ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10077-3295 |
Morphology of Maxillary Frenum and Correlation to Diastema in Children with Primary, Mixed, and Permanent Dentition
1–6Department of Pediatrics and Preventive Dentistry, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth (Deemed to be University), Vadodara, Gujarat, India
Corresponding Author: Anshula N Deshpande, Department of Pediatrics and Preventive Dentistry, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth (Deemed to be University), Vadodara, Gujarat, India, Phone: +91 7600916400, e-mail: dranshula@gmail.com
Received: 04 November 2023; Accepted: 07 February 2024; Published on: 27 April 2024
Context: The labial frenum is subject to change with growing age and physical development. It is thought to be a contributing factor to maxillary diastema. Aims: The study aims to check the frenal morphology and midline diastema at different stages of dentition. Materials and methods: Clinical examination of frenum and midline diastema of 515 children with different stages of dentition was carried out. Sewerin’s typology and Placek et al.’s classification for attachment level were used. Results: Association was found significant for both spacing (p = 0.001) and midline diastema (p = 0.018). Morphology of frenum, which was prevalent for all three types of dentition, was simple frenum and mucosal type of attachment in primary (47.1%) and permanent (37.6%), whereas it was gingival in mixed dentition (44.3%). The association between dentition and morphology and frenum attachment was found to be significant (p = 0.024 and 0.001, respectively). Crosstabulation for midline diastema with morphology and frenum attachment was found to be highly significant (p = 0.001). Conclusion: As the type of frenal attachment differs depending on the type of dentition, it is crucial to comprehend the relationship between a child’s age, the type of frenal attachment, and the morphology in order to prevent misdiagnosis and inconsequential treatment. How to cite this article: Deshpande AN, Jain A, Tailor B, et al. Morphology of Maxillary Frenum and Correlation to Diastema in Children with Primary, Mixed, and Permanent Dentition. J South Asian Assoc Pediatr Dent 2024;7(1):5–10. Source of support: Nil Conflict of interest: NoneABSTRACT
Keywords: Diastema, Incisor, Labial frenum
INTRODUCTION
The maxillary labial frenum is a soft, collagenous, fibrous vertical tissue band or fold of mucous membrane originating from the orbicularis oris muscle and connects the upper lip to the maxillary alveolar process.1 It differs in the size and location of the frenum’s insertion into the soft tissues and is also speculated to be the posteruptive remnant of tectolabial bands.2-6 The frenum has a propensity for apical transition as a result of the eruption of primary incisors, the growth of the maxillary sinus, and the alveolar process.5 Hindrance in the formation of seal between the tongue and upper lip as a result of the aberrant frenal attachment can make breastfeeding difficult for the infant.7,8 The permanent maxillary central incisors’ eruption marks the beginning of another phase of the maxillary arch’s vertical expansion.9
It is deemed abnormal when the frenum attachment inhibits lip mobility, results in difficulty in cleaning and maintaining oral hygiene, leads to diastema formation, and interferes with speech.2-4 Because the aberrant frenal attachment pulls more forcefully than it should, it causes a localized gingival recession, which necessitates later orthodontic treatment.10,11
The study aims to check the variations of the labial frenum and its correlation to midline diastema in the different dentitions of children using Sewerin typology12 and Placek et al. classification, 197413 to classify frenum attachment.
MATERIALS AND METHODS
This was an observational study conducted after ethical approval from the institutional ethics committee. The children of the age group of 3–14 years with healthy maxillary anterior teeth and whose parents gave consent were included in the study. Children with any systemic disorders, syndromes, congenital abnormalities, surgeries, trauma, or orthodontic corrective treatment in the anterior region of the maxilla, teeth with proximal caries, restorations on maxillary central incisors, any anomaly in incisor size and shape, or oral habits were excluded from the study.14 The Helsinki Declaration was followed in the study.
The sample size was calculated with N as the population size and e as the level of precision, utilizing the following formula.15
In our study based on the outpatient department (OPD), N is 720 children visiting the OPD for 24 months, and e is 0.05 at a 95% confidence interval, so n = 514. So, 515 subjects consisting of both genders and all three dentition were part of the study. By lifting the upper lip with both hands’ index finger and thumb while adhering to all coronavirus disease of 2019 standards, a clinical examination was carried out in the presence of natural light. Diastema width was measured clinically with a dental gauge caliper at two levels: the mesial-incisal angles of the central incisors (Fig. 1A) and 5 mm from the incisal line (Fig. 1B), and measurements averaged. Frenal morphology was classified according to Sewerin’s typology12 (Fig. 2A to H), and frenal attachment was classified according to Placek et al. classification, 1974 (Figs 3A to D).13
Figs 1A and B: Diastema width measured at two-different levels: (A) Diastema measurement at a mesial-incisal angle; (B) Diastema measurement 5 mm away from the incisal line
Figs 2A to H: Different types of frenal morphology observed in the study population: (A) Simple; (B) Persistent tectolabial; (C) Simple with appendix; (D) Simple with nodule; (E) Double; (F) With nichum; (G) Bifid; (H) Two or more variations at the same time
The clinical photographs were captured from the frontal, left, and right lateral view with an iPhone XS Max mobile camera with a camera of 12 MP, f/2.4 aperture, and 2688 × 1242 resolution at 458 ppi. The photos were shot with the image of the frenum in focus with the camera’s lens set around 15 cm away from the teeth and parallel to the vertical plane. This was carried out consistently throughout the study. The images were then transferred to a laptop and seen in full resolution.
