Phrenilectomy: What Is It For, Indications, Technique

The frenilectomy or frenectomy is the intervention that consists of the section or cut of the frenulum. However, we must clarify that we find three braces in our body that may require surgery, and each of them will require the intervention of a different specialist.

Likewise, both the indications and the techniques to be used in each one are of course different as well. 
Let’s review each of these braces and what is derived from each of them.

Article index

  • one

    Upper lip frenulum

    • 1.1

      Indications

    • 1.2

      Technique

  • two

    Lingual frenulum or ankyloglossia

    • 2.1

      Indications

    • 2.2

      Technique

  • 3

    Penile or penile frenulum

    • 3.1

      Indications

    • 3.2

      Technique

  • 4

    References

Upper lip frenulum

The upper lip frenulum is a band of fibrous or muscular tissue or both that usually joins the upper lip with the gum. In fact, there is an upper and a lower one. 
Its function is to keep the mucosa of the cheeks, tongue and lips fixed to the alveolar mucosa, gums and periosteum. 

When its anatomy is preserved, its base occupies the upper two-thirds of the gingiva and continues its ascent until it joins and fuses with the upper lip. 
The problem arises when there is an abnormal development of any of the braces (generally the upper one), which will lead to dental and speech problems.

upper lip frenulum

Upper lip frenulum

Indications

The fundamental indication for upper labial frenulum surgery is given when, due to its origin, very low insertion and thickness, it causes what is called the diastema (or separation) of the upper incisors, deforming the dental arch and causing an unsightly condition that requires its resolution.

A diastema will also cause problems of perfect dental occlusion. 
Another indication arises when the proximity of the insertion to the gingival margin produces a gingival resection or alters oral hygiene.

Additionally, the presence of this exaggerated frenulum will prevent adequate movement of the upper lip when speaking, limiting the pronunciation of some phonemes, with consequent speech problems.

In any of these cases, upper labial frenilectomy is indicated.

The lower lip frenulum very rarely causes any kind of problems, even when it is short and thick.

Technique

It can be performed using conventional techniques (classical, Miller, rhomboid, etc.) or laser techniques.

To perform conventional techniques, if the patient collaborates, the intervention can be performed in the office with infiltrative local anesthesia. 
The goal is complete removal, including its adherence to the bone.

It can be performed by the dentist duly trained in the procedure or by the oral-maxillo-facial surgeon.

The anesthesia is infiltrated and it is waited for its effect to take place. At the moment of instillation, adrenaline can be instilled together, which will cause vasoconstriction, thus reducing bleeding.

There are two possible interventions:

  • The total section of the frenulum, from the gum to the edge where it meets the lip. The so-called rhomboid excision is performed.
  • The partial section, occupying approximately halfway between the gum and the edge where it meets the lip. The so-called VY plasty or Schuchardt Technique is performed.

labial-superior-phrenilectomy

Rhomboid excision of the frenulum.

Source: Yuri Castro Rodríguez. Treatment of the aberrant frenulum.

In both cases, once the cut has been made (which can be with a manual scalpel or an electrosurgical knife), resorbable suture is placed in both the labial and gingival portions, to avoid subsequent bleeding.

It is complemented with the indication of analgesic-anti-inflammatory drugs or physical means (cryotherapy) for at least 48 hours, or as required by the patient. 
Because the suture is resorbable, it does not need to be removed as it will fall off on its own.

The laser technique (CO2, Nd-YAG, Er-YAG or diode laser) removes the frenulum in a faster way and with many more advantages.

It does not need anesthesia, it causes less pain, better visibility when operating, better healing and less scarring, it allows the area to be sterilized and does not require the use of sutures.

Lingual frenulum or ankyloglossia

Normally, the lingual frenulum is a thin mucous membrane that joins the base of the tongue with the floor of the mouth. 
When it limits the movements of the tongue, and with them makes speech difficult, we are in the presence of a short lingual frenulum or ankyloglossia.

Ankyloglossia means “anchored tongue”, and it is a congenital disorder that has different degrees of severity. 
Four types of lingual braces are defined:

  • Type 1 : anchors to the tip of the tongue. It is visible to the naked eye and limits both the extension and the elevation of the tongue.
  • Type 2 : anchored 2-4 millimeters from the tip of the tongue. It is visible to the naked eye and limits both the extension and the elevation of the tongue but is less restrictive than the previous one.
  • Type 3 : it anchors between the tip and the middle of the base of the tongue. It is less visible to the naked eye and limits the elevation of the tongue, not the extension.
  • Type 4 : it is found under the layer of submucosal tissue. It is not visible to the naked eye and almost entirely restricts the mobility of the tongue.

tongue tie

Ankyloglossia

Klaus D. Peter, Wiehl, Germany [GFDL (http://www.gnu.org/copyleft/fdl.html), CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/ 3.0 /), from Wikimedia Commons

Indications

If the frenulum prevents the child from moistening the lower lip normally with his tongue, there is an indication for a frenilectomy.

