Dr: Mohammed Shamiah

Tasneem Shamali
CONTENTS
- Introduction

- Classification of frenum attachment –

- Clinical feature of abnormal attachment

- Indications ‫۔‬

- Surgical technique
 FRENUM

Definition :

AFrenum is a fold of mucous membrane, usually with enclosed fibers, that attaches the lips and
cheeks to the alveolar mucosa and / or gingiva and underlying periosteum.
 Sickle shaped folds

- Found normally in maxillary and mandibular alveolar mucosa in canine premolar

area, and between central incisors.

Contain loose connective tissue with elastic and dense collagen fibers, fat cells &
sometimes acini of mucous producing salivary glands.

 Occasionally, muscle fibers may be present.

 CLASSIFICATION OF FRENUM ATTACHMENT

Depenging upon it morphology as:

 long and thin
 Short and broad
 BASED ON LOCATION OF ORIGIN OF FRENUM (placek rt al 1974)
1- mucosal Attachment- attachment to MG junction

2- Gingival attachment- to attached gingiva

3- Papillary attachment- within papilla

4- Papilla-penetrating attachment
 Mucosal Attachment

Gingival attachment
 Papillary attachmen

Papilla penetrating attachment

Clinical features of Abnormal frenum

Midline Diastema

Accumulation of debris by reflection & | opening of sulcus

Difficult oral hygiene maintenance

Gingival Recession
.Frenotomy:
It is a procedure that is relatating the frenal attach s s as a reference to the freeness
attachment of the gingiva and the frenum.

Frectomy:

It is the complex Excision of the frenum, Including it attachment to underlying bone.

Indications
1) To eliminate tension on & retraction of the gingival margin that has been caused by
the frenum during lip movements. If left untreated, it may cause
a) Distention of the orifice of the sulcus or pocket, leading to debris accumulation.
b) An increase in the severity of the pocket, | impairing healing

2) To eliminate a well developed frenum that penetrates the gingival papilla to its
origin on the incisive papilla. The coronally attached frenum may lead to a midline
diastema & prevent mesial drift, which usually closes this space, |

3) To facilitate orthodontic treatment, a thick frenum resists orthodontic forces & its
wedging area can be responsible for slight spacing of the maxillary Central Incisors
following orthodontic treatment,
4) To eliminate a frenum that makes it difficult or impossible to use a Tooth Brush
effectively in the area.

5) When combined with more sophisticated periodontal surgery, e. g. . to eliminate

periodontal pockets & increase Attached Gingiva & depth of vestibular trough. .
Surgical Techniques

 Simple excision

 Z – Plasty

 Vestibuloplasty with Secondary Epithelialization

 V - Rhomboid plasty in

 Modification ofV - Rhomboid plasty

 V - Y plasty in

 Simple Incision

 Submucosal frenotomy

 Lingual frenectomy
Simple Excision

Abnormal Frenum
 A narrow elliptic incision around the frenal area down on the periosteum is
completed.
 The fibrous frenum is then sharply dissected from the underlying periosteum and
soft tissue and the margins of the wound are gently undermined and
reapproximated.
Excised Wound ( elliptical )

Placement of the first suture at the

maximal depth of the vestibule . The
remainder of the incision should be than
closed with interrupted sutures .
Procedure - Removal of frenum
Two Haemostats Technique

- Local anaesthesia

Raise the lip, put a hemostat parralel to the alveolar ridge

Another hemostat parallel to the lip at right angle to the first,

With no. 11 or 15 blade, labial frenum is excised by cutting

around the outside surfaces of the | two hemostat leaving behind a diamond shaped
cut.
 Hemostats and incision

Excised Wound (Diamond shaped)

 Placement of the first suture at the
maximal depth of the vestibule.
 The remainder of the incision should
be than closed with interrupted
sutures.
Z - Plasty Technique

 For a narrow band of frenulum)

 Excision of fibrous connective tissue is
done similar to simple excision
Two Oblique incisions are made in z fashion,
one at each end of excision
Flaps reflected
Vertical flaps positioned
Horizontally and sutured
 Incision starting from apex to base

Mucosal flap sutured in the most depth of vestibule and the

exposed periosteum is allowed to heal by secondary
epithelization
 V – Yplasty

 Indicated in reducing height of attachment of frenum,

 V shaped incision is made in the Attachment of frenum.

 Underlying fibrous tissue is removed.

Wound margins closely adapted like the
letter Y and sutured
Simple Incision

 For a frenum attached too closely to gingival margin

 Incision made into the attachment of the frenum along the base.

 Frenum is raised up apically as a full thickness or split thickness flap.

 In split thicness, dissection is carried out, the underlying fibrous tissue should be
removed enough not to relapse.
Dissected frenum raised till MGJ &
an open wound surface is left &
pack is given
Submucosal Frenotomy

 Indicated in a frenum with a wide base


 A vertical incision along the ridge & two incisions bilaterally to the attachment.

 Surgical scissors inserted through the incised margin to dissect submucosal
tissue bluntly.

 Traversing muscle fibers are cut.

 Periosteum is revealed following cutting of the muscle fibers. Suturing done.

Healing After Frenectomy / Frenotomy

- The wound is triangular in shape.

- . It is bound on the two sides by attached gingiva (fixed tissue).

- It provides one source of granulation tissue.

- The other source of tissue is the exposed bone that occurs as all the tissue is
removed.

- When the bone is not exposed by the removal of periosteum, gingiva will also
regenerate.

- However, all the loose C. T, elastic fibers and fatty tissue elements must be
removed, leaving the dense fibrous collagen fibers over the periosteum.

- - The immovable base upto which newer granulation tissue can form results in
new