CONTENTS

0 INTRODUCTION

0 CLASSIFICATION OF FRENI ATTACHMENT

0 DIAGNOSIS OF ABNORMAL FRENA

0 INDICATIONS
0 TREATMENT PROCEDURES 0 REFERENCES

Introduction
0 Frena are sickle shaped folds normally found in

maxillary and mandibular alveolar mucosa, in the canine premolar area and between the central incisors.

0 These folds contain (between two layers of mucous

membrane ) a variable amount of loose connective tissue with elastic and dense collagen fibers, fat cells, and occasionally acini of mucous-producing salivary glands. (Henry et al. 1976)

CLASSIFICATION
0 Frenum may be classified depending upon its

morphology as: -Long and thin -Short and broad.

0 Depending upon the attachment level, frenum

has been classified as: (Placek et al. 1974) -Mucosal: refers to attachment of frenum to the mucogingival junction. -Gingival: refers to attachment of the frenum within the attached gingiva. -Papillary: refers to attcahment of the frenum within the papilla,. -Papillary penetrating: refers to an attachment of the frenum passing through the
papilla while inserting into attached gingiva (of the palate).

DIAGNOSIS OF ABNORMAL FRENA

0 Tension Test

The abnormal frena are detected visually by applying tension over the frenum to see the movement of the papillary tip or the blanch which is produced due to ischaemia in the region.

0 The frenum is characterized as pathogenic when it is

unusually wide or when there is no apparent zone of the attached gingiva along the midline or the interdental papilla shifts when the frenum is extended.

0 A detaching movement of the marginal gingiva

transferred from the lip by the frenum has been termed the pull syndrome (Placek et al. 1974).

0 This retraction of the gingival margin has been

indicated as an etiologic factor in pathogenesis of periodontal disease.

INDICATIONS
0 To eliminate tension on and retraction of the gingival margin

that has been caused by the frenum during lip movements.

0 To eliminate a well developed frenum that penetrates the

gingival papilla to its origin on the incisive papilla which may lead to midline diastema formation and prevent mesial drift.

0 Facilitate orthodontic treatment. 0 To eliminate frenum that makes it difficult or impossible to

use a toothbrush effectively in the area.

0 To control recession.

TREATMENT PROCEDURES
0 Frenotomy is defined as procedure that severs the

frenum by excising it from its apex toward its base.

0 Frenectomy involves excision of the frenum, including

its attachmemt to alveolar bone (Friedman, 1957)

0 Frenotomy and Frenectomy are localized procedures

that increase the width of attached gingiva.

The techniques which can be employed are

0 Conventional (Classical) frenectomy

(Dieffenbach V-plasty and Schuchardt Z-plasty) 0 V-Y Plasty 0 Millers technique 0 Frenectomy using electrosurgery 0 Frenectomy using Soft issue lasers

Conventional Technique
Dieffenbach V-plasty and Schuchardt Z-plasty

Dieffenbach V-plasty Armamentarium : Bard-Parker handles no. 3, No. 15 blade, mosquito haemostat, 3-0 or 4-0 black silk sutures, needle holder, scissors, and a periodontal dressing (Coe-pak).

Procedure: 0 Step 1. After anesthetizing the area, engage the frenum with a hemostat inserted to the depth of the vestibule. 0 Step 2. Incise along the upper surface of the hemostat, extending beyond the tip. 0 Step 3. Make a similar incision along the undersurface of the hemostat.

0 Step 4. Remove the triangular resected portion of the

frenum with the hemostat. This exposes the underlying fibrous attachment to the bone.

0 Step 5. Make a horizontal incision, separating the fibers, and

bluntly dissect to the bone.

0 Step 6. If necessary, extend the incisions laterally and suture

the labial mucosa to the apical periosteum. A gingival graft or connective tissue graft is placed over the wound.

0 Step 7. Clean the surgical field with gauze sponges until

bleeding stops .

0 Step 8. Cover the area with dry aluminum foil and

apply the periodontal dressing.

0 Step 9. Remove the dressing after 2 weeks and redress

if necessary. One month is usually required for the formation of an intact mucosa with the frenum attached in its new position.

Schuchardt Z-plasty 0 The main advantage of this method over the Vplasty method was minimal scar tissue formation. The method requires a skilled operator as it is tedious to perform

0 The length of the frenum is incised with the scalpel and at

each end, limbs at between 60 and 90 angulation, incisions were made in equal length to that of the band.

0 double rotation flaps of at least 1 cm long are obtained. 0 The resultant flaps which are created are mobilized and

transposed through 90 to close the vertical incisions horizontally.

0 This technique is indicated when there is hypertrophy of

the frenum with a low insertion, which is associated with an inter-incisor diastema, and when the lateral incisors have appeared without causing the diastema to disappear and also in cases of a short vestibule.

V-Y Plasty
0 V-Y plasty can be used for lengthening the localized area,

like the broad frena in the premolar-molar area.

0 An incision is made in the form of V on the undersurface

of the frenal attachment.

0 The frenum is relocated at an apical position and the V

shaped incision is converted into a Y.

Millers Technique
0 The Millers technique was advocated by Miller PD in 1985. 0 This technique was proposed for the postorthodontic diastema cases. 0 The ideal time for performing this surgery is after the orthodontic movement is complete and about 6 weeks before the appliances are removed.

0 Excision of the frenulum is done and labial alveolar bone is

exposed in the midline.

0 A horizontal incision is made to separate the frenulum from

the interdental papilla.

0 A laterally positioned pedicle graft (split thickness) can be

sutured across the midline.

0 A periodontal dressing is placed. 0 Care must be taken to extend the incisions into the lip as far as

necessary, to assure that a remnant of the frenulum is not left on the lip.

Frenectomy using Electro Surgery

0 Electrosurgery is recommended in cases of patients with

bleeding disorders, where the conventional scalpel technique carries a higher risk which is associated with problems in achieving a haemostasis and also in non-compliant patients. 0 Frenum is held with the haemostat and excised using a loop electrode tip. 0 Electrocautery offer the advantage of minimal procedural bleeding and no need of sutures

Frenectomy using soft tissue lasers

0 The frenum is stretched to visualize its extent. 0 The soft tissue laser ( Diode, Er-YAG etc) is applied with focused

beam for excision of the tissue. 0 The ablated tissue is continuously mopped using wet gauze piece. This takes care of the charred tissue and prevents excessive thermal damage to underlying soft tissue. 0 The tissue is lased until all the underlying muscle fibers are dissected.

0 No sutures are placed at the end of this procedure. 0 Patients prescribed analgesics only if needed.

Advantages of Laser technique:

0 No need of local anaesthesia. Its a painless procedure. As

a result there is less patient apprehension. 0 Bloodless operative field, thus better visibility. 0 No need of periodontal dressing. 0 Less time consuming.

REFERENCES
0 Carranzas Clinical Periodontology - 11th Ed. 0 Periodontal Therapy by Goldman and Cohen 6th Ed. 0 Frenectomy A Review with the Reports of Surgical

Techniques. Journal of Clinical and Diagnostic Research. 2012 November, Vol-6(9): 1587-1592.

0 Frenectomy review. Laser 3_2010: 14-18.