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11 . Facts and Myths Regarding the Maxillary Midline Frenum and Its Treatment a Systematic Review of the Literature

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  VOLUME 44     2        2013    177 QUINTESSENCE INTERNATIONAL  GENERAL DENTISTRY/ORAL SURGERY dible and maxilla, usually in the midline or premolar region. In the mandible, a frenum is generally also present lingually to the central incisors with a connection into the body of the tongue. 2  The maxillary midline frenum connects the mucosa of the maxil-lary alveolar process and central incisors to the upper lip. It srcinates as a remnant of the tectolabial bands, which are embryonic structures and connect the tubercle of the upper lip to the palatine papilla. 3  Histologically, it contains elastic fibers and collagen tissue components, although stri-ated (skeletal) muscle fibers are frequently found in biopsy specimens. 4 The maxillary frenum is a dynamic struc-ture, subjected to alterations in shape, size, and position during the stages of human growth and development. Generally, it           membrane that attaches the lips and cheeks to the alveolar process and limits their movements. 1  Frena are most prominently found in the vestibular mucosa of the man- 1 Research Fellow, Department of Oral Surgery and Stomatology, University of Bern, Bern, Switzerland. 2 Research Fellow, Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Bern, Switzerland. 3 Professor and Head, Department of Periodontology, University of Bern, Bern, Switzerland. 4 Professor and Head, Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Bern, Switzerland. 5 Assistant Professor, Department of Oral Surgery and Stomatology, University of Bern, Bern, Switzerland. Correspondence:  PD Dr Michael M. Bornstein, Department of Oral Surgery and Stomatology, Freiburgstrasse 7, 3010 Bern, Switzerland. Email: michael.bornstein@zmk.unibe.ch Facts and myths regarding the maxillary midline frenum and its treatment: A systematic review of the literature Konstantina Delli, DMD 1  /Christos Livas, DMD  2  /Anton Sculean, Prof Dr Med Dent 3  /Christos Katsaros, Prof Dr Med Dent 4  /Michael M. Bornstein, PD Dr Med Dent 5 Objective:  To systematically review the current literature on the maxillary midline frenum and associated conditions and complications, as well as the recommended treatment options. Method and Materials:           provide evidence about the epidemiology, associated pathologies, and treatment options regarding the maxillary frenum. Of the 206 initially identified articles, 48 met the inclusion criteria. Results:  The maxillary frenum is highly associated with a number of syndromes             of the midline diastema. There is also a tendency by orthodontists to suggest posttreat-ment removal of the frenum (frenectomy). Studies on the cause of gingival recession due              traumas and doubtful history might point to child abuse. The involvement of hyperplastic frena in the pathogenesis of peri-implant diseases remains uncertain. There seems to be a clinical interest regarding lasers for surgery for treatment of maxillary frena. The superiority of laser treatment in relation to conventional surgical methods has not yet been demon-strated in the literature. Conclusion:           syndromic conditions and plays a role in the development of the median midline diastema.             of the maxillary incisors is rather controversial. Laser techniques are reported as the method of choice for the surgical removal of frena; however, this needs to be substanti-ated by appropriate prospective controlled studies. (Quintessence Int 2013;44:177–187)  Key words:  frenectomy, gingival recession, maxillary frenum, midline diastema, peri-implantitis  178 VOLUME 44     2        2013  QUINTESSENCE INTERNATIONAL  Delli et al tends to diminish in size over the course of life. 5  The eruption of the permanent incisors, the development of the maxillary sinus, and the growth of the alveolar process all result in a more coronal insertion of the frenum. 6 Two approaches were presented in the literature to categorize the various types of maxillary midline frena according to mor-       attempt was made by Sewerin, who recom-mended that the labial frenum should be divided into eight categories. 7  In 1974, Mirko et al 8  suggested a new classification based on the interaction between the fre-num and the periodontium of the maxillary incisors. Four types of frena were suggest-ed, according to the site of the attachment: mucosal, gingival, papillary, or papillary penetrating 8  (Figs 1 and 2). This classifica-tion has gained wide acceptance and is commonly used by periodontists and ortho-dontists alike.       of interest to orthodontists, periodontists, and oral surgeons alike, there is no study available in the literature focusing on the various phenotypes of the maxillary frenum, their associated problems and conditions, or the recommended treatment strategies. Clinicians seem to substantiate their deci-sions on their experience and low-evidence data. The aim of the present study is to illu-minate all of these aspects and identify evidence based information provided by the contemporary scientific literature. SEARCH STRATEGY The authors conducted a search using the                        -           -               out for the same time period, using the com-bination of the following Medical Subject                   -          Only clinical articles were included and evaluated. The authors considered clinical Table 1 Different classi󿬁cations of maxillary midline frenum StudyType of study n Method of assessmentClassi󿬁cation Sewerin 7 Case series1430Inspection      Frenum with appendix Frenum with nodule           Coincidence of two or more of the aboveMirko et al 8  Case series465InspectionMucosal frenum attachmentGingival frenum attachment        VOLUME 44     2        2013    179 QUINTESSENCE INTERNATIONAL  Delli et al studies including case reports, if they reported on the following subjects:  Epidemiologic data including preva-lence and etiology      (ie, median diastema, gingival reces-sion, diminished retention and stability of removable dentures, peri-implantitis, syndromes, and child abuse)  Therapy of the maxillary midline frenum    In the first stage of the selection, titles were screened to identify duplicates and articles           -uated all the abstracts of the obtained arti-cles. The Kappa score for agreement between the reviewers for screening of abstracts was 0.87. For the abstracts that met the inclusion criteria, the respective full text was thoroughly studied. Finally, refer-ence lists of the retained publications were scanned for additional relevant articles that might have been missed in the initial data-base search. The details of the literature search strategy are presented in Fig 3.The quality of each study was assessed         to the classification for Evidence-based Medicine Levels of Evidence developed by     The criteria applied in the grading of the                              Fig 1 Clinical example of a papillary frenum attachment in a 16-year-old boy referred for frenectomy. (a)  Buccal and (b)  occlusal views. Fig 2 Clinical example of a papillary penetrating frenum attachment in a 9-year-old girl referred for frenec-tomy. (a)  Buccal and (b)  occlusal views. aabb  180 VOLUME 44     2        2013  QUINTESSENCE INTERNATIONAL  Delli et al                       case-controlled studies; 4, case series and poor quality cohort and case-controlled studies; and 5, expert opinions. EPIDEMIOLOGY Eight retrospective observational studies       6-13  were retrieved to investigate the prevalence of the different phenotypes of maxillary midline frena among different age groups, using one of the classification systems mentioned above.  7,8  The most common frenum types were the mucosal or gingival types (Table 2). FRENUM AND SYNDROMES There are numerous syndromes described in the literature that characteristically exhib-it variations of the norm of maxillary midline frenum phenotype (Table 3). Our search resulted in three retrospective observational     14-16  and three case reports (grade 4).  17-19 MAXILLARY FRENUM AND MIDLINE DIASTEMA The maxillary midline diastema, located between the maxillary central incisors, is relatively common during the mixed denti- Maxillary frenumMaxillary frenulumLabial frenumLabial frenulumFirst screening (n = 97)Included articles (n = 48)     Etiology (n = 119)   and complications (n = 69) Therapy and Treatment (n = 229)    EmbryologyGrowth and development  SurgeryLabial frenum(MeSH terms)Second screening (n =109) Fig 3 Flowchart visualizing the search strategy.
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