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The International Online Seminar Series on Periodontology in conjunction with
KnE Medicine Scientific Seminar
Volume 2022
Research article
Frenectomy as a Multidisciplinary
Prostho--Perio Management Approach for
Partial Denture: A Case Report
Nir Etriyani1* , Arni Irawaty Djais2 , Adam Mardiana2 , Nurhadijah Raja1 , and
Andriani Rukmana1
1
Periodontology Specialist Education Program, Faculty of Dentistry, Hasanuddin University,
Makassar, Indonesia
2
Periodontology Department, Faculty of Dentistry, Hasanuddin University Makassar, Indonesia
ORCID
Nir Etriyani: 0000-0001-8852-3129
Abstract.
Background: The frenulum is defined as a thin membrane attached to the alveolar
mucosa and periosteum which limits lip movement. The attachment of frenulum may
influence prosthetic construction in denture making.
Objective: To describe frenectomy in prostho–perio cases for the manufacture of partial
Corresponding Author: Nir
dentures.
Etriyani; email:
[email protected]
Case Report: A 38-year-old woman presented to the Prosthodontic Department of
Hasanuddin University Dental and Oral Hospital for an artificial tooth implant. The patient
Published: 25 April 2022 was referred to the periodontic department by a prosthodontist for frenectomy. Intraoral
examination showed a high frenulum from the alveolar crest to the labial mucosa of
Publishing services provided by
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the upper jaw. The patient had no history of hypersensitivity and was diagnosed with
gingival frenal attachment. Surgical excision was performed, and frenulum tissue was
Nir Etriyani et al. This article is excised, which was followed by irrigation and suturing.
distributed under the terms of
Results: The control period of one week post treatment showed good outcomes when
the Creative Commons
the patient was referred to the prosthodontist.
Attribution License, which
permits unrestricted use and
Conclusion: Frenectomy helps in preparing denture placement in high frenulum cases.
redistribution provided that the
Keywords: frenulum, frenectomy, prospective surgery
original author and source are
credited.
Selection and Peer-review under
the responsibility of the NaSSiP
1. Introduction
6 Conference Committee.
The maxillary labial frenulum is a normal anatomical structure in the oral cavity formed
by mucous membranes and fibrous tissue and muscle fibers attached to the lips,
cheeks to the alveolar, gingival and periosteal processes. Etiology The maxillary labial
frenum develops as remnants of the post-erect ectolabial band connecting the upper
lip tubercle to the palatine papilla. This can be detrimental if the fibrous attachment
is thick and wide or located near the peak of the residual ridge, thereby disrupting
the expansion of accurate denture limits so that stability and retention, and patient
satisfaction are low [1].
How to cite this article: Nir Etriyani, Arni Irawaty Djais, Adam Mardiana, Nurhadijah Raja, and Andriani Rukmana , (2022), “Frenectomy as
a Multidisciplinary Prostho–Perio Management Approach for Partial Denture: A Case Report” in The International Online Seminar Series on Page 70
Periodontology in conjunction with Scientific Seminar, KnE Medicine, pages 70–75. DOI 10.18502/kme.v2i1.10839
KnE Medicine
NaSSiP 6
Classification of attachment of the superior labial frenulum can be divided into 3
types, namely 1) Low frenulum is the entire frenulum attached to the alveolar mucosa,
2) medium frenulum is the entire frenulum attached to the alveolar mucosa to the fixed
gingiva,
3) the high frenulum is the entire frenulum attached to the alveolar mucosa, 2) the
medium frenulum is the entire frenulum attached to the alveolar mucosa to the fixed
gingiva, 3) the high frenulum is the entire frenulum attached to the alveolar mucosa up
to fixed gingiva and gingival edge. High attachment of the frenulum causes problems,
for example, maxillary midline diastema due to thickening or hypertrophy or extensive
fibrous frenulum tissue that will block orthodontic movement, block plaque release,
cause tension and gingival recession. In this case report, the patient had a high maxillary
frenulum so that it could interfere with denture resistance and retention [2,3].
Abnormal frenulum is detected visually by applying pressure to the frenulum to see
the movement of the papillary tip or blans produced due to ischemia in the region.
frenulum is characterized as pathogenic when there is no gingival zone attached along
the midline or interdental papillae, shifting when the frenulum is extended [4].
2. Case Report
Female patients aged 37 years came to Hasanuddin University Dental and Oral Hospital
with complaints of loss of maxillary and mandibular teeth. Remaining subjective exami-
nation of the patient does not suffer from systemic abnormalities and allergies. Dental
health history, the patient is a referral from the Prosthodontics Section. On intraoral
examination, four mandibular incisor teeth were lost, a high frenulum attached in the
interdental area of the central incisors.
Figure 1: Initial intraoral photo. The frenulum looks high.
