Frenum position and vestibule depth in relation to gingival health

Periodontia FRENUM

POSITION

AND VESTIBULE DEPTH GINGIVAL HEALTH

IN RELATION

TO

factors influencing girigival JION(: the riuiucr~ous local cmvironrnciital health is the attaclmeut position on the girigivao of the Iahial and hnc(*aI frt~nums. These frcnums arc> folds of lahial or’ huccal mu~~~us rnembranc which usually attach at a tlistaner of several ttlillirtleters 1’ronr the girrgivirl margin so that a zone of attachrtl gingiva lies ldween the attachrrrcnt irntl the margin. Frequently, however, they attach ~IOSC~I~ to the gilrgivirl Irlar-gill i ban is normal. so that no such zone of attached gingiva exists in that, locatiorr. k-d often it is the attachrnrnt of tliv superior or inferior IirhiLll t’rc~nums (*Ios:~ lo the labial gingival margins of the maxillar*~ or rr~antlihnl:~r cWrtrwI iri&brs wliivh is at t’ault. .2r~~itoriiicaII~. theso folds and frenums irr*(~sinil)ly two Iayc~rs of t>pit Iic~lillllr I~lic+losiiip :I loose, vascular, ~onric~ctirc I issue cdorintrr. Tlrcw may 01’ Illil\. t1ot \Ylien preschrit, these musc~lc fibers iir~l sniall slii)s IN% ~lluscle filwl% prcsc11t. 1’rom t Iiv orhicnlaris or%, or from oth(lr nrnsclrs of I’avial expression intcrvussating with fibers of thv orhicularis oris. They arise, in tlrchse instsncc>s, L’rorlr 1Iic alveolar process of the bone, rathrr than from its hotly. Trc~atnrent oi tlrvsc riialpositioned frenurns arid of t liese muscle attachments is similar, wlIliou~h there appears to lx, soiii~~ cliffercriee in tlic mcc~lianisms wlrcWh~- ili(~J inflrrericc~ their associated gingival disease. Illil\: (‘XC’Yt il tlt’l~‘7’11~ irI)errarrtl>- positioned fl*errrrrrls, I)iIIltls. III’ IIIllS(‘lt’S trriorrs effect 011 the gingi\-ac through one or iI vorrll)itlaiic)rl c,t’ se\.er.;rI tt~(~(*lr;rttisnls :

A

.1. Int,erferencr with tooth brushing 1)~ I)reverlting 1 hc toothl~rusl~ t’ro~t~ BWi3UW of the distention 01 I)eirrg piace(l at its proper lcvcl in the vestihulc. the lip by the hulk of the toothbrush, the fr*enum hancl is stretched and the bristles cannot, he positioned apicully enough to reach the cervical area of the toot,h. This holds trxe for lxdh the Stillmnn ant1 the (‘harter*s method of As a result of the lack of adequate hygiene. there are constant tooth brushing. foo~l clehris and sorcles retention and calcnlns formation in these nr-eas, lending I o chronic marginal gingivitis. From the School of Dental and Oral Swpery, Faculty of Medicine, Columbia University.