If you limit breastfeeding in younger infants or limit language in older infants and preschoolers, there is also an indication for frenilectomy.

Technique

It can be performed by a pediatrician duly trained in the procedure, a pediatric surgeon, a pediatric dentist with training in the procedure, or an oral-maxillofacial surgeon.

Depending on the age of the child, it may be practiced in the office or it may be necessary to take the minor to the operating room, to guarantee their immobility during the procedure.

For an infant younger than 6 months, it can be done in the office with or without local anesthesia (younger, less need for anesthesia). 
A spray anesthetic is applied and it is waited for its effect to take place.

Then, with the help of a grooved probe, the tongue is raised and with a scissor (from Mayo), resting on the floor of the mouth, the cut is produced until just the edge of union of the base of the tongue with the floor of the mouth.

In older children, in whom it is more difficult to achieve the required immobilization, the procedure is performed in the operating room. 
Anesthesia is induced (usually inhalational) and the frenulum is cut with scissors or an electrosurgical unit.

The latter has the advantage of coagulating at the same time as it cuts, which is why it is preferable to use this technique in the case of very thick braces, as it allows their complete section without subsequent bleeding.

Suturing is not required after the procedure because if it is carried out properly it will not compromise any important blood vessel.

lingual phrenilectomy

Lingual phrenilectomy (before and after)

Source: Cristina Adeva Quirós. Ankyloglossia in newborns and breastfeeding.

Penile or penile frenulum

The frenulum of the penis or frenulum of the foreskin (or preputial) is a fold of skin that joins the posterior aspect of the glans with the inner surface of the foreskin. 
Its usual function is to help retract the foreskin over the glans (helps the foreskin cover it) when the penis is flaccid.

However, on some occasions, this frenulum is very brief or short and restricts the movement of the foreskin, and can even cause exaggerated curvature of the penis down in erection, which is painful and makes sexual intercourse difficult.

In general, it is a very thin tissue that tears spontaneously without causing more than slight bleeding and temporary discomfort when the man begins his sexual activity.

Indications

There are, namely, two indications for performing penile frenilectomy.

  • When the frenulum tissue is excessively short and thick, and limits the retraction of the foreskin.
  • When it limits and causes pain with sexual intercourse.

Technique

It can be practiced by a pediatric surgeon, a general surgeon or a urologist, depending on each case and the age of the particular patient. 
It can be done in the office with infiltrative local anesthesia.

Anesthesia is instilled and it is waited for it to take effect. 
A solution of continuity is created between the portion of the frenulum closest to the skin and the skin; a kind of tunnel.

Once this tunnel is created, both the proximal and distal portions of the frenulum are ligated with resorbable sutures, and once the sutures are secured, the bridge of skin that remains between them is cut.

It is an extremely quick procedure and should not cause any bleeding. 
In those cases of very thick and short braces (which usually bleed profusely), the same procedure is performed but in the operating room, under simple or conductive epidural anesthesia.

In these cases, the frenulum is sectioned with an electrosurgical knife to guarantee the absence of postsurgical bleeding. 
In the case of boys, it should always be performed in the operating room, under general anesthesia, in which case (with the prior consent of the parents) simultaneous circumcision is performed.

penile phrenilectomy

Penile phrenilectomy (scheme)

By Man77, [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

References

  1. Castro-Rodríguez Y. Treatment of the aberrant frenulum, frenectomy and frenotomy. Topic review. Rev Nac de Odont 2017; 13 (26): 1-14.
  2. Narváez-Reinoso MC, Parra-Abad EN. Characterization of the different insertions and anatomical variants of the upper labial frenulum in children aged 8 to 12 years of the private educational units “Rosa de Jesús Cordero” and “Borja”. Cuenca – Azuay. 2017. Graduate work. University of Cuenca.
  3. Adeva-Quirós C. Ankyloglossia in newborns and breastfeeding. The role of the nurse in its identification and treatment. Common Nurse RqR 2014: 2 (2): 21-37.
  4. Sánchez-Ruiz I, González-Landa G, Pérez- González V et al. Sublingual frenulum section Are the indications correct? Cir Pediatr 1999; 12: 161-164.
  5. Teja-Ángeles E, López-Fernández R et al. Short lingual frenulum or ankyloglossia. Acta Ped Méx 2011; 32 (6): 355-356.
  6. Esprella-Vásquez JA. Frenectomy Rev Act Clín 2012; 25: 1203-1207.

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