Lip and cheek bands sometimes radiate into the marginal gingiva (the gum line). Here, their strong traction forces damage the periodontium (the tooth-supporting apparatus) and prevent natural or orthodontic gap closure, so they should be removed by the surgical procedure of frenectomy. Lip and cheek bands – called frenula – are made of muscle and connective tissue fibers and sometimes radiate far marginally into the gingiva (into the gum line) from the lips and cheeks. The typical areas for this are the central incisors, canines and premolars (anterior molars). The traction exerted by the frenula on the gingival margin or isolated papillae (triangular gum area between the teeth) during speech and chewing can be so strong that recession (non-inflammatory recession of the gums) is the result. A trema (synonym: diastema mediale superior – gap between the maxillary central incisors) seen in about seven percent of children may be caused by a frenulum running tightly between the teeth. If the entire papilla appears ischemic (bloodless) when the frenulum is pulled, it can be assumed that the frenulum tissue is the cause of the gap. In this case, the frenulum must be surgically removed to allow the gap to close – spontaneously or with orthodontic support. If a papilla has been lost, this means not only restrictions in esthetics but also that the affected interdental space becomes more susceptible to plaque retention (adhesion of bacterial plaque) and hygiene techniques must therefore be permanently intensified. In the gingival margin area, the recession means that exposure of the root dentin increases susceptibility to caries (tooth decay) and hypersensitive tooth necks (hypersensitive tooth necks). For the reasons mentioned above, frenulas are therefore often corrected surgically not only when they have caused damage, but already for prophylaxis (as a preventive measure). In the simplest case, this is simply a cutting (frenotomy) of the offending ligament. In addition, during frenectomy (synonyms: labial frenulum removal, labial frenulum excision, frenulotomy), which is explained below, the frenulum tissue is detached from the periosteum (bone skin) and relocated in order to reduce the risk of recurrence (relapse).
Indications (areas of application)
- Support of a spontaneous or orthodontic gap closure.
- Preventing the formation of a recession or the expansion of an existing recession.
- Avoidance of inflammatory events in the recession area.
- Avoidance of optic disc loss
- Avoidance of painful pressure points in the marginal area of prostheses due to moving ligaments.
- Improving prosthesis retention by eliminating the ligaments whose movement can lift off a prosthesis.
- Avoidance of complications in the area of implants (artificial roots of teeth) when frenula attach in their immediate vicinity.
Contraindications
- Severe, broad-based gingival recession.
- Operative procedure before the mixed dentition phase
Before surgery
- Radiological exclusion of a mesiodens (supernumerary tooth between the maxillary central incisors) or non-attachment of lateral incisors as the cause of a diastema mediale
- Information about the surgical procedure, possible complications and postoperative behavior.
The surgical procedures
I. Frenectomy with VY-plasty.
- Local anesthesia (local anesthesia) of the surgical area.
- V-shaped cutting around the ligament, keeping it under strong tension and the tip of the V-shape is the ligament tip. Only the mucosa (mucous membrane) is cut, not the periosteum (periosteum).
- Detach the muscle and connective tissue fibers with a raspatory (instrument for scraping, not cutting detachment) or undermining with scissors from the periosteum (periosteum), without injuring it.
- Moving the mucosal flap away from the gingiva into the vestibule (the oral vestibule).
- Fixation of the flap in the fold of the envelope by single button sutures in such a way that the traction triggered by the lip or cheek muscles does not cause any wrinkling in the flap area
- After suturing the triangular flap, an open wound corresponding to the vertical portion of a Y remains. The periosteum exposed in this area is left to free granulation under a wound dressing or covered by a free mucosal graft.
II Frenectomy with Z-plasty.
The incision and suture technique of the so-called Z-plasty is more demanding, but offers the advantage that the periosteum is covered here surgically. This means that it does not have to be left to free granulation or its additional surgical coverage can be omitted. Another advantage of Z-plasty is the greater gain in length.
- Local anesthesia (local anesthesia) of the surgical area.
- Z-shaped incision with the scalpel under traction on the frenulum, with the longitudinal part of the Z corresponding to the course of the ligament
- Detachment of the muscle and connective tissue fibers from the periosteum.
- Shifting of the mucosal flaps resulting from the loosening against each other in such a way that the formerly lower acute Z-angle is shifted upward.
- Fixing the mucosal flaps in the new position by single button sutures.
III. frenectomy by laser
The use of coherent, monochromatic laser light brings with it a special potential hazard, which must be taken into account by appropriate protective measures such as protective goggles for the patient and staff and appropriate continuing education. The surgical procedure with a soft tissue laser is comparatively painless and is characterized by a largely bleeding-free surgical area. This significantly reduces the risk of bacteremia. The resulting wound is often not even sutured or covered with a wound dressing. Initially free of germs, the exposed surgical area may nevertheless become infected postoperatively, especially since wound healing is delayed due to coagulation necrosis at the wound edges.
- If necessary, local anesthesia of the surgical area.
- Tensioning of the ligament, thereby punctual cutting of the respective tensioned ligament tip from gingival to vestibular (from the gum in the direction of the oral vestibule)
- Separation of the muscle and connective tissue fibers from the periosteum without injuring or overheating it by the laser.
- If necessary, wound closure by single button sutures.
- If necessary wound dressing
After the operation
- Oral hygiene instructions and dietary recommendations.
- VY-plasty: regular follow-up with cleaning of the wound in the granulation phase (formation of new connective tissue) until epithelization (sprouting of epithelial cells from the wound edges until complete coverage).
- Suture removal after one week
- Unless there is a spontaneous gap closure postoperatively: orthodontic gap closure only after the canines have been set
Possible complications
- Post-bleeding
- Inflammation
- Laser: necrosis (tissue death) of alveolar bone and periodontium (periodontium).
- Wound healing disorders
- Recurrence (recurrence of the disease)