THE WHAT, WHEN & WHY OF FRENECTOMY

John HyunBaek Ahn; Tim Newton & Catherine Campbell

What did the authors aim to do in this study?

The main motive of this study was to obtain the views of orthodontists in the United Kingdom regarding the various indications, timing & the recommended retention regimen of the frenectomy procedure after the correction of the median diastema.

How did the authors evaluate?

A 14-item online questionnaire was developed to investigate the orthodontist's demographics, experience and their views on the management of an abnormal labial frenum. This questionnaire was tested earlier for the ease of completion, and was initially piloted with orthodontists by sending out a link to the questionnaire by e-mail and their feedback was used to make modifications to form the final draft. The British Orthodontic Survey(BOS) was requested to distribute the questionnaire to orthodontists using their mailing lists. Three hundred and fifty three orthodontists with various backgrounds and experience reverted back to the survey and all of their inputs were taken into consideration & analyzed.

Chi-square & Fisher exact tests were used to assess the statistical significance.

What did the authors find?

The analysis of all the responses of the orthodontists revealed that about three hundred and fifteen orthodontists believed that an abnormal labial frenum was an important etiological factor in the development of median diastema. No statistical difference was obtained in the demographic variables of the participants. Two hundred and sixty five orthodontists were were found to routinely carry out a blanche test to aid in the diagnosis of an abnormal frenum. Fifty three orthodontists were found to take intraoral radiographs to assess midline bony clefts and forty six of these considered that these radiographic findings greatly influenced their diagnosis & clinical decision.

Two hundred and sixty six orthodontists considered frenectomy to reduce the risk of orthodontic relapse of the median diastema closure. The most favoured timing was after closure of median diastema followed by just before space closure.

When asked if the orthodontists would consider frenectomy as a part of the orthodontic treatment, One hundred and eighty of them stated that they would not consider frenectomy without orthodontic treatment.

A variation in the retention regimen after diastema closure and completion of orthodontic treatment was found. The most preferred retention regimen with frenectomy was a bonded retainer supplemented with a vaccum-formed retainer followed by a bonded retainer only. Similarly, a bonded retainer supplemented with a vacuum-formed retainer was the most favoured retention regimen (60%) without frenectomy, and this was followed by a bonded retainer only.

What did the authors conclude?

• This study concluded that all clinicians should be able to perform the blanche test for the correct diagnosis of abnormal frenum.

• A surgical procedure for an abnormal frenum could be considered to reduce the risk of orthodontic relapse of median diastema.

• Frenectomy should not be considered without orthodontic treatment.

• The most preferred timing of frenectomy was after diastema closure followed by just before space closure.

• Long-term retention with a bonded retainer supple- mented with a vacuum-formed retainer is recommended regardless of whether a frenectomy has been performed.

• Some variations exist among orthodontists in terms of diagnosis, indications, and timing of frenectomy as well as postorthodontic retention of median diastema.

• High-quality studies are required to provide supporting evidence for the development of guidelines.

What do we think about it?

Especially when it comes to the decision of frenectomy, there are different schools of thought regarding when it has to be performed. One school of thought says that the frenectomy has to be carried out before orthodontic space closure of the median diastema & another says it has to be done after. The rationale for closure of median diastema prior to frenectomy is to improve the stability of space closure by consolidating the teeth with scar tissues forming around the surgical site.

Some orthodontists recommend frenectomy to be carried out before commencing closure of median diastema, especially where the frenum is thick and bulky and space closure may cause discomfort to the patient. In addition, it is suggested that the frenum resists mesial pressure, and frenectomy before orthodontic closure could lead to faster tooth movement. But one major concern with this approach is that with early frenectomy, old scar tissue may impede orthodontic space closure. Hence, it's safe to say that this decision is clearly case specific and operator specific although most of the orthodontists according to this study prefer to carry out the frenectomy procedure after diastema closure for better stability.

Ahn JH, Newton T, Campbell C. Labial frenectomy: current clinical practice of orthodontists in the United Kingdom. Angle Orthod. 2022 Nov 1;92(6):780-786.