Frenectomy/Frenotomy of labial and lingual frenum
Frenectomy, frenoplasty, and frenotomy in dentistry are the surgical treatment of abnormal lingual(tongue) or labial (lips) frenum attachment to the gums and bone.
Frenectomy - is the complete excision of the lingual or labial frenum with its possible fibers (threads) to the periosteum.
Frenuloplasty -is a surgical method for correcting the attachment of the frenulum of the tongue and lips to the periodontal tissue.
Frenotomy - a method of transverse dissection of the frenum which is performed when the frenum is too narrow and is not attached to the edge of the alveolar ridge.
What is Frenum and what is it used for?
The frenulum or frenum is a small muscle , covered with a mucous membrane, that attaches the lips and tongue to the jaw bones. Normally there are seven frenums, but their number, shape and position may vary.
The main function of frenums is to keep the lips and tongue in harmony with the growing bones of the mouth during fetal development.
The frenums that have the most influence on dentition and the oral environment are the frenulum that attaches the tongue ( lingual frenulum ) and the one that attaches the middle of the upper lip ( labial frenulum ).
Anomamlies And Problems with Frenums
An abnormal frenulum, which is a congenital (genetic) defect , affects about 5% of the population and is more common in boys than in girls.
A frenulum that is too short can hold the upper lip and make it difficult to smile or normally smile.
The lingual frenum connecting the underside of the tongue to the floor of the mouth contributes to the development of the mouth.
Swallowing: this frenulum plays a crucial role in the mobility of the tongue . To swallow normally, the tongue should be raised against the palate. This creates a seal and helps give the palate its normal shape.
The frenulum acts much like a tendon rather than a muscle. Its stiffness determines the extent to which the tongue can rise or lengthen during function.
If the tongue cannot rise sufficiently because of too short a frenum, the tongue will be pushed forward to provide the necessary sealing at the front of the mouth, which can contribute to the development of a frenulum. maxillary protrusion and anterior open bite (absence of contact between the teeth).
The term used to describe a tongue “attached” by a too short frenum is ankyloglossia.
Defects with Lingual Frenum
The frenulum of the tongue is considered abnormal when, in the vertical direction, the tongue cannot be raised enough to come into contact with the anterior part of the palate and when, towards the front, the protraction of the tongue barely exceeds the lower dental arch.
During normal growth and development of the mouth, the tongue contributes to the development of the width and shape of the palate . If the lingual frenulum is too short, the tongue will not be able to generate enough pressure to create a normal palate and often the result will be a narrower and underdeveloped palate.
Fuctional Problems due to abnormal Lingual Frenum
Infants: In newborns, a short lingual frenulum can cause difficulty in breastfeeding and it is sometimes recommended that it be cut.
Between 20 to 50% of cases of short lingual Frenums will present breastfeeding difficulties.
Studies report a tight Frenum problem in 25 to 60% of breastfeeding difficulties 3 and 4 to 10% of babies have a “tight” or too short Frenum, with a predominance in boys (1.5 to 2.6 boys for 1 girl) 3 , 4, 5.
Phonation: Disturbances in pronunciation (speech) may result from abnormal lingual frenulum, particularly for “S”, “R” and Anglo-Saxon “TH” sounds.
Most children with short frenulum, however, do not have severe speech problems. Breastfeeding difficulties and major phonation problems may constitute situations or exceptions where it may be indicated to cut a lingual frenulum and more rarely an upper lip frenulum.
Orthodontic and dental problems: Abnormal Frenum has been associated with a multitude of orthodontic problems ( malocclusions ) such as: maxillary constriction, narrow palates and anterior open bite.
A frenulum that attaches too close to the edge of the gum tissue can cause gum recession and bone loss. Maintaining infantile swallowing resulting from a short frenulum can contribute to dental malposition.
The incidence of cavities may be greater as the tongue cannot sweep and clean the inner surface of the teeth (on the tongue side).
Social considerations: A limitation in the function of the tongue can make it difficult for certain actions like sticking out the tongue, licking, playing a wind instrument, kissing, etc. and cause some social embarrassment.
Treatment: Frenectomy or Frenotomy
When a lingual frenulum is problematic because it prevents normal mobility of the tongue, it is indicated to either remove it (frenectomy) or incise it (frenotomy).
This procedure allows sufficient lengthening of the lingual frenulum or its removal to restore better function of the tongue.
For the simplest cases, this procedure can be done under local anesthesia using a soft tissue laser.
The more complex cases, requiring excision of part of the muscle fibers, will be referred to a dentist or maxillofacial surgeon familiar with this procedure.
This frenulum is mostly common for the upper lip but is sometimes present on the lower lip.
The labial frenulum that attaches the upper lip is often associated with the presence of an interdental space between the upper incisors ( diastema ).