with IlLrough 1h(x acrylic to correspond I,C~~~lllSiOtl, xn(L polishc,d. Hole. ~vt~rc t hm (lrillr~l ‘1’11~~~ liol,~~ :1r0 for t 11(x lig,Lttlt.e \vire rvhich wilt IW pasisc~~t i he in tcrproximal spaces. t 111Y111~11 ancl nl.n1lllll tll‘, I‘Y’I Il. :\ st11;111a111out11 rrl’ Ihl:tit iv evils N~IIII)\.P~I fro711 t trc! insillv of the slt~nl to [~rovi~lt~ s~vwt’ ~‘III, I tlv s,lrgic:tl t~:ivI~. on Operation.-l.n(ltlr loc*:rl ill tilt rat i011 :IIIW~ tlvhia, :I gi~~givol~tast v \vits Ilerformcyt papillae mere rv1hts I:It)iiil s~tt~fart~ of the loc\.r~r (‘(antrat invi8ors a11(1 thv interprosinral .~II invision was thvn n~atlr at thv nirlcogingival linr from cuspid to cuspid, th? .shapt”I. t,la~lt~ I,caing it~arrtrd at right ang.1~~ to thck Iat)iat plate and making contact with bone. .\I us~lr litters and connec~tiv~~ tissue were then freetl i’rom t.he periosteum inferiorly, thus surgical ~lrepening the vf9tibule (Fig. I, (’ 1. A1fter hemostaqis wao effected: periodontal pack was Jllacell over thr operat,etl area and the o\-errst(~ud(d stent was ligated in place \vith .lllll stairtlthss steel ligature wire (Fig. I, I)). After live days the stcnt TVBS rcmove~t, the oprratr~~l xrea irrigated, a fresh dressing This was allowetl ta rthn~:~it~ for another week. t*pon the apptielt, anal the strnt replaced. renroval of the strut, the pativnt was illstl.ucted in hon~rl care, including gentle tooth Inrushing, antI toltl to gvntlv . massage a Illan salrc, sur~h as prtrotcum jelly. into the I:ltliill vc~.~tit)nle srrc~ral t irnvs a 11:~s. ,Sinc,e the oc*~~lusal rc~l:~tionships of the, incisor teeth hall not t,etan attended to caarlirlr in the trt’atnitant l,rogra~n~ they n-t’rtx corrected at this timr. One year titter the patient appearrtl for a follow-up inspection which revealed tha: the fornrerly rectvlctl lal,ial fiingi\-at niargins of the vrntral incisors were nom- at a more normal height (Fig. 1, B). Retraction of the lip shn~ved that there was no pnll transmitted (lirectly to the free gingival margins. and that ih(~r~: was now a broader zone of attached A slight sear market1 thv site of the incision gingiva than originally. (Fig. 1, F). The gingirnl vonfour 1~8s good; there was no inflanlluation antt no debris retention. Proper tooth brushing was possible. This patient was exarninetl again nine nlonthY late1 and the gingivae again were found to he in escf,llent condition. The scar had aoftenell and resolved considerably under 1he influence of gentle finger massage an11 now was l)arc*lJ- .isible. Case 2.-IV. TI.. a Syear-old man: presented with a papillary and marginal gingivitis in thr mandibular anterior area (Fig. -,.) A ). Between the central incisors was a deep interpapilla was divided from the proximal crater. The labial portion of the interproximal lingual portion and each stood as a loose, unconnertpd tab of tissue. TVhen the lower lip was retracted. the labial frenum was seen to insert onto the labial aspect of the inter11en1x1 papilla ant1 to pull this unsnpported tab of tissue labiall>-. E’ivr clays after routin<> sutq$ngival scaling. the gingivae wer’r apparently fret, of inflwnniation. The architectural defect tjetween the v~~rrtrai incoisors was still prrscnt, an,! I here W:,J debris retention in the crater (Fig, 2, S). An acrylic stent was prepared preoperatirely, as in (‘ast 1. (kingivoplasty and dtaeprning of the n~u~ol~uccal fold were carried 0x11 and the storlt was ligated in p]:l,ac!. Fig. 2, (’ shows the area one week postoperatively, with the stent in position. After two wrbeks. the stent and pack were removed and the teeth ligated with .010 stainless steel wire for temporary stabilization (Fig. 2, 1)). This ligature was allowed t,o remain for one month while complete healing took place and the mot)ility of the central incisors decrtaasrd. ]t was then removed. One year after operation (Fig. t’: /Z) the gingival tissue was hPalthy and well formed. There was no longer anp frenum pull on the papilla. 7%~ tip of the interproximal tissue t)et,weeu the central incisors w-as the base of the crater I)r“ol)rratirrl-. woman, presented in I!MO with recession and inflammaCase 3.-t:. G.. a 23.year-old tion of the labial gingival margin of the lower left, central incisor (Fig. 3> A). Below the receded gingival margin was a periodontal pocket measuring approximately 3 mm. A rlollt,te lmntl of reflected mucosa was found to insert directly into this gingival margin.

19 %!I. Xtvessiort of tbv labial gingiwl rn:Iwin csf tllc\ It,t’t 3. A? November. incisor with debris retention :m,l chronic* marginal infl;rmmation. R, Onv \verk postoperatively, showing stent in position. :~n(l one-half years ~ostope~atiwly. Thr It.\.(.I* of ttx. (~’ and II. October, 1953, thrw There is no frenunr pull transgingival margins of the lower anterior teeth are now equal. The dark line running’ dinronally below the lower right mitted to the attached gingiva. The smr fmrn the operation incision rv~n central incisor is a smztll supcrfici:ll hloorl vcsael. be seen. rcmtral

