Download Research paper : Technique of frenectomy of labial frenum

GI
CA
L SOCIETY
BALKAN JOURNAL OF STOMATOLOGY
ISSN 1107 - 1141
LO
TO
STOMA
Technique of Frenectomy of Labial Fraenum with
Combined Osteotomy at Intermaxillary Suture
SUMMARY
S. Dalampiras, C. Boutsiouki
Introduction: Maxillary midline diastema is often associated with
an abnormal labial fraenum. Labial frenectomy is a common surgical
procedure and is usually combined with orthodontic therapy for paediatric
patients.
Methods and Results: This case report describes the clinical condition
of a 14 year old patient with hypertrophied labial fraenum and maxillary
midline diastema. The treatment included frenectomy with osteotomy
combined with orthodontic therapy.
Conclusions: When an abnormal labial fraenum consists of fibrous
attachment inserting into the intermaxillary suture, frenectomy accompanied
by osteotomy seems to be the treatment of choice to prevent post-treatment
relapse.
Keywords: Frenectomy; Osteotomy; Intermaxillary suture; Maxillary midline diastema
School of Dentistry, Aristotle University of
Thessaloniki, Thessaloniki, Greece
CASE REPORT (CR)
Balk J Stom, 2012; 16:122-124
Introduction
Case Report
Maxillary labial fraenum is a normal, triangular,
anatomic structure in oral cavity, extending from
maxillary midline gingival area into the vestibule and
mid-portion of the upper lip1. Sometimes it is present
as a thick, broad, fibrous attachment (called abnormal
fraenum). Depending on the level of gingival insertion2
and the extent of trans-septal fibres chain disruption3,
this situation may lead to maxillary midline diastema
preservation at a “space-prone dentition”3. The diastema is
termed “developmental” as it can often fully or partially
close after eruption of permanent lateral incisors and
canines4 in absence of pathological aetiology. But a
wider intermaxillary suture accompanying the abnormal
fraenum sometimes implicates aetiology of diastema
preservation1. If intermaxillary suture persists due to
insufficient compressive force during canine eruption,
or due to trans-septal fibres insertion5, or if fraenum
consists of dense collagen fibres3,6, diastema closure
will relapse. Initial diastema size, familial history and
spacing in dentition are mentioned as significant pretreatment factors for possible relapse7. In order to avoid
post-treatment complications7, frenectomy combined with
osteotomy is advised5.
A 14-year-old patient was referred by the
orthodontist for management of labial fraenum (Fig. 1,
left). Clinical examination revealed the presence of an
abnormal, hypertrophied labial fraenum and midline
diastema of about 2 mm (Fig. 1, left). Blanch test
was positive3. Radiographic examination exhibited a
V-shaped radiolucency in crestal bone between central
incisors7. The need for treatment was clearly guided by
orthodontist’s instructions for combination of frenectomy
with osteotomy. Surgical procedure was performed
under local anaesthesia (lidocaine with 1:200.000
epinephrine). Technique included gaining access to
intermaxillary suture by labial rhomboidal incision with
a scalpel, which combined removal of labial fraenum
by dissection of fibrous tissue attached to the upper lip
(Fig. 1, right). Interdental papilla was not included in the
incision in terms of better aesthetic results. Osteotomy
was performed at low speed with a cylindrical bur, under
continuous irrigation with sterile water. Labial and palatal
maxillary bone cortex was included, leaving palatal
periosteum intact. The surgical procedure resulted in
local separation of right and left maxilla at width of bur
(1.6 mm - 2 mm) and at 5 mm height, starting from crestal
Balk J Stom, Vol 16, 2012
bone ridge and ending at cervical third of maxillary bone
(Fig. 1, right). Therefore, trans-septal fibre attachment
was destroyed. Sutures with 3-0 silk were made at upper
lip area, while gingival area was covered with gingival
Frenectomy with Combined Osteotomy 123
dressing (Septo-pack, Septodont). Analgesics and 0.2%
chlorhexidine mouthwash were prescribed for 5 days.
After 10 days healing was uneventful, orthodontic
treatment started and is still ongoing.
Figure 1. Left: Clinical and radiographic examination. Clinical examination reveals abnormal fraenum and midline diastema preservation after
lateral incisors and canines eruption. Radiographic image before intervention, indicating width of intermaxillary suture and V-shaped radiolucency
between maxillary central incisors, possibly due to fraenum fibre insertion. The gap is broader at the cervical third of the suture
Right: Immediate inter-surgical view. Excision of the fraenum creates rhomboidal wound. Radiographic image shows the extent of bone
removal, which is clearly guided by the need to eliminate fibrous attachment into the intermaxillary suture
Discussion
Management of maxillary midline diastema can be
treated with orthodontics, restorative dentistry, surgery
and with combinations of the above. The ideal treatment
should emphasize on the aetiology and on long-term
preservation of the therapeutic results, as it is noted that
relapses were twice as great in patients with abnormal
fraenum1.
Diastema treatment with frenectomy, fixed
orthodontic appliance and retainer, produces more stable
results, compared to treatment without frenectomy6,8.
Combination of frenectomy with osteotomy results in
stability in orthodontic closure of midline diastema5
as resistance against closure from alveolar bone is
eliminated9. Osteotomy results in de-cortication of
intermaxillary suture and elimination of possible transseptal fibres penetration5. However, trans-septal fibres can
124 S. Dalampiras, C. Boutsiouki
be reformed and create an elastic chain which preserves
tooth position and eliminates chance of displacement1,10.
Concerning gingival tissue aesthetics, in this case
interdental papilla was not violated and satisfying
aesthetic results are expected.
Conclusions
In cases of midline diastema combined with
abnormal labial fraenum and a radiographically diagnosed
persistent intermaxillary suture, frenectomy with
osteotomy seems to be the treatment of choice.
References
1. Edwards JG. The diastema, the frenum, the frenectomy. A
clinical study. Am J Orthod, 1977; 71:489-508.
2. Diaz-Pizan ME, Lagravere MO, Villena R. Midline diastema
and frenum morphology in the primary dentition. J Dent
Child (Chic), 2006; 73(1):11-14.
3. Ferguson MWJ. Pathogenesis of abnormal midlines spacing
of human central incisors. Br Dent J, 1983; 154:212-218.
Balk J Stom, Vol 16, 2012
4. Weyman J. The incidence of median diastemata during the
eruption of the permanent teeth. Dent Pract, 1967; 17:276-278.
5. Kraut RA, Payne J. Osteotomy of intermaxillary suture
for closure of median diastema. J Am Dent Assoc, 1983;
107:760-761.
6. Ziemba Z. Histomorphologic evaluation of upper lip frenum
in relation to the method of treating diastema. Ann Acad
Med Stetin, 2003; 49:353-365.
7. Shashua D, Artun J. Relapse after orthodontic correction
of maxillary median diastema: A follow-up evaluation of
consecutive cases. Angle Orthod, 1999; 69(3):257-263.
8. Antoni R, De Angelis D, Gravina GM, Accivile E. The
superior median frenulum. Surgical-orthodontic treatment of
a recurrence. Clin Ther, 1989; 130(2):95-100.
9. Bell WH. Surgical-orthodontic treatment of interincisal
diastemas. Am J Orthod, 1970; 57:158-163.
10. Stubley R. The influence of transseptal fibers on incisor
position and diastema formation. Am J Orthod, 1976;
70(6):645-652.
Correspondence and request for offprints to:
Boutsiouki Christina
Kallidopoulou 12, Faliro
54642, Thessaloniki, GREECE
E mail: [email protected]