IP International Journal of Periodontology and Implantology 2020;5(4):177–180

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IP International Journal of Periodontology and Implantology

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Case Report
Frenectomy by millers technique: A case report

Nishita Bhosale1, *, Yogesh Khadtare1 , Pramod Waghmare1 , Amit Chaudhari1 ,

Priya Lele1 , Neelam Gavali1
1 Dept. of Periodontology, Bharati Vidyapeeth Deemed to be University Dental College and Hospital, Pune, Maharashtra, India

ARTICLE INFO ABSTRACT

Article history: The Aberrant labial frenum results in diastema and gingival recession thereby compromising the esthetic
Received 20-10-2020 and functional needs of the patient. There are various procedure for the treatment of the aberrant frenum.
Accepted 30-11-2020 The classical frenctomy technique by Archer is an extensive procedure which results in Unesthetic scaring
Available online 24-12-2020 of the tissue, loss of interdental papilla. To overcome these drawbacks, Miller introduced a newer technique
where he combined the frencetomy technique with laterally displaced flap. The main advantage of this
technique is that the healing takes place by primary intention with no scaring of the tissue. This article is a
Keywords:
case report on frenectomy with laterally displaced flap (Millers technique).
Aberrant frenum
Frenectomy © This is an open access article distributed under the terms of the Creative Commons Attribution
Millers technique License (https://creativecommons.org/licenses/by/4.0/) which permits unrestricted use, distribution, and
Laterally displaced flap reproduction in any medium, provided the original author and source are credited.

1. Introduction resulting in an abnormal frenum attachment. When there

is a decreased vestibular depth and an inadequate width
The frenum is anatomic structure derived from the latin
of the attached gingiva, mandibular frenum is considered
word “fraenum”, which is formed by a membranous fold
as aberrant. 1,3 Frenum has been classified by Placek et
of mucous membrane, connective tissue and sometimes
al (1974) depending upon the extension of the attachment
muscle fibres. There are numerous frena which are present
fibers as: 4
in the oral cavity and the most commonly noted frena are
the maxillary labial frenum, the mandibular labial frenum, 1. Mucosal – here the frenal fibers are attached to the
and the lingual frenum. 1 mucogingival junction
The stability to the upper and lower lips and to the tongue 2. Gingival – here the fibers are inserted within the
is provided by the frena which is its primary function. 2 attached gingiva
The aberrant frenum can lead to gingival recession when 3. Papillary – here the fibers are extending into the
they are too closely attached to the gingival margin. This can interdental papilla
be either because of opening of the gingival crevice due to 4. Papilla penetrating – here the frenal fibers cross the
muscle pull or a interference with the improper placement alveolar process and extend up to the palatine papilla.
of a toothbrush. 1
The development of maxillary labial frenum is from Papillary and papilla penetrating frena are considered as
the post-eruptive remnant of the ectolabial bands which pathological and have been associated with recession,
connects the tubercle of the upper lip to the palatine papilla. loss of papilla, diastema, malalignment of teeth, difficulty
There is no bone deposited inferior to the frenum when in brushing and it may also prejudice the denture fit
the two central incisors erupt widely separated. A V-shaped or retention leading to psychological disturbances to the
bony cleft is formed between the two central incisors, individual. 5,6 Miller has recommended that the frenum
* Corresponding author. should be characterized as pathogenic when the frenum is
E-mail address: [email protected] (N. Bhosale). unusually wide or there is no zone of attached gingiva along

https://doi.org/10.18231/j.ijpi.2020.039
2581-9836/© 2020 Innovative Publication, All rights reserved. 177
178 Bhosale et al. / IP International Journal of Periodontology and Implantology 2020;5(4):177–180

the midline or when the frenum is extended the interdental Miller has given a surgical technique where the
papilla shifts. 7 frenectomy is combined with a laterally positioned pedicle
The abnormal frena can be diagnosed visually by moving graft. The primary advantage of this technique is complete
the upper lip outwards and downwards and lower lip is closure seen across the midline due to laterally positioned
moved outwards and upwards. If the gingival margin shows gingiva and the healing by primary intention which
movement or if blanching is seen due to ischemia, then the resulted in aesthetically acceptable attached gingiva across
test is positive and the frenum is said to be aberrant This test the midline. Interdental papilla remained undisturbed as
is known as the Blanching test or Tension test.(Figure 1) no attempt was made to dissect the trans-septal fibers.
Therefore esthetically and functionally better results were
obtained. 7
This article presents a case report on frenectomy by
Millers technique.

