Are upper labial frenectomies in children aged 11 and ...

14 RESEARCH
Asseel Al-Najjim and Pinaki Sen
DOI 10.1308/204268514X13859766312557

Are upper labial frenectomies in children aged 11 and
under appropriate? Is it time to change practice and agree
guidelines? by Asseel Al-Najjim and Pinaki Sen

A retrospective five-year review of upper labial frenectomies in a hospital in the east of England.
AIMS
Determine how many patients underwent surgery; indications for surgery; assess
awareness of practitioners to local guidelines; compare the results to set standards and
recommend change to our practice.
METHOD
A sample of 41 patients has been reviewed, ranging between 3–48 years old. Female-to-
male ratio is 4:1. Children aged 11 years or under represented 20% of the sample.
RESULTS
The rationale for upper labial frenectomy was varied, possibly owing to a lack of
consensus among practitioners regarding the timing of frenectomy.The majority of
patients (73%) were between 12–16 years old, of whom 81% were females. 59% of
patients were referred for orthodontic reasons and 78% of these had an orthodontic
opinion. 88% of referring practitioners were not aware of any guidelines for upper labial
frenectomy.
CONCLUSIONS
National guidelines based on a consensus view will streamline the referral pattern.

Authors: Asseel Al-Najjim,* Kettering
General Hospital, Rothwell Road,
Kettering, Northants, NN16 8UZ; Pinaki
Sen, Norfolk and Norwich University
Hospital NHS Trust, Colney Lane,
Norwich, Norfolk, NR4 7UY

* Corresponding author
E: [email protected]

Keywords: frenectomy, children,
guidelines, NICE, NHS

FACULTY DENTAL JOURNAL January 2014 • Volume 5 • Issue 1

RESEARCH 15

Introduction 3 patients […] were
A prominent labial frenum is a com- referred to have
mon finding in children; however, frenectomy as part
it raises concern, especially when of an orthodontic
it is associated with a diastema.1 treatment plan […]
The indications for an upper labial with no additional
frenectomy have been documented justification[…]
as follows: which contradicts
1. Pain: the frenum exerts trauma the local guidelines

to the gingiva, causing pain and FACULTY DENTAL JOURNAL January 2014 • Volume 5 • Issue 1
blanching of the papilla when
the upper lip is pulled;
2. Spacing: if a diaestema persists
after eruption of the permanent
canines and there is a prominent
frenum;
3. Oral health: interference with
oral hygiene measures;
4. Aesthetics; and
5. Teasing: psychological reasons.1
The prevalence of a midline dia-
stema reduces with age from 98%
of 6-year-olds, 49% of 11-year-olds to
7% of teenagers2–4 and therefore the
majority of diastemata will tend to
close spontaneously during teenage
years without any intervention.3,5
The aetiological factors associated
with spacing include: dentoalveolar
disproportion, hypodontia, super-
numerary teeth, proclination of the
upper labial segment, a prominent
labial frenum and physiological
spacing.3
There are two options for closing
space associated with a prominent
frenum. The first involves orthodon-
tic space closure with fixed appli-
ances prior to frenectomy.2,6
The rationale for this approach is to
allow healing of the tissues to occur
with the teeth in their newly estab-
lished positions,7 thus consolidat-
ing the space closure as scar tissue
contracts. The alternative option
is to undertake frenectomy before
commencing orthodontic space
closure. This is indicated particularly
where the tissues are excessively
bulky and when trauma and discom-
fort can arise during the movement
of the teeth. The timing of the refer-

16 RESEARCH
Asseel Al-Najjim and Pinaki Sen

5% 2% Or thodontic 2 Yes
1 No
Trauma to the
frenum 22%
Aesthetics
24%
10% 59% Affecting oral
health
Other 78%

Figure 1 Reasons for referral. Figure 2 Patients given an orthdontic opinion prior to referral.
........................................................................................................................... ...........................................................................................................................

ral will depend on different clinical 3–48 years, with a mean age of 13.7 63% of patients underwent frenec-
priorities and there appears to be years. tomy before starting orthodontic
variations among practitioners as to 73% of patients were aged between treatment, while 28% of patients
when to refer. 12–16 years. 81% of the total sample underwent frenectomy during orth-
The aim of this study was to deter- were female. odontic treatment (Figure 4).
mine how many patients underwent The total number of referring 20%8 of the patients underwent the
frenectomy, the indications for sur- practitioners was 17, of which 8 were frenectomy at 11 years and under.
gery, and the awareness of practitio- general dental practitioners, 8 were Five of these had a clear reason in
ners to guidelines. It would also assist orthodontists and 1 was a general the referral letter to have the frenec-
in identifying areas of consensus for medical practitioner. tomy – ie pain, trauma, teasing and
referral and in developing guidelines 59% of patients were referred for tethering – whereas three patients
to streamline patient care. orthodontic reasons, ie to close the were referred merely as part of an
diastema and prevent relapse, 24% orthodontic treatment plan at this
Method were referred for aesthetic reasons early age.
This was a retrospective review of 41 and the remainder were referred 29 patients had surgery under a gen-
patients who had an upper labial fre- because the prominent frenum was eral anaesthetic and 12 had surgery
nectomy carried out at the Norfolk either affecting oral hygiene (5%) or under local anaesthesia.
and Norwich University Hospital be- causing trauma to the gingiva from Reviewing the documentation in the
tween January 2007 and December toothbrushing (10%) or for psycho- patient’s notes at the time of the con-
2011. A telephone survey was also logical reasons, ie bullying at school sultation, 88% of hospital practitio-
carried out to determine whether (2%) (Figure 1). ners did not indicate that they had
the local dental practitioners were An orthodontic opinion was ob- performed the blanche test and all
aware of any local or national tained in 78% (n=32) of patients failed to document anything about
guidelines regarding upper labial who were either referred by an eruption of the permanent canines.
frenectomy. The practitioners were orthodontist directly or via the gen-
also asked whether they thought a eral dental practitioner (Figure 2). Discussion
guideline would be useful or not. 22% of practitioners didn’t identify Shah et al advised certain criteria
Demographic data, referral source, the need to obtain an orthodontic before performing frenectomy and
reasons for referral, type of an- opinion. regarded the following points as a
aesthetic used, clinical examina- When asked if they were aware of any gold standard:2 the upper six perma-
tion findings, ie blanche test and guidelines on referral for frenecto- nent anterior teeth fully erupted, the
eruption of permanent canines, my, 88% of practitioners replied they diastema closed by an orthodontic
orthodontic opinion and timing of were not aware of any guidelines. fixed appliance, a hypertrophic fre-
surgery were recorded. 71% of practitioners thought that num which is positive to the ‘blanche
a guideline would be useful, while test’ and a large midline maxillary
Results 24% thought a guideline would not suture present, preferably with signs
41 patients underwent frenectomies be useful (Figure 3). of clefting radiographically.
between January 2007 and Decem-
ber 2011. The ages ranged between

