The effect of superior labial frenectomy in eases with midline diastema

K. Bergstriim,
Rtockholm, Sweden

R. Jensen,

and

B. Mdrtensson

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

Figs.

1 and

2. Midline

diastema

and

labial

frenum

with

palatal

attachment.

Material

and

method

Erom 661 schoolchildren 8 to 9 years of age, we selected those who had a midline diastcma of more than 1 mm. as well as a frenum so that pulling on the upper lip resulted in ischemia in the incisive papilla as well as tissue displacement in the interdental region, as shown in Figs. 1 and 2. Roentgenograms were taken to exclude chiltlren wit,h supernumerary and missing teeth. These criteria were satisfied bg forty of the children, who were then subdivided at random into two groups of twenty children. At the start of the study bot,h groups had a mean age of 8 b-cars 8 months. Ilots were drawn to decide which group shoultl act as the control, Ihe intention being to perform frenectomy on all twenty children in the other groq). ,211 the children in the operated group wcrc followed throughout the study, but three of the controls were not available at the later follow-ups. An abnormal frenum is not the only factor cited in the literature as a concecivable cause of persistent midline t&sterna. Widely spaced upper anterior teeth, aplasia of lateral upper incisors, mesiodens, proclincd upper incisors, ant1 ovcrjet are mentioned as other ctiologic factors by TaylorlO and Cardiner. In view of this, the groups were compared in the following respects at the start of the study: 1. Eruption of lateral and incisors and canines. 2. Inclination of central incisors in the frontal plane. 3. Overbite, overjet, and the occlusal relationship of the upper central incisors to the lower anterior teeth. 4. Spatial relationships of upper anterior teeth (assessed by sectionxl

Table

I. Magnitude (n =

of

diastemal F =

closure mean group

z ? G

6 months closure, 5

and
=

2, 5, and error of gmup

r r 5

10 method

years for

after the

the mean

initial

measurement
Obsert~ation pwiod

number, Frenectomy
n

Control
rh mm. nlnl. mm. mm. 20 00 19 17 I 0.29 0.59 1.13 I.49

Val1te of t
mm. mm. mm. mn,. t = t = t zz t = 5.92 6.67 3.36 1.95

0.5
2 5 10

20
20 20 20

1.14 1.35 1.50 1.5::

+ 0.11 +_ 0.09 ? 0.10 2 0.12

+_ 0.06 + 0.07 +_ 0.08 $ 0.12

measurements of the dental arch ad modurn Lundstriim and approximate estimates ot the crowtling or spacin g bctwcmt the first premolars) . The comparisons were based on casts of each child, made of plaster from alginate impressions of the upper and lower dental arches, together with an index in central occlusion. No systematic differences were found between the groups. The casts were also used for measuring the size of the diastema. This was done with a set of circular stainless steel wires of progressively increasing diameter (interval 0.1 mm.). These wires were inserted between the central incisors, as shown in Fig. 3, to determine the shortest, distance between their rnesial surfaces. At the start of the study the mean size of the diastema was the same for both groups (1.61 mm. and 1.66 mm., the error of the method determined from duplicate determinations on the same cast being 0.04 mm.). All of the frenectomics were performed immediately after the initial measurement by the same surgeoq using the same technique as far as possible. The labial part of the frenum was cscisecl with a sc*alpel and the wound was closed with silk sutures, after which the interdental and palatal parts n-ere dissected free, including the incisirr papilla. Any remaining fibrous tissue between the teeth was removed with a raspatory. A surgical tlressing was applied and left in place for 6 days. Casts were again prepared 6 months and 2, r>, ancl 10 ycbwrs after the initial examination, and the size of the cliast,crna was measnrccl as described above.
Results

in

After 5 yrars the tlifferrnc~c~ in closurt> was still signific*ant ; it was complete scventcen of the twenty operated chihlren as cdompared with xl-en of nineteen controls (tlierta was one drop-out). The final measurements 10 years after t,hc initial examination showed that t,he difference in closure was no longer significant. (It was now no greater than the error of the method.) TOP tliastcma hat1 closet1 c*ompletely in eighteen of the

Ant.