It is sometimes indicated to “cut” this frenum. However, if orthodontics is being considered, it is preferable to close the space before the frenectomy in order to avoid the formation of scar tissue between the incisors, which would tend to promote reopening of the previously closed space.
Once the space is closed, it is indicated to maintain a fixed long-term retention splint to help keep the space closed.
Labial Frenectomy Controversy
Some clinicians erroneously recommend an early frenectomy between the upper central incisors because they believe that the central diastema is caused by the presence of the labial frenulum, which prevents the centrals from moving to the center. The aim of the frenectomy would therefore be to cut this frenulum before orthodontic corrections because this will facilitate the closing of the space using orthodontic appliances.
However, it should be realized that a space between the permanent centrals is normal as long as the permanent canines have not emerged.
On the other hand, a frenectomy can cause scar tissue that can prevent a normal and natural closure of the diastema during the eruption of the canines.
Most authors therefore agree on the fact that it is preferable to wait for the exit of the permanent canines before considering a frenectomy.
In cases of severe diastemas (6-8 mm) present during the transition from temporary to permanent dentition, a frenectomy may however be indicated in order to close the orthodontically space by bringing the centrals closer together and thus minimize the chances that the lateral ones and / or the canines come out ectopically (on the palate side). In this case, the purpose of the frenectomy is not to allow spontaneous closure of the space but to facilitate it with the help of devices.
CONCLUSION: When a frenectomy of the upper lip is considered in the presence of a significant diastema, it is preferable to wait for the output of the upper canines and the end of the orthodontic corrections in order to ensure better stability of the corrections and avoid reopening. from space.
The “classic” procedure for performing a frenectomy, as described by Edwards in 1977, involves the removal of the incisor papilla. This procedure is the main cause of the presence of “tough” scar tissue after healing and may cause a diastema to reopen or prevent it from spontaneously closing with the eruption of other anterior teeth.
Doyle and other clinicians have however proposed a modified technique which preserves the gum papilla, thus reducing the chances of having scar tissue present between the incisors after the procedure while allowing, according to them, to decrease the exerted tension. by the frenulum on the gum.
Although the concept behind this technique supports a certain logic, some still recommend doing such a frenectomy at an early age, immediately after the eruption of the plants under the pretext that it "can help" to decrease the diastema and less "flatten" the taste bud over time.
There is no scientific basis to support such a statement and recognized orthodontic communities still recommend waiting for the output of the permanent canines before considering a lip frenectomy, except in rare exceptional cases.
After the operation, there is a slight discomfort due to the novelty of sensations, fresh wounds may ache a little at first, but the patient quickly returns to normal. To minimize discomfort and consolidate the result, the following rules should be observed:
Refrain from eating solid and hot foods for 2-3 days;
Strictly observe oral hygiene;
Be sure to see the surgeon the next day or the day after the plastic surgery;
To strengthen the chewing and facial muscles, one week after the operation, regularly perform special myogymnastic exercises.
A complete frenectomy will result in a complete release of the tension caused by the tight and fibrous inadequate tie. The best way to tell if the frenectomy was complete is to look at the shape of the wound.
For lingual frenotomies, there must be a diamond shape for the frenectomy to be complete. If there is no diamond shape, then the frenectomy was not complete. For the upper lip, maximum flexibility of the central lip should be observed and the frenulum should be fully lifted from the jaw.
If only a small incision is made in the tongue or lip frenulum, there is little chance that there will be any improvement because the wound is small. Along the same lines, if the initial procedure was incomplete and it heals quickly, there is no reformation - it just wasn't open enough.
On the contrary, a completely open wound will reform systematically if care is not carried out on a regular basis. This reformation is different from the scarring that we normally see. What we are aiming for is a headband that is more flexible than it was before the procedure.
This sketch represents frenectomy of the tongue frenulum and proper care, when one uses his finger to gently separate the lip from the jaw and no or rare care, or the lip has been allowed to adhere too much to the jaw again.
Remember that if the frenectomy was not complete you would never have been able to achieve enough mobility from the start anyway so it can look like a reform of the lip frenulum.
The tongue frenulum wound is more complex. First, just cutting an anterior frenulum does not significantly improve the functionality of the tongue in breastfeeding.
There is always a posterior part, submucosa to the frenulum which must be cut. If the entire frenectomy is not done and only the front part of the frenulum is cut, there is no apparent wound. To have a complete frenectomy you need a diamond-shaped wound.
Stretching is unnecessary after an incomplete procedure because the size of the wound is minimal so it will heal with little scar tissue. The problem under this scenario is that the tension on the tongue back is still present and the functionality of the tongue does not improve. What we want is an intervention that completely releases the tension and a frenum that does not reform. This can only be achieved with regular stretching of the wound. Here is my protocol.
Principles of wound healing
While some of the principles of healing inside the mouth also apply to sores on the skin, there are certain characteristics that are specific to sores in the mouth. The best description of these characteristics can be found in the book “Oral Wound Healing” by Hannu Larjava (2012).
