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Year : 2014? |? Volume : 3? |? Issue : 1? |? Page : 5-10 |
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Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children
Nandanahosur Basavanthappa Nagaveni1, Kagathur V Umashankara2
1?Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Karnataka, India
2?Department of Oral and Maxillofacial Surgery, Bapuji Dental College and Hospital, Davangere, Karnataka, India
| Date of Submission |
29-Oct-2013 |
| Date of Acceptance |
21-Feb-2014 |
| Date of Web Publication |
11-Apr-2014 |
Correspondence Address:
Nandanahosur Basavanthappa Nagaveni
Departments of Pedodontics and Preventive dentistry, College of Dental Sciences, Davangere, Karnataka - 577 004
India
DOI: 10.4103/2278-9588.130430
Background: Maxillary Labial frenum is a soft tissue structure that may exhibit the most diverse types.
Objective: To estimate the incidence of different morphologic types of maxillary labial frenum in primary, mixed, and permanent dentitions of Indian children.
Materials and Methods: A study was conducted involving 3000 Indian children. The 3000 children were divided into three groups (primary, mixed, and permanent dentition) according to the dentition of the patients with each group containing 1000 children. The maxillary labial frenum was examined and classified according to Sewerin's frenum typology using direct visual method. The data obtained was subjected to statistical analysis.
Results: The most prevalent frenum types observed in all the threee groups (primary, mixed, and permanent dentition) were the simple frenum followed by persistent tectolabial frenum and frenum with nodule. The prevalence of simple frenum was found to be increased with age, while the persistent tectolabial frenum decreased proportionally. There was no statistically significant gender difference found with respect to the frenum morphology in all three groups.
Conclusion: Simple frenum is the most prevalent morphologic type recorded in all the three groups studied, followed by persistent tectolabial frenum. The prevalence of simple frenum was found to increase with age, whereas the persistent tectolabial frenum decreased gradually. Dentists should give due importance for frenum assessment during oral examination of children to avoid misdiagnosis of normal variations as abnormal frenum.
Keywords:?Frenum classification, maxillary labial frenum, morphology, tectolabial frenum
How to cite this article:
Nagaveni NB, Umashankara KV. Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Max Dis 2014;3:5-10 |
How to cite this URL:
Nagaveni NB, Umashankara KV. Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Max Dis [serial online] 2014 [cited?2014 Sep 7];3:5-10. Available from:?https://craniomaxillary.com/text.asp?2014/3/1/5/130430 |
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??Introduction |
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Maxillary labial frenum is one of the more interesting and often misunderstood soft tissue anatomic structure in the oral cavity. The frenum is also called superior labial frenum or frenulum labii superioris and provides stability and support for the upper lip. [1],[2] In its composition, it consists of epithelium, collagen fibers, blood vessels and nerves, and sometimes few elements of minor salivary glands and isolated stratified muscle fibers. [3] It has a wide and relatively deep origin or base on the inferior surface of the upper lip. It extends to the middle portion of the labial surface of the alveolar process, between the maxillary central incisors and here it is attached to the periosteum, the maxillary suture's connective tissue, and the alveolar process. [1],[2],[3],[4]
Labial frenum is a dynamic and often changeable structure and is subject to variation in shape, size, and position during the different stages of growth and development. [5],[6] During growth, it tends to decrease in size and lose clinical importance. [7] In young children, the frenum is generally wide and thick, and during growth it becomes thin and small. [8],[9]
Literature review reflects that maxillary labial frenum has diverse morphology and clinical implications. Sewerin [10] has described eight types of normal variations of this frenum as simple, persistent tectolabial, simple with appendix, simple with nodule, double frenum, frenum with nichum, bifid frenum and frenum with two or more variations at the same time. Whereas, Placek in 1974 [9] classified the maxillary frenum into types based on the attachment location. They are mucosal, gingival, papillary, and papillary penetrating. Among these, the last two types are clinically considered as abnormal types as they lead to midline diastema and needs to be surgically treated during orthodontic treatment. The classification given by Sewerin is just a normal variation in the morphology of the frenum.
It is difficult for the clinician to distinguish between abnormal and normal variations of maxillary frenum. The high prevalence of tectolabial frenum seen in younger children increased the possibility of making misdiagnosis during the first few years of age and resulted in unnecessary surgical intervention of the frenum. [7] Therefore, it is important to distinguish between a wide normal frenum and an abnormal one in young children. And also the clinician should be aware of normal frenum morphological variations to diagnose the abnormal frenum as abnormal frenum may be associated with some other dental complications like midline diastema. Thus the present study was undertaken to estimate the incidence of normal morphology of maxillary labial frena in primary, mixed, and permanent dentition of Indian children.
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??Objective |
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Estimate the incidence of different morphologic types of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children.