For statistical analysis, the acquired data was entered into a Microsoft Excel (2016) spreadsheet. Excel statistical operations were used to conduct descriptive statistical tests, and the findings for continuous data were displayed as mean + standard deviation (SD) and the results for categorical measurements as a number (%). Statistical Package for the Social Sciences version 21 was used for inferential statistics. Utilizing Chi-square analysis, the significance of study factors was assessed on a categorical scale. The significance level was set at 0.05, and any value ≤0.05 was considered statistically significant.
RESULTS
Table 1 depicts the sociodemographic data of all participants, along with the presence or absence of spacing and midline diastema in all three dentitions. As the p-value is <0.05, the association between spacing and type of dentition is statistically significant. The association between midline diastema and spacing is also statistically significant, and clinically, there are more cases in primary dentition followed by mixed and then permanent dentition.
| Dentition | Primary | Mixed | Permanent | p-value |
|---|---|---|---|---|
| Age [N (mean ± SD)] | 172 (4.87 ± 0.78) | 173 (8.21 ± 1.29) | 170 (12.87 ± 0.90) | |
| Gender [N (%)] | ||||
| Male | 118 (68.6) | 98 (56.6) | 103 (60.6) | |
| Female | 54 (31.4) | 75 (43.4) | 67 (39.4) | |
| Spacing | 45.176 (0.001) HS | |||
| Spaced | 82 | 44 | 26 | |
| Nonspaced | 90 | 129 | 144 | |
| Midline diastema [N (%)] | 8.071 (0.018) S | |||
| Present | 66 (38.4) | 55 (31.8) | 41 (24.1) | |
| Absent | 106 (61.6) | 118 (68.2) | 129 (75.9) |
Chi-squared test p-value; HS, highly significant (p-value, 0.001); S, significant (p-value < 0.05)
Table 2 depicts that the association between the type of dentition and frenum morphology is statistically significant since the p-value is <0.05. There are a total of 310 individuals with simple morphology, 65 with persistent tectolabial, 24 with a simple appendix, 22 with simple nodule, two with double, 56 with nichum, 34 with bifid, and two with two or more. The p-value is <0.05, indicating an association between the type of dentition and the position of frenum attachment to be statistically significant. There are a total of 182 individuals with mucosal type of attachment, 202 with gingival, 69 with papillary, and 62 with papillary penetrating.
| Dentition | Primary | Mixed | Permanent | p-value |
|---|---|---|---|---|
| Morphology [N (%)] | 29.624 (0.000) HS | |||
| Simple | 100 (58.1) | 97 (56.1) | 113 (66.5) | |
| Persistent tectolabial | 29 (16.9) | 23 (13.3) | 13 (7.6) | |
| Simple appendix | 12 (7.0) | 7 (4.0) | 5 (2.9) | |
| Simple with nodule | 10 (5.8) | 4 (2.3) | 8 (4.7) | |
| Double | 1 (0.6) | 1 (0.6) | 0 (0.0) | |
| With nichum | 10 (5.8) | 29 (16.8) | 17 (10.0) | |
| Bifid | 9 (5.2) | 11 (6.4) | 14 (8.2) | |
| Two or more | 1 (0.6) | 1 (0.6) | 0 (0.) | |
| Frenum attachment [N (%)] | 26.201 (0.024) S | |||
| Mucosal | 81 (47.1) | 37 (21.4) | 64 (37.6) | |
| Gingival | 63 (36.6) | 77 (44.5) | 62 (36.5) | |
| Papillary | 14 (8.1) | 30 (17.3) | 25 (14.7) | |
| Papillary penetrating | 14 (8.1) | 29 (16.8) | 19 (11.2) |
*Chi-squared test p-value; HS, highly significant (p-value, 0.001); S, significant (p-value of <0.05)
Table 3 depicts that the association between the midline diastema and morphology of the frenum, as well as attachment of the frenum, is statistically significant as the p-value is <0.05. Figures 4 and 5 also depict that the association between the midline diastema and morphology of frenum and frenum attachment are statistically significant, respectively.
