Aberrant Frenum !! No worries... When Frenectomy is here. Hello Periodontists, Here's the entire process of Frenectomy in a nutshell and various ways to encounter the same. Lets Shoot ...

1. FRENECTOMY
Dr. Rinisha Sinha
MDS Part I

2. CONTENTS
 Gaining an Insight
 What is a Frenum ?
 Etiology of an Aberrant Frenum
 Classification
 Diagnosing an Abnormal Frenum
 Syndromes and Frenal Attachments
 Indications for Frenal Correction
 Let’s Understand : Frenectomy or Frenotomy
 Conventional Frenectomy
 Electrosurgery
 Lasers
 References

3. References : American Academy of Periodontology; 1989, 1996
Surgical Procedures performed to correct or
eliminate anatomic, developmental, or
traumatic deformities of the gingiva or
alveolar mucosa
Surgical Procedures for the
correction of relationships between
the gingiva and the oral mucous
membrane with reference to three
specific problem areas
GAINING AN INSIGHT
Mucogingival Surgery Periodontal Plastic Surgery
FRIEDMAN
Attached
Gingiva
Shallow
Vestibules
Aberrant
Frenum
MILLER
• Esthetic Surgical Corrections
• Crown Lengthening
• Ridge Augmentation
• Reconstruction of papilla

4. A Frenum is a mucous
membrane fold which
contains muscle and
connective tissue fibers
that attach the lip and
the cheek to the
alveolar mucosa, the
gingiva and the
underlying periosteum.
WHAT IS A FRENUM !?
References : Jhaveri H. The Aberrant Frenum; 2006
Normal Frenal Attachment
Apical to the Free
Gingival Margin

5. ETIOLOGY OF ABERRANT FRENUM
MAXILLARY LABIAL FRENUM MANDIBULAR FRENUM
When the two central incisors erupt widely
separated, no bone is deposited inferior to the
frenum A V-shaped bony cleft between
the two central incisors and an abnormal frenum
attachment results.
A decreased vestibular depth and an
inadequate width of the attached gingiva
Aberrant Mandibular Frenum
References : Huang WJ, Creath CJ –
1995; Jhaveri H - 2006

6. Sewerin’s Classification
[ 1971 ]
CLASSIFICATION
Merko et al’s Classification
[ 1974 ]
Papilla – Penetrating Frenal
AttachmentPapillary Frenal Attachment
Mucosal Frenal Attachment Gingival Frenal Attachment
References : Sewerin I – 1997; Mirko P, Miroslav S, Lubor M - 1974
Normal Frenum Persistent Tectolabial Frenum With Appendix Frenum With Nodule
Duplication of Frenum Recess of the frenum Bifid Frenum

7. Blanch Test
DIAGNOSING AN ABNORMAL FRENA
Tension Test
Detected visually by applying
tension over the frenum to see the
movement of the Papillary tip
The lip is pulled superiorly and anteriorly
(For maxillary frenum) and (For mandible)
the lip is pulled outward and downward
Midline
Diastema
The frenum is
pathogenic when
• unusually wide
• no apparent
zone of
attached
gingiva along
the midline
• the interdental
papilla shifts
when the
frenum is
extended
Reference : Miller - 1985

8. References : Da Felice C, Toti P, Maggio G, Parinmi S, Bagnoli F; Martin RA, Jones
KL; Kusiak A, Sadiak-Nowicka J, Limon J, Kochanska B; Ichida M, Komuro Y et al
SYNDROMES
AND FRENAL
ATTACHMENTS
Ehlers-
Danlos
Syndrome
Infantile
hypertrophic
pyloric
stenosis
Holoprosencephaly
Ellis-van
Creveld
Syndrome
Oro-facial
Digital
syndrome
Pallister-hall
Syndrome

9. INDICATIONS
Aberrant Frenal
Attachment
causing Midline
Diastema
Aberrant Frenal
Attachment
causing Gingival
recession
Aberrant Frenal
Attachment causing
hindrance in
maintaining oral
hygiene
Aberrant Frenal
Attachment
interfering with
Speech
ANKYLOGLOSSIA
Aberrant Frenal
Attachment
indicating
Shallow vestibule
Aberrant Frenal
Attachment visible as
a pendulous piece of
tissue in the midline
of the upper lip

10. FRENECTOMY FRENOTOMY

11. • FRENECTOMY
The complete removal of the
frenum, including its
attachment to the underlying
bone.
LET’S UNDERSTAND
• FRENOTOMY
The incision and the
relocation of the frenal
attachment.
References : Dibart S, Karima M

