Surgical Management of Aberrant Labial Frenum Using Modified Z

Surgical Management of Aberrant Labial Frenum Using Modified Z

Case Report
DOI: 10.17354/cr/2015/37
Surgical Management of Aberrant Labial Frenum
Using Modified Z-Frenuloplasty: A Case Report
Gurpreet Kaur1, Sujata Malik1, Deepak Grover1, Anupriya Sharma2
Reader, Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India, 2Assistant Professor,
Department of Dentistry, R.P. Government Dental College, Kangra, Himachal Pradesh, India
1
Frenum is a mucous membrane fold that attaches lips and cheek to the alveolar mucosa, gingiva, and the underlying periosteum. The
maxillary frenum can contribute to esthetic problems and can compromise the orthodontic outcome in cases of midline diastema,
thus leading to treatment relapse. In addition to this, it may jeopardize the health of the gingival, when it is attached too tightly to the
gingival margin, by interference in the plaque control or owing to the muscle pull. These situations can be managed with the help of
frenectomy. The presenting case report demonstrates the frenectomy of an anomalous labial frenum in a 20-year-old male using modified
Z-frenuloplasty technique.
Keywords: Diastema, Frenectomy, Frenum, Z-plasty
Mucosal: When the frenal fibers are attached up to
mucogingival junction.
INTRODUCTION
Esthetic concerns have led to an increased demand in
seeking dental treatment for achieving perfect smile.
Midline diastema in central incisors is one of the major
esthetic problems encountered in adults. Since the presence
of an aberrant frenum is one of the causative factor of the
persistence of a midline diastema, it becomes essential to
focus on the importance of frenum in terms of morphology
and attachment.1 The frenum is a mucous membrane fold
that attaches the lip and the cheek to the alveolar mucosa,
the gingiva, and the underlying periosteum.2 Oral cavity
exhibits most notably the maxillary labial frenum, the
mandibular labial frenum, and the lingual frenum. Labial
frenum attachments are thin folds of mucous membrane
containing muscle fibers originating from orbicularis
oris muscle of upper lip which provides attachment
to the alveolar mucosa and underlying periosteum.
Developmentally, the maxillary labial frenum is a posteruptive remnant of the ectolabial band that connects the
tubercle of the upper lip to the palatine papilla.2 Based on the
extension of the attachment of fibers, they are classified as:3
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Gingival: When fibers are inserted within attached gingiva.
Papillary: When fibers are extends into interdental papilla.
Papilla penetrating: When fibers cross the alveolar process
attach to palatine papilla.
The maxillary frenulum provides stability to the upper
lip. It is composed of attachment of thin fibrous tissue
connecting the upper lip to the gingival tissue between the
central incisors. When the two central incisors erupt widely
separated, no bone is deposited inferior to the frenum.
This leads to a V-shaped bony cleft formation between the
two central incisors and an aberrant frenum attachment.
The mandibular frenum is considered anomalous when
it is associated with a decreased vestibular depth and an
inadequate attached gingival width. When there is a thick
fibrous tissue attachment between the upper incisors, it
results in the formation of hyperplastic frenum and is often
associated with a midline diastema. It can lead to periodontal
and speech problems. The abnormal frenal attachment can
be detected visually by applying tension over the frenum
to see the movement of the papillary tip or blanching of
the associated area because of the resulting ischemia in
the region.4 Unusually, wide frenum is characterized as
pathogenic. Clinically, papillary and papilla penetrating
frenal attachments are considered pathological and are
associated with papillary loss, gingival recession, diastema
Corresponding Author:
Dr. Gurpreet Kaur, Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India.
Phone: +91-9914505540. E-mail: [email protected]
IJSS Case Reports & Reviews | March 2015 | Vol 1 | Issue 10
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Kaur, et al.: Modified Z-Frenuloplasty
formation, difficulty in brushing, misaligned teeth, and
psychological disturbances.5
Frenal attachments that encroach on the marginal gingival
leads to distention of the gingival sulcus, favoring plaque
accumulation, increasing the rate of progression of gingival
recession and thereby leading to recurrence after treatment.6
The management of an aberrant frenum can be accomplished
by “frenectomy” or “frenotomy” procedures. The terms
frenectomy and frenotomy signify operations that differ in
degree of surgical approach.
