Prevalence of variations in morphology and attachment of maxillary labial frenum in various skeletal patterns - A cross-sectional study

Assessment and Management of Maxillary Labial Frenum-A Scoping Review

BACKGROUND

The maxillary labial frenum (MLF) is a soft tissue fold connecting the upper lip to the alveolar process. Abnormal attachment can cause periodontal, functional, and esthetic problems. Differential diagnosis is important and can prevent unnecessary interventions. This study aims to summarize the current evidence on the assessment and management of abnormal MLF.

METHODS

A thorough review of the literature was conducted. Five online databases were searched for relevant peer-reviewed human studies. Article screening and data extraction were performed independently by two reviewers using predefined inclusion/exclusion criteria. Information about article type, study design, participants' characteristics, interventions, and outcomes was extracted and synthesized.

RESULTS

52 articles met the review criteria. MLF is a dynamic structure characterized by a wide normal morphological variation. MLF assessment in infants has not been standardized. Studies in pre-adolescents reported a change in the thickness and position of the MLF observed over time, resulting in a lower prevalence of abnormal MLF morphology. Studies in adolescents and adults reported variable differential diagnosis criteria. Lasers appear as the most advantageous frenectomy modality.

CONCLUSIONS

There is a need for more objective MLF diagnostic protocols and treatment guidelines, which could prevent unnecessary surgical interventions.

Z-plasty surgery combined with orthodontic-prosthodontic approach in the rehabilitation of aberrant frenum with congenitally multiple agenesis: A case report

INTRODUCTION

Orthodontists often encounter a clinical challenge while dealing with a big space of anterior teeth. Aberrant frenum with congenitally multiple agenesis is a complex case that requires an interdisciplinary approach. The purpose of this paper is to describe the well-synchronized periodontal surgery, orthodontic, and prosthodontic treatment of an aberrant frenum cases with congenitally multiple agenesis.

CASE PRESENTATION

A female patient, aged 20, presented with complaints of misaligned, spaced teeth, and several missing teeth. A Class III malocclusion type 1 with a high and hypertrophied maxillary labial frenum was found and diagnosed. A positive blanch test, diastemata, as well as persistent teeth 53, 71, and 81, were detected. Panoramic radiographs confirmed the teeth's agenesis. Orthodontic treatment was performed using the straightwire technique to close the spaces. The frenulum was corrected by a frenectomy utilizing the Z-plasty surgical procedure. Subsequently, prosthodontic treatment involved the fabrication of lucitone dentures to close the remaining space.

DISCUSSION

This case alerted periodontists, orthodontists, and prosthodontists that collaboration is essential to intervene in such specific congenital anomalies. An interdisciplinary effort should focus on eliminating the etiology of malocclusion, considering periodontal factors, maintaining dental arch integrity, addressing biomechanical elements, designing appropriate prostheses, ensuring better retention of tooth position, and achieving aesthetic appearance.

CONCLUSION

The Z-plasty frenectomy surgery treatment resulted in successful and rapid healing after the operation, with no occurrence of hypertrophic scar formation. The final outcome of orthodontic-prosthodontic treatment was also pleasing for both the patient's aesthetic and functional requirements and the operator's satisfaction.

Associations between maxillary labial frenum Morphology, Attachment, and Patient-Related clinical factors in Saudi Arabian Adults: Cross-sectional study

Objective

This study investigated the prevalence of maxillary labial frenum morphologies and attachment types and their associations with various patient-related clinical variables in a population of Saudi Arabian adults.

Methods

This study comprehensively examined 100 participants of both genders to categorize frenum types and attachment sites. The following clinical variables were recorded: probing depth, clinical attachment loss, attached gingiva width, overjet, overbite, diastema width, central incisor condition, occlusion, previous orthodontic treatment, and the incidence of gummy smile.

Results

The mean age was 32.6 years, and the average diastema width was 0.23 mm. The study found that the simple frenum type was the most common morphology (57 %), and gingival attachment was the most frequent attachment type (54 %). Simple frenum was significantly associated with class I occlusion (p = 0.018), and frenum with nichum was significantly associated with class II occlusion (p = 0.019). Females were more likely to exhibit simple frenum with nodule frenum than males (p = 0.042). Mucosal frenum attachment was significantly correlated with the absence of previous orthodontic treatment (p = 0.042).

Conclusion

The study identified a relationship between the features of the maxillary labial frenum and occlusion as well as previous orthodontic treatment. Our findings suggest that understanding each patient's unique frenum features can lead to more effective and personalized dental care, thus improving patient satisfaction.

The Common Retention Practices Among Orthodontists from Different Countries

Objective

To investigate the most common retention practices, factors influencing the retention protocol, and the differences among orthodontists regarding retention practices.

