscle pull. techniques, like Millers technique, V-Y plasty, Z-plasty and
In addition to this, the maxillary frenum may present aesthetic frenectomy by using electrocautery. A series of clinical cases of
problems or compromise the orthodontic result in the midline frenectomy which were approached by various techniques have
diastema cases, thus causing a recurrence after the treatment. also been reported.

Key Words: Frenum, Frenectomy, Mucogingival techniques

Introduction Diagnosis
Aesthetic concerns have led to an increasing importance in seeking The abnormal frena are detected visually by applying tension over
dental treatment, with the purpose of achieving perfect smile. The the frenum to see the movement of the papillary tip or the blanch
continuing presence of a diastema between the maxillary central which is produced due to ischaemia in the region. The frenum is
incisors in adults, has often been considered as an aesthetic characterized as pathogenic when it is unusually wide or when
problem. The presence of an aberrant frenum being one of the there is no apparent zone of the attached gingiva along the midline
aetiological factors for the persistence of a midline diastema, the or the interdental papilla shifts when the frenum is extended.
focus on the frenum has become essential [1].
Classification
The frena may also jeopardize the gingival health by causing
The labial frenal attachments have been classified as mucosal,
a gingival recession when they are attached too closely to the
gingival, papillary and papilla penetrating, by Placek et al (1974) [3].
gingival margin, either because of an interference with the proper
placement of a toothbrush or through the opening of the gingival 1. Mucosal when the frenal fibres are attached up to the
crevice because of a muscle pull [2]. mucogingival junction.
2. Gingival when the fibres are inserted within the attached
The Muscular Anatomy of the Frenum gingiva.
A frenum is a mucous membrane fold which contains muscle and 3. Papillary when the fibres are extending into the interdental
connective tissue fibres that attach the lip and the cheek to the papilla.
alveolar mucosa, the gingiva and the underlying periosteum [2]. 4. Papilla penetrating when the frenal fibres cross the alveolar
process and extend up to the palatine papilla.
Knox and Young histologically studied the frenulum, and they have
reported both elastic and muscle fibres (Orbicularis oris - horizontal
Indications
bands and oblique fibres). However, Henry, Levin and Tsaknis have
The frenum is characterized as pathogenic and is indicated for
found considerably dense collagenous tissue and elastic fibres but
removal when
no muscle fibres in the frenulum [2].
An aberrant frenal attachment is present, which causes a
Aetiology midline diastema.
The maxillary labial frenum develops as a post-eruptive remnant A flattened papilla with the frenum closely attached to the
of the ectolabial bands which connect the tubercle of the upper gingival margin is present, which causes a gingival recession
lip to the palatine papilla. When the 2 central incisors erupt widely and a hindrance in maintaining the oral hygiene.
separated, no bone is deposited inferior to the frenum. A V-shaped An aberrant frenum with an inadequately attached gingiva and
bony cleft between the two central incisors and an abnormal a shallow vestibule is seen.
frenum attachment results. The mandibular frenum is considered
as aberrant when it is associated with a decreased vestibular depth Treatment
and an inadequate width of the attached gingiva [1,2]. The aberrant frena can be treated by frenectomy or by frenotomy
procedures. Frenectomy is the complete removal of the frenum,

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including its attachment to the underlying bone, while frenotomy is The techniques which were employed were:
the incision and the relocation of the frenal attachment [3].
Conventional (Classical) frenectomy
Frenectomy can be accomplished either by the routine scalpel Millers technique
technique, electrosurgery or by using lasers. The conventional V-Y Plasty
technique involves excision of the frenum by using a scalpel. Z Plasty
However, it carries the routine risks of surgery like bleeding and Frenectomy which was done by using electrocautery
patient compliance.

