Frenula – anatomical structure, clinical significance, and surgical correction techniques

• The lower labial frenulum is considered abnormally attached when it leads to a shallowing of the vestibule and an improper width of the attached gingiva.

• The upper labial frenulum develops as a remnant of erupting ectolabial bands connecting the tubercle of the upper lip with the palatal papilla. When the central incisors erupt and diverge, bone is not deposited beneath the frenulum.

• Among all available frenuloplasty techniques, electrocoagulation and laser procedures offer minimal procedural time, no intraoperative bleeding, and eliminate the need for suturing.

The upper labial frenulum may cause aesthetic concerns and compromise orthodontic outcomes in the presence of a diastema. In such cases, the treatment of choice is a surgical correction—either frenulotomy (incision) or frenectomy (complete excision). This article provides a brief overview of frenula, including their clinical implications, indications, contraindications, and available surgical techniques.

Keywords: frenulum, gingiva, plastic surgery

Esthetic implications

The growing emphasis on facial esthetics has led to an increased demand for dental procedures aimed at achieving the ideal smile. One common aesthetic concern is the persistent maxillary midline diastema in adult patients. An aberrant attachment of the upper labial frenulum is recognized as one of the etiological factors responsible for the persistence of a diastema. The clinical relevance of this condition has prompted practitioners to focus more on frenular anomalies and their correction methods. Abnormal frenula may compromise periodontal health by contributing to gingival recession when attached too close to the marginal gingiva or by creating gingival clefts through muscle traction. Furthermore, they may impair effective toothbrushing, complicating oral hygiene.

Etiology

The upper labial frenulum arises as a remnant of erupting ectolabial bands connecting the upper lip tubercle to the palatal papilla. When the central incisors erupt and diverge, bone fails to deposit beneath the frenulum. This results in a V-shaped bony cleft between the maxillary central incisors and aberrant frenular attachment. The lower labial frenulum is considered abnormally attached when it contributes to reduced vestibular depth and improper width of the attached gingiva.

Aberrant frenula are diagnosed visually by pulling the tissue to the point of tension, observing for gingival papilla movement or localized blanching due to ischemia. A pathological frenulum may appear broad and elongated, with an absence of attached gingiva or displacement of the interdental papilla.

Classification

The classification of frenular attachments proposed by Placek et al. (1974) includes four types:

1. Mucosal attachment – the frenulum does not extend beyond the mucogingival junction.

2. Gingival attachment – the frenulum inserts within the attached gingiva.

3. Papillary attachment – the frenulum extends to the interdental papilla between the upper central incisors.

4. Papilla-penetrating attachment – the frenulum penetrates the interdental papilla and reaches the incisive papilla.

Treatment

Indications for surgical correction of aberrant frenula include:

• Gingival margin detachment,

• Muscle pull syndrome (pull syndrome),

• Type IV frenulum per Placek classification (papilla-penetrating),

• Prosthetic considerations to increase prosthetic field,

• Orthodontic indications,

• Speech therapy requirements.

Surgical techniques for correction of aberrant frenula:

• Dieffenbach’s technique (X–Y method): A V-shaped incision is made, tissues are repositioned and sutured in a Y-shaped fashion near the vestibular floor. The wound is covered with a surgical dressing.

• Schuchardt’s technique: A Z-shaped incision is created, yielding two triangular flaps. After dissection and mobilization, the upper flap is sutured into the lower bed and vice versa. This method is recommended for large, soft, mucosal frenula.

• Rhomboid technique: The frenulum is excised while grasping the tissue fold with a needle holder. Two incisions are made above and below the instrument. The resulting rhomboid wound is closed centrally with simple interrupted sutures.

• Modified rhomboid technique: Soft tissues are excised similarly to the classic rhomboid technique, but only the upper part of the wound is sutured. The open part is covered with a surgical dressing.

• Free gingival graft technique (FGG): After frenulum excision, a full-thickness graft harvested from another site within the oral cavity is sutured in place.

• Simple frenulotomy: Performed using high-frequency electrosurgery (electrocoagulation) or high-power lasers (CO₂, Nd:YAG, or diode lasers).

