Q U I N T E S S E N C E I N T E R N AT I O N A L

GENERAL DENTISTRY/ORAL SURGERY

Facts and myths regarding the maxillary midline

frenum and its treatment: A systematic review of
the literature
Konstantina Delli, DMD1/Christos Livas, DMD2/Anton Sculean, Prof Dr
Med Dent3/Christos Katsaros, Prof Dr Med Dent4/Michael M. Bornstein,
PD Dr Med Dent5

Objective: To systematically review the current literature on the maxillary midline frenum
and associated conditions and complications, as well as the recommended treatment
options. Method and Materials:
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provide evidence about the epidemiology, associated pathologies, and treatment options
regarding the maxillary frenum. Of the 206 initially identified articles, 48 met the inclusion
criteria. Results: The maxillary frenum is highly associated with a number of syndromes
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of the midline diastema. There is also a tendency by orthodontists to suggest posttreat-
ment removal of the frenum (frenectomy). Studies on the cause of gingival recession due
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traumas and doubtful history might point to child abuse. The involvement of hyperplastic
frena in the pathogenesis of peri-implant diseases remains uncertain. There seems to be a
clinical interest regarding lasers for surgery for treatment of maxillary frena. The superiority
of laser treatment in relation to conventional surgical methods has not yet been demon-
strated in the literature. Conclusion:
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syndromic conditions and plays a role in the development of the median midline diastema.
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of the maxillary incisors is rather controversial. Laser techniques are reported as the
method of choice for the surgical removal of frena; however, this needs to be substanti-
ated by appropriate prospective controlled studies. (Quintessence Int 2013;44:177–187)

Key words: frenectomy, gingival recession, maxillary frenum, midline diastema,

peri-implantitis

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dible and maxilla, usually in the midline or

membrane that attaches the lips and cheeks
to the alveolar process and limits their
movements.1 Frena are most prominently
found in the vestibular mucosa of the man-
1 Research Fellow, Department of Oral Surgery and Stomatology,
University of Bern, Bern, Switzerland.
2 Research Fellow, Department of Orthodontics and Dentofacial
Orthopedics, University of Bern, Bern, Switzerland.
3 Professor and Head, Department of Periodontology, University
of Bern, Bern, Switzerland.
4 Professor and Head, Department of Orthodontics and
Dentofacial Orthopedics, University of Bern, Bern, Switzerland.
5 Assistant Professor, Department of Oral Surgery
Stomatology, University of Bern, Bern, Switzerland.
Correspondence: PD Dr Michael M. Bornstein, Department of
Oral Surgery and Stomatology, Freiburgstrasse 7, 3010 Bern,
Switzerland. Email: michael.bornstein@zmk.unibe.ch
premolar region. In the mandible, a frenum
is generally also present lingually to the
central incisors with a connection into the
body of the tongue.2 The maxillary midline
frenum connects the mucosa of the maxil-
lary alveolar process and central incisors to
the upper lip. It originates as a remnant of
the tectolabial bands, which are embryonic
structures and connect the tubercle of the
upper lip to the palatine papilla. 3
Histologically, it contains elastic fibers and
collagen tissue components, although stri-
ated (skeletal) muscle fibers are frequently
found in biopsy specimens.4
and
The maxillary frenum is a dynamic struc-
ture, subjected to alterations in shape, size,
and position during the stages of human
growth and development. Generally, it