The use of electro surgery and lasers has also been proposed CLINICAL CASES
for frenectomy [4-9]. Researchers have advocated the use of an
Classical Frenectomy[2]
electrocautery probe due to its efficacy and due to the safety of
The classical technique was introduced by Archer (1961) and
the procedure, the mild bleeding and the absence of postoperative
Kruger (1964). This approach was advocated in the midline
complications. However, it is associated with certain complications
diastema cases with an aberrant frenum to ensure the removal of
which include burns, the risk of an explosion if combustible gases
the muscle fibres which were supposedly connecting the orbicularis
are used, interference with pacemakers and the production of
oris with the palatine papilla [2]. This technique is an excision type
surgical smoke. These complications have not been reported with
frenectomy which includes the interdental tissues and the palatine
the new improvement in the electro surgical techniques, like the
papilla along with the frenulum.
argon beam coagulation (ABC) [4,5].
Armamentarium - Haemostat, scalpel blade no.15, gauze sponges,
Recently, the use of a CO2 laser in lingual frenectomies has been
4-0 black silk sutures, suture pliers, scissors, and a periodontal
reported as a safe and effective procedure with the advantages
dressing (Coe-pak).
of a shorter duration of the surgery, simplicity of the procedure,
the absence of postoperative infections, lesser pain, swelling The present case was a papilla type of frenal attachment [Table/
and the presence of a small or no scar [4]. A delayed healing as Fig-1]. The area was anaesthetized with a local infiltration by
compared to that in the conventional scalpel techniques, a reduced using 2% lignocaine with 1:80000 adrenaline. The frenum was
surgical precision which results in an inadvertent laser-induced engaged with a haemostat which was inserted into the depth of
thermal necrosis and/or a photo acoustic injury, are some of the the vestibule [Table/Fig-2] and incisions were placed on the upper
complications which are associated with lasers. The application and the undersurface of the haemostat until the haemostat was
of diode and Er:YAG lasers [6] in labial frenectomies in infants and free [Table/Fig-3]. The triangular resected portion of the frenum
Er,Cr:YSGG lasers [7] in labial frenectomies in the adolescent and with the haemostat was removed. A blunt dissection was done
the pre-pubescent populations have also been reported. on the bone to relieve the fibrous attachment. The edges of the
diamond shaped wound were sutured by using 4-0 black silk with
Since the conventional procedure of frenectomy was first prop
interrupted sutures [Table/Fig-4]. The area was covered with a
osed, a number of modifications [10-12] of the various surgical
periodontal pack. The pack and the sutures were removed 1 week
techniques like the Millers technique, V-Y plasty and Z-plasty have
post-operatively.
been developed to solve the problems which are caused by an
abnormal labial frenum. The post-operative sequelae at 1 month of follow-up included un
aesthetic or labial tissue scarring [Table/Fig-5].
The present article is a compilation of a series of clinical cases of
an aberrant frenum which were approached by various surgical
Millers Technique [2,14]
techniques which were employed for frenectomy, with an added
The Millers technique was advocated by Miller PD in 1985. This
note on the merits and the demerits of each procedure.
technique was proposed for the post-orthodontic diastema cases.

Classical Technique

[Table/Fig-1]: Pre-operative papilla type of frenal

attachment
[Table/Fig-2]: Frenum held with hemostat
[Table/Fig-3]: Frenum excised
[Table/Fig-4]: Sutures placed
[Table/Fig-5]: One month post-operative

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Millers Technique

[Table/Fig-6]: Pre-operative attached type of

frenal attachment
[Table/Fig-7]: Frenum excised
[Table/Fig-8]: Lateral pedicle graft obtained
[Table/Fig-9]: Graft sutured across the
midline
[Table/Fig-10]: 2 weeks post-operative

