Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Frenal Attachments: An Overview

Dr. Laavanya. M , MDS1 Dr. Sri Devi. S , BDS2
Professor Intern
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Thai Moogambigai Dental College and Hospital. Thai Moogambigai Dental College and Hospital.
Chennai, Tamil Nadu , India. Chennai, Tamil Nadu , India.

Dr. Varshini. S ,BDS3 Dr. Sri Ranjani. T , BDS4

Intern Intern
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Thai Moogambigai Dental College and Hospital. Thai Moogambigai Dental College and Hospital.
Chennai, Tamil Nadu , India. Chennai, Tamil Nadu , India.

Dr. Sathish Kumar, MDS5

Professor
Department of Oral and Maxillofacial Surgery
Thai Moogambigai Dental College and Hospital.
Chennai, Tamil Nadu , India.

Abstract:- The fenum, a slender fold of mucous II. CLASSIFICATION

membrane with contained muscle fibres, connects the lips
to the alveolar mucosa and underlying periostium. The A. Mirko et al(1974)'s classification of frenal attachments
frenum, a mucosal connection that joins a flexible section [4].
to a more stiff part, is one of the more fascinating yet Papilla penetrating – frenal fibers penetrate the papilla
sometimes misunderstood anatomical structures in the and stretch upto the palatine papilla [figure 1]
oral cavity. When the frenum are attached too closely to
the gingival margin, either because of difficulty with
plaque control or because a muscle pulls, the health of the
gingiva may be at risk. Unaesthetic diastema is more
common and can be caused by abnormal frenum, which
can also be a sign of a syndrome or create serious
mucogingival issues. In the following, we will provide a
brief summary of the many varieties of frenum, as well as
how they relate to different syndromes, indications, Fig. 1 courtesy - [16]
complications, and benefits.
Mucosal – Upto mucogingival junction,frenal fibers are
Keywords-Aberrant frena; frenal attachments; frenectomy; attached [figure 2]
syndromes

I. INTRODUCTION

The lingual frenum, mandibular labial frenum, and

maxillary labial frenum are the three most prominent frenum
in the oral cavity. They provide the main purpose of Fig. 2 courtesy – [16]
stabilising the tongue, upper and lower lips[1]. The alveolar
mucosa and underlying periosteum are attached at the lips by Papillary – fibers are spreading into the interdental
labial frenal attachments, which are small folds of mucous papilla[figure 3]
membrane with encased muscle fibres that originate from the
orbicularis oris muscle of the upper lip[2]. When the frenum
is excessively closely linked to the gingival margin, it can
lead to diastema, gingival recession, bone loss from the
muscle strain, and impaired lip mobility, especially when
speaking and smiling[3].

Fig. 3 courtesy – [16]

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Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Gingival – fibers extend and are inserted within attached C. Holoprosencephaly
gingiva[figure 4]  It is an autosomal dominant disorder defined by a brain
malformation brought on by prosencephalon
abnormalities
 .Absence of labial maxillary frenum is one of the
characteristic features of this condition[10].

D. Ellis-van Creveld (EvC) syndrome

 It is an autosomal recessive disorder, mainly affecting the
Fig. 4 courtesy – [16] ectodermal components.
 The anterior portion of the lower ridge is often serrated
B. Sewerin's classificationoffrenalattachments(1971) [5]. and presents with multiple small labial frenula.
 The maxillary and mandibular alveolar process presents
1. Regular frenum with notching or submucous clefts and continuous or
2. A nodule in a typical frenum broad labial frenula with dystrophic philtrum[11].
3. Regular frenum with appendix
4. Regular frenum with nichum E. Ehlerdanlos syndrome
5. Bilateral labial frenum  It is characterized by hyper extensive skin and hyper
6. Persistent tectolabial frenum mobile joints with no gender predilection.
7. Double frenum  Absence of the inferior labial and lingual frena has been
8. Wider frenum described [12].

