Bergstrom 1973 Frenectomy

8/13/2019 Bergstrom 1973 Frenectomy

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The effect of superior labial frenectomyin eases with midline diastemaK. Bergstri im, R. Jensen, and B. Mdrtensso nRtockholm, Sweden


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A,m. J. Orthod.Jw?w 1973

Figs. 1 and 2. Midlin e diastema and labial frenum with palatal attachment.

Mater ia l and methodErom 661 schoolchildren 8 to 9 years of age, we selected those who had a

midline diastcma of more than 1 mm. as wel l as a frenum so that pulling on theupper lip resulted in ischemia in the incis ive papilla as well as tissue displace-ment in the interdental region, as shown in Figs. 1 and 2. Roentgenograms weretaken to exclude chiltlren wit,h supernumerary and missing teeth. These criteriawere satisfied bg forty of the children, who were then subdivided at randominto two groups of twenty children. At the start of the study bot,h groupshad a mean age of 8 b-cars 8 months. Ilots were drawn to decide which groupshoultl act as the control, Ihe intention being to perform frenectomy on alltwenty children in the other groq). ,211 the children in the operated groupwcrc followed throughout the study, but three of the controls were not availableat the later follow-ups.An abnormal frenum is not the only factor cited in the literature as a con-cecivable cause of persistent midline t sterna. Widely spaced upper anteriorteeth, aplasia of lateral upper incisors , mesiodens, proclincd upper incisors ,ant1 ovcrjet are mentioned as other ctio logic factors by Taylor lO and Cardiner.In v iew of this, the groups were compared in the following respects at the startof the study:

1. Eruption of lateral and incisors and canines.2. Inclination of central incisors in the frontal plane.3. Overbite, overjet, and the occlusa l relationship of the upper central

inciso rs to the lower anterior teeth.4. Spatial relationships of upper anterior teeth (assessed by sectionxl


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Table I. Magni tude of diastem al closure 6 months and 2, 5, and 10 years after the initialmeasurem ent (n = number, F = mean closure, 5 = error of method for the mean

Obsert~ation Frenectomy group Control gmuppwiod n z ? G rh I r r 5 Val1te of t0.5 20 1.14 + 0.11 mm . 20 0.29 +_ 0.06 mm . t = 5.922 20 1.35 +_ 0.09 nlnl . 00 0.59 + 0.07 mm . t = 6.675 20 1.50 ? 0.10 mm . 19 1.13 +_ 0.08 mm . t zz 3.36

10 20 1.5:: 2 0.12 mm . 17 I .49 0.12 mn,. t = 1.95

measurements of the dental arch ad modurn Lundstriim and approxi-mate estimates ot the crowtling or spacin g bctwcmt the first premolars) .

The comparisons were based on casts of each child, made of plaster fromalginate impressions of the upper and lower dental arches, together with an in-dex in central occlusion. No systematic differences were found between the groups.

The casts were also used for measuring the size of the diastema. This wasdone with a set of circular stainless steel wires of progressive ly increasingdiameter (interval 0.1 mm.). These wires were inserted between the centralincisors, as shown in Fig. 3, to determine the shortest, distance between theirrnesial surfaces. At the start of the study the mean size of the diastema was thesame for both groups (1.61 mm. and 1.66 mm., the error of the method deter-mined from duplicate determinations on the same cast being 0.04 mm.).

Al l of the frenectomics were performed immediately after the initial measure-ment by the same surgeoq using the same technique as far as possible. The labialpart of the frenum was csc isec l with a sc*alpel and the wound was closed with silksutures, after which the interdental and palatal parts n-ere dissected free, includ-ing the incisirr papilla. Any remaining fibrous tissue between the teeth wasremoved with a raspatory. A surgical tlressing was applied and left in placefor 6 days.

Casts were again prepared 6 months and 2, r>, ancl 10 ycbwrs after the init ialexamination, and the size of the cliast,crna was measnrccl as described above.Results

After 5 yrars the tlifferrnc~c~ in closurt> was stil l signific*ant ; it was completein scventcen of the twenty operated chihlren as cdompared with xl-en of nineteencontrols (tlierta was one drop-out).

The final measurements 10 years after t,hc init ial examination showed thatt,he difference in closure was no longer signif icant. (It was now no greater thanthe error of the method.) TOP tliastcma hat1 closet1 c*ompletely in eighteen of the


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Ant. J. Orthod.June 1973

---CONTROL GROUP- FRENECT OMY GROUP

8 I0 0.5 2 5 16 EARSFig. 3, Measuring a mid line diastema with circular wires of known diameter . Mean sizeof diastema at start of study: 1.66 mm. for the frenectomy group, 1.61 mm . for the con-trols (error of method , 0.04 mm.).

twenty frenectomized children and in thirteen of seventeen contro ls (two morehad dropped out). By this time, the subjects were about 19 years old.

