An Antique Approach to Frenectomy: Replenishing Functional Esthetics - A Case Report

Introduction

A frenum is a mucous membrane fold that connects the lip and cheek to the gingiva, alveolar mucosa, and underlying periosteum. The frenum's primary function is to keep the lower and upper lips, as well as the tongue, in place. It is considered abnormal with increased marginal gingival pull associated with reduced vestibular depth and inadequate width of attached gingiva.¹ Frenal attachments are distinguished based on the attachment of fibers as:²

1. Mucosal – Extends to mucogingival junction

2. Gingival – Extends to attached gingiva

3. Papillary – Extends to interdental papilla

4. Papilla penetrating – Fibers extend from the alveolar process to the palatine papilla.

Papillary and papilla penetrating frenal attachments are regarded as pathologic in clinical terms as they initiate interdental papilla loss, recession, diastema, leading to difficulty in tooth brushing and provoke psychological distress in patients.^3,4

Classic frenectomy, Schuchardt Z-plasty, V-Y plasty, and Miller's (unilateral single pedicle flap) procedure are some of the scalpel frenectomy techniques. Traditional frenectomy has the disadvantage of completely excising the interdental tissue, palatine papilla and frenum exposing the underlying alveolar bone and causing scarring.^5,6 This can interfere with healing of the underlying tissues and create an unsightly appearance. To overcome this disadvantage, Miller described a surgical procedure in which frenectomy was combined with a pedicle graft placed laterally. The key benefit of this approach is full closure of the midline due to lateral positioning of the tissue and primary intention healing, resulting in formation of new attached gingiva. The interdental papilla is not disrupted since the trans-septal fibers are not dissected. Consequently, greater aesthetic and practical benefits are achieved.⁷

Having known the shortcomings of classical frenectomy and acknowledging the modifications for post orthodontic removal of frenum, we attempted this antique approach by Miller with considerable follow-up.

Case Presentation

A 16-year-old male patient consulted to the Department of Periodontology at Maratha Mandal’s Nathajirao G Halgekar Institute of Dental Sciences and Research Center, Belagavi, Karnataka, India for frenectomy. Patient provided a history of midline diastema which was closed by an orthodontist and was referred because of the post orthodontic frenulum which was clinically judged “abnormal” by the orthodontist (Figure 1a). On clinical examination, the frenum was observedto be broad, with an insufficient zone of attached gingiva along the midline, and the tension test revealed retraction of the marginal gingiva. This corroborated the frenal attachment to be papillary; thus frenectomy by Miller’s technique (1985) was planned. No significant medical history and history of any drug allergies was reported by the patient. After elucidating the complete surgical procedure, an informed consent was collected from the patient.

Surgical technique

Local anaesthesia was achieved with 2% lignocaine hydrochloride with 1:80,000 adrenaline. To separate the inter-dental papilla from the frenal tissue, a horizontal incision was performed (Figure 1b). Excision of the superficial frenum wedge was done using a no.15 blade and a hemostat (Figure 1b). Remnants of frenal tissue were undermined and released with a Goldman fox scissors. On the mesial side of the right lateral incisor, a vertical parallel incision was performed 2-3 mm apical to the gingival margin to reach vestibular depth (Figure 1c). By elevating a partial thickness flap, the gingiva and alveolar mucosa between two incisions were compromised (Figure 1c). In order to combine two vertical incisions, a parallel incision was created in the attached gingiva (Figure 1d).

Flap was raised and displaced mesially towards the frenum (Figure 2a). A simple interrupted non-absorbable 4-0 black braided silk suture was placed first at the base of the excised frenum. Following this, suturing of the rest of the tissue was done (Figure 2b). Surgical area was covered with periodontal pack (Figure 2c). Patient received postoperative instructions which included Ibufrofen 400 mg prescribed to manage pain, cold compress using ice pack, soft diet and avoiding biting from front teeth and 0.12% chlorhexidine gluconate mouthrinse twice daily for two weeks. The patient was instructed to report back if the periodontal dressing gets dislodged, and was recalled seven days later for the removal of pack and sutures. After seven days, satisfactory healing was observed (Figure 2d).

A follow up visit scheduled post-operatively at one month showed satisfactory healing (Figure 3a). A three month post- operative view demonstrated beneficial results (Figure 3b).

Discussion

The focus of surgical approach is not the eradication of frenum per se, but rather to achieve orthodontic stability without sacrificing aesthetics. The Miller’s method has two benefits. First, instead of "scar" tissue, a continuous collagenous band of gingiva extends across the midline following healing. This collagenous band may act as a "bracing" device, helping to avoid orthodontic relapse (reopening of the diastema). The second benefit is that transseptal fibres are not surgically disturbed. Subsequently, there is no aesthetic loss between the central incisors due to surgical trauma.

Miller treated 27 participants with aberrant frenum who had previously undergone orthodontic diastema closure with a frenectomy and a laterally placed pedicle graft. No evidence of interdental papilla loss was observed in the study. There was no diastema relapse in 24 of the patients studied, and mild relapse (less than 1 mm) was noted in just three instances. He proposed that the newly produced wide attached gingiva, which includes collagenous fibres may have a bracing effect, which could have prevented the diastema from closing. According to Miller, this surgery should be scheduled after completion of all the orthodontic movements and approximately six weeks before the removal of orthodontic appliances.⁷

In the current case, frenectomy was performed six weeks prior to the removal of orthodontic appliance, and the follow-up visits were scheduled at one week, one month and three months post the surgery. The outcome at one week showed adequate healing with good aesthetic results. The outcome at one and three months showed no scar tissue, wider zone of attached gingiva and color comparable with neighboring tissue. 

No loss of inter-dental papilla was observed. There were no issues during the healing process.

Anubh et al.,⁸ used a laterally displaced pedicle graft to perform frenectomy and achieved aesthetically acceptable results with no scar development in the midline and no loss of the interdental papilla. In the current case report, a similar outcome with good color matching was also attained.

Chaubey et al.,⁹ also reported that the frenectomy technique along with lateral pedicle graft had comparable results with a scarless aesthetic zone and without loss of the interdental papilla as observed in the current study.

Bhosale et al.,¹⁰ reported that Miller’s technique of frenectomy can achieve esthetically pleasing results without scar formation.

The surgical treatment conducted in the present study involving the excision of frenal tissue post-orthodontically showed efficient results without leaving any scars with maintenance of the functional esthetics.

Conclusion

Miller specifically advised laterally displaced flap technique for post-orthodontic frenectomy. Our procedure also demonstrated healing by primary closure, resulting in a wide area of attached gingiva along with color matching of the neighbouring tissues, maintaining minimal scarring; the interdental papilla was not lost as transseptal fibres were released rather than dissected. Thus this approach can be an effective for the management of post orthodontic frenulum balancing the functional esthetics and healing.

Conflict of interest

None