The ideal time for performing this surgery is after the orthodontic The area was anaesthetized with a local infiltration by using 2 %
movement is complete and about 6 weeks before the appliances lignocaine with 1:80000 adrenaline. The length of the frenum was
are removed. This not only allows healing and tissue maturation, incised with the scalpel [Table/Fig-12] and at each end, limbs at
but it also permits the surgeon to use orthodontic appliances as a between 60 and 90 angulation, incisions were made in equal
means of retaining a periodontal dressing length to that of the band. By using fine tissue forceps, with care
not to damage the apices of the flaps, the submucosal tissues
Armamentarium - Haemostat, scalpel blade no.15, gauze sponges,
were dissected beyond the base of each flap, into the loose non-
5-0 black silk sutures, suture pliers, scissors, and a periodontal
attached tissue planes. Thus, double rotation flaps which were
dressing (Coe-pak).
at least 1 cm long were obtained. The resultant flaps which were
An attached type of frenal attachment was treated with the created were mobilized and transposed through 90 to close
following surgical procedure after the area was anaesthetized with the vertical incisions horizontally [Table/Fig-13]. Absorbable 5-0
a local infiltration by using 2% lignocaine with 1:80000 adrenaline: vicryl sutures were placed, first through the apices of the flaps,
[Table/Fig-1-10]: to ascertain the adequacy of the flap repositioning and then
they were evenly spaced along the edges of the flaps, to close
Excision of the frenulum and exposure of the labial alveolar
the wound along the cut edges of the attached mucoperiosteum
bone in the midline.
and the labial mucosa [Table/Fig-14]. A periodontal dressing
A horizontal incision was made to separate the frenulum from
was placed. After 1 week, the dressing was removed, while
the interdental papilla.
the remnants of the sutures were left, as resorbable sutures
A laterally positioned pedicle graft (split thickness) was
were used.
obtained and it was sutured across the midline.
A periodontal dressing was placed. At 1 month of follow-up [Table/Fig-15], the healing was found to
be uneventful, with no hypertrophic scar formation and tension at
Care must be taken to extend the incisions into the lip as far as
the frenum area.
necessary, to assure that a remnant of the frenulum is not left on
the lip. After 1 week, the periodontal dressing was removed, while
the remnants of the sutures were left, as resorbable sutures were V-Y Plasty [18]
used. At 1 month of follow-up, there was a gingiva across the V-Y plasty can be used for lengthening the localized area, like the
midline and the interdental papilla was maintained. broad frena in the premolar-molar area.

Armamentarium: Haemostat, scalpel blade no.15, gauze sponges,

Z Plasty [15-17] 4-0 black silk sutures, suture pliers, scissors, and a periodontal
This technique is indicated when there is hypertrophy of the frenum dressing (Coe-pak).
with a low insertion, which is associated with an inter-incisor
This technique was employed in a case of a papilla type of frenal
diastema, and when the lateral incisors have appeared without
attachment [Table/Fig-16] After the area was anaesthetized with a
causing the diastema to disappear and also in cases of a short
local infiltration by using 2 % lignocaine with 1:80000 adrenaline,
vestibule.
the frenum was held with the haemostat [Table/Fig-16] and an
Armamentarium - Scalpel blade no.15, gauze sponges, tissue incision was made in the form of V on the undersurface of the frenal
forceps, 5-0 vicryl sutures, suture pliers, scissors, and a periodontal attachment [Table/Fig-18] The frenum was relocated at an apical
dressing (Coe-pak). position and the V shaped incision was converted into a Y, while it
was sutured with 4-0 silk sutures [Table/Fig-19]. A periodontal pack
A case of a hypertrophic attached type of frenal attachment
was placed. The periodontal pack and the sutures were removed
[Table/Fig-11] was operated by using the Z-plasty technique.

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Z plasty

[Table/Fig-11]: Pre-operative attached type

of frenal attachment
[Table/Fig-12]: Incision given through the
frenum
[Table/Fig-13]: Incision given at both ends of
the frenum to obtain 2 triangular flaps
[Table/Fig-14]: Flaps transposed across the
midline sutured in the form of Z
[Table/Fig-15]: 1 month post-operative

