Maxillary Frenectomy

Maxillary midline diastemas are relatively simple to close during orthodontic treatment, but there are a number of factors that can contribute to the reopening of this space. The presence of “abnormal” maxillary labial frenum is the most frequently alleged etiologic agent in this relapse scenario. Most practitioners agree that this band of tissue must be surgically excised at some point in order to achieve a successful long-term result.

The questions surrounding this issue are:

• What constitutes an “abnormal” maxillary labial frenum?
• When should it be removed?
• What success rate should be expected to avoid relapse?

These questions are answered in a classic paper by Edwards. Most clinicians agree that three of four conditions exist in the presence of an abnormal frenum. First, the frenal attachment closely approximates the interdental margin and/or inserts palatally lingual to the incisors. Second, the attachment is wider than usual ant its insertion point. Third, there is movement and “blanching” of the interdental and/or palatal tissue upon stretching of the frenum and upper lip. The fourth condition that many clinicians agree upon is the presence of an invagination of the interseptal bone between the central incisors.

Almost all authors on the subject agree that an abnormal frenum should not be excised until the space is closed orthodontically because there is little evidence that spontaneous closure will result. Removing this tissue prior to space closure poses the risk of scar tissue formation, which can slow down subsequent attempts to space closure.

Edwards recommends a three-stage procedure when performing a frenectomy. The frenum is repositioned apical with denudation of the alveolar bone. The transept fibers are severed between the approximated central incisors, and the labial and/or palatal gingival papillae are recontoured in cases of excessive tissue accumulation.

Edwards’ study demonstrates that his procedure greatly increases the long-term stability of an orthodontically closed maxillary midline diastema.