Perio-esthetic surgery: Using LPF with frenectomy for prevention of scar.

An aberrant frenum is postulated to create functional and aesthetic problems. Archer's 'classical frenectomy' is an extensive procedure including the excision of fibers, interdental papilla, and exposure of alveolar bone up to the palatine papilla. The resultant delayed healing, loss of interdental papilla, and abnormal scar led towards the conservative approaches like Edward's frenectomy, frenum relocation by Z-plasty and free gingival graft; with their technical and aesthetic limitations. A better approach to make a primary closure in midline and to avoid anesthetic scar by creating a zone of attached gingiva, frenectomy is assisted with lateral pedicle graft. The interdental papilla is left surgically undisturbed and healing takes place by primary intention. Miller, in his study on 27 subjects, suggested that the newly created zone of attached gingiva might have bracing effect inhibiting reopening of diastema. A case series of this technique with its distinct advantages is presented.

INTRODUCTION

A frenum is an anatomic structure formed by a fold of mucous membrane and connective tissue, sometimes muscle fibers. The superior labial frenum is triangular in shape and attaches the lip to the alveolar mucosa and/or gingiva. It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration.[1] Taylor has observed that a midline diastema is normal in about 98% children between six and seven years of age, but the incidence decreases to only 7% in persons 12-18 yrs old.[2] But in some instances, the infantile arrangement is retained. This high coronal attachment is generally associated with a hypertrophy of the frenum. Depending upon the extension of attachment of fibers, frena have been classified as:[3]

Mucosal – when the frenal fibers are attached up to mucogingival junction;

Gingival – when fibers are inserted within attached gingiva;

Papillary – when fibers are extending into interdental papilla; and

Papilla penetrating – when the frenal fibers cross the alveolar process and extend up to palatine papilla.

Clinically, papillary and papilla penetrating frena are considered as pathological and have been found to be associated with loss of papilla, recession, diastema, difficulty in brushing, alignment of teeth, and psychological disturbances to individual.[45]

Abnormal or aberrant frena are detected visually by applying tension over it to see the movement of papillary tip or blanch produced due to ischemia of the region.[6] Miller has 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 papilla shifts when the frenum is extended.[7]

In such cases, it is necessary to perform a frenectomy for aesthetic, psychological, and functional reasons. There are numerous surgical techniques for the removal of labial frenum. In the “classical frenectomy” by Archer[8] and Kruger,[9] the frenum, interdental tissue, and palatine papilla are completely excised leading to exposure of underlying alveolar bone and thus leading to scarring. Though this technique resulted into an anesthetic scar, but this approach was advocated to assure removal of muscle fibers, supposedly connecting the orbicularis oris with the palatine papilla. It was thought that if this was not done, the diastema would reopen.

Henry et al. studied thoroughly the histological constituents of frenum and found considerably dense collagenous tissue, loose connective tissue, and elastic fibers, but no muscle fibers.[1] So Edward,[10] evaluating 308 patients who demonstrated either a diastema or an abnormal frenum or a combination of both, advocated a “conservative surgical procedure”. His method consisted of three procedures:

Apically repositioning of the frenum (with denudation of alveolar bone),

Destruction of the trans-septal fibers between the approximating central incisors,

Gingivoplasty of any excess labial and/or palatal tissue in the interdental area.

One of the salient aspects of Edward's technique was the aesthetic maintenance of the interdental papilla. But the healed scar in the midline appeared anesthetic to the subjects.

Coleton[11] and Lawrence[12] have used free gingival graft combined with frenectomy. This procedure avoids the scar, but a mismatched gingival color in midline and need of a second surgical site to achieve donor tissue complicate the technique. Laser has been used by various clinicians which has its relative advantages and disadvantages.[1314]

Miller has presented a surgical technique combining the frenectomy with a laterally positioned pedicle graft. Closure across the midline by laterally positioned gingiva and healing by primary intention resulted in aesthetically acceptable attached gingiva across the midline. No attempt was made to dissect the trans-septal fibers and hence, interdental papilla remained undisturbed. Aesthetically and functionally better results were obtained.[7]

So in the following case-series, this technique has been attempted and results are presented.