When a wound is created, it will undergo specific and predictable changes in order to heal. Within 24 hours, the edges of the wound begin to migrate towards the center of the wound in such a way that the edges will eventually merge with the mucous membrane.
This migration is facilitated by a scaffold that forms above the wound (which is the white / yellow color seen when a sore in the mouth is healing). At the same time, granulation tissue begins to fill the wound.
The granulation tissue serves to reform the connecting tissue that allows the new wound to have strength. It does this by migrating new blood vessels into the area and creating a matrix of fibers which are the precursors of scar formation.
It takes months for a mature wound to form. During this time, the wound contraction sets in and the scar tissue organizes itself.
How does this apply to lip and tongue frenums?
When a professional creates a wound in the mouth to release the frenulum, the mouth will try to close the wound.
In the context of tongue and lip frenulum, we want the wounds to heal without an open structure rather than reform. Lip frenums heal very quickly and are rarely subject to what happens under the tongue. It is important, however, to understand that there will be a new clip connecting the lip to the jawbone - this is part of normal healing.
For the tongue, during the first 5-7 days after the frenotomy there is a flexible wound with good mobility, and the more time passes, the more the diamond under the tongue will contract and become firm. This is basically seen 10-20 days after the procedure.
Horizontal healing VS vertical healing
Remember that once a sore is created in the mouth, the body will try to close the sore and contract towards its center. The end result is that the lip will try to stick to the bottom of the jaw and the tongue will try to stick to the floor of the mouth.
The trick to getting successful results is to try and guide the tissue, with appropriate stretching, to heal in such a way that it maximizes vertical movement.
These vertical movements are important for the upward curl of the tongue, and even more important for the upward movement of the tongue towards the palate to form the seal necessary for the generation of vacuum.
Procedure and Instruments
To my knowledge there is no published study that demonstrates better healing results with a particular surgical technique or instrument. Some laser studies show potential benefits when done in the lab or on animals, but so far there are no studies in humans that show a difference.
What is important to recognize is that the tool used for the intervention does not matter. What matters is the depth of the frenotomy - an adequate frenotomy resulting in a diamond-shaped wound, which needs stretching regardless of the tool used to make the wound.
Why do some wounds not behave as expected and cause inflexible scars? Here are some potential reasons.
The frenotomy was inadequate from the start so scar tissue formed over an already immobile tissue No regularity in the practice of stretching.
Poor surgical technique - cutting too deep (muscle damage) causing a stronger inflammatory reaction Use of too much force on the wound, either by the poorly trained professional who turns a 45 second procedure into a longer laser exposure, or the laser settings are not adequate.
Care of the patient to heal quickly.
While the success of the procedure does not come from the tool used, my experience tells me that the use of electrocautery causes more damage (compared to scissors or lasers) causing more scarring. There are always exceptions to this rule, so it's important to choose your professional carefully.
The most optimal post-frenotomy rehabilitation approach includes e IBCLC, which will help to obtain a better technique of latching and positioning as well as better sucking. e therapist who will help relieve muscle tension that can interfere with both grip and healing.
The professional who should create a suitable wound and manage the healing in such a way as to maximize the mobility of the lip and / or tongue.
Why is it necessary to do exercises before AND after the frenectomy?
When the too short frenum has been removed (with a scissor or laser) by the dentist or ENT, it is important to do exercises to prevent it from reattaching. Indeed, the mucous membranes of the mouth tend in a certain way to heal too quickly or too strongly.
These exercises will aim to separate the scarring of the floor of the mouth and the lower part of the tongue. These two parts should not stick together and heal together. For 4 to 6 weeks, every 4 hours, it is important to go and massage the underside of the tongue in a certain way on either side of the white diamond for optimal healing.
Without training by the parents and especially for the baby before the ablation of the frenulum, it will be more difficult to achieve them.
Why must the tongue be re-educated before AND after the frenectomy?
The tongue is a set of 8 muscles (intrinsic and extrinsic). You read correctly that the tongue is therefore muscular! Imagine this. You are in a cast in one leg for several weeks.
This will therefore result in the muscle wasting of this plastered leg. The muscles will have melted. They will therefore be less effective and weaker than those on the other leg when the plaster is removed! This therefore means that it will be necessary to re-educate this dislodged leg, to do exercises, to strengthen it!
However, I have just told you that the tongue is a set of muscles. The restrictive tongue frenulum being present from the 1 st trimester of pregnancy, when this frenum will be cut, it will therefore be necessary to re-educate the tongue, to strengthen it with a series of very specific exercises!
Finally, if while you have your cast you stop moving completely, your rehabilitation afterwards will be that much longer and more difficult. In addition, when your plaster is removed, the expected result will be less good since nothing has been put in place in terms of rehabilitation already before the operation.