The mean size of the midline diastema in the two groups at the various stagesin this study is presented in Fig. 1, which thus serves to illustrate the course ofclosure. At the start the mean size was about the same in both groups, and thiswas also found to be the case 10 years later. There was thus no difference in thefinal result between the operated and unoperated groups. In between, however,closure had proceeded very differently, progressing slowly throughout the lo-yearperiod in the unoperated cases but occurring considerably more rapidly in theearly part of the period in the frenectomized children. In the latter group themean size of the diastema had thus diminished substantia lly after only 6 monthsand closure was almost complete after 2 years.Discussion

The findings show that, in the control group, a midline diastema underwenta continuous reduction throughout the IO-year observation period, that is, from9 to 19 years of age. This is in line with data from many cross-sectional studies,which have demonstrated that a midline separation is a normal phenomenonduring the mixed dentition and that it closes as the person matures. In a studyof 1,500 schoolchildren, for instance, Tay lorlO showed that the incidence ofmidline diastema fell from 98 per cent among 6-year-olds to 49 per cent amongIl-year-olds and 7 per cent at the age of 12 to 18 years. Similarly, a cross-sec-

t,ional st,udy of 1,243 children by JakobssonG demonstrated a midline diastemaof more than 0.1 mm, in 90 per cent of 6-year-olds but in only 25 per cent ofchildren with erupted canines.


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VOlUwh? 63Numnber 6 Superior labial frerrectomy 637

Fig. 4. Mean size of midline diastema during a lo-year period.

Fig. 5. Hyperplastic type of frenum with persisting mid line diastema .

Diastcmal reduction in the control group, as indicated by Fig. 4, was some-what more rapid in the early part of the observation period, when the dentitionwas mixetl, t,han toward the end. This agrees with findings in a S-year study of133 children with midline diastema, the greatest change in the diastema beingassociated with eruption of lateral incisors and canines. According to the samestudy, no change in the diastema is to be expected once the canines have erupted,but this is not supported by the present investigation, which revealed furtherc~losurc al such n late age as 14 to 19 years. In all but one of the patients(lisplaying this late closnrt~, the canines had erupted by the time t,he child wasI,xamint>cl at the agcl of 11 years.

The Irrescnt~ study shows that in children with midline diastema, the prob-:rbility of a tliastema closing in the To)iq W)I is the same, whet,her or not frenec-lomy is l)crformetl, but that c losurr is achieved very much earlier in operatedcxases.Thus, ~hesc results imply that frenectomy is indicated if early closure ofa tliastema is considered desirable (for instance, because the patient finds it veryunsightly).

It must be noted that the present findings are average and are related tolimit4 material. Besides, none of the subjects had the very hyperplastic typeof frenum sometimes encountered, often with a fanlike attachment, as shown in


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638 Bergslrl im, Jewen, and Mcirtensson Am. J. Orth,od.June 1973Fig. 5. In such cases the frenum unquestionably obstructs diastemal closure andshoultl bc removed. The closure of a midline diastema can present highly com-plicated orthodontic problems if the permanent dentition has already eruptedwith t,he molars and prcmolars fixed by their cuspal relationship. A spontane-ous effect from frenectomy is not to be expected at such a late sta.ge, but it isconceivable that a persistent midline diastema can be avoided if the operation isperformed while the permanent teeth are sti ll erupting.

The indications for frenectomy should therefore be assessed individua llywith reference to the desirabilit,y of rapid closure and/or the risk of a midlinediastema persist ing in the permanent dentition.Summary

An investigation has been made into the possible contribution of a super iorlabial frenum to the occurrence of a persisting midline diastema.Forty schoolchild ren 8 to 9 years of age with prominent frenums and midlinediastemas of more than 1 mm. were subdivided into two groups. One group wassubjected to frenectomy; the other served as a control group.

Two years after the start of the study the diastemal closure was significantlygreater in the frenectomized group than in the control group. However, thediffercnc*e in closure between the two groups was gradually reduced, and after10 years there was no longer any significant difference.REFERENCES

1. Angle, E. W.: Treatment of malocclusion of the teeth, ed. 6, Philadelphia , 1900, S. S.White Dental Mfg. Co., pp. 177-178.2. Bergstram, K., and Jensen, R.: Diastema med iale och frenulum labi i superioris, Sven.TandlBk. Tidskr. 55: 59-72, 1962.

3. Ceremello, P. J.. : The superior labial frenum and the midlin e diastema and their relationto growth and developm ent of the oral structures, Ax J. ORTHOD. 39: 120-139, 1953.

4. Gardiner, J. H.: A survey of malocclus ion and some aetiolo gical factors in 1,000 Sheff ieldschoolchildren, Dent. Pratt. 6: 187-201, 1956.

5. Gardiner, J. H.: Mid line spaces, Dent. Pratt. 17: 287-298, 1967.6. Jakobsson, S. 0.: Diastema med iale i Gverklken; en frekvensunderstikning, Sven. Tandlilk.

Tidskr. 55: 549-562, 1962.7. Jakobsson, S. 0.: Diastema med iale; en long itudi nell underdkning, Odontol. Tidskr. 73:

127-148, 1965.8. James, 0. A.: Clini cal implic ations of a follow-up study after fraenectomy, Dent. Pratt.

17: 299-305, 1967.9. Kelsey, Harry E.: When is the frenum labi um a problem in orthodontics, AM . J. ORTHOD.

25: 124-129, 1939.10. Taylor, John E.: Clini cal observations relating to the normal and abnorm al frenum Iabii

superioris, AM. J. ORTHOD. 25: 646-650, 1939.

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Bergstrom 1973 Frenectomy