CASE-SERIES

The present surgical technique was undertaken at Kothiwal Dental College and Research Centre, Moradabad. It was approved by Ethical Committee on Human and/or Animal Subjects’ Research, Kothiwal Dental College and Research Centre, Moradabad. The subjects underwent frenectomy for functional, aesthetic, periodontal or orthodontic reasons. A frenum was judged abnormal if it was unusually broad and there was no apparent attached gingiva in the midline and the interdental papilla could be stretched by the frenum.[7]

CASE REPORT

Case 1

A 32-year-old male complained of receding gingival tissue in upper mid line region. On clinical examination, a papilla-penetrating upper mid frenum was found [Figure 1a]. After local anesthesia, a horizontal incision was taken to separate the frenum from the base of interdental papilla. This incision was extended apically up to the vestibular depth to completely separate the frenum from alveolar mucosa. Any remnant of frenal tissue in the mid line and on the under surface of lip was excised [Figure 1b]. A vertical parallel incision was taken on the mesial side of lateral incisor, 2-3 mm apical to marginal gingiva, up to vestibular depth. The gingiva and alveolar mucosa in between these two incisions were undermined by partial dissection to raise the flap [Figure 1c]. A horizontal incision was then given 1-2 mm apical to gingival sulcus in the attached gingiva connecting the coronal ends of the two vertical incisions. Flap was raised, mobilized mesially, and sutured to obtain primary closure across the midline [Figure 1d]. No attempt was made to dissect trans-septal fibers between approximating central incisors. Gingivoplasty of any excess labial and/or palatal tissue in the interdental area was done, preserving the integrity of the interdental papilla. The surgical area was dressed with COE PAKTM (GC America Inc., Alsip, IL, 60803, U.S.A.). Dressing and the sutures were removed one week later. A healing zone of attached gingiva was clearly visible with no loss of interdental papilla [Figure 1e].

Figure 1a

Pre-operative with thick frenum and loss of interdental papilla

Figure 1b

Resected frenum site

Figure 1c

Vertical incision mesial to lateral incisor and undermining of the pedicle

Figure 1d

Displacement and suturing of the pedicle at midline

Figure 1e

Post-operative at one week showing healing in proliferative phase

Case 2

In this case, high frenum was associated with the loss of interdental papilla and diastema [Figure 2a]. The same surgical steps were followed. Ten days post-operative observations showed the formation and maturation of attached gingiva in the midline [Figure 2b].

Figure 2a

Intra-operative postioning of the blade

Figure 2b

Post-operative at 10 days showing later stage of proliferative stage

Case 3

The patient had a complaint of a small nodular mass under upper lip. He had developed a habit of playing with it. On examination, a high frenum with a nodule was found [Figure 3a]. Same surgical steps were followed. Ten days post-operative view [Figure 3b] shows elimination of the nodule and healing with epithelialization in midline apical to the interdental papilla.

Figure 3a

Pre-operative

Figure 3b

Post-operative at 10 days showing epithelislization in late proliferative stage

Case 4

A 20-year-old male patient was referred from the Department of Orthodontics for frenectomy. On examination, a papillary frenum associated with midline diastema was found [Figure 4a]. It was thereafter managed surgically following the above mentioned technique. Two weeks post-operative view [Figure 4b] shows a healing zone of attached gingiva in midline. One month post-operatively, the healing was complete and no scar was observed [Figure 4c]. Three months follow-up showed the results were static. The tissues were more matured and remodeled. There was no loss of interdental gingiva. The zone of attached gingiva was increased and the color was comparable to the adjacent tissue [Figure 4d].

Figure 4a

Pre-operative view revealing thick frenum with midline diastema

Figure 4b

Two-week post-operative view showing healing zone with epithelialization in midline

Figure 4c

One-month post-operative view showing a zone of attached gingiva and no scar in midline

Figure 4d

Three-months post-operative view showing almost completion of maturation/remodeling phase. A zone of attached gingiva in midline, neither scar nor loss of interdental papilla is observed

RESULTS

The outcome of this surgical procedure shows this technique produced a pleasing aesthetic result. Scar formation in the midline could be avoided. On healing, a wider zone of attached gingiva was obtained. It was color matched with adjacent tissue. Healing was obtained by primary intention. No loss of interdental papilla was observed. No complication was noted during healing period. Patient's compliance was also very good.