Methods

An online validated questionnaire was anonymously sent to 3,000 orthodontic residents and clinicians. The survey consisted of 19 questions regarding the participants' demographics, prescribed retention appliances, factors affecting retention appliance choices, and adjunctive retention procedures. Descriptive statistics, Chi2 and Kendall's Tau-b tests were applied.

Results

Five hundred fifty-five orthodontic residents and clinicians, 53.3% males and 46.7% females, completed the survey, indicating a response rate of 18.5%. Although participants' demographics, type of treatment and pre-treatment malocclusion influence the choice of retention protocols, thermoplastic retainers (TR) were the most popular retention regime for the maxillary arch for both adults (47.4%) and adolescents (42.3%). Bonded retainers (BR) were the favored option for the mandibular arch (44.9% of adults and 40.7% of adolescents). The degree of arch expansion (64.1%) and the degree of interdigitation (50.1%) after treatment were the most influential factors for the choice of the preferred type of retainers by the respondents. 68.6% of the participants thought professional retention guidelines would be useful.

Conclusion

Thermoplastic retainers were the most common retention appliances for adults and adolescents in the maxilla. At the same time, BR was the most favored retainer in the mandibular arch, with clinical experience, practice setting, and malocclusion- and treatment-related factors influencing the type of the chosen appliance. The demographic differences and the uneven participation in the survey need to be considered while interpreting the findings of this study.

Prevalence of Maxillary and Mandibular Frenal Attachment and Its Association with Age, Gender, and Oral Hygiene Status in Nepalese Population Seeking Dental Treatment

Objective

Frenum attachments are folds of mucous membrane that connect the lips to the alveolar mucosa and underlying periosteum. Aberrant positioning of the maxillary and mandibular labial frenum can lead to various clinical issues, including mucogingival problems and midline diastema. The objective of this study was to assess the prevalence of maxillary and mandibular frenal attachments and their association with age, gender, and oral hygiene status in the Nepalese population seeking dental treatment.

Materials and Methods

This descriptive cross-sectional study was conducted over a period of 6 months, from February 2023 to August 2023, among patients visiting the Department of Periodontology and Oral Implantology, aged 6 years and above, after obtaining official permission from the Institutional Review Committee (IRC-KUSMS Approval No. 8/23). The study collected data on morphological variations of frenal attachment and various periodontal parameters such as Oral Hygiene Index-Simplified (OHI-S), pocket depth, recession, and midline diastema in both arches. Descriptive statistics, including frequency and percentage, were used to analyze the data. The χ2-test was employed to determine the correlation between gender and types of frenulum attachment, while analysis of variance was used to assess the association of frenal attachments with oral hygiene status.

Results

Among 380 patients, the prevalence of frenal attachment was as follows: gingival 248 (65.30%), mucosal 71 (18.70%), papillary 42 (11.10%), and papillary penetrating 19 (5.00%) in the maxilla, and mucosal 225 (59.20%) and gingival 155 (40.78%) in mandible. Among the different morphological variations of frenal attachments, normal frenum was the most common, accounting for 231 cases (60.80%), followed by frenum with a nodule, with 101 cases (26.60%).

Conclusions

The study found significant associations between frenal attachment and gender, as well as oral hygiene status. The prevalence of frenal attachments in this study was comparable to findings from previous research.

Lingual frenulum length: A prospecting link to craniofacial morphology in adults

OBJECTIVES

The aim of this study was to evaluate the correlation of the length of the lingual frenulum with the craniofacial morphology in adults.

METHOD AND MATERIALS

The study comprised a total of 144 subjects, aged 18 to 28 years, divided into 3 groups (48 in each group), based on ANB angle i.e., Skeletal Class I, Skeletal Class II & Skeletal Class III. To measure the length of the lingual frenulum direct and indirect methods were used. A Lingual frenulum ruler was used for direct measurement and the differences between the maximum mouth opening reduction (MMOR) with and without the tip of the tongue touching the incisive papilla measurement were taken for the indirect method. A lateral cephalogram was collected from each subject and a cephalometric analysis was done to assess craniofacial morphology. Statistical analysis was done by ANOVA and the significance of the mean difference between (inter) the groups was done by Tukey's HSD (honestly significant difference) post hoc test after ascertaining normality by Shapiro-Wilk's test and homogeneity of variance between groups by Levene's test.

RESULTS

The lingual frenulum length and maximum mouth opening reduction were significantly increased in the Skeletal Class III subjects with a statistically significant value of P < 0.001 when compared with the Skeletal Class I and Skeletal Class II subjects.

CONCLUSION

A balance in the teeth positioning is maintained by orofacial musculature and any disturbance which occurs in this, results in malocclusion. Malocclusion can result in a long lingual frenulum that pushes the mandibular anterior forwards. Hence, the malocclusion and lingual frenulum length relationship are essential to eliminate the erratic forces and to attain excellent results, following the elimination of malocclusion.

