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Frenulums and frenectomy

Maxillary labial frenulum

Maxillary labial frenulum at 2 years of age

It is very common to see young children with a large labial frenulum which inserts between both primary incisors up to the palatine papilla. This frenulum is the cause of space between both incisors. This is absolutely normal. The extra space is used to accommodate future permanent teeth which will erupt starting at 6-7 years of age. The prevalence of interdental space in the primary dentition is 70% of cases for the maxilla and 63% of cases for the mandible.

The direction of growth of the maxilla (green arrows) is downward and a lengthening of the alveolar bone and the gingiva occurs as the child’s face grows. The insertion of the frenulum will gradually migrate upward as the dentition migrates downward.

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Evolution of dentition and selfclosing of an interincisal diastema

 

Interincisive diastema and maxillary labial frenulum

The picture on the right shows the eruption of upper central incisors. The attachment of the labial frenulum has migrated superiorly, but we can see its insertion up to the incisive papilla. A diastema between both central incisors is obvious.

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Evolution of the eruption of lateral incisors and closing of the diastema.

A year later, the lateral incisors erupt. They apply a force which makes the central incisors become closer to one another. The space between both incisors is used to accommodate the alignment of the lateral incisors. When the eruption of lateral incisors is completed, the diastema will generally be closed completely or in part.

If the diastema remains at this age, we have to wait for the permanent canines to erupt, because the same force and movement mechanism applies.

If space is still there despite these steps, we then have to think about closing this space with orthodontic movements and brackets. A frenectomy has to be considered only after the closing is completed. In all cases, a permanent retention using a wire bonded on the back of the teeth is recommended.

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Persistance of interdental space and treatment

Orthodontic closing of a diastema

Here is a teenager who shows a diastema and excessive space between incisors. At this stage, a frenectomy is useless and contraindicated, because the space between both central incisors will not close by itself, even if the frenulum is removed. An orthodontic closing with brackets was performed. There was no frenectomy. The interdental papilla is healthy.

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Hypertrophic labial frenulum. Closing of a diastema on an adult.

This other case about a 55-year-old female adult shows the presence of a hypertrophic labial frenulum and a very large space between both incisors. The closing resulted in a pinch in the gingival tissue ( C ). A frenectomy was necessary. The final picture ( E ) shows adequate embrasure and interdental papilla.

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Diasteme-interincisif-orthodontiste-chamberland-Quebec

I present a case whose treatment lasted 16 months. At the end of treatment, you will notice that the diastema between the two incisors is closed, but there are spaces on each side. These spaces were filled with composite restorations on the lateral incisors.

At the beginning of treatment, I indicated to the patient that he would likely need a frenectomy at the end of orthodontic treatment. Now the patient is satisfied with the result, it was never acted on the recommendation of the frenectomy and I confess that the picture 9 months post treatment demonstrates satisfactory results, although we note the presence of labial frenum . In other words, it does not harm him.

For more details, refer to this link orthodontisteneligne du Dr Jules Lemay

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Questions and comments

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  1. Mel says:

    This was very informative and alleviated any doubt regarding my decision to not put my 6 year old through this procedure.
    We were referred to a surgeon for a consult, because her doctor was concerned that the frenum would cause her central incisors to erupt in a way that would prevent them from closing.
    After researching and reading up on the techniques, results and both sides of the debate, I just don’t think we need to put her through this, yet. As stated here and elsewhere, we’ll just wait til her canines erupt and take it from this.
    Honestly, before her doctor brought it up, I had never heard of a frenectomy or frenotomy. It seems to be much more common than I initially thought.
    Thank you for providing such thorough information and pictures.

    1. Thank you for your kind remarks and I am glad that this blog help you.

      Please note that the french version of this page contain more photos en comment. You may be interested to look. Even if you can’t read french you will get interesting info.

      Best regards

      Dr Sylvain Chamberland

  2. Dr. Francy Templo, DMD says:

    Dear Dr. Sylvian Chamberland,
    I have a 4 year old girl patient who came for consultation of her frenum accidentally cut crosswise upon her fall on the stairs, hitting the upper anterior and labial frenum. She had her antiobiotic therapy and looks normal on her smiling profile but she is just complaining of some sort of pain when such part is being touched obviously because the accident happened just a week ago. The parents are praying for a normal healing process so she will not undergo suturing. May I asked for your opinion if that could be possible that it shall heal by itself? I am just worried of the developing tooth buds underneath if disrupted of its normal growth which might cause an abnormality in its eruption and which might call for orthodontic concern in the future. Please advice. Thank you.

    1. Dental trauma on primary teeth

      Hi Dr Templo,

      I agree that it may not be necessaury to suture the frenum and let it heal by itself. The accident occurred a week ago and it would be too late. At this age, healing is often very fast and there will be no sequelae for the frenum.

      Concerning the tooth buds, it would be important to know if the primary teeth were hitted directly, if they were mobile, if they were displaced, if there was bleeding.

      Here are some possible diagnostics:
      Concussion:

      An injury to the tooth-supporting structures without increased mobility or displacement of the tooth, but with pain to percussion and without gingival bleeding.
      Subluxation:

      An injury to the tooth supporting structures resulting in increased mobility and pain to percussion, but without displacement of the tooth. Bleeding from the gingival sulcus is evident if the child is seen shortly after the accident.
      Extrusion:

      Bo-Elod-iof-traumatisme-dentoalveolaire-dent-primaire-extrusion-Chamberland-Orthodontiste-a-Quebec-21-08-2013Partial displacement of the tooth out of its socket
      An injury to the tooth characterized by partial or total separation of the periodontal ligament resulting in loosening and displacement of the tooth. The alveolar socket bone remains intact. In addition to axial displacement, the tooth usually will have some protrusive or retrusive orientation.

      In the picture on the right, white arrow show the extruded primary teeth. The black arrow show site of bleeding resulting from separation of the periodontal ligament.

      If you need more information, I recommend that you visit the website The Dental Trauma Guide. It contains all the info you would need.

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