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Frenectomy plus free graft
Frenectomy plus free graft Sherman Axinn, M.Ed., D.D.S.,* and W. James Brasher, D.M.D., M.S.D.** Madigan Army Medical Center, Tacoma, Wash., and Salem, Ore.
T
lhe maxillary labial frenum is a potential complicating factor in both complete and partial denture construction, A large frenum, particularly one that is broad based or attached near the crest of the ridge, can be an obstruction that may have to be eliminated prior to denture construction. In many patients who have worn complete dentures for long periods of time, frena appear to have migrated to the crest (Fig. l), probably because of reduction in height of the residual ridge.’ The denture notch that is required to accommodate the frenum is a cleavage point responsible for a large number of denture fractures. Whether the prominent frenum is recognized during the stages of initial denture construction or at the time of remake, a more satisfactory result will be possible if elimination of the frenum and improvement of the mucosal tissue in the frenum area are accomplished prior to impression procedures. Several methods for frenum excision have been proposed. A simple excision around a pair of hemostats clamped on the frenum, with a little or no effort to remove the deep fibers,2 will almost invariably result in regrowth of the frenum. More adequate techniques include “2-plasty, V-Y-plasty for lengthening tissue, Y-V-plasty for shortening tissue, and cross-diamond excision of frena.“3 These approaches include a supraperiosteal dissection of the fibrous attachment and give a satisfactory result, with infrequent regrowth of the frenum. Following successful surgical elimination of the maxillary midline frenum, the sulcular depth is increased and a V-shaped area of alveolar mucosa confluent with the. labial mucosa is usually observed. This article presents a technique for predictably eliminating the frenum, in combination with a soft tissue graft technique to improve tissue character in the area so as to enhance denture base support and retention. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army. *Colonel, DC, USA; Chief, Removable Prosthodontics. **Private practice, Salem, Ore.
16
PROCEDURE The frenum and adjacent mucosal tissues are anesthetized by infiltration of a local anesthetic containing a vasoconstrictor. The frenectomy is accomplished by grasping the center of the frenum with a straight hemostat and incising with a scalpel blade held parallel to the long axis of the hemostat to eliminate the insertion of the frenum into the lip. The blade is then turned to incise toward the alveolar ridge to sever the insertion of the frenum into the periosteum. Sharp dissection is carried out to extend the surgical site laterally and to eliminate any residual fibers on the periosteal surface that would serve as a recipient site for a free graft of masticatory mucosa. The frenectomy incision on the inner surface of the lip is completed by undermining the mucosa and loosely approximating the margins with 4-O silk sutures. A saline-moistened gauze is placed over the exposed periosteum until the graft donor tissue is obtained. A free graft of masticatory mucosa is obtained from an appropriate site on the posterolateral aspect of the hard palate. Infiltration anesthesia is again used at the donor site, An estimation of the size of donor tissue required is obtained by use of a periodontal probe or similar instrument. Donor tissue is obtained by use of a strip of stainless steel razor blade contoured and held in a blade holder such as the Paquette instrument (HuFriedy Mfg. Co., Inc., Chicago, Ill.). Such a blade and holder offer the advantages of being very sharp, allow: ing contouring to fit the shape of the palate, and providing a means of gaining accessfor easy and rapid removal of a thin strip of palatal tissue.4 The blade is placed at the distal extent of the donor area. Incision is carefully begun to establish the proper depth (1 to 1.25 mm), and the blade is then gently brought forward in a slight side-to-side motion while an even thickness of excised tissue is maintained (Fig. 2). The incision is terminated by slightly turning the cutting edge and bringing it out to the mucosal surface. Care must be exercised by the assistant to avoid aspirating the graft tissue during this procedure. After the tissue is obtained, it is immediately placed on the recipient site. A moistened gauze sponge is placed over
JULY 1983
VOLUME
50
NUMBER
1
FRENECTOMY
PLUS FREE GRAFT
Fig. 1. Preoperative view of large frenum attachment near crest of ridge.
with
Fig. 3. Suturing in place.
of graft. Note two suture needles
Fig. 2. Removal of donor tissue with Paquette instrument.
