Surgical Management of Aberrant Labial Frenum Using ...

Case Report DOI: 10.17354/cr/2015/37

Surgical Management of Aberrant Labial Frenum
Using Modified Z-Frenuloplasty: A Case Report

Gurpreet Kaur1, Sujata Malik1, Deepak Grover1, Anupriya Sharma2
1Reader, Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India, 2Assistant Professor,
Department of Dentistry, R.P. Government Dental College, Kangra, Himachal Pradesh, India

Frenum is a mucous membrane fold that attaches lips and cheek to the alveolar mucosa, gingiva, and the underlying periosteum. The
maxillary frenum can contribute to esthetic problems and can compromise the orthodontic outcome in cases of midline diastema,
thus leading to treatment relapse. In addition to this, it may jeopardize the health of the gingival, when it is attached too tightly to the
gingival margin, by interference in the plaque control or owing to the muscle pull. These situations can be managed with the help of
frenectomy. The presenting case report demonstrates the frenectomy of an anomalous labial frenum in a 20-year-old male using modified
Z-frenuloplasty technique.

Keywords: Diastema, Frenectomy, Frenum, Z-plasty

INTRODUCTION Mucosal: When the frenal fibers are attached up to
mucogingival junction.
Esthetic concerns have led to an increased demand in
seeking dental treatment for achieving perfect smile. Gingival: When fibers are inserted within attached gingiva.
Midline diastema in central incisors is one of the major
esthetic problems encountered in adults. Since the presence Papillary: When fibers are extends into interdental papilla.
of an aberrant frenum is one of the causative factor of the
persistence of a midline diastema, it becomes essential to Papilla penetrating: When fibers cross the alveolar process
focus on the importance of frenum in terms of morphology attach to palatine papilla.
and attachment.1 The frenum is a mucous membrane fold
that attaches the lip and the cheek to the alveolar mucosa, The maxillary frenulum provides stability to the upper
the gingiva, and the underlying periosteum.2 Oral cavity lip. It is composed of attachment of thin fibrous tissue
exhibits most notably the maxillary labial frenum, the connecting the upper lip to the gingival tissue between the
mandibular labial frenum, and the lingual frenum. Labial central incisors. When the two central incisors erupt widely
frenum attachments are thin folds of mucous membrane separated, no bone is deposited inferior to the frenum.
containing muscle fibers originating from orbicularis This leads to a V-shaped bony cleft formation between the
oris muscle of upper lip which provides attachment two central incisors and an aberrant frenum attachment.
to the alveolar mucosa and underlying periosteum. The mandibular frenum is considered anomalous when
Developmentally, the maxillary labial frenum is a post- it is associated with a decreased vestibular depth and an
eruptive remnant of the ectolabial band that connects the inadequate attached gingival width. When there is a thick
tubercle of the upper lip to the palatine papilla.2 Based on the fibrous tissue attachment between the upper incisors, it
extension of the attachment of fibers, they are classified as:3 results in the formation of hyperplastic frenum and is often
associated with a midline diastema. It can lead to periodontal
Access this article online and speech problems. The abnormal frenal attachment can
be detected visually by applying tension over the frenum
Month of Submission : 01-2015 to see the movement of the papillary tip or blanching of
Month of Peer Review : 02-2015 the associated area because of the resulting ischemia in
Month of Acceptance : 02-2015 the region.4 Unusually, wide frenum is characterized as
Month of Publishing : 03-2015 pathogenic. Clinically, papillary and papilla penetrating
frenal attachments are considered pathological and are
www.ijsscr.com associated with papillary loss, gingival recession, diastema

Corresponding Author:
Dr. Gurpreet Kaur, Department of Periodontics and Oral Implantology, National Dental College and Hospital, Derabassi, Punjab, India.