12. FRENECTOMY
Scalpel
Technique
LasersElectrosurgery
• Safe and effective
• Shorter duration of
the surgery
• Simplicity of the
procedure
• Absence of
postoperative
infections
• Lesser pain, swelling
• Small or no scar
• Efficient
• Mild bleeding
• Absence of
postoperative
complications
Disadvantages
• Bleeding
• Patient
compliance
• Conventional
technique
• Excision of the frenum
through scalpel
• Cost-effective
Argon Beam Coagulation References : Dibart S, Karima M; Cunha RF, Silva JZ, Faria MD

13. CONVENTIONAL ( CLASSICAL )
FRENECTOMY
Archer (1961) and Kruger (1964)Indication
For midline diastema cases
Armamentarium
• Haemostat
• BP handle
• Scalpel blade no.15
• Gauze sponges
• 3-0 black silk sutures
• Suture pliers
• Scissors
• A Periodontal dressing
(Coe-pak)
References : Jhaveri H. The Aberrant Frenum – 2006; Archer WH. Oral surgery for a dental prosthesis - 1975

14. MILLER’S TECHNIQUE
Miller PD - 1985Indication : For the post-orthodontic diastema cases
References : Miller PD. Frenectomy combined with a laterally positioned pedicle graft -functional and esthetic considerations. J Periodont, 1985
A Horizontal
incision to
separate the
frenulum from the
interdental papilla
Excision of the
frenulum and
exposure of labial
alveolar bone in
the midline
Laterally
positioned
pedicle graft
taken to obtain
primary closure
across midline
Gingivoplasty
of any excessive
interdental
tissue labially or
palatally

15. Z PLASTY TECHNIQUE
Indication : Hypertrophic labial frenum with a low insertion, which is associated with an
inter-incisor diastema and also in cases of a short vestibule
Length of the
frenum was incised
with scalpel
The sub - muscosal
tissue were
dissected beyond
the base of each
flap by using fine
tissue forceps
The resultant flaps
were mobilized
and transposed
through 90º to
close vertical
incisions
horizontally
Absorbable 5-0
vicryl sutures were
placed and a
periodontal
dressing was
placed. No
hypertrophic
scar formation
References : Howe GL; Puig JR, Lefebvre E, Landat F. The Z-plasty technique – 1977; Langdon JD, Patel MF. Reconstructive surgery - 1998
1 cm long Double
rotation flaps
were obtained

16. V-Y PLASTY TECHNIQUE
Indication : For lengthening the localized area, like the broad frenum in the premolar-molar area
A V-shaped
Incision on the
undersurface of the
frenal attachment
The frenum was
relocated at an
apical position
Sutured with 4-0
silk suture and a
periodontal
pack was placed.
After 1 month -
Frenal attachment
was found to be
relocated at an
apical position,
with an
uneventful
healing
References : Kruger GO. Acquired defects of the hard and soft tissues of the face
The V-shaped
incision was
coverted into a Y

17. ELECTROSURGERY
Armamentarium
• An Electrocautery unit
with the loop electrode
• A Haemostat
Indication
 In cases of Patients with bleeding disorders
 In non-compliant Patients
The frenum was held with the haemostat
It was excised by using a loop electrode tip
Advantages
 minimal procedural bleeding
 there was no need of sutures
The healing was by Secondary intention, as the
wound edges were not approximated with
sutures
References : Cunha RF, Silva JZ, Faria MD – 2008; Verco PJW. “A case report and a
clinical technique: argon beam electrosurgery for the tongue ties and maxillary
frenectomies in infants and children - 2010

18. LASERS
940 nm Diode Laser
removing Mandibular
Frenum
Robert N. Hall – 1962
DIODE LASER uses a combination of
Gallium and Arsenide along with
Aluminium and Indium  changes
Electro-magnetic energy into Heat
DIODE LASER are highly absorbable by
MELANIN and HAEMOGLOBIN, hence
allows soft-tissue manipulations;
accompanied by improved epithelization
and wound healing.
Carbon dioxide Laser

19. REFERENCES
 Carranza’s Clinical
Periodontology :
10th Edition
 Periobasics : A
textbook of
Periodontics and
Implantology
 Journal of
Pharmaceuticals and
Scientific Innovation
 Devi Shree, Sheela Kumar Gujjari,
ShubhaShini P.v. – 2012
Frenectomy: A Review with the
Reports of Surgical Techniques
 Puneet Sharma, Sanjeev Kumar
Salaria, Ravi Kiran N Gowda,
Sameer Ahuja, Sidharth Joshi,
Deepak Kumar Bansal – 2016
Frenectomy- A Brief Review
 Dr. Manish Ashtankar, Dr. Mala
Dixit Baburaj and Dr. Abhishek
Singh – 2018
LABIAL FRENECTOMY- A REVIEW
AND CASE REPORTS