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??Materials and Methods |
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The study was conducted in the Department of Pedodontics and Preventive Dentistry involving 3000 children, ages ranging from 3 to 16 years, who visited the Department from January 2009 to March 2010. An informed consent signed by parents of respective children was obtained prior to the examination. A total of 3000 children were divided into three groups based on the dentition present and age group with each group containing 1000 children. Group 1 (516 males and 484 females) consisted of children with only primary dentition (3-5 years). Group 2 (472 males and 528 females) included children with mixed dentition (7-14 years), and Group 3 (522 males and 478 females) having children with complete permanent dentition (15-16 years). Children who exhibited congenital anomalies, syndromes, systemic diseases, any type of trauma or surgery in the maxillary anterior region, habits, or any history of previous hard and soft tissue corrective treatment were excluded from the study.
Children were examined lying in supine position using direct visual method under natural light by lifting the upper lip with the index finger and thumb of both hands by a single examiner. A thorough intraoral examination was carried out to assess the morphology of the maxillary labial frenum and the frenum was classified into different groups according to the Sewerin's frenum classification [10] [Table 1], [Figure 1]. Only the normal variations given by Sewerin [10] was examined and not the attachment location of the frenum.
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Figure 1: Diverse morphologic types of maxillary labial frenum (arrows and circles) (a) Simple frenum, (b) Persistent tectolabial frenum, (c) Simple with appendix, (d) Simple with nodule, (e) Double frenum, (f) Frenum with nichum, (g) Bifid frenum
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Table 1: Sewerin's maxillary labial frenum classification (based on morphology)[11]
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The data obtained was subjected to statistical analysis. The gender-wise distribution of frenum types in the three groups was analyzed using the Chi-square test.
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??Results |
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The most prevalent frenum type found in the Group 1 (Primary dentition) of the present study was the simple frenum (60%) followed by persistent tectolabial frenum (21%), and simple with nodule (18%). There was no significant difference between males and females for the different types of frenum observed (P = 0.99) [Table 2]. In Group 2 (Mixed dentition), the most prevalent morphologic type of frenum was the simple type (70%) followed by simple with nodule (19.4%) [Table 3]. And in Group 3 (Permanent dentition), again the simple frenum (78%) was the most prevalent morphologic frenum observed followed by simple frenum with appendix (16%) [Table 4]. There was no significant difference between male and female distribution for the different types of frenums observed even in mixed and permanent dentition groups (P = 0.95 and P = 0.31).
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Table 2: Incidence of labial frenum type by gender in group 1 (primary dentition)
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In the permanent dentition (Group 3), the prevalence of simple frenum was high (78%) as compared with primary dentition (Group 1) (60%). Whereas the prevalence of tectolabial frenum recorded was high (21.2%) in the primary dentition (Group 1) and its lower prevalence (5.6%) was found in the permanent dentition (Group 3) [Table 5]. This was found statistically highly significant when analyzed using the Chi-square test (P < 0.001).
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Table 3: Incidence of frenum type in group 2 (mixed dentition)
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Table 4: Incidence of labial frenum type in group 3 (permanent dentition)
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Table 5: Comparison of incidence of frenum types in different groups
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??Discussion |
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Sewerin's frenum typology is the most frequently used classification system for maxillary labial frenum morphology that was introduced in 1971. [10] In this typology, he has classified the maxillary labial frenum into eight types based on its morphology and each type designated with letters from A to H [Table 1]. Although many studies have been undertaken on the maxillary frena, these show different terminologies for the same frenum. [1],[6] In the present study, the terminology and classification given by Sewerin [10] was used as majority of the other studies found this classification as practical, useful and easy to use on every patient whether the patient is a child, adolescent, or adult. [1],[12]
The current study included children with three types of dentition like children with complete primary dentition, children with mixed dentition and complete permanent dentitions. Whereas other studies show children with only primary dentition, [10] children or adolescents with mixed [13] and permanent dentition [14] and studies involving only adults. [15] In one study carried by Diaz-Pizan et al., [1] the study design was similar but only differed with respect to the age of the sample assessed, which was 0-6 years (primary dentition) and he has also assessed the different frenum attachments and its relation to midline diastema as contrast to the present study, which examined primary, mixed and permanent dentition (3-16 years). Whereas Sewerin [10] conducted a study involving 1430 subjects, ages ranging from 0 to 60 years, and given the classification system for the diverse frenum.