Associations among the occurrence or types of maxillary canine impaction, labial frenum attachment types, lateral incisor anomalies, and midline diastema in patients with and without impaction: A case-control study

INTRODUCTION

We tested whether the labial frenum attachment types may affect the occurrence or type of maxillary canine impaction.

METHODS

This case-control study was performed on 96 subjects (48 with maxillary canine impaction [20.50±4.99 years, 32 females], 48 controls [21.94±3.79, 31 females]). Types of canine impaction (buccal/palatal, bilateral/unilateral, left/right), types of upper lip middle frenums (mucosal, gingival, papillary), the anatomy of lateral incisors (impacted, peg shaped, small, normal), and the midline diastema were evaluated clinically and radiographically. Associations were examined using multiple binary logistic regression, 3-way repeated-measures ANCOVA, and Fisher tests (α=0.05, β=0.2).

RESULTS

The numbers of mucosal, gingival, and papillary frenums in the case group were '29, 14, and 5', respectively; in the control group, they were '25, 21, and 2' (Fisher, P=0.248). The numbers of mucosal, gingival, and papillary frenums were respectively '25, 11, and 1' in the palatally impacted canine subgroup; they were '4, 3, and 4' in the buccally impacted subgroup (Fisher, P=0.010). Abnormal laterals were present in 12 cases and 4 controls; normal laterals were observed in 36 cases and 44 controls (Fisher, P=0.053). Abnormal laterals were seen in 10 cases with palatally impacted canines and 2 cases with buccally impacted canines; normal laterals existed in 27 cases with palatally impacted canines and 9 cases with buccally impacted canines (Fisher, P=0.705). Lateral anatomy was not associated with frenum attachment (Fisher, P=0.827). Greater midline diastemas were seen in cases with maxillary canine impaction, papillary frenums, and abnormal laterals (ANCOVA, P≤0.016).

CONCLUSIONS

Buccal type of canine impaction is positively associated with papillary labial frenums. Canine impaction is 3.6 folds more prevalent in cases with lateral abnormality. Midline diastema is positively and independently associated with canine impaction, papillary frenums, and abnormal laterals.

Labial Frenectomy using Laser: A Scoping Review

Labial frenectomy is a surgical technique, that aims to remove the frenulum with its attachment to the underlying bone. Frenectomy, is indicated if the frenulum attachment causes midline diastema, gingival recession, hindrance in maintaining oral hygiene, or if it interferes with lip movements and for prosthetic needs. A labial frenectomy can be performed either by the routine scalpel technique, electrocautery, and most recently medical lasers. The aim of this study was to evaluate, whether the laser technique is more effective than the conventional surgical technique, and whether there are differences between the different types of lasers. The scoping review was conducted and prepared on the basis of the indications of the PRISMA guidelines (PRISMA Extension for Scoping Reviews, PRISMA-ScR) of PRISMA checklist, and nine papers were considered admissible to the qualitative analysis for the following outcomes: bleeding during intervention, use of sutures, duration of the intervention, and use of analgesic drugs in the days following the intervention. This review suggests that laser-performed labial frenectomy is faster and offers better intra- and postoperative management; however, due to the limited number of available papers, the final results of the present review are not absolute.

High frenal attachment and its prevalence among children - A retrospective study

The frenum is a narrow mucosa fold surrounded by muscle fibers that connect the lips to the alveolar mucosa and the periosteum beneath. Midline spacing, commonly called as diastema, recession, interference with prosthodontic therapy, and difficulty speaking are all symptoms of a high frenal attachment. Frenectomy is a surgical treatment that involves removing the aberrant frenal connection. The frenum is a connective tissue membrane that connects one mouth surface to the next. The purpose of this study is to see how popular high frenal attachment is among children who visit a university dentistry hospital. This was a retrospective investigation evaluating the prevalence of high frenal attachment in patients visiting a Chennai dental institution. From June 2019 to March 2021, 11278 patients visited a dental clinic.

Comparative frenectomy with conventional scalpel and dual-waved laser in labial frenulum

Aim

The purpose of the study is to compare the labial frenectomy between the laser surgery (erbium yttrium aluminum garnet and neodymium-doped yttrium aluminum garnet (Er:YAG and Nd:YAG)) and the scalpel method.

Methods

The trial was a randomized controlled test. Thirty four patients aged from 5 to 10 years requiring the frenectomy were included in this study. Patients were randomly divided into two groups: group A: Er:YAG and Nd:YAG laser group and group B: scalpel group. In addition, this comparison considered the following factors: surgical time and Visual Analog Scale (VAS) pain score, which includes intraoperative pain, postoperative pain and complications, such as speaking and chewing, for 1 day and 7 days following labial frenectomy. After 3 months, we recorded the healing outcome by photos.

