Frenum attachment and it's management.

Frenum attachment and it's management. Classification. Syndromes. Treatment.

1. FRENUM ATTACHMENT AND IT’S MANAGEMENT. DR BHAUMIK THAKKAR. PART II P.G. DEPT OF PERIODONTOLOGY.

2. CONTENTS INTRODUCTION DEVELOPMENT TYPES OF FRENAL ATTACHMENT VARIATIONS DIAGNOSIS ANKYLOGLOSSIA COMPLICATIONS OF ANKYLOGLOSSIA CLASSIFICATION SYNDROMES ASSOCIATED WITH ABNORMAL FRENUM COMPLICATIONS OF ABNORMAL FRENUM TREATMENT CONCLUSION REFERENCES

3. INTRODUCTION What is a frenum? Frenum is a thin fold of mucous membrane with enclosed muscle fibers that attach the lips to the alveolar mucosa and underlying periosteum . ( Carranza 10 th edition) A frenulum is a small frenum. There are several frena that are usually present in a normal oral cavity, most notably the maxillary labial frenum, the mandibular labial frenum, and the lingual frenum. Their primary function is to provide stability of the upper and lower lip and the tongue.

4. Development The maxillary labial frenum develops as a post eruptive remnant of the ectolabial bands which connects the tubercle of the upper lip into the palatine papilla . It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration.

5. TYPES OF FRENAL ATTACHMENT Depending upon the extent of attachment of fibres, frena have been classified by Placek et al. 1974 as: MUCOSAL - T he frenal fibres are attached up to the mucogingival junction. GINGIVAL - T he fibres are inserted within the attached gingiva. PAPILLARY - T he fibres extend into the interdental papilla. PAPILLA PENETRATING - The frenal fibres cross the alveolar process and extend up to palatine papilla.

6. VARIATIONS Other variations of normal frenal attachment Include: • Simple frenum with a nodule • Simple frenum with appendix • Simple frenum with nichum • Bifid labial frenum • Persistent tectolabial frenum • Double frenum • Wider frenum

7. Mucosal frenal attachment

8. Gingival frenal attachment

9.  Papillary frenal attachment

10. Papilla penetrating frenal attachment

11. Simple frenum with a nodule

12. Simple frenum with appendix

13. Wider frenal attachment

14. Simple frenum with nichum

15. DIAGNOSIS Tests for frenal attachment: Tension Test. Blanch Test. Miller et al(1985) recommended that the frenum should be characterised as pathogenic when it is unusually wide or there is no apparent zone of attached gingiva along the midline or the interdental papilla shift when the frenum is extended .

16. ANKYLOGLOSSIA (TONGUE TIE)

17. ANKYLOGLOSSIA Ankyloglossia or tongue-tie is an uncommon congenital anomaly that occurs as a result of a short, tight, lingual frenulum causing difficulty in speech articulation due to limitation of tongue movement. WALLACE et al 1963 defined tongue-tie as “a condition in which the tip of the tongue cannot be protruded beyond the lower incisor teeth because of a short frenulum linguae, often containing scar tissue.”

18. CLINICAL FEATURES OF ANKYLOGLOSSIA Ankyloglossia leads to : Limited mobility of tongue. Difficulty in swallowing. Difficulty in speech articulation which is evident for consonants like “s, z, t, d, l, j, zh, ch, th, dg” and it is especially difficult to roll an “r”. Notched or “heart-shaped” tongue when it is protruded. FREE-TONGUE: The term free-tongue is defined as the length of tongue from the insertion of lingual frenum from the base of the tongue to the tip of the tongue. Clinically acceptable, normal range of free-tongue is greater than 16 mm . ( Kotlow et al 1999)

19. CLASSIFICATION Ankyloglossia can be classified into 4 classes based on Kotlow’s assessment in 1999 (based on length of tongue from insertion of lingual frenum at base of the tongue to the tip of the tongue) as follows: CLASS I: MILD ANKYLOGLOSSIA (12 to 16 mm) CLASS II: MODERATE ANKYLOGLOSSIA (8 to 11mm) CLASS III: SEVERE ANKYLOGLOSSIA (3 to 7 mm) CLASS IV: COMPLETE ANKYLOGLOSSIA (< 3mm)

