A labial fraenectomy is indicated in various clinical situations and is performed to facilitate orthodontic closure of a maxillary midline diastema. In these clinical situations, timing of surgery during the phase of orthodontic treatment is important. Labial fraenectomy can be performed before, during or after the orthodontic closure of the maxillary midline diastema, depending on the individual case. It is important to understand how to perform the procedure efficiently and effectively. Success relies as much on accurate diagnosis of the fleshy, prominent or persistent fraenum as it does on meticulous technique to ensure its complete elimination. This article presents the indications for labial fraenectomy. The appropriate timing of the labial fraenectomy procedure to facilitate orthodontic treatment is discussed.
Clinical Relevance: A surgical technique to perform maxillary labial fraenectomy procedure in an effective and efficient manner is a useful addition to the clinician's armamentarium.
Article
The maxillary labial fraenum is a fold of tissue, usually triangular in shape, extending from the maxillary midline area of the gingiva into the vestibule and mid-portion of the upper lip. It originates as a post-eruptive remnant of the tectolabial bands, which are embryonic structures appearing at approximately three months in utero and connecting the tubercle of the upper lip to the palatine papilla.1
Relocation of this soft tissue attachment, in an apical direction, usually occurs during the normal vertical growth of the alveolar process. Failure of the attached fraenal fibres to migrate apically results in a residual band of tissue which sometimes extends between the maxillary central incisors (Figure 1). This has been implicated in the literature as a causative factor of persistent midline diastemas. The residual fraenal fibres which persist between the maxillary central incisors may also attach to the periosteum and the internal connective tissue of the V-shaped intermaxillary suture (Figure 2). In addition to the persistent fraenum sometimes preventing complete and permanent space closure between the maxillary central incisors, the fraenum has also been implicated in gingival inflammation associated with poor oral hygiene owing to the difficulty in carrying out effective toothbrushing leading to a resultant inflammatory periodontal destruction2 (Figure 3).
Figure 1. Fraenum extends to gingival margin and tethers upper lip.Figure 2. V-shaped notch of interdental septum and persistent interdental suture.Figure 3. Fraenum prevents excellent oral hygiene by impeding good toothbrushing.
Abnormal fraenal attachments have been described as occurring most frequently on the labial surface between maxillary and mandibular central incisors, but also in canine and premolar areas.3 High fraenal attachments on the lingual surface are much less common. The insertion point of the fraena may become a problem when the gingival margin is involved.4 This can be due to an unusually high fraenal insertion or recession of gingival margin down to the area affected by the fraenal pull. High fraenal insertion can pull the marginal gingiva or gingival papilla away from the tooth when the lip is stretched, which may contribute to persistent gingival inflammation and interferes with efficient plaque removal5 (Figure 4). An abnormal fraenal attachment can involve insertion of the labial fraenum into a notch within the alveolar bone, resulting in a band of heavy fibrous tissue lying between the central incisors.6
Figure 4. High fraenal attachment pulls directly on gingival papilla when lip stretched.
Henry et al concluded that, of four basic types of tissues within the human body (epithelium, connective tissue, nerve and muscle), only the muscle tissue was notably absent as an integral component of the maxillary fraenum. No microscopic differences exist between an aberrant superior labial fraenum and a fraenum of more normal configuration and position. A significant number of elastic fibres, which originate in the periosteum covering the anterior maxillary alveolus, traverse the entire length of the fraenum. It is believed that the detrimental capabilities of the maxillary midline fraenum are entirely due to its elastic and collagenous component, not a result of direct muscle tension.7
Indications for labial fraenectomy
Clinical situations in which a labial fraenectomy is performed include:
To facilitate orthodontic treatment for closure of a diastema;
To enhance the chances of the diastema remaining closed after treatment;
To eliminate undesirable tension on the gingival papilla or gingival margin;
To facilitate lip lengthening procedure;
To allow effective toothbrushing in the area of the fraenum.
Fraenectomy to facilitate orthodontic treatment
A prominent labial fraenum may delay or even prevent complete apposition of the maxillary central incisors. Opinion varies within the orthodontic community as to the timing and, indeed, the need at all for labial fraenectomies. Some orthodontists believe that the fraenum should be removed in its entirety, as soon as possible, to prevent any obstacles to complete diastema closure. Another school of thought is to close the diastema first then carry out the fraenectomy in the hope that the resultant scar tissue will ‘hold together’ the teeth in close apposition. A third body of clinicians rarely, if ever, consider surgical removal of the fraenum. They prefer to combat the undeniably increased relapse potential when a diastema is closed, by using bonded retainers on the two central incisors.
There are no doubt situations where any one of these three approaches is the most appropriate solution.
When should a fraenectomy be performed in orthodontics?
Early surgery
The fraenectomy must be carried out in a way that will produce a good aesthetic result and must be properly co-ordinated with orthodontic treatment. It is in some circumstances better to align the teeth after the fraenectomy, particularly where the fraenum is extremely large and fleshy or extends well into the suture line, as it may act as a physical obstruction to diastema closure. Before the diastema is closed is the only time that a complete removal of all residual fibrous tissue from the interdental suture area is really possible.