Results

There was a statistically significant difference in mean surgical time between laser surgery (mean=224±59 s) and scalpel surgery (mean=740±168 s). According to VAS scores of the intraoperative period (3 hours after the operation and 1st postoperative day of pain), chewing and speaking were statistically higher in group B than those in group A; but in the 7th postoperative day of pain, there was no significant difference in speaking and chewing. After 1 month, all of the patient results were recorded, including the healing of wound and scar. Except for one patient in group B who had a scar, all patients achieved good results.

Conclusion

Based on the results of this study, it can be concluded that Nd:YAG laser is an efficient and more comfortable alternative to the scalpel for a frenectomy in upper lip frenulum.

Diode versus CO2 Laser Therapy in the Treatment of High Labial Frenulum Attachment: A Pilot Randomized, Double-Blinded Clinical Trial

Background: The labial frenula are triangular plicas departing from the alveolar mucosa and attaching themselves at different heights of the gingiva. Sometimes a high attachment can determine a gingival recession. The most suitable surgical resolution is the use of laser devices. The aim of this study was to compare the labial frenulectomy through the use of Diode and CO₂ laser techniques in pediatric patients with a high labial frenulum attachment, clarifying at the same time the preventive role of the surgical treatment to avoid further recession. Methods: A pilot randomized, double-blinded clinical trial was conducted to compare both the surgical advantages and the preventive treatment of laser technology using two different wavelengths within a population of pediatric patients with a high labial frenulum attachment. Different parameters intra and post-surgery were taken into account (Bleeding, Wound Healing, Gingival Recession, Periodontal pocket and Numerical Scale Value for pain) to compare Diode versus CO₂ laser therapy. Results: Although both the laser devices provide a good performance in the post-operative period, the Diode laser shows better results (p < 0.001) in three of the five parameters evaluated. Conclusions: From the results it was found that the Diode Laser device is more suitable compared to the CO₂ device.

Frenal attachment and its association with oral hygiene status among adolescents in Dakshina Kannada population: A cross-sectional study

BACKGROUND AND OBJECTIVE

Frenum is a mucous membrane fold that attaches the lip and the cheek to the alveolar mucosa, gingiva, and the underlying periosteum. The frena may jeopardize the gingival health when they are attached too closely to the gingival margin, either due to interference in the plaque control or due to muscle pull. Identifying labial frenum attachment and its association with oral hygiene helps in primary prevention of gingival health. The purpose of this study was to examine the prevalence of the various types of maxillary labial frenum attachment and its association with oral hygiene status in adolescent population.

METHODOLOGY

A total of 300 adolescents between 13 and 18 years were selected randomly. They were clinically examined for maxillary frenum attachment. Placek's classification of the labial frenum attachments was used to check the origin of frenum. Oral hygiene index (simplified) was recorded and results were subjected to statistical analysis.

RESULTS

Among 300 examined children 53% were males and 47% were females. The prevalence of the maxillary labial frenum was gingival type (39%) followed by mucosal (28.3%), papillary (23.7%), and papillary penetrating type (9.0%). The gingival type of frenal attachment was statistically significant among different age of children and also between different types of frenal attachment and oral hygiene status (p value < 0.001). There was no significance between frenum attachment and gender.

CONCLUSION

The type of frenal attachment is strongly associated with oral hygiene status. as the age progresses the frenum tends to migrate apically. However, our study did not reveal any relationship between the gender and type of frenal attachment.

An Insight into the Role of the Maxillary Labial Frenum in the Growth of the Maxilla: A Systematic Review

Background: The review attempts to provide synthesis of published studies evaluating the influence of an aberrant frenum attached close to the gingival margin or with inadequate width of attached gingiva on the growth of the maxilla.

Methodology: This review was reported using the PRISMA checklist as a template. PubMed, EBSCO and Google scholar were searched for in earlier publications up to January 2019. In addition, reference lists of the included studies were hand searched. The eligibility criteria were listed out based on Population, Intervention, Comparison, Outcome, Study type (PICOS) concept.

Results: A total of 148 articles were found by database search strategies and 27 additional studies by hand search. Finally three cross sectional and one longitudinal study were selected based on the eligibility criteria. A meta-analysis was not justified. Risk of bias was assessed using AXIS tool for cross sectional studies and Newcastle-Ottawa scale for longitudinal study. Common weaknesses of the studies were failure to justify or calculate the sample size and insufficient statistical reporting.

Conclusion: This review reveals that there is a need for methodologically standardized studies that will throw light on to the physiological importance of labial frenum in the growth of the nasomaxillary complex.