Fig. 3--(‘se

Discussion It is not the purpose oi’ this artic~le to attenlpt to prove a11etiological relationship between the frrnum (or muscle) attaching c*losc to t,he gingival mat*gin and any gingival disease that may 1~ presrnl. Rather, attention is tlirected to the keatment of the caonditicrn. In cases of recession, as in (lasts 1 and 3, the question of whct,her the gingival margin receded to the frenum or whether the frenum caused the re-

c.cxssion is acatletrlie, for, whatever the eausta-ef’t’ec+ t.elationshil), the fact. that gitlpival disease is present and a frenum inserts at, or (*lose to, t,hat- point t~lt:atis that the frenum problem must be dealt with in ortIer lo c:otnpletel~t rea t the gingivae. surgc~ry in thtw t JVO In1 t~reslitigl~*. l’c~llowing the 3 gill@\-oplast~ a11tl frt~~lwn (‘ases. tlic~w \V;IS a i~etluctiotl it1 the aitrount of t*t~c~rssiott. This is :I rt~al chanqe ant1 not met~cly an optical illusic~n causetl 1)~ levelliiig of gingival margins. This c)l)s(lt*r;ltioll is demonst~rated more conclusi\-ely in the case shown in Fig. -I. 11~~. k’ig. 4. 11 and the upper model in Fig. 4, C show the case before treatto the ~~wilrd tncllt. I~rottr tlic ilicisal etlgc of the lower right ~~~11x1 in&or SC\.CJtl 1~10lll tlS it f’tet’ tile surgical lal)i;tl ginyival illargin tt~casntw 12.5 ntnt. I)roc~rtlurc~ tlrsc+ril)etl previously, tltcre is a illore itlc*isal positioning of Ihr gin‘I’1it’ tlistnllctl from ilie in&al t~clycxto Ihe gingiral margin now Kiv:ll tlrargill. lncasures slightI!- o\x~r 11 mm. (Pi:. 1, .R ant1 the lower model in 4, CO. The in&a I edge has Trot lien gronutl. Since a prolw cc~ltl not br introducetl IFt wt~cn 1.1~1new gingival margins iI tl(l the root in t,hesr locations, there is either \‘Ct*?- light ilCl~ptZltiOll or altaclllncwt. So opinioll cmi 1)~ espresscd on this lattclr I)ossibilit)- without fnrtllcr invcstigatioii. Sor is thercl enough cridcuctj al- present to t>splain why the tlcel)t~ning of the \-c~stil~nle should result in this iii&l1 iiligrnt ion of the rcrctletl gitlgirill nlargin. ‘l’hc~ use of the overcstended acrylic stent, is an innovation which has I)ro\~rtI \-alual)le iti tn:itty casw. Tlowri-et*. il c,l)\-iously is not necessary in all V~SPSof frenectot~l~~. Others, such as Goltlm:tn,‘~ 5 I”c,x,~ and Schluger,” wh(, ha 1-t’ t~t~cognisc(l the 1v1e of the frrtuutt itI gingiyal disease and who haye leer! ~loi~rg surgic~nl correct,ion. have r~~p~1r1cclKLICCCSS wit 11the pc~rioclontal surgical clrc3sinp alotrt~ (as have I, iI1 a large nuuil)~r of (a;ist’~). I f the frenuiit is a slinl l’olcl of tissue it-hiczh tloes not sprtantl widely towartl its hasc, and if t,he mucoI)u(*tai\l reflec*tion is at an adqnatt~ distance front 1-11~gingival margin, a simple I‘rcllrc~totrl~ will l)t: ill1 that is 1.equirctl. If, on the other hand, the -frenunl sprra(ls 1)1wttlly toward its base and Mends with iI m~~cob~~ccalfold which is shallow. the proccdnre ljecornes more than a frencctomy; it, becomes a vt~stibnlc tle(>pcnitrg. In such taases! if the lip is heavily In;lscalrd a11cl ;lrtire, the sten! will 1~ Inure reliable than the surgical dressing alone in l)reser\-ing the del)tll 01’ the incision during healing. ‘l’he periotlontal t)il- the steel ligature wires, remains as a barrier to adhesion between the lip portion and the gingival portion of the wound. I~~pithelializat~ion takes place under the stent, lining the wound surface facing it’, so that when the stent is removed adhesion and union will no longer occur. as two epithelialized surfaces, rat,her t,han two connective tissue surfaces, now face each other.

(‘.