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This case, it begins with an examination of the vein with a blanch test, which is by
pulling the labial frenulum upward and looking pale interdental papillae. This shows that
the attachment of the frenulum is high and indicated to be carried out with frenectomy,
which is the removal of the entire frenulum, including attachment to the bone in order to
obtain retention and stability of the dentures. The maxillary frenulum is a complicating
factor in the construction of dentures so it is indicated for preprosthetic surgery before
starting treatment. If the frenulum extends to the top of the ridge and can interfere with
the retention of dentures [5,6].
At the first visit an initial therapy was performed namely dental education, scaling and
root planing. At the next visit, continued with a frenectomy. It is performed by excision
the frenulum using a hemostat (Figure 3). Before the surgery perform, the patient sign
informed consent Excision of the upper and lower frenulum of the hemostat with a
scalpel. Blunt dissection is performed to remove the attachment of fibrous tissue from
the periosteum. The wound is sutured with interrupted suture using 4-0 nylon thread,
then the operation is closed with a non-eugenol periodontal dressing. Amoxicillin 500
mg postoperative antibiotics, 3x1 for 5 days and analgesics such as paracetamol 3x1 for
3 days. Patients are advised to use chlorhexidine mouthwash 12 hours for one week.
Control visits were performed two week after surgery for aff hecting and three month
after surgery to try-in the prothesis. Patient felt very satifaction with the treatment.
A B
Figure 2: A Disinfection before surgery, B Local Anastesi.
A B
Figure 3: A Labial Frenulum is clamped with two hemostats, B Excision frenulum.
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A B
Figure 4: A Suturing with nylon 4.0, A Two weeks postoperatively, the gingival color of coral pink and the
frenulum.
A A
Figure 5: A Three month post frenectomy healing, B Installation of full maxillary denture by prostodontics.
3. Discussion
The attachment of the labial frenulum is classified 1) mucosal: the frenulum is attached
to the mucogingival junction, 2) gingival : the frenulum is attached to the fixed gingiva, 3)
papillary : the attachment extends to the interdental papillae, 4) the penetrating papilla
: the attachment of the frenulum extending to the palatine papilla. [7,8] Based on the
classification, this case included in the gingival classification. In this case the frenectomy
modification method used the two-hemostat technique. The hemostat holds the top and
bottom of the frenulum and is excised above and below the clamp. Excision does not
cause enlarged sores on the lip mucosa, due to the pull of the muscles.
Preprosthetic surgery is intended for surgical modification of the alveolar bone and
surrounding tissue to facilitate the creation of accurate, comfortable, and aesthetic
dentures. When natural teeth are lost, changes will occur in the alveoli and surrounding
soft tissue. Some of these changes will disrupt the convenience of making artificial
teeth. Frenectomy is a soft tissue surgical procedure that aims to improve the comfort
and stability of dentures.
Deviated vein resection was initially included in the term mucogingival surgery given
by Friedman in 1957. Then it was included in the category of periodontal plastic surgery.
As previously mentioned the scalpel, electrosurgery, and LASER methods can be used
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to remove annoying frena. The classic scalpel technique was introduced by Archer
(1961) and Kruger (1964). After the introduction of this technique, various modifications
were proposed, such as the Z-plasty, V-Y-plasty, and Miller techniques. Until now the
classic technique remains the most widely used method. But classic techniques can
leave longitudinal surgical scars that can cause periodontal problems and un-aesthetic
appearance [9].
The stability and retention of removable dentures, whether full dentures or partial
dentures, are influenced by four strength components described more than 50 years
ago by Sir Wilfred Fish: (1) surface tension at the intaglio prosthesis network interface,
(2) atmospheric pressure, (3) occlusal force, and (4) peripheral neutral zone force. The
neutral zone is the area inside the oral cavity where the strength of the buccinator
and orbicularis oris muscles is equal to the strength of the outer muscles produced
by the lateral border of the tongue. These four components can be interfering with the
prosthesis which can be detached if misplaced, or may be a very strong stabilizing force
if positioned correctly. The fifth power can easily be added to the list above: the power
of disruptive dynamic networks. This report
illustrates the intruding power in the form of hamular frenulum. When this frenulum
becomes dynamic, it has the capacity to destabilize and release denture bases that
can be released by destroying intagliotissue surface tension, negating the effect of
positive atmospheric pressure on retention surface suction and tension, misdirecting
the occlusal force and moving the denture base out of the neutral zone. Disruptive
strength can be minimized by reducing frenulum through surgery in a better direction
[10].
4. Conclusion
From the management of this case, it was concluded that a careful examination and an
appropriate treatment plan provided more satisfactory denture results. The frenectomy
procedure is an effective treatment to restore aesthetic function and also the stability
of denture.
References
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