20. SYNDROMES ASSOCIATED WITH ABNORMAL FRENUM Ehlers- Danlos syndrome  Infantile hypertrophic pyloric stenosis Holoprosencephaly Ellis-van Creveld syndrome  Oro-facial-digital syndrome

21. EHLERS-DANLOS SYNDROME It is a genetic disorder characterized by hyper extensive skin and hyper mobile joints with no gender predilection.

22. Hypermobile joint and hyper extensive skin seen in a patient with Ehlers- danlos syndrome

23. EHLER DANLOS SYNDROME ORAL MANIFESTATION DE FELICE ET AL 2001

24. INFANTILE HYPERTROPHIC PYLORIC STENOSIS Occurs commonly in males at a ratio of 4.5 to 1 with an unknown etiology . The absence or hypoplasia of mandibular frenum is seen in patients with this syndrome.

25. INFANTILE HYPERTROPHIC PYLORIC STENOSIS DE FELICE ET AL 2000

26. HOLOPROSENCEPHALY It is an autosomal dominant condition characterized by a brain malformation due to defects in prosencephalon. It is characterized by defects including cyclopia, single nostril, single central incisor and premaxillary agenesis. Absence of labial maxillary frenum is one of the characteristic features of this condition .

27. HOLOPROSENCEPHALY

28. ELLIS‑VAN CREVELD SYNDROME It is an autosomal recessive disorder mainly affecting enamel, hair and nails. Patients with this syndrome characteristically present with congenitally missing teeth, abnormal frenal attachment, microdontia and hexadactyly . The most common finding is fusion of the anterior portion of the upper lip to the maxillary gingival margin, as a result of which no mucobuccal fold exists, causing the upper lip to present a slight V-shaped notch in the middle (partial hare lip or lip-tie). The anterior portion of the lower ridge is often serrated and presents with multiple small labial frenula.

29. Oral manifestations seen in Ellis-van C reveld syndrome

30. COMPLICATIONS OF ABNORMAL FRENUM A frenum becomes a problem if the attachment is too close to the marginal gingiva. Tension on the frenum may pull the gingival margin away from the tooth. This condition may be conducive to plaque accumulation and inhibit proper tooth brushing. Abnormal frenum has been found to be associated with: Loss of papilla. Recession. Persistence of midline diastema. Difficulty in brushing. Malalignment of teeth . Compromised denture fit or retention.

31. TREATMENT Techniques for removal of aberrant frenum are : Frenotomy Frenectomy Frenectomy : Refers to the complete removal of frenum, including its attachment to the underlying bone. It is required in the correction of abnormal diastema between maxillary central incisors (Friedman 1957). Frenotomy : Is the incision of the frenum. It is usually done to relocate the frenal attachment so as to create a zone of attached gingiva between the gingival margin and the frenum.

32. FRENECTOMY INDICATIONS 1. Gingival or papillary frenal attachment : Where frenal fibres radiate into marginal gingiva producing gingival retraction and localized gingival recession. 2 . High frenal attachment: Where oral hygiene is hindered by shallow vestibule caused by high frenal attachment . 3 . A nkyloglossia: When lingual frenum interferes with speech.

33. TECHNIQUES OF FRENECTOMY Conventional (classical) frenectomy Miller’s technique V-Y plasty Z plasty Frenectomy by using electrocautery Laser frenectomy

34. CLASSICAL FRENECTOMY The classical technique was introduced by Archer et al 1961 and Kruger et al 1964. This approach was advocated in midline diastema cases with an aberrant frenum to ensure the removal of muscle fibres which were supposedly connecting the orbicularis oris with the palatine papilla.

35. hemostat Bp blade no.15 Suture pliers scissors Periodontal pack gauze

36. One month post-operative view

37. DISADVANTAGES Causes un-aesthetic labial tissue scarring. This may become a matter of concern in case of high smile line exposing the anterior gingiva.