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Delli et al
Table 1 Different classifications of maxillary midline frenum
Study Type of study n Method of assessment
Sewerin7 Case series 1430 Inspection
Mirko et al8 Case series 465 Inspection
tends to diminish in size over the course of
life.5 The eruption of the permanent incisors,
the development of the maxillary sinus, and
the growth of the alveolar process all result
in a more coronal insertion of the frenum.6
Two approaches were presented in the
literature to categorize the various types of
maxillary midline frena according to mor-
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attempt was made by Sewerin, who recom-
mended that the labial frenum should be
divided into eight categories.7 In 1974,
Mirko et al8 suggested a new classification
based on the interaction between the fre-
num and the periodontium of the maxillary
incisors. Four types of frena were suggest-
ed, according to the site of the attachment:
mucosal, gingival, papillary, or papillary
penetrating8 (Figs 1 and 2). This classifica-
tion has gained wide acceptance and is
commonly used by periodontists and ortho-
dontists alike.
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of interest to orthodontists, periodontists,
and oral surgeons alike, there is no study
available in the literature focusing on the
various phenotypes of the maxillary frenum,
their associated problems and conditions,
or the recommended treatment strategies.
Clinicians seem to substantiate their deci-
sions on their experience and low-evidence
178
Classification
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Frenum with appendix
Frenum with nodule
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Coincidence of two or more of the above
Mucosal frenum attachment
Gingival frenum attachment
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data. The aim of the present study is to illu-
minate all of these aspects and identify
evidence based information provided by
the contemporary scientific literature.
SEARCH STRATEGY
The authors conducted a search using the
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out for the same time period, using the com-
bination of the following Medical Subject
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Only clinical articles were included and
evaluated. The authors considered clinical
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 Q U I N T E S S E N C E I N T E R N AT I O N A L
Delli et al

a b
Fig 1 Clinical example of a papillary frenum attachment in a 16-year-old boy referred for frenectomy. (a)
Buccal and (b) occlusal views.

a b
Fig 2 Clinical example of a papillary penetrating frenum attachment in a 9-year-old girl referred for frenec-
tomy. (a) Buccal and (b) occlusal views.

studies including case reports, if they abstracts was 0.87. For the abstracts that
reported on the following subjects: met the inclusion criteria, the respective full
t
Epidemiologic data including preva- text was thoroughly studied. Finally, refer-
lence and etiology ence lists of the retained publications were
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scanned for additional relevant articles that
(ie, median diastema, gingival reces- might have been missed in the initial data-
sion, diminished retention and stability base search. The details of the literature
of removable dentures, peri-implantitis, search strategy are presented in Fig 3.
syndromes, and child abuse) The quality of each study was assessed
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to the classification for Evidence-based
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screened to identify duplicates and articles The criteria applied in the grading of the
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Delli et al

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Maxillary frenum Etiology (n = 119)

Maxillary frenulum
First screening (n = 97)
Labial frenum 1SPCMFNT
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Labial frenulum and complications (n = 69)

Therapy and
Treatment (n = 229)

Included
articles (n = 48)
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Embryology
Labial frenum
Second screening (n =109)
(MeSH terms)
Growth and development

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Surgery

Fig 3 Flowchart visualizing the search strategy.

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case-controlled studies; 4, case series and There are numerous syndromes described
poor quality cohort and case-controlled in the literature that characteristically exhib-
studies; and 5, expert opinions. it variations of the norm of maxillary midline
frenum phenotype (Table 3). Our search
resulted in three retrospective observational
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14-16 and three case
EPIDEMIOLOGY reports (grade 4).17-19

Eight retrospective observational studies

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6-13 were MAXILLARY FRENUM AND
retrieved to investigate the prevalence of MIDLINE DIASTEMA
the different phenotypes of maxillary midline
frena among different age groups, using
one of the classification systems mentioned The maxillary midline diastema, located
above.7,8 The most common frenum types between the maxillary central incisors, is
were the mucosal or gingival types (Table 2). relatively common during the mixed denti-

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Table 2 Phenotype of maxillary midline frena according to Mirko’s classification8

Frenum type Mirko et al8 Lindsey9 Addy et al10 Kaimenyi11 Boutsi & Tatakis12 Janczuk & Banach13
Mucosal 46.5% - 19.5% 26% 10.2% 39%
Gingival 34.3% - 76.6% 50% 41.6% 36%
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16.1% 43% (infants) 24% 26.1% 5%
penetrating 14% (children with 6 permanent
anterior teeth)
≥7% (adults with all maxillary
permanent teeth)

Table 3 Syndromes that characteristically exhibit variations of the norm in maxil-

lary midline frenum phenotype

Syndrome Type of maxillary frenum Clinical importance

&IMFST%BOMPT14 "CTFOU Indication to identify newborns at risk
Holoprosencephaly 15
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Turner16 Gingival, papillary, or pene- -
trating frenum attachment
False median cleft "CTFOU Helps to differentiate true, false, or intermediate cleft
of the upper lip17
Orofacial-digital18 Hyperplastic Minimum diagnostic criterion
Ellis van Creveld19 Hyperplastic The most prominent oral finding

tion stage. However, a midline diastema
wider than 2 mm rarely closes spontane-
ously during further development. This per-
sistent presence has long been considered
a pathologic entity and dental abnormality.9
The current search strategy came up with
one prospective observational study (grade
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20 four retrospective observational stud-
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21-24 and one case report
(grade 4).25