FACULTY DENTAL JOURNAL January 2014 • Volume 5 • Issue 1

RESEARCH 17

5% Useful 6% Before
3 Not useful 4 During
No answer After
24% 6% Not known

71% 28%
63%

Figure 3 Dentists views on usefulness of a guideline. Figure 4 Timing of frenectomy in relation to orthodontic treatment.
........................................................................................................................... ...........................................................................................................................

The local guidelines circulated to the frenectomy. This could be due Acknowledgements
dental practitioners in Norfolk in- to publications advocating closure The authors wish to thank Mr David
cluded the following circumstances of the diastema before having a Tewson, Consultant Orthodontist,
as reason for referral: periodontal frenectomy.2,10,11 29 out of 41 patients and Miss Sharon Prince, Consultant
disease, oral hygiene and part of having frenectomies had a general Oral and Maxillofacial Surgeon, at
orthodontic treatment plan.8 The anaesthetic despite the fact that this Norfolk and Norwich University for
guideline emphasised that if the operation can be carried out safely their help and support.
patient is under 10 or 11 years of age under local anaesthesia, thereby re- References
and canines are not erupted, then ducing risks associated with the use
the patient should not be referred of general anaesthesia. 1. American Academy of Paediatric Dentistry.
for an upper labial frenectomy. 3 Guideline on Paediatric Oral Surgery Reference
patients aged 11 years and under Conclusion Manual. V33/No. 6 11/12. Chicago: AAPD;
were referred to have frenectomy Although the sample size was small 2011.
as part of an orthodontic treatment (41 patients over the course of 5
plan according to the referral letter, years had an upper labial frenec- 2. Shah J, Dyer F. Current practice for
with no additional justification for tomy), this study highlights that 20% performing labial frenectomies a service
the procedure, which contradicts the of patients underwent the procedure evaluation. The British Orthodontic Society
local guidelines.9 when they were under the age of Clinical Effectiveness Bulletin 2008; 21: 4.
This study has revealed that the age 11. The information in the referral
group of the Norfolk sample cor- letters of these patients was not clear 3. Edwards JG. The diastema, the fraenum,
responds with the age when most of about the exact reason of the refer- the frenectomy: a clinical study. Am J Orthod
the orthodontic treatment is being ral and whether that reason justifies 1977; 71: 489–508.
done. The predominance of females having a frenectomy.
in this study reflects similar results in Referrers should state clearly in their 4. Bergstrom K, Jensen R, Martensson B. The
previous studies.2,5 referral letter the reason for under- effect of superior labial frenectomy in cases
One three-year-old patient under- going a frenectomy if the patient is with midline diastema. Am J Orthod 1973; 63:
went an upper labial frenectomy 11 years of age or under. 633–638.
having been referred by her general This review strongly advocates for
medical practitioner. The child’s clear documentation of blanching 5. James GA. Clinical implications of a follow-
parents were very keen to have the of the incisive papilla when pulling up study after frenectomy. Dent Pract Dent
procedure done as the prominent the upper lip, stage of eruption of
frenum was traumatised by the tooth- canines and whether orthodontic 6. Attia Y. Midline diastemas: Closure and
brush despite the child’s young age. opinion was obtained. A national con- stability. Angle orthodontist 1993; 63: 209–212.
78% of patients were referred by sensus will help design a clear guide- Rec 1967; 17: 299–305.
an orthodontic specialist. How- line and thereby improve the referral
ever, 63% of these patients had the pattern of upper labial frenectomies. 7. Bishara SE. Management of diestemas in
frenectomy carried out early, before Clinicians need to make a conscious orthodontics. Am J Orthod 1972; 61: 55–63.
starting the orthodontic treatment. effort to encourage patients and
This indicates the variation between accompanying parents to have the 8. Minor oral surgery in dental practice.
practitioners regarding the timing of procedure under local anaesthesia. Norfolk LDC. Labial frenectomy
management guideline. www.norfolkldc.
co.uk/Guidelines_files/labial%20
frenectomy.pdf (cited 18 November 2013).

9. Campbell PM, Moore JW, Matthews
JL. Orthodontically corrected midline
diaestemas: A histologic study and surgical
procedure. Am J Orthod 1975; 67: 139–58.

10. Dewel BF. The normal and the abnormal
labial fraenum: Clinical differentiation. Am
J Orthod 1946; 33: 318–329.

11. Proffit WR, Fields HW. Contemporary
Orthodontics. 4th ed. St Louis: Mosby; 2006.

FACULTY DENTAL JOURNAL January 2014 • Volume 5 • Issue 1