Frenectomy with Laterally Displaced Flap: A Case Report

 

Dr. Arvina. R¹, Dr. Vinoth Kumar. B. Na²

¹Senior Lecturer, Department of Periodontology, Saveetha Dental College and Hospitals, Chennai.

²Final Year Post Graduate, Department of Periodontology, Indira Gandhi Institute of Dental Sciences, Pondicherry

 

ABSTRACT:

The frenum is a mucous membrane fold that attaches the lip and the cheek to the alveolar mucosa, the gingiva and the underlying periosteum. An aberrant frenum may jeopardize the gingival health when they are attached too closely to the gingival margin, either due to an interference in the plaque control or due to a muscle pull. In addition to this, an aberrant maxillary labial frenum may result in diastema and recession resulting in compromised aesthetics. The management of such an aberrant frenum is accomplished by performing frenectomy. The “classical frenectomy” technique is an extensive procedure exposing the alveolar bone and thus leading to scar formation. To minimize these defects, Miller proposed a frenectomy technique combined with a laterally positioned pedicle graft. This article presents a case report of aberrant frenum which was corrected using frenectomy with laterally displaced flap technique.

 

 

 

INTRODUCTION:

Esthetics is always a major concern for both the patient and the dentist. Presence of diastema between maxillary anterior teeth is often considered as onerous esthetic problem. The most common factor associated with maxillary midline diastema is a hypertropic labial frenum.

 

A frenum is a mucous membrane fold which contains muscle and connective tissue fibres that attach the lip and the cheek to the alveolar mucosa, the gingiva and the underlying periosteum.⁽¹⁾ Placek et al (1974)⁽²⁾ classified frenum depending upon the extension of attachment of fibres,

 

1.     Mucosal–when the frenal fibres are attached upto mucogingival junction.

2.     Gingival–when fibres are inserted within attached gingiva.

3.     Papillary–when fibres are extending into interdental papilla; and

4.     Papilla penetrating-when the frenal fibres cross the alveolar process and extend upto palatine papilla.

 

Frenum may affect the gingival health when they are attached too closely to the gingival margin, either due to an interference in the plaque control or due to a muscle pull. Clinically, papillary and papilla penetrating frena are considered as pathological and have been found to be associated with papillary loss, recession, diastema, difficulty in brushing and malalignment of teeth.

 

The aberrant frenum can be treated by frenectomy or by frenotomy procedures. Frenectomy is the complete removal of the frenum, including its attachment to the underlying bone, while frenotomy is the incision and the relocation of the frenal attachment.⁽³⁾ There are numerous frenectomy techniques for the correction of aberrant frenum. The commonly used technique is the “classical frenectomy” by Archer⁽⁴⁾ and Kruger,⁽⁵⁾ where the complete frenum is excised. But it has a major disadvantage of labial tissue scarring which might be unaesthetic⁽⁶⁾ and be a matter of concern in case of high smile line exposing the anterior gingiva. To overcome this limitation, Miller in 1985 advocated a surgical technique combining frenectomy with a laterally displaced flap.⁽⁷⁾ Esthetically acceptable attached gingiva across the midline was attained by laterally positioned gingiva and wound healing occurs by primary intention. In this technique, no attempt was made to dissect the transseptal fibers and hence interdental papilla remain undisturbed. This article presents a case report of aberrant frenum which was corrected using frenectomy with laterally displaced flap technique.

 

Case Report:

A 25 year old female reported with the complaint of spacing between the upper front teeth which was initially minimal and gradually increased to the present state since 6 months. On examination, the patient was systemically and periodontally healthy. On clinical examination, aberrant labial frenum associated with midline diastema in relation to maxillary anterior teeth was detected (Fig.No.1). Tension test was positive and hence frenectomy procedure was planned. Scaling and root planning as phase I therapy was carried out. Patient was explained about the frenectomy procedure and written consent was obtained.

 

Surgical Procedure:

After local anesthesia, using 2% lignocaine with 1;80000 adrenaline, primary incision was given at the base of the papilla and extended to the depth of vestibule to separate the frenum from underlying alveolar mucosa (Fig. No.2). Any remnant of frenal tissue in the midline was excised. A vertical incision parallel to the primary incision was given on the mesial side of lateral incisor, 2-3mm apical to marginal gingiva, upto vestibular depth (Fig.No.3). The gingiva and alveolar mucosa in between these two incisions were undermined by partial dissection to raise the flap (Fig.No.4). A horizontal incision was then given 1-2 mm apical to gingival sulcus in the attached gingiva connecting the coronal ends of the two vertical incisions. Flap was raised, mobilized mesially and sutured to obtain primary closure across the midline (Fig.No.5). No attempt was made to dissect transseptal fibers between approximating central incisors. Periodontal dressing was given in the surgical site. Post operative instructions were given. Antibiotics and analgesics were prescribed.

 

After 1 week sutures were removed, healing was uneventful and no post operative complications were noticed. A healing zone of attached gingiva with no loss of interdental papilla was observed.

 

 

The patient was followed for three months and at the end of three months healing was satisfactory, a wider zone of attached gingiva with no scarring in the midline was clearly visible. The colour matched well with the adjacent tissue. No loss of interdental papilla was observed (Fig.No.6).

