Upper labial frenum is a normal anatomic structure in the oral cavity. Sometimes this normal structure is present as a thick, broad fibrous attachment. Adjacent attached gingiva was used to achieve a zone of attached gingiva with excellent color match.
Upper labial frenum is a normal anatomic structure in the oral cavity. Sometimes this normal structure is present as a thick, broad fibrous attachment. Adjacent attached gingiva was used to achieve a zone of attached gingiva with excellent color match.
Upper labial frenum is a normal anatomic structure in the oral cavity. Sometimes this normal structure is present as a thick, broad fibrous attachment. Adjacent attached gingiva was used to achieve a zone of attached gingiva with excellent color match.
The upper labial frenum is a normal anato- mic structure in the oral cavity. Sometimes this normal structure is present as a thick, broad fibrous attachment and thus inter- feres with normal function of the upper lip and oral hygiene and causes compromised esthetics, diastema formation, 1 and gingival recession. Since the procedure of frenectomy was first proposed, a number of modifications 24 have been developed to solve the problem caused by an abnormal labial frenum. In most of these procedures the esthetic out- come in terms of attached gingiva with color matching was not considered. The present article reports on a new technique in which adjacent attached gingiva in the central inci- sor region, bilaterally, was used to achieve a zone of attached gingiva with excellent color match at the site of the abnormal frenum. CASE REPORT A 25-year-old male patient was referred from the Department of Oral Medicine and Diagnosis for an abnormal upper labial frenum. The patient was well aware and con- cerned about the abnormal attachment of the frenum. Examination revealed a hypertro- phied, broad, thick labial frenum of papillary- type attachment and a maxillary central diastema (Figs 1a and 1b). The blanch test was positive on pulling the upper lip. A full complement of teeth was present with ade- quate buccal vestibular depth except in the frenal area. An adequate amount of attached gingiva was present at the maxillary anterior region without any mucogingival problems. A new technique of frenectomy was planned considering the patients concern for esthetics and the wide, thick hypertrophied frenum with high abnormal attachment, which can leave a wide defect after excision by traditional techniques, leading to scar for- mation. Hematologic investigation was car- ried out, and results were within normal limits. Medical history was noncontributory. Esthetic management of the upper labial frenum: A novel frenectomy technique Sukhchain Bagga, BDS 1 /K. Mahalinga Bhat, BSc, BDS, MDS 2 / G. Subraya Bhat, BDS, MDS, MFGDP 3 /Betsy S. Thomas, BDS, MDS 4 An abnormal upper labial frenum is capable of retracting the gingival margin, creating a diastema, limiting lip movement, and in cases of a high smile line, affecting esthetics also. When an abnormal frenum is present, frenectomy is advised. This technique has been modified in many ways. But in most of the techniques the zone of attached gingiva and esthetics are not considered. This case report highlights a new technique of frenectomy that results in good esthetics, excellent color match, gain in attached gingiva, and healing by primary intention at the site of the thick, extensive abnormal frenum. (Quintessence Int 2006;37:819823) Key words: attached gingiva, diastema, esthetics, frenectomy, frenum 1 Postgraduate student, Department of Periodontics, Manipal College of Dental Sciences, Manipal, Karnataka, India. 2 Professor and Head, Department of Periodontics, Manipal College of Dental Sciences, Manipal, Karnataka, India. 3 Professor, Department of Periodontics, Manipal College of Dental Sciences, Manipal,Karnataka, India. 4 Associate Professor, Department of Periodontics, Manipal College of Dental Sciences, Manipal, Karnataka, India. Reprint requests: Dr Sukhchain Bagga, Department of Periodontics, Manipal College of Dental Sciences, Manipal-576104, Karnataka, India. Fax: 91-820-2571966. E-mail: drsukhchainbagga@yahoo.com Bagga.qxd 9/20/06 12:02 PM Page 819 COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 820 VOLUME 37 NUMBER 10 NOVEMBER/DECEMBER 2006 QUI NTESSENCE I NTERNATI ONAL Bagga et al SURGICAL TECHNIQUE The maxillary anterior region was anes- thetized with 1:200,000 lidocaine hydrochlo- ride with adrenaline (Xylocaine 2% Adrena- line, Astra Zeneca) by local infiltration on the buccal and palatal aspects. A V-shaped full-thickness incision was placed at the gingival base of the frenal attachment with an external bevel (Figs 2a and 2b). Tissue along with periosteum was separated from underlying bone. The initial incision resulted in a V-shaped defect on the gingival side (Figs 3a and 3b). Fibrous tissue attached to the lip was dissected with scis- sors, and undermining of the labial mucosa was done. An oblique partial-thickness inci- sion was placed on the adjacent attached gingiva (Figs 4a and 4b), beginning 1 mm apical to the free gingival groove and extend- ing beyond the mucogingival junction. Partial-thickness dissection from the medial margin was carried out in an apico- coronal direction (Fig 5) to create a triangular pedicle of attached gingiva with its free end as the apex and its base continuous with the alveolar mucosa (Figs 6a and 6b). Alveolar mucosa at the base was undermined to facil- itate repositioning of the pedicle without ten- sion. A similar procedure was repeated on the contralateral side of the V-shaped defect, resulting in 2 triangular pedicles of attached gingiva. These 2 pedicles were sutured with each other at the medial side and laterally with the adjacent intact periosteum of the donor site (Figs 7a and 7b) by 4-0 silk suture Figs 2a and 2b V-shaped