Fig. 4. Graft sutured in place.
the donor site and pressure is applied to effect initial hemostasis. Minor alterations of the size and shape of the donor graft tissue may be done with fine scissors to align it to the recipient site. Care is taken to minimize the time the donor tissue is not in contact with the recipient bed. Frequently, trimming may be done after initial suturing. It is essential that the oral surface of the graft not be transposed and placed against the periosteal bed, for the graft will not take. Attention to detail will prevent such accidents. It may be advisable to mark the surface of the donor tissue with an indelible pencil prior to its excision. Suturing of the graft is simplified by using either a double-armed 4-O (needle at both ends) or two sutures (Fig. 3). A suture needle is placed through the coronal aspect of the graft and underlying periosteum, and the point is brought out in the unexcised marginal tissue; the second needle is inserted similarly in the graft, pulled through, and tied. The first needle, which has
been used to hold the graft in place during tying of the first knot, is then pulled through and tied. Using the suture needles in this manner to stabilize the graft while tying the sutures has been a definite time-saver in the grafting process. A minimum number of sutures is used. Usually, one at each proximal margin and one in the center will ‘suffice (Fig. 4). After completion of suture placement, a saline-soaked gauze is used to apply gentle pressure to adapt the graft to the underlying periosteum. This pressure will create initial immobilization of the graft and encourage an initial fibrin adhesion. At the completion of suturing of the graft, the donor site on the palate is inspected and carefully cleaned of excess blood clot. Usually there will be no continued active hemorrhage at this time, and it is important to leave the initial clot undisturbed. A soft denture liner is mixed and placed in the patient’s maxillary denture, and the denture is carefully inserted. Care is taken to avoid disturbing the
THE JOURNAL
OF PROSTHETIC
DENTISTRY
17
Fig. 5. Soft denture liner in place immediately ter surgery.
afFig. 7. Surgical site 7 weeks after surgery.
Fig. 6. Surgical site 3 weeks after surgery.
Fig. 8. New denture in place.
sutured graft. Light mucosal border trimming is done prior to removal of the denture and trimming of excess liner material from the periphery (Fig. 5). The denture is then reinserted, and the patient is instructed to allow it to remain in place overnight before removing it and gently rinsing the mouth. The patient is encouraged to minimze the number of times the denture is removed during the first few days of healing to avoid unnecessary trauma to the graft site. Suture removal is usually scheduled 3 to 7 days after surgery. During the early stages of healing, there is a tendency for the apical extent of the grafted tissue to appear “cupped.” This appearance diminishes after 3 to 6 weeks of healing, as the surgical site blends in with the adjacent mucosa. The “cupping” effect may be minimized by preparing the recipient site somewhat larger than the graft donor tissue and leaving a recipient site border of exposed periosteum of approximately 2 mm around the apical and lateral borders of the graft.
Zingales has shown that the size and appearance of free gingival grafts will not significantly change after the sixth week following surgery. Our clinical experience supports this interval as a general guide to the appropriate time to start final impressions and denture construction (Figs. 6 and 7).
18
DISCUSSION Frenectomy combined with a free graft of masticatory mucosa provides several advantages over the frenectomy alone. The presence of the graft prohibits the regrowth of the frenum and at the same time provides an area of masticatory mucosa, which effectively enlarges the denture-bearing keratinized mucosal surface. The sulcus is also deepened, which allows for a longer anterior flange, which contributes to a stable, retentive, and mechanically stronger denture (Fig. 8). The major disadvantage of the described procedure is the necessity of a second surgical site (for donor graft tissue). The most suitable site for donor tissue is
JULY 1983
VOLUME
50
NUMBER
1
FRENECTOMY
PLUS FREE GRAFT
usually the posterolateral surface of the hard palate. Because the graft is obtained by surface excision, an open wound must remain to epithelialize by secondaryintention healing. Protection of this site must be provided by relining the patient’s old denture with a soft liner, or by making a temporary denture or stent prior to the surgical procedure. With this sort of protection, the palatal donor site will heal with minimal hemorrhage and patient discomfort. The postoperative discomfort encountered with this combined surgical procedure was not proved to be greater than that caused by frenectomy alone. A second disadvantage may be considered to be the additional time required for obtaining and suturing the graft. Use of the curved blade holder speeds up the procedure of obtaining the graft. Furthermore, the blade sharpness and contour allow for easy acquisition and placement of a graft of the proper split thickness. The importance of graft stabilization by “tacking” with a suture needle while another is used to approximate and tie as described cannot be overemphasized.