Frenectomy is a complete removal of the frenum, including
its attachment to the underlying bone whereas frenotomy
involves relocation of the frenal attachment.2 According to
Olivi et al., clinical indications for frenum removal are as
follows:7
1. Anomalous frenum associated with inflamed gingiva,
resulting from poor oral hygiene
2. Anomalous frenum associated with gingival recession
3. Maxillary frenum associated with diastema after
complete eruption of the permanent canines
4. Abnormal maxillary frenum (Class III or IV), resulting
in the presence of a diastema during the mixed
dentition
5. High frenal attachment resulting in gingival recession.
Surgical Interventions Available
Several surgical procedures have been employed to correct
abnormal frenula. These include excision, Millers technique,
V-Y plasty and Z-plasty.8 However, frenectomies commonly
fail due to a high risk of reoccurrence and hypertrophic
scarring. The likelihood of failure can be reduced by using
a technique known as Z-frenuloplasty, which is a soft
tissue surgery used to lengthen frenum and to improve the
functional and cosmetic appearance of scars. It provides
excellent outcomes in cases of hypertrophic thick frenula
with a low insertion and a shallow sulcus. In this technique,
the length of the frenum is incised with a scalpel and
releasing incisions are used, one on the superior border
of frenum and other on the inferior boarder in opposite
directions. The two flaps are raised and then interchanged
with each other so that the frenal length is increased. 9
Primary Z-plasty flaps are created using an angle of 60
degrees on each side. Classic 60° Z-plasty lengthens scars
by 75%, while 45° and 30° designs lengthen scars by 50%
and 25%, respectively.10 A curvilinear form of Z-plasty
(also known as S-plasty) may be used when straight lines
may be particularly evident, for e.g., in the cheek. Design
of the Z-plasty with unequal angles and limbs creates a
situation, in which the smaller triangle moves significantly
less than the larger triangle. This may be useful in areas
where small amounts of tissue need to be moved with as
6
little distortion as possible e.g. near eyes, lips.11,12 Another
modified approach include, a horizontal incision without
severing the frenum in the midline along with basic Z-plasty
flaps that are transposed in the similar manner.13 The Z
pattern is efficient as:
• It facilitates re-distribution of tension on the skin and
the wound and helps in healing along the skin lines
• It minimizes scar formation and has got a camouflaging
effect.
The present case report aimed to approach aberrant
labial frenula using novel modified Z-plasty technique of
frenectomy with an added note on merits and the demerits
of this procedure.
CASE REPORT
We report here a case of a 20-year-old male referred to the
Department of Periodontology and Oral Implantology,
National Dental College and Hospital, Derabassi. Patient
reported with the chief complaint of a midline diastema
between the maxillary central incisors. On examination, a
hypertrophied papillary frenum associated with midline
diastema was found (Figure 1). Along with it, tension test
was positive with inadequate width of attached gingiva.
Patient was told about the procedure and an informed
consent was taken.
Surgical Procedure
The area was anesthetized using local infiltration by using
2% lignocaine with 1:80,000 adrenaline. The “Z-shape”
triangular flap was prepared using incisions as depicted in
Figure 2. The length of the base of the frenum was incised
with 6 a scalpel and at each end, incisions (ranging between
60° and 90° angulation) were made in equal length to that of
the band. With the help of a tissue forceps, the submucosal
tissues were dissected beyond the base of each flap, into
the loose non-attached tissue planes. A double rotation
Figure 1: Pre-operative photograph
IJSS Case Reports & Reviews| March 2015 | Vol 1 | Issue 10
Kaur, et al.: Modified Z-Frenuloplasty
flap of at least 1 cm in length was prepared (Figure 3). With
the surgical blade, the deeper fibers are detached from the
underlying periosteum in a criss-cross manner. Periosteal
scoring was done so as to prevent the reattachment of
fibers. The resultant flaps were mobilized and transposed
at 90° to close the vertical incisions horizontally. They were
then sutured to the defect on the opposite side of the other
flap base and secured in position by using interrupted
braided silk suture (Figure 4). After the above procedures,
patient was asked to maintain a soft diet for a week, and
antibiotics and analgesics were also prescribed. Patient was
instructed to follow routine post-operative instructions
and to maintain good oral hygiene using mechanical and
chemical plaque control techniques. Patient was followed
after 10 days, later for review (Figure 5).
In the present arena of periodontal plastic surgeries,
more conservative and precise techniques are being
adopted to achieve more functional and esthetic results.
The management of anomalous and aberrant frenum
has gained much of interest in the present era. Recent
techniques added frenal relocation by Z-plasty, frenectomy
with soft-tissue graft and laser applications to avoid
typical diamond-shaped scar and facilitate healing. Each
method has its advantages and disadvantages.14 A study
by Heller et al.15 in 2005 compared the treatment outcome
for Z-frenuloplasty and the traditional horizontal to vertical
frenuloplasty in the management of ankyloglossia. Of
16 patients recruited in the study, 11 patients underwent
a Z-frenuloplasty and 5 patients had their ankyloglossia
corrected with the horizontal to vertical frenuloplasty.
The frenulum length, length of tongue protrusion and
speech was analyzed pre and post-operatively. The results
revealed that Z-frenuloplasty was a superior technique
than the other, with an improvement in frenulum length
and tongue protrusion of 37.5 ± 13.5 mm compared to the
other method at 36.2 ± 7.6 mm respectively. In addition, it
was also found that 91% of the patients with Z-frenuloplasty
showed improvement in speech compared to other 40% who
underwent the horizontal-to-vertical frenuloplasty.15 Since
Figure 2: Z-shaped incisions
Figure 4: Flaps secured with interrupted sutures
Figure 3: Flaps reflected and periosteal scoring performed
Figure 5: 10 days post-operatively
DISCUSSION
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Kaur, et al.: Modified Z-Frenuloplasty
the conventional procedure of frenectomy, a number of
modifications of the various surgical techniques including
Miller’s technique, V-Y plasty and Z-plasty have been
utilized to manage problems associated with an anomalous
labial frenum. The main advantage of the Z-plasty method
over the conventional technique is minimal scar tissue
formation. The disadvantage of this method is its technique
sensitivity.13,14
CONCLUSION
To achieve a functional and an esthetic outcome, adequate
technique should be selected based on the type of the frenal
attachment. The Z-frenuloplasty procedure is considered
to be safe and a cost efficient procedure resulting in better
functional and esthetic appearance. This technique allows
for tissue healing by primary intentions, increasing recovery
and reducing the risk of tissue contractures. However, due
to the limited evidence currently available on this method,
further research is needed to compare the different surgical
approaches of frenectomy to obtain the desired outcome.
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How to cite this article: Kaur G, Malik S, Grover D, Sharma A. Surgical
Management of Aberrant Labial Frenum Using Modified Z-Frenuloplasty:
A Case Report. IJSS Case Reports & Reviews 2015;1(10):5-8.
Source of Support: Nil, Conflict of Interest: None declared.
IJSS Case Reports & Reviews| March 2015 | Vol 1 | Issue 10