external bevel incision (dotted lines in Fig 2a) at the gingival base of the frenum. Figs 1a and 1b Thick hypertrophied frenum. Bagga.qxd 9/20/06 12:02 PM Page 820 COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. VOLUME 37 NUMBER 10 NOVEMBER/DECEMBER 2006 821 QUI NTESSENCE I NTERNATI ONAL Bagga et al (Mersilk, Ethicon, Johnson & Johnson), com- pletely covering the underlying defect created by the initial frenal excision. Periodontal dressing (Coe-Pak, GC Ameri- ca) was used to cover the surgical site. Analgesics and 0.2% chlorhexidine mouth- wash (Hexidine, ICPA Health Products) were prescribed for 5 days during the postopera- tive period. Postoperative instructions were given. Sutures were removed on the 10th day, and the patient was scheduled for follow-up recall visits at 2 weeks and 1, 2, and 3 months. The 3-month follow-up revealed a zone of attached gingiva with esthetic color match in the area previously covered by the abnormal frenum (Fig 8). Normal healing was seen with- out any visible scarring or complication. Figs 3a and 3b V-shaped defect on the attached gingiva after frenal excision. Figs 4a and 4b Oblique partial-thickness incision on adjacent attached gingiva extending beyond the mucogingival junction (dotted lines in Fig 4a). Fig 5 Partial-thickness dissection of attached gingiva in an apicocoronal direction. Bagga.qxd 9/20/06 12:02 PM Page 821 COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. QUI NTESSENCE I NTERNATI ONAL Bagga et al DISCUSSION Various surgical techniques have been pro- posed for the correction of an abnormal upper labial frenum. Some of these pro- duce unsatisfactory results; for example, a simple frenectomy that is made with a V- shaped incision (known as Archer incision 5 or diamond-shaped incision) leaves a longi- tudinal surgical incision and scarring, which may lead to periodontal problems and an unesthetic appearance. Several other procedures have com- bined frenectomy with a lateral pedicle graft, free papilla graft, and free gingival graft taken from the palate. The lateral pedicle graft technique 6 also positions the unilateral pedicle at the midline but prevents com- 822 VOLUME 37 NUMBER 10 NOVEMBER/DECEMBER 2006 Fig 8 New zone of attached gingiva at the previous frenal site, with excellent color match, 3 months postoperatively. Figs 6a and 6b Triangular pedicle of attached gingiva with the free end as apex and the base continuous with the alveolar mucosa. Figs 7a and 7b Bilateral triangular pedicle sutured at the center, covering the underlying defect. Bagga.qxd 9/20/06 12:02 PM Page 822 COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. VOLUME 37 NUMBER 10 NOVEMBER/DECEMBER 2006 823 QUI NTESSENCE I NTERNATI ONAL Bagga et al plete coverage of the wound. In the tech- nique presented, 2 triangular pedicles, when sutured together medially, completely cover the V-shaped defect on the gingiva and act as a tissue dressing, thus facilitating healing by primary intention and minimizing any chance of scar formation. 7 Also, an external bevel in the initial V-shaped incision helps to achieve better marginal adaptation of the pedicles. Frenectomy followed by free gingival graft taken from the palate 4,8 covers the wound area completely but creates an esthetic con- cern of unsatisfactory color match by pro- ducing a keloid, 9 tattoo-like 9 or tire- patch 10 appearance at the grafted area. Techniques like simple excision 4 and modi- fication of V-rhomboplasty 4 fail to provide sat- isfactory esthetic results in the case of a broad, thick hypertrophied frenum. This may be due to an inability to achieve primary closure at the center, consequently leading to secondary intention healing at the wide exposed wound. It may become a matter of concern in the case of a high smile line exposing anterior gingiva. The technique presented here provides many advantages, such as gain in attached gingiva in the region previously covered by the frenum, excellent color match, healing by primary intention, minimal scar formation, and prevention of coronal reformation. This technique may be suitable in situations where anterior esthetics is of primary impor- tance. Presence of an adequate zone of attached gingiva is an important parameter during consideration of this technique. The technique is reliable and easy to perform and provides excellent esthetic results. REFERENCES 1. Huang WJ, Creath CJ. The midline diastema: A review of its etiology and treatment. Pediatr Dent 1995;17:171179. 2. Coleton SH. Mucogingival surgical procedures employed in re-establishing the integrity of the gin- gival unit (III). The frenectomy and the free mucosal graft. Quintessence Int 1977;8(7):5361. 3. Kahnberg KE. Frenum surgery. I. A comparison of three surgical methods. Int J Oral Surg 1977;6:328333. 4. Ito T, Johnson JD. Frenectomy and frenotomy. In: Ito T, Johnson JD (eds). Color Atlas of Periodontal Surgery. London: Mosby Wolfe, 1994:225239. 5. Archer WH. Oral surgery for dental prosthesis. In: Archer WH (ed). Oral and Maxillofacial Surgery. Philadelphia: Saunders, 1975:135210. 6. Miller PD, Jr.The frenectomy combined with a lateral- ly positioned pedicle graftFunctional and esthetic considerations. J Periodontol 1985;56:102106. 7. Hupp JR. Wound repair. In: Peterson LJ, Ellis E, Hupp JR, Tucker MR (eds). Contemporary Oral and Maxillofacial Surgery. St Louis: Mosby, 2004:5355. 8. Breault LG, Fowler EB, Moore EA, Murray DJ. The free gingival graft combined with the frenectomy: A clinical review. Gen Dent 1999;47:514518. 9. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:397402. 10. Cohen ES. Cosmetic root coverage: Gingival aug- mentation. In: Cohen ES (ed). Atlas of Cosmetic and Reconstructive Periodontal Surgery. Philadelphia: Lea and Febiger, 1989:189232. Bagga.qxd 9/20/06 12:02 PM Page 823 COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.