38. MILLER’S TECHNIQUE This technique was advocated by Miller PD et al in 1985 . This was proposed for post-orthodontic diastema cases. The ideal time for performing this surgery is after the orthodontic movement is complete and about 6 weeks before the appliances are removed. This allows healing and tissue maturation.

39. 2 weeks post-operative

40. ADVANTAGES OF MILLER’S TECHNIQUE Post-operatively, on healing, there is a continuous band of gingiva across the midline, that gives a bracing effect than the scar tissue, thus preventing orthodontic relapse. The transseptal fibres are not disrupted surgically and so, there is no loss of interdental papilla.

41. Z- PLASTY TECHNIQUE This technique is indicated when: There is hypertrophy of the frenum with a low insertion, associated with distema . There is a short vestibule.

42. one month post-operative view

43. V-Y PLASTY TECHNIQUE This technique can be used for lengthening the localized area, like a broad frena . This technique is mostly employed in a case of a papilla type of frenal attachment.

44. ELECTROSURGERY This technique is recommended for patients with bleeding disorders and non-compliant patients.

45. ADVANTAGES This technique offers the advantages of: Minimal time consumption. Minimal procedural bleeding. No need of sutures. Healing is by secondary intention as the wound edges are not approximated with sutures.

46. LASER FRENECTOMY The benefits of a laser frenectomy are greater as compared to traditional techniques . These include : Reduced bleeding during surgery. R educed operating time and rapid postoperative hemostasis , thus eliminating the need for sutures. The lack of need for sutures , as well as improved postoperative comfort and healing, make this technique particularly useful for very young patients .

47. DIODE LASER UNITS

48. DIODE LASER APPLIED IMMEDIATE POST-OPERATIVE VIEW PAPILLA PENETRATING FRENAL ATTACHMENT

49. POST-OP 2 DAYS POST-OP 1 WEEK POST-OP 2MONTHS

50. POST OPERATIVE INSTRUCTIONS NOT to eat anything until the anesthesia wears off, as there are chances of biting the lips, cheek or tongue. Avoid extremely hot foods for the rest of the day and do NOT rinse out your mouth, as these will often prolong the bleeding.   If bleeding continues, apply light pressure to the area with a moistened gauze  for 20-30 minutes. F ollow a soft food diet, taking care to avoid the surgical area when chewing.  Chew on the opposite side and do NOT bite into food. Be sure to maintain adequate nutrition and drink plenty of fluids.  Do NOT use a drinking straw, as the suction may dislodge the blood clot .  Avoid alcohol and smoking until after your post-operative appointment .   Maintain normal oral hygiene measures in the areas of mouth not affected by the surgery.  In areas where there is dressing, lightly brush only the biting surfaces of the teeth . Vigorous rinsing should be avoided ! Do NOT pull down the lip or cheek.

51. CONCLUSION Frenum may not regularly draw close scrutiny on routine dental examination . While an aberrant frenum can be removed by any of the modification techniques that have been proposed, a functional and an aesthetic outcome can be achieved by a proper technique selection, based on the type of frenal attachment.

52. References. Carranza 10 th and 12 th edition. Priyanka M, Sruthi R, Ramakrishnan T, Emmadi P, Ambalavanan N. An overview of frenal attachments. J Indian Soc Periodontol 2013 Mirko P, Miroslav S, Lubor M. Significance of the labial frenum attachment in periodontal disease in man. Part I. Classification and epidemiology of the labial frenum attachment. J Periodontol 1974 Devishree et al. Journal of Clinical and Diagnostic Research. 2012 November. Kotlow LA. Oral diagnosis of abnormal frenum attachments in neonates and infants: Evaluation and treatment of maxillary frenum using the Erbium YAG Laser. J Pediatr Dent Care 2004. De Felice C, Toti P, Di Maggio G, Parinni S, Bagnoli F. Absence of the inferior labial and lingual frenula in Ehlers‑Danlos syndrome. Lancet 2001