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Histologic studies have revealed that
bundles of transseptal fibers of the peri-
odontal ligament are normally
between the central incisors.
fibers of certain labial frena disrupt these
transseptal fibers, and this disruption is
related to midline diastema.21
The management of midline diastema
usually involves orthodontic
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heavy orthodontic forces also deprive the
transseptal fibers of sufficient blood supply.
Thus, completely new transseptal fibers are
formed, replacing the old ones, which were
destroyed by ischemia.23 Therefore, it is
suggested that the hypertrophic frenum
should be removed only after the comple-
tion of the active treatment, since the newly
developed tissue is expected to contribute
to the retention of the final outcome.
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ies that have evaluated this hypothesis.
In rare cases, the maxillary frenum is
found exceptionally hypertrophic, inhibiting the
Collagen orthodontic closure or becoming trauma-
tized and painful. In these cases, it is
advised to surgically remove it before the
end of the orthodontic therapy.25
Furthermore, it has been shown that the
treatment. removal of the frenum before orthodontics
leads to a more rapid crown approximation
of the incisors. However, this method is not

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Delli et al
widely accepted, because an abundance

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of granulation tissue may complicate dia-
stema closure.24
MAXILLARY FRENUM AND
GINGIVAL RECESSION
Gingival recession is characterized
exposure of the root of the affected tooth,
which occurs when the gingival margin
moves apically from the cementoenamel
30
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and three case reports (grade 4).31-33 The
observed a relationship between the attach-
ment of the frenum and periodontal dis-
ease.26 This systematic review considered
three retrospective observational studies
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(grade 5).2,29
It has been reported that when the
attachment of a maxillary frenum is very
pronounced and also exhibits a crestal
insertion point close to the gingival margin
of the incisors, it can retract the marginal
gingiva or papilla, thus contributing to the
initiation or progression of periodontal dis-

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ease.2 Furthermore, oral hygiene proce-
dures may be complicated and the accu-
mulation and retention of plaque may be
promoted when the periodontal pocket is
pulled and opened, allowing food debris to
enter more readily.29
Mirko et al found that certain types of
maxillary frenum influence periodontal con-
dition. The periodontal resistance was sig-
nificantly lower in cases of gingival, papillary,
and papillary-penetrating types of maxillary
frenum attachment in persons with patho-
logic changes in the papilla in comparison to

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persons with the same type of attachment
37-40 and
but with healthy papilla.
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27
recent study revealed that the correlation
between a maxillary frenum with crestal
attachment and the gingival recession was
more pronounced in men than women.28 In
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BM10 reported that plaque wearers are affected by these lesions.38
and bleeding scores of the maxillary incisors
decreased when increasing the proximity of
the frenum to the gingival margin. Therefore,
they support that the position of the maxil-
lary frenum is not relevant for plaque accu-
mulation and gingivitis.10
182
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ing a clear cause-and-effect relationship
between the presence of an abnormal max-
illary frenum and gingival recession are
lacking.
MAXILLARY FRENUM AND
CHILD ABUSE
by
Our literature screening revealed one retro-
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maxillary frenum can be accidentally torn in
falls during the early stages of walking,31 in
car accidents with airbag deployment,34 or
after cardiopulmonary resuscitation. 35
that tears of the frenum are one of the most
frequent intraoral findings in child abuse.31-33
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that there are no studies comparing the
incidence of torn frena in abused and non-
abused children. Therefore, a torn frenum
alone cannot be considered pathogno-
monic of child abuse.36
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presence of this condition, especially in
combination with signs of trauma on other
parts of the body without conclusive anam-
nestic data, should alert health care profes-
sionals.
MAXILLARY FRENUM AND
DENTURES
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one case report (grade 4)41 were found.
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denture, denture-induced lesions are the
most common complaint. It has been
shown that 45% of full maxillary denture
They usually appear at the frena (midline
and lateral) and the regions of muscular
attachment.39
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that the most frequent areas of denture-
induced irritations in the maxilla were the
vestibular sulcus between the midline and
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Table 4 Analysis of the articles with a high level of evidence
Author Patients
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Haytac & Ozcelik 48 40
clinicial trials
Kara49 40
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Clinical trials Kahnberg45 30
Genovese & Olivi 47 50
lateral frenum (44%), followed by the maxil-
lary tuberosity (37%).40
In patients wearing dentures for many
years, frena tend to migrate to the crest,
probably due to the reduction of the height
of the residual ridge.41 One report docu-
menting instability of dentures due to a fre-
num concerned the hamular frenum.42 It
may be that clinicians, when taking impres-
sions, are particularly cautious of the maxil-
lary midline frenum area or that problems
caused by the maxillary frenum are noted
and modified already in the early stages of
manufacturing of the denture.
MAXILLARY FRENUM AND
PERI-IMPLANT DISEASES
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frenum, while in frenotomy, the frenum is
two case reports (grade 4)43,44 could be
retrieved.
Otto and Gluckman43 proposed that