SUMMARY Where an unfavorable frenum is present, the technique of frenectomy plus free graft is perceived as an efficient, predictable procedure to improve the prognosis of a complete or partial denture. REFERENCES 1. Hickey, J. C., and Zarb, G. A.: Boucher’s Prosthodontic Treatment for Edentulous Patients, ed 8. St. Louis, 1980, The 2. 3. 4.
5.
C. V. Mosby Co. Sharry, J. J.: Complete Denture Prosthodontics, ed 3. New York, 1974, McGraw-Hill Book Co. Inc., pp 182-183. Kruger, G. 0.: Textbook of Oral and Maxillofacial Surgery, ed
5. St. Louis, 1979, The C. V. Mosby Co., p 109. Brasher, W. J., Rees, T. C., and Boyce, W. A.: Complications of free grafts of masticatory mucosa. J Periodontol 46:133, 1975. Zingale, J. A.: Observations on free gingival autografts. J Periodontol 45:748, 1974.
Reymnt requests to: DR. SHERMAN AXINN UNIVERSITY OF NEBRASKA MEDICAL COLLEGE OF DENTISTRY LINCOLN, NE 68583
CENTER
Bound volumes available to subscribers Bound volumes of the JOURNAL OF PROSTHIWIC DENTISTRY are available to subscribers (only) for the 1983 issues from the publisher at a cost of $39.00 ($49.00 international) for Vol. 49 (January-June) and Vol. 50 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mr. Deans Lynch at The C. V. Mosby Co., 11830 Westline Industrial Drive, St. Louis, MO 63146, USA. Subscriptions must be in force to qualify. Bound volumes are not availabie in place of a regular JOURNAL subscription.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
19
T
lhe maxillary labial frenum is a potential complicating factor in both complete and partial denture construction, A large frenum, particularly one that is broad based or attached near the crest of the ridge, can be an obstruction that may have to be eliminated prior to denture construction. In many patients who have worn complete dentures for long periods of time, frena appear to have migrated to the crest (Fig. l), probably because of reduction in height of the residual ridge.’ The denture notch that is required to accommodate the frenum is a cleavage point responsible for a large number of denture fractures. Whether the prominent frenum is recognized during the stages of initial denture construction or at the time of remake, a more satisfactory result will be possible if elimination of the frenum and improvement of the mucosal tissue in the frenum area are accomplished prior to impression procedures. Several methods for frenum excision have been proposed. A simple excision around a pair of hemostats clamped on the frenum, with a little or no effort to remove the deep fibers,2 will almost invariably result in regrowth of the frenum. More adequate techniques include “2-plasty, V-Y-plasty for lengthening tissue, Y-V-plasty for shortening tissue, and cross-diamond excision of frena.“3 These approaches include a supraperiosteal dissection of the fibrous attachment and give a satisfactory result, with infrequent regrowth of the frenum. Following successful surgical elimination of the maxillary midline frenum, the sulcular depth is increased and a V-shaped area of alveolar mucosa confluent with the. labial mucosa is usually observed. This article presents a technique for predictably eliminating the frenum, in combination with a soft tissue graft technique to improve tissue character in the area so as to enhance denture base support and retention. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army. *Colonel, DC, USA; Chief, Removable Prosthodontics. **Private practice, Salem, Ore.