In the present study, the most prevalent frenum type recorded was the simple frenum in all the three groups followed by persistent tectolabial and simple with nodule. This finding is in accordance with other studies. [1],[12],[13],[14],[15] The prevalence of simple frenum was found to be increased with age, whereas the persistent tectolabial frenum decreased proportionately. Even in the Diaz-Pizan et al. [1] study, higher prevalence of the tectolabial frenum was found in infants (0-6 months) and this prevalence gradually decreased significantly with age, a tendency that was also suggested by other similar studies. [10],[13] Vera [13] supported this change in frenum type and reported that in younger children during the first few years of age the prevalence of tectolabial frenum is high, but as the age advances, that is, in permanent dentition vertical growth of the alveolar process occurs, which in turn allows the frenum's gingival insertion to change position farther away from the alveolar ridge. One more factor attributed for this phenomenon is that, due to the maxillary sinus development and intraalveolar eruption of the permanent maxillary incisors, apical migration of the frenum insertion occurs. Therefore, high proportion of the persistent tectolabial frenum was seen in the primary dentition, which gradually evolves to normal simple frenum during the permanent dentition. [1],[12] This change in position during the child growth from primary to permanent dentition was believed to be caused by the frenum's static position while the surrounding structures grow. Therefore what may appear to be an abnormal frenum at the age of 4 years may become a normal frenum at the age of 8-10 years.
The high prevalence of tectolabial frenum seen in younger children caused misdiagnosis during the first few years of age and resulted in unnecessary surgical correction of the frenum. [7] The potential for misdiagnosis is even greater if the frenum is associated with a wide midline diastema. [1] Therefore, it is very important to distinguish between a wide normal frenum and an abnormal one in young children, and knowledge about the frenum types in children is highly essential among the clinicians to avoid unnecessary surgical intervention.
The present study also showed presence of other frenum types like simple with nodule and double frenum were recorded more in the primary and mixed dentition as compared with permanent dentition. Whereas, in the permanent dentition, frenum with appendix was the second most prevalent frenum noticed. And the 'H' type of frenum, that is, frenum with two or more variations at the same time was not recorded in none of the groups examined. Other reports also confirmed that the other types of frenum like simple frenum with nichum, appendix, double, bifid type, with two or more variation, and the absent frenum are rarely found with less than 1% of the population. However, the absent or agenesis of labial frenum was found to be associated with a holoprosencephaly [16] and association of W syndrome with bifid frenum has been reported by Goizet et al. [17]
Although maxillary labial frenum is a tiny, often neglected soft tissue component of the mouth, it has various clinical significances with respect to all specialists of the dentistry whether he/she is a Periodontist, Maxillofacial surgeon, Orthodontist, Pediatric Dentist, or Prosthodontist.
Kaimenyi [18] stated that, an abnormal frenum attachment can lead to frenum pull, which may result in distention of gingival sulcus, and, which in turn encourages plaque accumulation and increase the severity of periodontal pockets. Some authors have reported that maxillary labial frenum is the main etiological factor as well as intervening factor for the closure of the midline diastema. [1],[2],[15],[18] However, there are no studies that establish a relationship between the different types of frenum and the development of midline diastema in children with primary dentition, mixed dentition, or permanent dentition. Midline diastema may be considered normal for many children during the eruption of permanent maxillary central incisors. It has been concluded that the presence of papilla penetrating frenum is cause for midline diastema and this view was supported by other researchers. [15] Dewel [2] stated that the frenum is an effect and not a cause for the incidence of diastema. It is also stated that if the midline diastema persists even after the orthodontic treatment, the surgical correction of the frenum attachment has to be corrected. Therefore an accurate diagnosis is necessary before any treatment can be initiated.
Presence of abnormal labial frenum may also interfere with retention of denture fit, [18] can cause gingival recession, [19] can interfere with effective tooth brushing leading to incomplete plaque removal. [20] It has been observed that abnormal frenum can indicate the presence of a syndrome. [21] However, it was also noted that hyperplastic, hypoplastic, or agenesis of the labial frenum may be observed in the absence of syndromic disease. Biber [22] in his review paper has presented various complications resulting from oral piercings and maxillary labial frenum piercing is one among the different piercing sites in the mouth and it is popular in teenagers and can result in complications. [11] A torn labial frenum has been reported as an indicator of child abuse. [23] Hyperplastic labial frenum can cause gingivitis [20] and notching of alveolar ridges. [21] All these clinical significances show that every specialist of dentistry must give more importance for frenum assessment during oral examination of children.
The present study shows the prevalence of different morphologic types of maxillary labial frenum in Indian children. However, there are very few studies showing the prevalence of diverse frena in different locations and races. And also, the exact etiology behind the development of different frenum is not yet established. Therefore, further studies including other regions of the world and races are highly essential to reveal more knowledge about the maxillary labial frenum morphology.
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??Conclusion |
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The following conclusions were drawn from the present study based on the results concerning Indian children population:
- Maxillary labial frenum being a small anatomic structure in the oral cavity exhibits diverse morphology and the frenum type was found to be changing with age
- Simple frenum is the most prevalent morphologic type in all the three groups (primary, mixed, and permanent dentition) studied followed by persistent tectolabial frenum
- The prevalence of persistent tectolabial frenum observed less in the permanent dentition compared with primary dentition.
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? [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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