V-Y Plasty

[Table/Fig-16]: Pre-operative papilla type of

frenal attachment
[Table/Fig-17]: Frenum held with hemostat
[Table/Fig-18]: Frenum incised by V-shaped
incision
[Table/Fig-19]: V-shaped incision sutured in
the form of Y
[Table/Fig-20]: 1 month post operative

at 1 week of follow-up. At 1 month of follow-up [Table/Fig-20] the healing was by secondary intention, as the wound edges were not
frenal attachment was found to be relocated at an apical position, approximated with sutures [Table/Fig-24].
with an uneventful healing.
Discussion
Electro Surgery [4,5] Nevertheless, inspite of the various modifications which have been
Electrosurgery is recommended in cases of patients with bleeding proposed for frenectomy, the widely followed procedure which
disorders, where the conventional scalpel technique carries a higher remains is the classical technique. The classical technique leaves
risk which is associated with problems in achieving a haemostasis a longitudinal surgical incision and scarring, which may lead to
and also in non-compliant patients. periodontal problems and an unaesthetic appearance, thereby
necessitating other modifications.
Armamentarium: An electrocautery unit with the loop electrode and
a haemostat. Among all the approaches for frenectomy which were employed
in the present case series, the electrocautery procedure offered
The conventional approaches with the scalpel do offer some dis
the advantage of minimal time consumption and a bloodless
advantages. To overcome these, a case of an attached type of frenal
field during the surgical procedure, with no requirement of
attachment [Table/Fig-21] was approached with electrocautery.
sutures. The techniques like simple excision and a modification
After the area was anaesthetized with local infiltration by using 2%
of V-rhomboplasty fail to provide satisfactory aesthetic results
lignocaine with 1:80000 adrenaline, the frenum was held with the
in the case of a broad, thick hypertrophied frenum. This may be
haemostat and by using a loop electrode tip, it was excised [Table/
due to the inability to achieve a primary closure at the centre,
Fig-22] Electrocautery offered the advantage of minimal procedural
consequently leading to a secondary intention healing at the wide
bleeding and there was no need of sutures [Table/Fig-23] The
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Electrocautery

[Table/Fig-21]: Pre-operative attached type of frenal attachment

[Table/Fig-22]: Frenum held with hemostat and excised with a loop electrode
[Table/Fig-23]: Excision of frenum completed with no requirement for suture placement
[Table/Fig-24]: 1 month post operative

Treatment Conclusion
Modality Clinical Research References While an aberrant frenum can be removed by any of the modification
Electrosurgery Case report and clinical technique: 5 techniques that have been proposed, a functional and an aesthetic
argon beam electrosurgery for tongue outcome can be achieved by a proper technique selection, based
ties and maxillary frenectomies in infants
and children on the type of the frenal attachment. Though the approaches to the
problem of not using the traditional scalpel, like electro surgery and
Lasers Application of diode and Er:YAG lasers 6
in labial frenectomy in infants lasers have merits, further improvements can still be attempted.
Er,Cr:YSGG laser (1.5 W and 20 to 30 7
pulses per second) labial frenectomy: a Acknowledgement
clinical retrospective evaluation of 156 The authors express their gratitude to Dr. Shabana Anjum for her
frenectomies on 143 children
assistance in the clinical work. The authors report no conflicts of
A case report of maxillary frenectomy 8
interest which are related to this work.
using a carbon dioxide laser in a
pediatric patient
A case report of upper-lip laser 9 References
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AUTHOR(S): NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING
1. Dr. Devishree AUTHOR:
2. Dr. Sheela Kumar Gujjari Dr. Devishree
3. Dr. Shubhashini P.V. No. 1761, Shubhalaya
Third Main Road, Hebbal Second Stage
PARTICULARS OF CONTRIBUTORS:
Mysore-570017 Karnataka India.
1. Post Graduate Student, Department of Periodontics,
Phone: 09448786968
JSS. Dental College & Hospital, Mysore-570015,
E-mail: [email protected]
Karnataka, India.
2. Professor, Department of Periodontics, JSS. Dental Financial OR OTHER COMPETING INTERESTS:
College & Hospital, Mysore-570015, Karnataka, India. None.
3. Senior Lecturer, Department of Periodontics, JSS. Dental
Date of Submission: Feb 02, 2012
College & Hospital, Mysore-570015, Karnataka, India. Date of Peer Review: Apr 17, 2012
Date of Acceptance: Aug 06, 2012
Date of Publishing: ???, 2012

6 Journal of Clinical and Diagnostic Research. 2012 October, Vol-6(8): 000-000