Phone: +91-9914505540. E-mail: [email protected]

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Kaur, et al.: Modified Z-Frenuloplasty

formation, difficulty in brushing, misaligned teeth, and little distortion as possible e.g. near eyes, lips.11,12 Another
psychological disturbances.5 modified approach include, a horizontal incision without
severing the frenum in the midline along with basic Z-plasty
Frenal attachments that encroach on the marginal gingival flaps that are transposed in the similar manner.13 The Z
leads to distention of the gingival sulcus, favoring plaque pattern is efficient as:
accumulation, increasing the rate of progression of gingival • It facilitates re-distribution of tension on the skin and
recession and thereby leading to recurrence after treatment.6
the wound and helps in healing along the skin lines
The management of an aberrant frenum can be accomplished • It minimizes scar formation and has got a camouflaging
by “frenectomy” or “frenotomy” procedures. The terms
frenectomy and frenotomy signify operations that differ in effect.
degree of surgical approach.
The present case report aimed to approach aberrant
Frenectomy is a complete removal of the frenum, including labial frenula using novel modified Z-plasty technique of
its attachment to the underlying bone whereas frenotomy frenectomy with an added note on merits and the demerits
involves relocation of the frenal attachment.2 According to of this procedure.
Olivi et al., clinical indications for frenum removal are as
follows:7 CASE REPORT
1. Anomalous frenum associated with inflamed gingiva,
We report here a case of a 20-year-old male referred to the
resulting from poor oral hygiene Department of Periodontology and Oral Implantology,
2. Anomalous frenum associated with gingival recession National Dental College and Hospital, Derabassi. Patient
3. Maxillary frenum associated with diastema after reported with the chief complaint of a midline diastema
between the maxillary central incisors. On examination, a
complete eruption of the permanent canines hypertrophied papillary frenum associated with midline
4. Abnormal maxillary frenum (Class III or IV), resulting diastema was found (Figure 1). Along with it, tension test
was positive with inadequate width of attached gingiva.
in the presence of a diastema during the mixed Patient was told about the procedure and an informed
dentition consent was taken.
5. High frenal attachment resulting in gingival recession.

Surgical Interventions Available Surgical Procedure
Several surgical procedures have been employed to correct The area was anesthetized using local infiltration by using
abnormal frenula. These include excision, Millers technique, 2% lignocaine with 1:80,000 adrenaline. The “Z-shape”
V-Y plasty and Z-plasty.8 However, frenectomies commonly triangular flap was prepared using incisions as depicted in
fail due to a high risk of reoccurrence and hypertrophic Figure 2. The length of the base of the frenum was incised
scarring. The likelihood of failure can be reduced by using with 6 a scalpel and at each end, incisions (ranging between
a technique known as Z-frenuloplasty, which is a soft 60° and 90° angulation) were made in equal length to that of
tissue surgery used to lengthen frenum and to improve the the band. With the help of a tissue forceps, the submucosal
functional and cosmetic appearance of scars. It provides tissues were dissected beyond the base of each flap, into
excellent outcomes in cases of hypertrophic thick frenula the loose non-attached tissue planes. A  double rotation
with a low insertion and a shallow sulcus. In this technique,
the length of the frenum is incised with a scalpel and Figure 1: Pre-operative photograph
releasing incisions are used, one on the superior border
of frenum and other on the inferior boarder in opposite
directions. The two flaps are raised and then interchanged
with each other so that the frenal length is increased.9
Primary Z-plasty flaps are created using an angle of 60
degrees on each side. Classic 60° Z-plasty lengthens scars
by 75%, while 45° and 30° designs lengthen scars by 50%
and 25%, respectively.10 A curvilinear form of Z-plasty
(also known as S-plasty) may be used when straight lines
may be particularly evident, for e.g., in the cheek. Design
of the Z-plasty with unequal angles and limbs creates a
situation, in which the smaller triangle moves significantly
less than the larger triangle. This may be useful in areas
where small amounts of tissue need to be moved with as