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muscles and active frenum should be care-
fully examined as potential cofactors for
peri-mucositis and peri-implantitis, and in
the case of a pull, they should be surgically
45,47
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48-50 two ret-
removed. They additionally suggested that
the best technique is vestibuloplasty, where
51,52 and five case reports (grade 4)53-57
a split-thickness flap is sutured in the lower
level of the vestibule, combined, for better
results, with an epithelial transplant from the
palate to augment the attached gingiva.43
1BSL44 has published a case report describ-
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Delli et al
Results
Carbon dioxide laser treatment offers less postoperative pain
and functional complications than the scalpel technique
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than conventional surgery
980-nm diode laser in oral surgery is efficient, safe, and well
accepted by patients
Z-plasty is the technique that mostly reduces the frenum height
Erbium lasers are very effective in pediatric dentistry
ing a technique to correct the frenal pull
and to increase the width of keratinized
mucosa around implants in the maxillary left
molar area.
MAXILLARY FRENUM AND
FRENECTOMY
The indications for surgical removal of
the maxillary midline frenum are usually the
following45: prevention of median diastema
formation, prevention of postorthodontic
relapse of a median diastema, facilitation of
oral hygiene procedures, and prevention of
gingival recession (although maxillary fre-
num have never been clearly shown to lead
to recession) .
Frenectomy implies total removal of the
partially removed. These techniques are
also classified as excisional (total removal
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alteration of the frenum’s normal position).46
With regard to frenectomy, the present
review identified two clinical trials (grade
#
rospective observational studies (grade
#
(Table 4).
Various surgical techniques have been
proposed by clinicians (Table 5). The sim-
plest method is performed with two parallel
incisions on each side of the frenum joined
183
Q U I N T E S S E N C E I N T E R N AT I O N A L
Delli et al

Table 5 Surgical techniques for frenectomy

Type of technique Advantages Disadvantages

7TIBQFE"SDIFS
JODJTJPO Easy to perform Scar tissue formation
diamond incision45 Loss of papilla
High relapse rate
Z-plasty45 Less scar formation Surgically demanding
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Vestibular sulcus - High relapse rate
extension45
Morselli et al53 Less tissue contracture Surgically demanding
Less scar formation
Less healing time
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Minimal scar tissue formation attached gingiva

in the vestibule by a scissor cut. The wound "EEJUJPOBMMZ
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edges are closed with a single suture.
This technique, known also as a V-shaped
JODJTJPO

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EJBNPOE recently reported a modified V-shape tech-
shaped incision, is reported to leave a scar
contracture that can lead to periodontal
problems, as well as loss of the interdental
papilla between the maxillary central inci-
sors.53
In the Z-plasty incision, a vertical inci-
sion is made along the frenum from the
gingival margin to the vestibule. Then two
incisions are made at each end of the pri-
mary incision at an angle of 60 degrees,
pointing in opposite directions, forming
Z-shaped incisions. The two mucosal flaps,
without periosteum, are elevated and
sutured in a reverse position.45 This tech-
nique permits better distribution of the scar
contracture lines, but is more complicated
and aggressive than the V-shape
approach.53