DISCUSSION

In the era of periodontal plastic surgery, more conservative and precise techniques are being adopted to create more functional and aesthetic results. The management of aberrant frenum has travelled a long journey from Archer's[8] and Kruger's[9] “classical techniques” of total frenectomy to Edward's[10] more conservative approach. Recent techniques added frenal relocation by Z-plasty,[15] frenectomy with soft-tissue graft[1112] and Laser[1314] applications to avoid typical diamond-shaped scar and facilitate healing. Each method has its own advantages and disadvantages.

A frenum is evaluated in relation to vestibular depth, zone of attached gingiva, interdental papilla, and diastema. If there is an adequate zone of attached gingiva, coronal to the frenum, it is of no clinical significance. A zone of attached gingiva is considered to prevent recession and it also gives an aesthetically pleasant appearance.

In this context, Miller's technique combined with a laterally positioned pedicle graft[7] was attempted in this case series due to its salient features. A wound, produced by incision during periodontal plastic surgery, undergoes a complex and dynamic process of healing and results in a better aesthetic anatomical configuration and function. The purpose of elevating a partial thickness of gingival tissue for lateral displacement is to achieve a healing with primary union that heals rapidly with minimal edema, no local infection or serous discharge, no separation of wound edges, and no or minimal scar formation.[16] This takes place in three distinct phases.[17]

Phase-I: Inflammatory phase (day 1 through 5) - marked by classic features of inflammation, exudation of serum and migration of neutrophils followed by monocytes for removal of surgical debris. In the latter part of this phase, the epithelial cells from the margin begin migrating over the incision. Simultaneously, fibroblasts begin reconstruction of connective tissue.

Phase-II: Proliferative phase (day 5 through 14) – there is continuation of epithelial cell migration towards closer of wound. Fibroblasts lay down collagen and ground substance. The lymphatics re-canalize, blood vessels proliferate, and numerous capillaries develop. Granulation tissue forms, but it does not gain appreciable tensile strength. Clinically the area appears red, puffy and edematous, as is evident in [Figures 1a and 2a]. In the later part of this stage, many of the inflammatory and proliferative changes start disappearing. Wound contraction begins and tissue gains appreciable tensile strength as is evident in [Figure 4b].

Phase-III: Maturation/remodeling phase (day 14 through complete healing). Usually, by this time, epithelial continuity is maintained. Cross linking of collagen fibers takes place which results in gain in tensile strength. Inflammation and edema diminish. It is evident clinically in one month post operative photograph [Figure 4c]. Further maturation and remodeling, depending upon severity of wound, may continue. Wound contraction occurs over a period of few weeks and months.[18] The tissue gradually becomes normal, healing is complete and no scar is observed. The three month post operative photograph, [Figure 4d] represents this stage.

The healing process is regulated delicately by different cytokines like interleukins, platelet derived growth factor, transforming growth factor, fibroblast growth factor, epithelial derived growth factor, insulin like growth factor and others.

This technique offers two distinct advantages. First, on healing, there is a continuous band of gingiva across the midline rather than anesthetic scar. The second advantage is that trans-septal fibers are not disrupted surgically to avoid any trauma to interdental papilla. This prevents loss of interdental papilla.

In a study on 27 subjects with abnormal frenum who had undergone orthodontic closer of diastema, Miller did frenectomy combined with a laterally positioned pedicle graft. There was no loss of interdental papilla. No relapse of diastema was found in 24 cases and in three cases only minimal relapse (less than 1 mm) was noted. He has suggested that the newly formed broad attached gingiva contains collagenous fibers which may have a bracing effect and prevented reopening of diastema. He has further suggested that the ideal time for performing this surgery should be after orthodontic movement is complete and about six weeks before appliances are removed. This not only allows for healing and tissue maturation, but also permits the surgeon to use orthodontic appliances as a means of retaining periodontal dressing.[7] This observations can be utilized during post-orthodontic retention period, but gain of attached gingiva in place of scar and no loss of interdental papilla are definite advantage of this technique.

CONCLUSION

The present study describes the surgical technique combining frenectomy with a lateral pedicle graft. This method has certain distinct advantages e.g.-

Healing takes place by primary intention

A zone of attached gingiva, matching with adjacent tissue, forms in midline which is pleasing to the individual

No unesthetic scar formation

No recession of interdental papilla occurs because the transseptal fibers are not severed out

The attached gingiva in midline may have a bracing effect which helps in prevention of orthodontic relapse.