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Kaur, et al.: Modified Z-Frenuloplasty

flap of at least 1 cm in length was prepared (Figure 3). With The management of anomalous and aberrant frenum
the surgical blade, the deeper fibers are detached from the has gained much of interest in the present era. Recent
underlying periosteum in a criss-cross manner. Periosteal techniques added frenal relocation by Z-plasty, frenectomy
scoring was done so as to prevent the reattachment of with soft-tissue graft and laser applications to avoid
fibers. The resultant flaps were mobilized and transposed typical diamond-shaped scar and facilitate healing. Each
at 90° to close the vertical incisions horizontally. They were method has its advantages and disadvantages.14 A study
then sutured to the defect on the opposite side of the other by Heller et al.15 in 2005 compared the treatment outcome
flap base and secured in position by using interrupted for Z-frenuloplasty and the traditional horizontal to vertical
braided silk suture (Figure 4). After the above procedures, frenuloplasty in the management of ankyloglossia. Of
patient was asked to maintain a soft diet for a week, and 16 patients recruited in the study, 11 patients underwent
antibiotics and analgesics were also prescribed. Patient was a Z-frenuloplasty and 5  patients had their ankyloglossia
instructed to follow routine post-operative instructions corrected with the horizontal to vertical frenuloplasty.
and to maintain good oral hygiene using mechanical and The frenulum length, length of tongue protrusion and
chemical plaque control techniques. Patient was followed speech was analyzed pre and post-operatively. The results
after 10 days, later for review (Figure 5). revealed that Z-frenuloplasty was a superior technique
than the other, with an improvement in frenulum length
DISCUSSION and tongue protrusion of 37.5 ± 13.5 mm compared to the
other method at 36.2 ± 7.6 mm respectively. In addition, it
In the present arena of periodontal plastic surgeries, was also found that 91% of the patients with Z-frenuloplasty
more conservative and precise techniques are being showed improvement in speech compared to other 40% who
adopted to achieve more functional and esthetic results. underwent the horizontal-to-vertical frenuloplasty.15 Since

Figure 2: Z-shaped incisions Figure 4: Flaps secured with interrupted sutures

Figure 3: Flaps reflected and periosteal scoring performed Figure 5: 10 days post-operatively
IJSS Case Reports & Reviews | March 2015 | Vol 1 | Issue 10
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Kaur, et al.: Modified Z-Frenuloplasty

the conventional procedure of frenectomy, a number of 4. Gottsegen R. Frenum position and vestibule depth in relation to
modifications of the various surgical techniques including gingival health. Oral Surg Oral Med Oral Pathol 1954;7:1069-78.
Miller’s technique, V-Y plasty and Z-plasty have been
utilized to manage problems associated with an anomalous 5. Chaubey KK, Arora VK, Thakur R, Narula IS. Perio-esthetic
labial frenum. The main advantage of the Z-plasty method surgery: Using LPF with frenectomy for prevention of scar. J Indian
over the conventional technique is minimal scar tissue Soc Periodontol 2011;15:265-9.
formation. The disadvantage of this method is its technique
sensitivity.13,14 6. Newman MG, Takei HH, Klokkevold PR, Carranza FA. Carranza’s
Clinical Periodontology. 10th ed. Philadelphia: WB Saunders Co.;
CONCLUSION 2006. p. 866-70.

To achieve a functional and an esthetic outcome, adequate 7. Olivi G, Chaumanet G, Genovese MD, Beneduce C, Andreana S.
technique should be selected based on the type of the frenal Er,Cr: YSGG laser labial frenectomy: a clinical retrospective
attachment. The Z-frenuloplasty procedure is considered evaluation of 156 consecutive cases. Gen Dent 2010;58:e126-33.
to be safe and a cost efficient procedure resulting in better
functional and esthetic appearance. This technique allows 8. Puig JR, Lefebvre E, Landat F. Z-plasty technic, applied to
for tissue healing by primary intentions, increasing recovery hypertrophy of the upper labial frenum. Rev Stomatol Chir
and reducing the risk of tissue contractures. However, due Maxillofac 1977;78:351-6.
to the limited evidence currently available on this method,
further research is needed to compare the different surgical 9. Burke M. Z-plasty. How, when and why. Aust Fam Physician
approaches of frenectomy to obtain the desired outcome. 1997;26:1027-9.

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How to cite this article: Kaur G, Malik S, Grover D, Sharma A. Surgical
Management of Aberrant Labial Frenum Using Modified Z-Frenuloplasty:
A Case Report. IJSS Case Reports & Reviews 2015;1(10):5-8.

Source of Support: Nil, Conflict of Interest: None declared.

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