 

 

Fig.No.1: Pre-operative

 

 

Fig.No.2: Excised frenum site

 

 

Fig.No.3: Vertical incision mesial to lateral incisor

 

 

Fig.No.4: Undermining of the pedicle

 

 

Fig.No.5: Lateral displacement and suturing of the pedicle

 

Fig.No.6: 3 months post operative

 

DISCUSSION:

The prevalence of different types of the frenum attachment and its significance in periodontal health is an important aspect of treatment plan. Aberrant frenum has been considered detrimental to periodontal health by pulling away the gingival margin from the tooth and thus contributing to accumulation of plaque and calculus, leading to periodontal inflammation. The management of aberrant frenum has travelled a long way from Archer's and Kruger's “classical technique”^(4,5) to Edward's⁽⁸⁾ more conservative approach. Till date, there are so many modifications of classical technique to create more functional and aesthetic results and to avoid scar tissue formation. Vestibular depth, attached gingival zone, interdental papilla and midline diastema are the features that help in assessment of a frenum. An adequate zone of attached gingiva gives an esthetically pleasing appearance and also helps in the avoidance of recession.

 

In this context, Miller's technique combined with a laterally positioned pedicle graft was attempted in this case due to its salient features. This technique offers two distinct advantages. First, on healing, there is a continuous band of gingiva across the midline rather than unesthetic scar. The second advantage is that transseptal fibers are not disrupted surgically to avoid any trauma to interdental papilla. This prevents loss of interdental papilla.

 

Hungund S et al⁽⁹⁾ compared classical technique, Miller's technique using unilateral pedicle flap and frenectomy technique using bilateral pedicle flap and reported that the classical frenectomy failed to provide pleasing esthetic result whereas, frenectomy technique using pedicle flap resulted in good aesthetic results, colour match, gain in attached gingiva and no scar formation as healing takes place by primary intention. In the case of our patient, similar results were obtained.

 

Similarly, Chaubey K et al⁽¹⁰⁾ showed the same result with a scar free esthetic zone without loss of interdental papilla when frenectomy procedure using lateral pedicle graft was performed. Mani A et al⁽¹¹⁾ and Devishree SK et al⁽¹²⁾ in their studies using lateral pedicle frenectomy also observed that healing by primary intention did not cause scarring.

 

In the case of our patient, frenum was assessed for aesthetic appearance after three months. The healing was satisfactory, a wider zone of attached gingiva with no scarring in the midline was clearly visible. The colour matched well with the adjacent tissue. No loss of interdental papilla was observed.

 

CONCLUSION:

Miller’s technique for frenectomy results in formation of wider zone of attached gingiva, good colour match and interdental papilla remained undisturbed. Hence the Miller’s technique can be used as an effective means to eliminate aberrant frenum with predictable esthetic outcome. However, the advantages of Miller’s technique for frenectomy over the classical technique can be better established with comparative clinical studies using both techniques.

 

REFERENCES:

1.      Henry SW, Levin MP, Tsaknis PJ. Histological features of superior labial frenum. J Periodontol 1976; 47: 25-28.

2.      Placek M, Miroslavs, Mrklas L. Significance of the labial frenal attachment in periodontal disease in man. Part 1: Classification and epidemiology of the labial frenum attachment. J Periodontol 1974; 45: 891-94.

3.      Dibart S, Karima M. Labial frenectomy alone or in combination with a free gingival autograft. In: Serge Dibart, Mamdouth Karima (eds) Practical Periodontal Plastic Surgery. Germany: Blackwell Munksgaard: p53.

4.      Archer W H (ed). Oral surgery- a step by step atlas of operative techniques, 3rd edition. Philedelphia ,W B Saunders Co.,1961; 192.

5.      Kruger GO (ed). Oral surgery, 2nd edition. St. Louis, The C.V. Mosby Co.,1964;146.

6.      Jhaveri H. The Aberrant Frenum. In: Dr. Hiral Jhaveri, Dr. PD Miller the father of periodontal plastic surgery, 2006; 29-34.

7.      Miller PD. The frenectomy combined with a laterally positioned pedicle graft: Functional and aesthetic consideration. J Periodontol1985; 56: 102-6. 

8.      Edwards JG. The diastema, the frenum, the frenectomy: A clinical study. Am J Ortho 1977; 71: 489-508.

9.      Hungund S, Dodani K, Kambalyal P, Kambalyal P. Comparative results of frenectomy by three surgical techniques-conventional, unilateral displaced pedicle flap and bilateral displaced pedicle flap. Dentistry 2013; 4(183): 183.

10.   Chaubey KK, Arora VK, Thakur R, Narula IS. Perio-esthetic surgery: Using LPF with frenectomy for prevention of scar. J Indian Soc Periodontol 2011; 15(3): 265.

11.   Mani A, Marawar P, Furtado L, Furtado LF, Loni T, Ahmednagar RD. Frenectomy with laterally displaced flap: a Case Report. International Dental Journal of Students Research. 2012; 1(3): 63-6.

12.   Devishree SK, Shubhashini PV. Frenectomy: A review with the reports of surgical techniques. J Clin Diagn Res 2012; 6(9): 1587.

 

 

 

Accepted on 20.05.2019           © RJPT All right reserved

Research J. Pharm. and Tech 2019; 12(8):3669-3671