III. DIAGNOSIS V. COMPLICATIONS [13]

By exerting stress across the frenum and looking for  When the frenum is excessively closely linked to the
movement of the papillary tip or a blanch caused by local gingival margin, it can lead to diastema, gingival
ischemia, the aberrant frena are clinically identified. recession, bone loss from the muscular strain, and
impaired lip mobility, especially when speaking and
Miller et al. (1985): When the frenum is abnormally smiling[14].
wide, when there is no discernible zone of the associated  Papilla loss
gingiva along the midline, or when the interdental papilla  Midline diastema and gingival recession
changes when the frenum is expanded, the frenum is  Since the basic function of the frenum is to maintain
classified as pathogenic. stability between the growing bones and musculature of
the lip, the presence of an aberrant frenal attachment can
IV. SYNDROMES modify the movement of these structures and may have an
impact on the position of the jaws and arrangement of the
The variation in frenal attachment, or any abnormality dentition.
may be seen in a variety of disorders,that may include -[6].  Difficulty in maintaining oral hygiene.
● Oro-facial-digital syndrome  Malaligned teeth.
● Ellis van creveld syndrome  Compromised denture fit or retension.
● Ehler's danlos syndrome
● Infantile hypertrophic pyloric stenosis VI. MANAGEMENT TECHNIQUES [15].
● Holoprosencephaly
A. Classical Frenectomy
A. Oro-facial-digital syndrome  Archer and Kruger first described classical frenectomy in
 It results from a single gene abnormality with X-linked 1961 and 1964, respectively.
dominant inheritance[7].  Used in treating high frenal attachments such as in
 The lingual frenum is hypertrophied and incompletely interdental papillae.
differentiated from the floor of the mouth. The tongue is  In this procedure,the surgical site is anasthetized with 2 %
lobulated with hamartomata between lobules[8]. Lignocaine with 1:80,000 adrenaline.
 An incision is made on the frenal site down the underlying
B. Infantile hypertrophic pyloric stenosis bone i.e., periosteum.
 Usually found in males, unclear cause.  The frenum and the interdental tissue are entirely
 Mandibular frenum hypoplasia or absence serves as a key detached from the periosteum and surgically removed.
diagnostic indicator for this illness[9].  Advantage - Easy to perform.
 Disadvantages - Scar tissue formation, loss of papilla,high
relapse rate.

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Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Pre-operative papilla type of frenum Frenum held with hemostat

Frenum excised Sutures placed

One month post operative

Fig. 5 courtesy-[17]

B. Miller’s Technique:[15]. incisions were undermined by partial dissection to raise

 Miller PD described this technique in 1985,where he the flap which is mobilised mesially and sutured to obtain
combined frenectomy with laterally displaced flap. primary closure across the midline and the surgical area is
 It is commonly performed in individuals with orthodontic sutured.
relapse.After complete tooth. movement , six weeks  The dressings are removed after one week.
before removing appliance , this technique is used.  Advantages-
 An incision is made on the frenum apically and its  It is aesthetic with minimum of surgical intervention.
separated from the interdental gingiva.  No scar tissue formation and no loss of the interdental
 The frenum is removed completely from the gingiva and papilla.
lips, an vertical parallel incision was made.  Orthodontic stability and healing by primary intention.
 The gingiva and alveolar mucosa between these two

Pre-operative attached frenum Frenum excised

Lateral pedicle graft obtained Graft sutured across the midline

Two months post operative

Fig. 6 courtesy- [17]

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Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
C. Z-Plasty  Advantages:
 When the frenum attaches very deeply into the gingiva  Scarring is minimised because it encourages the re-
and creates a midline diastema, it is used. distribution of strain on the skin and the wound and aids
 For the purpose of removing the frenum and closing the in skin-line healing.
suture site, a Z-shaped incision (two cuts) is made.  Enhanced aesthetics

Pre-operative attached frenum Incision given through the frenum

Incision at both the ends Sutured in Z form

Fig. 7 courtesy-[17]

D. V-Y Plasty incision is converted into a Y,and it is sutured with 4-0 silk
 It is used to correct the papillary type of frenal attachment. sutures.Cover the area with periodontal dress to keep it
 V and Y-shaped incisions are made under the surface of dry.
the frenum, then it is detached from the interdental  Disadvantage-It fails to provide satisfactory aesthetic
gingiva and repositioned. results in case of a thick hypertrophied frenum.
 The frenum is relocated more apically and the V shaped

Pre-operative papillary frenum Frenum held with hemostat

V- shaped incision Y-suture placed

One month post operative

Fig. 8 courtesy [17]

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Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
E. Electrosurgery not required
 An electrode delivering electric heat is used here.  Curved electrodes aid visibility and thus they are efficient
 Advantages- minor bleeding , quick healing, and suturing and effective for soft tissue removal.

Pre-operative attached type frenum Excised with loop electrode No suture required

Fig. 9 courtesy [17]

F. Laser Treatment REFERENCES

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