Later surgery
Scar tissue formed after fraenectomy should theoretically help to maintain diastema space closure, in the medium to long term. Access to the surgical procedure is, however, more limited after orthodontic closure of maxillary midline diastema, and it will not be possible to remove all the residual fibrous tissue thoroughly from the interdental suture area in these cases.
It is an error to remove the fraenum surgically at a very early age and then delay orthodontic treatment in the hope that the diastema will close spontaneously. Scar tissue inevitably forms between the teeth as healing progresses and a long delay may result in a space that is more difficult to close than it was previously.6
From the literature, it can be seen that patients have to fulfil one or more of the following criteria for a maxillary fraenectomy to be considered justified:
The upper six permanent anterior teeth fully erupted;
A persistent midline diastema;
A diastema which has been closed by orthodontic fixed appliances;
A positive ‘blanch test’’ of the incisal papilla when pulling the lip forwards (Figure 6);
A large midline maxillary suture present radiographically;
Effective toothbrushing prevented by the midline fraenum.
Figure 5. Fleshy fraenum extends between the teeth.Figure 6. Palatal papilla blanches when lip stretched if fraenum extends interdentally.
Technique
Fraenectomy
Fraenectomy is the complete removal of the fraenum, including its attachment to underlying bone. While fraenotomy is the partial removal of the fraenum, and is used for periodontal purposes to relocate the fraenal attachment so as to create an increased zone of attached gingiva between the gingival margin and the fraenum.2
The key to successful fraenectomy is removal of the fraenum itself and, where appropriate, the interdental fibrous tissue. The surgical technique recommended involves the use of two mosquito forceps and a number 15 blade and can be outlined as follows:
Adequate and complete local anaesthesia is established using a local infiltration technique. Topical anaesthetic has more of a ‘placebo’ effect but can be useful, particularly with nervous patients. First give a local infiltration of a few drops of local anaesthetic under the lip (Figure 7). Wait patiently until those few drops have worked completely, then re-infiltrate proceeding extremely slowly, infiltrating both mesially and distally to the maxillary midline. Again, wait a few minutes whilst massaging in the small amount of local anaesthetic solution to maximize the area affected.
An intraseptal injection in the incisal papilla area can be provided and then wait a couple of minutes and repeat to minimize the subsequent discomfort of the incisal nerve block. Only after 5–10 minutes should the first part of the surgery be attempted.
The lip can be pulled upwards and forwards by the assistant then the operator should use a mosquito forceps to clip the fraenum as close to the alveolus as possible. A second mosquito forceps is used to clip the fraenum as close to the inside of the upper lip as possible (Figure 8).
A number 15 blade is then carefully drawn underneath the beaks of the forceps which is clipping the fraenum near the alveolus. The incisions are directed medially to meet at the periosteum beneath the fraenal mucosa, separating the fraenum from its alveolar attachment, which is then kept under tension as the number 15 blade is now drawn down underneath the beaks of the forceps clipping the fraenum adjacent to the inside of the upper lip (Figure 9).
The fraenum has now been completely removed and a large diamond-shaped wound results. If accessible, the labial alveolar periosteum, that lies directly beneath the fraenum and invades the interdental septum, is also incised and carefully removed using the sharp end of a Mitchell's trimmer.
If thought appropriate, the fibres can also be destroyed by reciprocal movements of a number 15 blade in the interdental zone overlying the marginal alveolar crest. If a ‘cleft’ or ‘notch’ in the interseptal bone is discovered by probing, during removal of the transeptal fibres, an instrument such as the pointed end of a Mitchell's trimmer can be used to scrape out the connective tissue in the cleft.
The final step is to undermine the attached gingival tissue sufficiently to allow the furthest distant lateral margins of the diamond-shaped wound to be approximated (Figure 10). Resorbable sutures are placed to close the wound completely (Figures 11a and b). The palatal tissue and the labial interdental papilla are very rarely surgically reduced unless there is a gross excess of gingival tissue in these areas. In such situations, a gingivoplasty can be performed with great care so as not to remove the entire gingival papilla.
Figure 7. Painless infiltrations entirely possible if the clinician is patient.Figure 8. Two mosquito forceps used to grip the fraenum.Figure 9. No. 15 blade used to remove the fraenum.Figure 10. Wound edges approximated after undermining sufficiently.Figure 11.
(a, b) Resorbable sutures used to close the rest of the wound.
All cases should be reviewed by the surgeon who has performed the operation, 2–4 weeks after the fraenectomy, to allow the operator to observe whether or not an effective surgical procedure has been carried out (Figure 12).
Figure 12. Two week review; healing is more than satisfactory.
Summary
Whilst the fraenectomy is only occasionally used, it is vital to understand how to carry out the procedure efficiently and effectively. Success relies as much on accurate diagnosis of the fleshy, prominent or persistent fraenum as it does on meticulous technique to ensure its complete elimination.