16
PROCEDURE The frenum and adjacent mucosal tissues are anesthetized by infiltration of a local anesthetic containing a vasoconstrictor. The frenectomy is accomplished by grasping the center of the frenum with a straight hemostat and incising with a scalpel blade held parallel to the long axis of the hemostat to eliminate the insertion of the frenum into the lip. The blade is then turned to incise toward the alveolar ridge to sever the insertion of the frenum into the periosteum. Sharp dissection is carried out to extend the surgical site laterally and to eliminate any residual fibers on the periosteal surface that would serve as a recipient site for a free graft of masticatory mucosa. The frenectomy incision on the inner surface of the lip is completed by undermining the mucosa and loosely approximating the margins with 4-O silk sutures. A saline-moistened gauze is placed over the exposed periosteum until the graft donor tissue is obtained. A free graft of masticatory mucosa is obtained from an appropriate site on the posterolateral aspect of the hard palate. Infiltration anesthesia is again used at the donor site, An estimation of the size of donor tissue required is obtained by use of a periodontal probe or similar instrument. Donor tissue is obtained by use of a strip of stainless steel razor blade contoured and held in a blade holder such as the Paquette instrument (HuFriedy Mfg. Co., Inc., Chicago, Ill.). Such a blade and holder offer the advantages of being very sharp, allow: ing contouring to fit the shape of the palate, and providing a means of gaining accessfor easy and rapid removal of a thin strip of palatal tissue.4 The blade is placed at the distal extent of the donor area. Incision is carefully begun to establish the proper depth (1 to 1.25 mm), and the blade is then gently brought forward in a slight side-to-side motion while an even thickness of excised tissue is maintained (Fig. 2). The incision is terminated by slightly turning the cutting edge and bringing it out to the mucosal surface. Care must be exercised by the assistant to avoid aspirating the graft tissue during this procedure. After the tissue is obtained, it is immediately placed on the recipient site. A moistened gauze sponge is placed over
JULY 1983
VOLUME
50
NUMBER
1
FRENECTOMY
PLUS FREE GRAFT
Fig. 1. Preoperative view of large frenum attachment near crest of ridge.
with
Fig. 3. Suturing in place.
of graft. Note two suture needles
Fig. 2. Removal of donor tissue with Paquette instrument.
Fig. 4. Graft sutured in place.
the donor site and pressure is applied to effect initial hemostasis. Minor alterations of the size and shape of the donor graft tissue may be done with fine scissors to align it to the recipient site. Care is taken to minimize the time the donor tissue is not in contact with the recipient bed. Frequently, trimming may be done after initial suturing. It is essential that the oral surface of the graft not be transposed and placed against the periosteal bed, for the graft will not take. Attention to detail will prevent such accidents. It may be advisable to mark the surface of the donor tissue with an indelible pencil prior to its excision. Suturing of the graft is simplified by using either a double-armed 4-O (needle at both ends) or two sutures (Fig. 3). A suture needle is placed through the coronal aspect of the graft and underlying periosteum, and the point is brought out in the unexcised marginal tissue; the second needle is inserted similarly in the graft, pulled through, and tied. The first needle, which has
been used to hold the graft in place during tying of the first knot, is then pulled through and tied. Using the suture needles in this manner to stabilize the graft while tying the sutures has been a definite time-saver in the grafting process. A minimum number of sutures is used. Usually, one at each proximal margin and one in the center will ‘suffice (Fig. 4). After completion of suture placement, a saline-soaked gauze is used to apply gentle pressure to adapt the graft to the underlying periosteum. This pressure will create initial immobilization of the graft and encourage an initial fibrin adhesion. At the completion of suturing of the graft, the donor site on the palate is inspected and carefully cleaned of excess blood clot. Usually there will be no continued active hemorrhage at this time, and it is important to leave the initial clot undisturbed. A soft denture liner is mixed and placed in the patient’s maxillary denture, and the denture is carefully inserted. Care is taken to avoid disturbing the
THE JOURNAL
OF PROSTHETIC
DENTISTRY
17
Fig. 5. Soft denture liner in place immediately ter surgery.
afFig. 7. Surgical site 7 weeks after surgery.
Fig. 6. Surgical site 3 weeks after surgery.