Electrosurgery

This procedure is particularly recommended for patients with coagulation disorders and prolonged bleeding. However, the authors of this article apply it as a standard approach for all patients. Hemostasis is easy to maintain, the procedure is quick and predictable, and it is well tolerated even by the youngest patients. It is performed under infiltration anesthesia using an electrosurgical unit, which is relatively inexpensive to purchase and operate—unlike lasers. A loop-shaped cutting tip is used (the photos included in the article show the method of frenulum plasty performed with diathermy for orthodontic indications at the Ortoidea Specialist Dental Clinic in Poznań). In addition to the advantage of a bloodless procedure, another major benefit is the lack of need for sutures. Secondary healing by granulation (Latin: per secundam intentionem) causes no postoperative pain and is very well accepted by patients.

.

Discussion

Despite various modifications, the classic technique remains the most commonly used frenulum plasty procedure. However, it leaves a linear incision scar, which may lead to periodontal problems and an unaesthetic appearance, often necessitating further correction. Among all frenulum plasty techniques, electrosurgery and laser use offer the greatest advantages in terms of time efficiency, bloodless operation, and no need for sutures. Techniques such as simple excision and the modified rhomboid method do not provide satisfactory aesthetic results in cases of wide and thick frenulum hypertrophy.

Conclusions

An abnormally attached frenulum can be corrected using any of the aforementioned surgical techniques. The choice of method should be based on a thorough clinical examination, taking into account the patient's functional and aesthetic conditions as well as the operator’s manual skills. The trend toward replacing traditional scalpel-based techniques with electrosurgical or laser methods offers many benefits, and it is believed that these will soon become the standard approach in frenulum plasty procedures.

Authors:

Jakub Lipski

Graduate and currently a research and teaching assistant at the Poznań University of Medical Sciences, serving in the Department and Clinic of Oral Surgery and Periodontology. An active member of the Greater Poland Medical Chamber, involved in the structures of the Regional Medical Council. Focused on oral surgery, periodontology, and implantology, gaining experience through trainings, courses, and congresses both in Poland and abroad.

Natalia Partyka

Graduate of the Pomeranian Medical University in Szczecin. Enthusiast of periodontology and oral surgery, deepening her knowledge and skills through numerous courses and trainings.

1. Miller PD, Allen EP. The development of periodontal plastic surgery. Periodontology 2000. 1996; 11: 7 – 17.
2. Bagga S, Bhat KM, Bhat GS, Thomas BS. Esthetic management of the upper labial frenum: a novel frenectomy technique. Quintessence Int. 2006 Nov-Dec; 37(10): 819 – 23.
3. Queiroz Marchesan I. Lingual frenulum: classification and speech interference. Int J Orofacial Myology. 2004 Nov; 30: 31 – 38.
4. Macdonald RE, Avery DR, Hartsfield JK. Acquired and developmental disturbances of the teeth. Dentistry for the child and adolescent. 8th ed. St. Louis (MO): Mosby; 2004. pp. 103 – 147.
5. Ziemba Z. Histomorfologiczne badania wędzidełka wargi górnej w odniesieniu do metod leczenia diastemy. Praca doktorska. Szczecin, 2002.
6. Delli K, Livas C, Sculean A, Katsaros C, Bornstein MM. Facts and myths regarding the maxillary midline frenulum and its treatment: a systematic review of the literature. Quintessence Int. 2013; 44: 177 – 187.
7. Jhaveri H. Jhaveri Hiral. The Aberrant Frenum. Dr. PD Miller the father of periodontal plastic surgery. 2006: 29 – 34.
8. O’Callahan C, Macary S, Clemente S. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. Int J Pediatr Otolaryngol. 2013; 77: 827-832.
9. Kafas P, Stavrianos C, Jerjes W, Upile T, Vourvachis M, Theodoridis M, et al. Upper-lip laser frenectomy without infiltrated anaesthesia in a paediatric patient: a case report. Cases Journal. 2009; 2: 7138.
10. Shetty K, Trajtenberg C, Patel C, Streckfus C. Maxillary frenectomy which was done by using a carbon dioxide laser in a pediatric patient: a case report. Gen Dent. 2008; 56: 60 – 3.
11. Olivi G, Chaumanet G, Genovese MD, Beneduce C, Andreana S. The Er,Cr:YSGG laser labial frenectomy: a clinical retrospective evaluation of 156 consecutive cases. Gen Dent. 2010; 58: 126 – 33.
12. Cunha RF, Silva JZ, Faria MD. A clinical approach of ankyloglossia in babies: a report of two cases. J Clin Pediatr Dent. 2008; 32: 277 – 82.