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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]