Fig. 8. New denture in place.
sutured graft. Light mucosal border trimming is done prior to removal of the denture and trimming of excess liner material from the periphery (Fig. 5). The denture is then reinserted, and the patient is instructed to allow it to remain in place overnight before removing it and gently rinsing the mouth. The patient is encouraged to minimze the number of times the denture is removed during the first few days of healing to avoid unnecessary trauma to the graft site. Suture removal is usually scheduled 3 to 7 days after surgery. During the early stages of healing, there is a tendency for the apical extent of the grafted tissue to appear “cupped.” This appearance diminishes after 3 to 6 weeks of healing, as the surgical site blends in with the adjacent mucosa. The “cupping” effect may be minimized by preparing the recipient site somewhat larger than the graft donor tissue and leaving a recipient site border of exposed periosteum of approximately 2 mm around the apical and lateral borders of the graft.
Zingales has shown that the size and appearance of free gingival grafts will not significantly change after the sixth week following surgery. Our clinical experience supports this interval as a general guide to the appropriate time to start final impressions and denture construction (Figs. 6 and 7).
18
DISCUSSION Frenectomy combined with a free graft of masticatory mucosa provides several advantages over the frenectomy alone. The presence of the graft prohibits the regrowth of the frenum and at the same time provides an area of masticatory mucosa, which effectively enlarges the denture-bearing keratinized mucosal surface. The sulcus is also deepened, which allows for a longer anterior flange, which contributes to a stable, retentive, and mechanically stronger denture (Fig. 8). The major disadvantage of the described procedure is the necessity of a second surgical site (for donor graft tissue). The most suitable site for donor tissue is
JULY 1983
VOLUME
50
NUMBER
1
FRENECTOMY
PLUS FREE GRAFT
usually the posterolateral surface of the hard palate. Because the graft is obtained by surface excision, an open wound must remain to epithelialize by secondaryintention healing. Protection of this site must be provided by relining the patient’s old denture with a soft liner, or by making a temporary denture or stent prior to the surgical procedure. With this sort of protection, the palatal donor site will heal with minimal hemorrhage and patient discomfort. The postoperative discomfort encountered with this combined surgical procedure was not proved to be greater than that caused by frenectomy alone. A second disadvantage may be considered to be the additional time required for obtaining and suturing the graft. Use of the curved blade holder speeds up the procedure of obtaining the graft. Furthermore, the blade sharpness and contour allow for easy acquisition and placement of a graft of the proper split thickness. The importance of graft stabilization by “tacking” with a suture needle while another is used to approximate and tie as described cannot be overemphasized.
SUMMARY Where an unfavorable frenum is present, the technique of frenectomy plus free graft is perceived as an efficient, predictable procedure to improve the prognosis of a complete or partial denture. REFERENCES 1. Hickey, J. C., and Zarb, G. A.: Boucher’s Prosthodontic Treatment for Edentulous Patients, ed 8. St. Louis, 1980, The 2. 3. 4.
5.
C. V. Mosby Co. Sharry, J. J.: Complete Denture Prosthodontics, ed 3. New York, 1974, McGraw-Hill Book Co. Inc., pp 182-183. Kruger, G. 0.: Textbook of Oral and Maxillofacial Surgery, ed
5. St. Louis, 1979, The C. V. Mosby Co., p 109. Brasher, W. J., Rees, T. C., and Boyce, W. A.: Complications of free grafts of masticatory mucosa. J Periodontol 46:133, 1975. Zingale, J. A.: Observations on free gingival autografts. J Periodontol 45:748, 1974.
Reymnt requests to: DR. SHERMAN AXINN UNIVERSITY OF NEBRASKA MEDICAL COLLEGE OF DENTISTRY LINCOLN, NE 68583
CENTER
Bound volumes available to subscribers Bound volumes of the JOURNAL OF PROSTHIWIC DENTISTRY are available to subscribers (only) for the 1983 issues from the publisher at a cost of $39.00 ($49.00 international) for Vol. 49 (January-June) and Vol. 50 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mr. Deans Lynch at The C. V. Mosby Co., 11830 Westline Industrial Drive, St. Louis, MO 63146, USA. Subscriptions must be in force to qualify. Bound volumes are not availabie in place of a regular JOURNAL subscription.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
19