Main indications for surgical intervention
Correction surgeries of the frenula (Frenulectomia, Frenuloplastica) are an essential stage of surgical preparation for prosthetic and orthodontic treatment. The intervention is indicated in the presence of the following factors:
- Anatomically shortened labial frenulum, which limits the natural mobility of soft tissues and often causes diastema formation.
- Obstacles to denture retention. Pronounced frenula and connective tissue strands in the oral vestibule have high mobility, causing them to displace and dislodge the removable acrylic denture.
- Presence of cicatricial contractures of the mucosa, sharp alveolar edge, or a shallow oral vestibule (requires comprehensive surgical preparation).
The choice of a specific technique is always up to the operating surgeon, based on the clinical presentation.
Frenulectomy techniques (frenulum excision)
Classical excision is used to relieve tissue tension, although the approach varies depending on the width of the strand and the amount of available mucosa.
Simple frenulectomy Consists of the complete excision of the upper lip frenulum tissues using surgical scissors at the site of its attachment to the lip and alveolar process. After mobilization of the mucosa, the wound is partially closed with interrupted sutures. A characteristic diamond-shaped wound defect forms on the alveolar process. Feature: in case of pronounced tissue deficiency, it is impossible to close the wound tightly, so it heals by secondary intention.
Frenulectomy for a wide frenulum (preferred technique) This option avoids tension on the wound edges.
- Two vertical incisions are made, diverging toward the base of the frenulum, thereby lengthening it.
- Separation and partial excision of the strand are performed.
- The tissues are approximated with the mobilized lateral areas of the mucosa.
- The wound is secured with interrupted sutures.
As a rule, this method allows for primary wound closure, ensuring healing by primary intention. In addition, in cases of a shallow oral vestibule, this technique allows for its simultaneous deepening.
Limberg frenuloplasty
This surgical technique, also known as Z-plasty (using transpositional triangular flaps), is considered the preferred method for lengthening a short labial frenulum. The method is also indicated in the presence of cicatricial mucosal changes.
Surgical procedure:
- The surgeon incises the frenulum longitudinally along its entire length, forming a central vertical incision.
- From the apices of this incision, two additional incisions are made at an angle of about 90°.
- Two triangular mucosal flaps are dissected. An important condition for a successful operation is the elevation of the flaps along with the periosteum.
- Mutual transposition (relocation) of the triangular flaps is performed with their subsequent fixation.
The main advantages of the Limberg method are the absence of postoperative mucosal deficiency and the achievement of optimal functional and aesthetic results. However, the technique has limitations and may not be feasible depending on the initial state of the mucosa.
Comprehensive surgical preparation of the vestibule
In situations where correction of a single frenulum is insufficient, more extensive interventions are applied.
In the presence of multiple mucosal folds and connective tissue strands, combined techniques are used. If the patient is diagnosed with pronounced cicatricial contractures or fibrous mucosal overgrowths, vestibuloplasty becomes the mandatory and only effective treatment method.
Combined preparation of the mandible A complex method involving an incision along the alveolar crest and elevation of the mucosal flaps together with muscle fibers from the periosteum. The flaps are displaced downward and sutured at the depth of the wound. If necessary, the surgeon corrects the exposed area of the crest (alveolectomy or bone grafting). The resulting defect is closed with an autograft (skin, mucosa) or allograft, which is secured by surrounding sutures. The method yields good results, but its disadvantage is the need for an additional surgery to harvest the autograft and the complex accounting for its characteristics.
Briefly: answers to topical questions
What surgical instruments are required to perform a simple frenulectomy?
Performing a simple frenulectomy requires surgical scissors and specialized instruments for soft tissue approximation.
The kit for frenulum excision and subsequent placement of interrupted sutures includes:
- Scissors — used for the complete surgical excision of frenulum tissues at the attachment site.
- Surgical needles — used for tissue suturing.
- Needle holders — necessary for handling surgical needles.
- Forceps — intended for grasping and holding tissues.
- Suturing material — used for partial or primary closure of the resulting wound.
What author techniques for vestibuloplasty exist?
To deepen the oral vestibule and eliminate cicatricial contractures, the following author vestibuloplasty techniques are used:
- Obwegeser technique (Obwegeser) — submucoal vestibuloplasty performed with the main purpose of increasing the vestibule depth.
- Kazanjian technique (Kazanjian) — surgery using a displaced labial mucosal flap, also known as the Lip Switch technique.
- Edlan technique (Edlan) — a modification characterized by the displacement of the periosteum instead of the mucosa to cover the wound on the lip.
- Wassmund technique — used to eliminate cicatricial contractures of the oral vestibule mucosa.
Class and exam questions
Why does atrophy of the alveolar process occur in secondary edentulism?
The main cause of atrophy of the alveolar process of the maxilla and the alveolar part of the mandible is the lack of adequate masticatory load after tooth loss.
What is the difference between healing in a simple frenulectomy and the modification for a wide frenulum?
Simple frenulectomy often results in tissue deficiency, making primary wound closure impossible, so it heals by secondary intention. When excising a wide frenulum, the tissues are mobilized, allowing for primary closure and healing by primary intention.
When is vestibuloplasty indicated?
Vestibuloplasty is a mandatory procedure in the presence of pronounced pathologies in the oral vestibule, such as cicatricial contractures and the development of fibrous mucosal overgrowths.
What else to study on this topic
- Features of harvesting autografts (skin, mucosa) to close defects.
- Types and properties of allografts used in vestibule plastics.
- Technique for performing alveolectomy and alveolar ridge bone grafting.
- Principles of postoperative wound management during healing by secondary intention.
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Other topics in "Chapter 16. Surgical Preparation of the Oral Cavity for Prosthetic Treatment (A.V. Shchipsky)"
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