J. Orthod. June 1973

---CONTROL GROUP FRENECTOMY GROUP

0 0.5

2 with mm. for

5 circular wires the frenectomy of known group,

16 EARS diameter. 1.61 mm. Mean for the size con-

Fig. 3, Measuring a midline diastema of diastema at start of study: 1.66 trols (error of method, 0.04 mm.).

twenty frenectomized children and in thirteen of seventeen controls (two more had 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 stages in this study is presented in Fig. 1, which thus serves to illustrate the course of closure. At the start the mean size was about the same in both groups, and this was also found to be the case 10 years later. There was thus no difference in the final result between the operated and unoperated groups. In between, however, closure had proceeded very differently, progressing slowly throughout the lo-year period in the unoperated cases but occurring considerably more rapidly in the early part of the period in the frenectomized children. In the latter group the mean size of the diastema had thus diminished substantially after only 6 months and closure was almost complete after 2 years.
Discussion

The findings show that, in the control group, a midline diastema underwent a continuous reduction throughout the IO-year observation period, that is, from 9 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 phenomenon during the mixed dentition and that it closes as the person matures. In a study of 1,500 schoolchildren, for instance, TaylorlO showed that the incidence of midline diastema fell from 98 per cent among 6-year-olds to 49 per cent among Il-year-olds and 7 per cent at the age of 12 to 18 years. Similarly, a cross-sect,ional st,udy of 1,243 children by JakobssonG demonstrated a midline diastema of more than 0.1 mm, in 90 per cent of 6-year-olds but in only 25 per cent of children with erupted canines.

VOlUwh? 63 Numnber 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

midline

diastema.

Diastcmal reduction in the control group, as indicated by Fig. 4, was somewhat more rapid in the early part of the observation period, when the dentition was mixetl, t,han toward the end. This agrees with findings in a S-year study of 133 children with midline diastema, the greatest change in the diastema being associated with eruption of lateral incisors and canines. According to the same study, no change in the diastema is to be expected once the canines have erupted, which revealed further but this is not supported by the present investigation, c~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 was I,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 freneclomy is l)crformetl, but that closurr is achieved very much earlier in operated cxases.Thus, ~hesc results imply that frenectomy is indicated if early closure of a tliastema is considered desirable (for instance, because the patient finds it very unsightly). It must be noted that the present findings are average and are related to limit4 material. Besides, none of the subjects had the very hyperplastic type of frenum sometimes encountered, often with a fanlike attachment, as shown in

638

Bergslrlim,

Jewen,

and Mcirtensson

Am.

J. Orth,od. June 1973

Fig. 5. In such cases the frenum unquestionably obstructs diastemal closure and shoultl bc removed. The closure of a midline diastema can present highly complicated orthodontic problems if the permanent dentition has already erupted with t,he molars and prcmolars fixed by their cuspal relationship. A spontaneous effect from frenectomy is not to be expected at such a late sta.ge, but it is conceivable that a persistent midline diastema can be avoided if the operation is performed while the permanent teeth are still erupting. The indications for frenectomy should therefore be assessed individually with reference to the desirabilit,y of rapid closure and/or the risk of a midline diastema persisting in the permanent dentition.
Summary

An investigation has been made into the possible contribution of a superior labial frenum to the occurrence of a persisting midline diastema. Forty schoolchildren 8 to 9 years of age with prominent frenums and midline diastemas of more than 1 mm. were subdivided into two groups. One group was subjected to frenectomy; the other served as a control group. Two years after the start of the study the diastemal closure was significantly greater in the frenectomized group than in the control group. However, the differcnc*e in closure between the two groups was gradually reduced, and after 10 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 mediale och frenulum labii superioris, Sven. TandlBk. Tidskr. 55: 59-72, 1962. 3. Ceremello, P. J.. : The superior labial frenum and the midline diastema and their relation to growth and development of the oral structures, Ax J. ORTHOD. 39: 120-139, 1953. 4. Gardiner, J. H.: A survey of malocclusion and some aetiological factors in 1,000 Sheffield schoolchildren, Dent. Pratt. 6: 187-201, 1956. 5. Gardiner, J. H.: Midline spaces, Dent. Pratt. 17: 287-298, 1967. 6. Jakobsson, S. 0.: Diastema mediale i Gverklken; en frekvensunderstikning, Sven. Tandlilk. Tidskr. 55: 549-562, 1962. 7. Jakobsson, S. 0.: Diastema mediale; en longitudinell underdkning, Odontol. Tidskr. 73: 127-148, 1965. 8. James, 0. A.: Clinical implications of a follow-up study after fraenectomy, Dent. Pratt. 17: 299-305, 1967. 9. Kelsey, Harry E.: When is the frenum labium a problem in orthodontics, AM. J. ORTHOD. 25: 124-129, 1939. 10. Taylor, John E.: Clinical observations relating to the normal and abnormal frenum Iabii superioris, AM. J. ORTHOD. 25: 646-650, 1939.