2. Case
A 23 years old male patient reported to the Department
of Periodontology. On clinical examination, according to
Miller, the frenum was considered abnormal as it was
unusually wide and there was inadequate zone of attached
gingiva along the midline 7 and also the tension test was
positive and therefore frenectomy by Millers technique was
decided. The entire surgical procedure was explained to the
patient and written informed consent was obtained from the
patient before the surgical procedure.
Fig. 1: Blanching/Tension test
2.1. Surgical technique
According to Olivi et al, clinical indications for frenum Armamentarium - no.15 surgical blade, Haemostat,
removal include: 8 Gauze, 5-0 black silk sutures, Needle holder, suture cutting
scissors and a periodontal dressing.
1. Abnormal frenum with inflamed gingiva due to poor Procedure: 9 (Figure 2)
oral hygiene 2% lignocaine with 1:80000 adrenaline was used as an
2. Abnormal frenum associated with inflamed gingival local infiltration to anaesthetized the area. To separate the
recession frenulum from the interdental papilla a horizontal incision
3. Maxillary frenum associated with Diastema after was made. This incision was extended apically up to the
complete eruption of permanent canines vestibular depth to completely separate the frenum from the
4. Abnormal maxillary frenum (Class III or IV), resulting alveolar mucosa. (Any remnant of frenum tissue in the mid
in the presence of a diastema during mixed dentition. line and on the under surface of lip was excised). 2-3 mm
5. Abnormal mandibular frenum with high insertion apical to marginal gingiva up to vestibular depth ,an vertical
leads to the onset of gingival recession parallel incision was made on the mesial side of lateral
incisor The gingiva and alveolar mucosa in between these
The treatment of the aberrant frena can be either done two incisions were undermined by partial dissection to raise
by frenectomy or by frenotomy procedures. Frenectomy is the flap. 1-2 mm apical to gingival sulcus in the attached
defined as the complete removal of the frenum, with its gingiva a horizontal incision was made, connecting the
attachment to the underlying bone, while Frenotomy is the coronal ends of the two vertical incisions. Flap was raised,
relocation of the frenal attachment. 9 mobilised mesially and sutured to obtain primary closure
There are various surgical techniques of frenectomy across the midline. Postoperative instructions were given to
which include Classical frenectomy by Archer and the patient. Patient was recalled 1 week postoperatively for
Kruger, Millers technique (unilateral single pedicle flap), the removal of the sutures.
Schuchardt Z-plasty, V-Y Plasty, Frenectomy using
electrocautery, Laser – Diode,CO2, Nd:YAG, Er:YAG and
2.2. Post-operative care and follow up
other soft tissue lasers.
The main drawback of the classical frenectomy Patient was asked not to consume any hot and spicy food.
technique is scarring which may lead to periodontal Patient was prescribed analgesic for 3 days and was recalled
problems and unesthetic appearance. after 7 days for suture removal.
 Bhosale et al. / IP International Journal of Periodontology and Implantology 2020;5(4):177–180 179

no relapse of diastema was seen and in only three cases

minimal relapse (less than 1 mm) was noted. He suggested
that the reopening of diastema was prevented by the newly
formed broad attached gingiva which contains collagenous
fibres which may have a bracing effect. According to Miller
theideal time for performing this surgery must be after
orthodontic movement is completed and about six weeks
before appliances are removed. 7
The Millers technique offers two distinct advantages.
Firstly, on healing, there is no anesthetic scar formation as
a continuous band of gingiva ids formed across the midline
and secondly there is no trauma to the interdental papilla as
the trans-septal fibres are not disrupted surgically.
In a study done by Nirwal Anubh et al, 12 performed
frenectomy using laterally displaced pedicle graft. They
achieved esthetically pleasing result as there was no loss
of interdental papilla and no scar formation in the midline.
Similar results were obtained in the present case report with
good colour match.
A similar study was conducted by Ameet Mani et al 13
and Devishree et al 14 where they performed lateral pedicle
frenectomy. They too observed that healing was by primary
intention without any scaring in the midline.
In our case report, postoperatively we were able to
achieve esthetically pleasing result without scar formation.
Assessment of Pain was done using the Visual analogue
scale during and after 24and 72 hrs. Mild to moderate
pain was there during and soon after the procedure. Post
operative review after 2 days reveals absence of pain in the
Fig. 2: surgical site. 15

4. Conclusion
3. Discussion
The present case report describes the Millers surgical
To create more functional and aesthetic results more
technique i.e., frenectomy with a lateral pedicle graft. The
conservative and precise techniques are being adopted in
main advantage of this techniques is that the healing takes
this era of periodontal plastic surgery, 10 Management of
place by primary intention, a thick zone of attached gingiva
abnormal frenal attachment started from Archers classical
is formed, the colour matches with the adjacent tissue, no
frenectomy to modern concepts by Edwards. To evade
scarring takes place and there is no loss of interdental papilla
the formation of scar and to facilitate healing, application
as the transseptal fibers are not severed. We were able to
of laser and soft tissue grafts helped in evolving the
achieve the above in our Case. More Comparative studies
newer frenectomy procedures. 11 The features that help
need to be done.
in assessment of a frenum are vestibular depth, attached
gingival zone, interdental papilla and midline diastema.
An adequate zone of attach gingival gives an aesthetically 5. Source of Funding
pleasing appearance and also help in the avoidance of None.
recession which necessitates removal of the same. 11
Frenum is said to be pathogenic when it is unusually wide 6. Conflicts of interest
or there is no apparent zone of attached gingiva along the
midline or the interdental papilla shifts when the frenum is The authors declare no conflicts of interest in the present
extended. 7 study
In a study conducted by Miller on 27 subjects with
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