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Kahnberg45 also described the vestibu-

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lar sulcus extension, where a horizontal

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incision reaching the periosteum is made 2
to 3 mm beneath the gingival margin,

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extending from one maxillary canine to the
other. The elevated mucosal flap is then
positioned apically and sutured to the peri-
osteum. The wound area is usually covered
with a surgical pack. However, this proce-
dure has a high rate of relapse, and its use
is consequently limited. 45
45 technique inspired by upper labial rhino-
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nique in cases of high esthetic require-
ments. Two triangular pedicles are sutured
together medially and completely cover the
V-shaped region, inducing healing by pri-
mary intention and minimizing scar forma-
tion.
Often, frenectomy is combined with the
use of a laterally positioned flap or free gin-
gival grafts to minimize relapse or exces-
sive scar formation and maximize esthetic
results.55,56 In cases of minimal esthetic
concerns, a palatal mucosal graft can be
used, since it creates a tire-patch or tattoo-
like appearance in the grafted area.54
The use of lasers for frenectomy has
been promoted recently, and diode laser,
neodymium-doped: yttrium, aluminum and
HBSOFU
/E:"(
&S:"(
/FWFSUIFMFTT
probably the most frequently used57,58 (see
'JH

when frenectomy is executed with lasers,
the patient experiences markedly less
bleeding during surgery, no need for
sutures or periodontal dressing,57 fewer
functional complications,48,49 minimal swell-
ing, less discomfort,50 and requires fewer
analgesics than when a scalpel frenectomy
was performed.49

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 Q U I N T E S S E N C E I N T E R N AT I O N A L
Delli et al

a b

c d
Fig 4 The use of lasers for frenectomy has been promoted, and the carbon dioxide laser is most frequently
used. (a) Initial clinical aspect, (b) immediately after carbon dioxide laser surgery, (c) 1 month after interven-
tion, and (d) 1 year after the intervention.

CONCLUSIONS #BTFE
PO
UIF
BWBJMBCMF
EBUB
JU
DBO
CF

To the best of our knowledge, the current
systematic review is the first in the literature
to address the prevalence of different phe-
notypes, associated complications, and
treatment of the maxillary midline frenum.
The most common types of article analyzed
for this study were reviews and case reports.
Only three randomized controlled trials
were found, two concerning the patients’
perception during frenectomy using carbon
dioxide laser vs scalpel48,49 and one con-
cerning the safety and efficacy of 980 nm
diode laser in oral surgery.50 Therefore, cur-
rent therapeutic concepts have to be con-
sidered as not being based on high levels
of evidence.
suggested that:
t
"COPSNBMJUJFT
PG
UIF
NBYJMMBSZ
GSFOVN

are present in numerous syndromes.
t
"
IZQFSUSPQIJD
NBYJMMBSZ
GSFOVN
JT
IJHIMZ

associated with a midline diastema.
"MUIPVHI
DMJOJDJBOT
BOE
SFTFBSDIFST

suggest that its removal should be per-
formed after the completion of the orth-
odontic therapy, this hypothesis is not
based on any controlled studies.
t
The involvement of the maxillary frenum
in the formation and promotion of gingi-
val recessions of the maxillary incisors is
not clear.
t
"
UPSO
NBYJMMBSZ
GSFOVN
NJHIU
CF
B
TJHO

of abuse.
t
The maxillary frenum rarely causes
problems in removable denture reten-
tion and stability.

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Delli et al
t
The involvement of hyperplastic frena in
the pathogenesis of peri-mucositis and
peri-implantitis is questionable and has
only been reported on an anecdotal
basis.
t
Various surgical techniques have been
proposed for successful removal of the
maxillary frenum. The use of lasers is
JODSFBTJOHMZ
QPQVMBS
/FWFSUIFMFTT

2011;21:284-288.
more randomized controlled trials with
clear outcome parameters are needed
to demonstrate potential benefits of laser
vs scalpel use for surgical therapy.
ACKNOWLEDGMENT
The authors would like to thank Mrs Brigitte Leuenberger,
librarian at the School of Dental Medicine at the
University of Bern, Switzerland, for her assistance during
the literature search.
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