X cv~rollarl\- prol)lem to that of’ thr frennnts is thztt of the type of tissue in which the gingiral margin is lo(aitted. IThen. in Ringi\-al cliseasr, recession into or pocket formation adrances lwyond the Icvel of l‘he ;tttacahrcl gingi\xr ]~rOl)lellls Of ttYiitUl(~llt ill’(’ the soft, Ct’~ely nloval)le nl\~eoli~~* IIIIICOSZ~.“’ sprci:il raisccl. These problems c~eiiter altout the fill:)1 loc;ttion of the ittr-olvcd gicgivnl tttarpin. Normally in health, an(l itleitlly followittg thrrill)y, the gil~giri~l tnnrpins should 1~ snhstantially crownw;~rtl to the ttlucoginpi\-;]I line so thitt it relatively hrontl zone of stil)plrd. u~ell-k(~~~;tt-ittiz(~~l, :ltt;tchrtl ginpiv;l lies ~WIOW the ln:lrgin. This tissue is so c~ottstrudttl i h;rt it c:rn withstancl thet rw~iiii;~ of food impinging 011 it illld j);tssiiip 0Yet it iti ttr:rsticnt~iott :iitd vittt resl)c)ntl fa\-orably to this form of stitnul;ttiott. ‘l‘h(~ ;llrtwl;ll~ 1LlLLcos;t. Ott the ot1t(bt* hittttl, is softct*, utt:ttt;tcht~tl. is cc~vt~t~ctl 1)~ ittl r~l)ithvlintlt \\.llic*h is 1hitttlot.. tlttkrt,;ttittizc‘tI. ittt(l 11as ;I voriuttl ~olltl~ost~tl it’ l~~ost~t~~IIIO:‘~ \-itscttlitt’. votttrvc*tivc~ 1issue. It is lllOt’(’ tl~li(*itt(~ illld Itot it(lal)tC’tl to rtvc4\-i~rg tltc clit~tvt itllI);tc’t rbf 1’00cl. Ai gittgiritl tltargin of this ~n~~c~os;tltissue will II(‘VP~ I)(> it hc;tIthy ottt’. This ~onclitioti is rnconntcrc~tl iriost frec~ticittl~- otl the I)llV(‘ill SlLI’fitPt’S of itIlt ~o\~~cI~SPCO~I~ itntl thircl Ill0lirr.s. I~SS SO OII thr lt\l<~(~;tl ~tlt*t’a~(b~ (\f tlpl)c’r and lower first n~ol:itx ant1 least so oii the otlit~r teeth; iti otlitlr words. wherever the zone of attached gingival is nortiiall~- narrow. A\ 7 111111. pocket 011 ltUC~C~il1SUl’f~C!t’ Of ;I lO\V(‘I’ SeCOlltl l~t’~lllOli1t’~ tht’ \zhetne the t~tuc~ogittpival litic is only 2 IIUII. front the gingival Itl;rrgin. ol)\riously It;ls its I)ast’ in the ZOTI(’ oJ the it.l\c(~lilt* tItLt(‘()sit. Siitiplr rvscvtiott of the, qil:gi\-il to t hc clrl)t II Of t tIC Ito?k(‘t WO~~CI I)I~CC the 11~~ gitlgi\,;tl ntnrgin itt thtb ~~t’t. Ltttittt;t(*lttJtI. tIttI(‘os;t! tissue ~~V~CIY~ the l);tst: of tllc l)ovkrt is loc;rtctl) itTt(l this t*tJsltlt. t It~~rc~l’ot~c~. \YOIll(l ItOt l)C il fit~‘Ol’~ll~lC? OtlP. Succtbssful tt*(‘ittlttt’tlt, of ;t Itovket slt(‘h ;IS t Iti? IW~llit’W i1lt ilttt’IIll)t to lOLVt>r the tttl~cogitlgivitl line itl)ie;tl 10 lh(b I)oc*kclt I);Is(‘, xottc . SO thttt the l)its(l ot t 11~s ittc4t8cl:tsing the width of the att;tchctl gillgiv;il pocket is in the new attached gingiva. T’rc~lintinary e\-itlencc with the procedure tlescril~ed herein suggests that this (*an 1~ ;ic*comptishd (,~<*;tsion;tll~. Lll)]wt’

Summary ‘he effect oii ttlr! IO~iltiOtl of thv labial illld l)UCCill 1‘~~~Illlrtls 011 giilgival disease has been discussed, particularly in relation to recession and chronic inflammation. A fairly vomtno~t finding is a frcnunr :ttti~(~hing close to. or itt, it recetlrd labial pingivill lllil?gitl 01’ an anterior tooth. The mechanisms l,y