Frenal Attachement

1. 1 Frenal attachment Frenal attachment Prepared by: Prepared by: Dr Mohammed Alruby Dr Mohammed Alruby عفصت بنذ يأب لاعنلا تكش مههوجو لاعنلا سم اذا موق Frenal Frenal attachment attachment Dr. Mohammed Alruby Dr. Mohammed Alruby

2. 2 Frenalattachment Frenum: is a vertical band of oral mucosa that attaches the cheeks and lips to the alveolar mucosa of maxillary and mandibular arches OR: is a thin fold of mucous membrane with enclosed muscle fibers that attach the lips to the alveolar mucosa and underlying periosteum Function: limiting the movement of the lips and cheeks Origin: The Frenum has its origin from the remnant of central cells of vestibular lamina which predominantly has connective tissue and least amount of muscle fibers = when the Frenum inserts into the soft tissue covering the alveolar process = the abnormal Frenum inserts into the gingiva in a manner that allows the Frenum to retract the gingival margin to facilitate diastema development or to limit up movement == Placek et al, introduce a clinical morphological classification of maxillary Frenum insertion, depending on the anatomic location of attachment -Attached gingiva -Interdental papillae -Papillae extending to palate == abnormal Frenum attachment acts as a hindrance of the tongue and the upper lip to form seal, thus making it difficult for children for breast feeding == as the pull of Frenum attachment is greater than normal, it produces constant force on the attached gingiva leading to localized gingival recession and requires orthodontic later. It may lead to midline diastema which lead to flaring of the two upper central incisors due to presence of thick bands of Frenum which is not self-correcting like ugly duckling stage and it require minor surgical correction = the orthodontic correction may also not be very efficient and it may lead to post orthodontic relapse = in young children, the Frenum is generally wide and thick which becomes thin and small during growth Types of Frenal attachment: Depending on the extent of attachment of fibers, it classified by Placek et al 1974 as: 1-Mucosal: The Frenum inserting up and including the muco-gingival junction with no evidence of crossing into attached gingiva as: the stretched Frenum did not appear to elevate the keratinized tissue 2-Gingiva: the Frenum inserting into the attached gingiva and not extending coronal to the line demarcating the base of midline papillae was defined as the line connecting the gingival zeniths of the two central incisors 3-Papillary: the fiber extends into the interdental papillae 4-Papillary penetrating: the Frenal fibers cross the alveolar process and extend up to palatine papillae. Variations: Variations of Frenal attachment include the following according to Sewerain 1971: 1-Simple Frenum with a nodule 2-Simple Frenum with appendix 3-Simple Frenum with nichum 4-Bifid labial Frenum 5-Persistent tecto labial Frenum Frenal Frenal attachment attachment Dr. Mohammed Alruby Dr. Mohammed Alruby

3. 3 6-Double Frenum 7-Wider Frenum Diagnosis: Tests of frenal attachment: tension test, and blanch test Miller et al 1985: recommended that the Frenum should be characterized as pathogenic when it is unusually wide or there is no apparent zone of attached gingiva along the midline or the interdental papillae shift when Frenum is extended. Ankyloglossia: tongue tie: Uncommon congenital anomaly that occurs as a result of short, tight lingual Frenum causing difficulty in speech articulation due to limitation of tongue movement Walace et al defined tongue tie as: a condition in which the tip of the tongue can not protruded beyond the lower incisors teeth because of short Frenum linguae, often containing scar tissue Clinical features: 1-Limited mobility of tongue 2-Difficulty in swallowing 3-Difficulty in speech articulation like, S, Z, T, CH ---- and it is especially difficult to roll on R 4-Notcjed or heart shaped, tongue when it is protruded Free tongue: the length of tongue from the insertion of lingual Frenum from the base of the tongue to the tip of the tongue Normal range of the free tongue is greater than 16mm (Kotlow et al 1999) Classification: Based on the length of tongue from insertion of lingual Frenum to the tip of tongue Class I: mild ankyloglossia: 12 – 16mm Class II: moderate ankyloglossia: 8 -11mm Class III: severe ankyloglossia: 3 -7mm Class IV: complete ankyloglossia: less than 3mm Complication of abnormal Frenum: A Frenum become a problem if the attachment is too close to the marginal gingiva, tension on the frenum may pull the gingival margin away from the tooth, this condition may induce plaque accumulation and inhibit proper tooth brushing Abnormal frenum has been found to be associated with: 1-Loss papillae 2-Midline diastema 3-Malalignment teeth 4-Recession 5-Difficulty of brushing 6-Compromised denture fit Frenal Frenal attachment attachment Dr. Mohammed Alruby Dr. Mohammed Alruby

4. 4 Treatment of abnormal frenum 1-Frenectomy: Complete removal of frenum including its attachment to the underlying bone, it is required in the correction of abnormal diastema between maxillary central incisors 2-Freotomy: 3- Incision of the frenum, it is usually done to relocate the frenal attachment so as to create a zone of attached gingiva between the gingival margin and the frenum Frenectomy techniques: 1-Conventional classical tyoe: Introduce by archer 1961 and Kruger 1964 This approach advocated in midline diastema cases with an aberrant frenum to ensure removal of muscle fibers which were correcting the orbicularis oris with palatine papillae Disadvantages: 1-Cause un esthetic labial tissue scaring 2-Become matters of concern in case of high smile line exposing the anterior gingiva 2-Miller’s technique: Advocated by Miller et al 1985 Proposed for post orthodontic diastema cases The ideal time for performing this surgery is after orthodontic movement is complete and about 6 weeks before the appliance are removed Advantages: 1-Post-operative, on healing, there is a continuous band than the scar tissue, thus preventing orthodontic relapse The transeptal fibers are not disrupted surgically and so, there is no loss of interdental papillae 3-Z plasty technique: Indications: 1-Short vestibule 2-Hypertrophy of the frenum with a low insertion associated with diastema 4-V-Y plasty technique: This technique can be used for lengthening the localized area, like broad frenum This technique is mostly employed in case of papillae type of frenal attachment 5-Electro-surgery: Recommended with patients with bleeding disorder and non-compliant patients Advantages: 1-Minimal time consuming 2-Minimal bleeding 3-No need of sutures 4-Healing by secondary intention as the wound edge are not approximated with sutures Frenal Frenal attachment attachment Dr. Mohammed Alruby Dr. Mohammed Alruby

5. 5 6-Laser frenectomy: The benefits of laser frenectomy are greater as compared to traditional type: 1-Reduced bleeding during surgery 2-Reduced operating time and rapid post-operative hemostasis 3-Lack of need of sutures, improve post-operative comfort and healing Post-operative instruction: 1-Not eat anything until the anesthesia wears off, as there are chances of biting the lips, cheeks or tongue 2-Avoid extremely hot food for the rest of the day 3-If bleeding continuous, apply light pressure to the area with a moistened gauze for 20-30 minutes 4-Avoid alcohol and smoking until after your post-operative appointment 5-Vigorous rainsing should be avoided 6-Do not pull down the lip or cheek 7-Maintain normal oral hygiene measures in the area of mouth not affected by the surgery 8-Follow soft diet, taking care to avoid the surgical area when chewing, chewing on the opposite side 9-Be sure to maintain adequate nutrition and drink plenty of fluids Frenal Frenal attachment attachment Dr. Mohammed Alruby Dr. Mohammed Alruby