| Midline diastema | Yes | No | p-value |
|---|---|---|---|
| Morphology [N (%)] | 35.398 (0.000) HS | ||
| Simple | 83 | 227 | |
| Persistent tectolabial | 40 | 25 | |
| Simple appendix | 6 | 18 | |
| Simple with nodule | 3 | 19 | |
| Double | 0 | 2 | |
| With nichum | 18 | 38 | |
| Bifid | 11 | 23 | |
| Two or more | 1 | 1 | |
| Frenum attachment [N (%)] | 112.201 (0.000) HS | ||
| Mucosal | 49 | 133 | |
| Gingival | 37 | 165 | |
| Papillary | 21 | 48 | |
| Papillary penetrating | 55 | 7 |
*Chi-squared test p-value; HS, highly significant (p-value, 0.001); S, significant (p-value of <0.05)
Figs 3A to D: Different types of frenal attachment observed in the study population: (A) Mucosal; (B) Gingival; (C) Papillary; (D) Papillary penetrating
Fig. 4: Association between labial frenal morphology with midline diastema in the study population
Fig. 5: Association between labial frenal attachment with midline diastema in the study population
DISCUSSION
Children with all three types of dentitions were part of the present study. The study design used in this study was similar in concept to that of Diaz-Pizán’s study in 2016.16 This study differs from that of Diaz-Pizán in terms of the age of the sample analyzed, as their study included children aged 0–6 years. In the current study, 319 boys and 196 girls aged 3–14 years actively participated. The spacing in dentition was most prevalently seen in primary dentition, followed by mixed dentition. Spacing in primary dentition is mostly due to the physiologic and primate spacing. In the mixed dentition, during the eruption of the canine due to the Broadbent phenomenon, spacing is often seen, which self-corrects after the complete eruption of the canine. With the eruption of all permanent teeth, spacing usually closes on its own. The association between the spacing and type of dentition was statistically significant as the p < 0.05.
The maxillary labial frenum, around 8–10 weeks of gestation, connects the palatine papilla to the upper lip tubercle.17,18 The frenum resembles the abnormal frenum of postnatal life in terms of morphology by the 3rd month in utero. The frenum appears to be regressing up the labial surface of the alveolar process over time.19 As stated by Popovich et al., the frenal attachment remains in place, although the alveolar process grows in a coronal direction during the primary dentition, increasing the height of the alveolar ridge.20 With the eruption of permanent maxillary central incisors, the maxillary arch’s accelerated vertical expansion also begins.9 As a result, with age, the attachment of frenum shifts to a more apical position.21 There may be a midline diastema and potential impacts on the development of the premaxillary region if the continuous band of the maxillary labial frenum passes between the two maxillary central incisors.16,22,23 Thus, the maxillary alveolar process and the maxillary labial frenum. have a passive interaction, and the alveolar growth pattern determines how the frenum develops.12,20 The frenum is typically wide and thick in young children, shrinking and becoming thinner as they develop until eventually becoming smaller and less significant.10,11,24
In this study, we observed that the vast majority of the population (60%) have simple frenum morphology according to Sewerin’s typology. Studies by Christabel and Gurunathan, Pandiyan and Hedge, Joshi et al., and Thosar et al. have found that 80–90% of participants had simple frenum.5,25-27 The second most prevalent morphology is persistent tectolabial in the primary dentition (16.8%), which is similar to studies by Nagavent and Umashankara and Biradar et al.28,29 Persistent tectolabial can be considered a pathologic reason for the presence of midline diastema since there was a clear association of it with midline diastema (61.5%) in the present study. A study by Pandiyan and Hedge also found association between persistent tectolabial and midline diastema.25 Simple frenum with nichum is the second most prevalent morphology in mixed (16.8%) and permanent dentition (10%) in the present study. Whereas studies by Joshi et al. and Thosar et al. found simple frenum with nodules were more prevalent (2.9 and 7.3%, respectively).26,27
The incidence of tectolabial frenum is high in younger children in the initial few years of life, but as they grow older, that is, when they enter permanent dentition, the alveolar process grows vertically, enabling the frenum’s insertion gingivally to relocate farther away from the alveolar ridge.1,30 Another contributory factor to this phenomenon of frenum insertion moving apically is the result of the development of the maxillary sinus and the intra-alveolar eruption of the permanent maxillary incisors. Therefore, similar to the present study, studies by Díaz-Pizán et al. and dos Santos et al. found that persistent tectolabial frenum was more prevalent in the primary dentition, which eventually, in the permanent dentition, changes to simple frenum.16,31 Study conducted by Dewel found that the high incidence of the tectolabial frenum in early children resulted in incorrect diagnosis and unrequired correction of the frenum during the first few years of life.6
Although there is literature on the incidence of various types of frenal attachments, very few are there that have shown an association with the type of dentition.8,21,32-34 Mucosal type of attachment is most prevalent in primary (47.1%), and permanent dentition (37.7%), and gingival type is most prevalent in mixed dentition (44.5%) in this study, similar to a study by Christabel and Gurunathan.5 Different authors have found either mucosal or gingival to be the most prevalent type of attachment. Studies by Nadar, Pandiyan and Hedge, and Joshi et al. found the mucosal type of attachment to be the most prevalent, whereas studies by Boutsi and Tatakis, Upadhyay and Ghimire, Christabel and Gurunathan, and Zakirulla et al. found gingival type as the most prevalent type of attachment.5,19,21,25,26,35,36 Papillary penetrating is the least prevalent type of frenum morphology (12%). Upadhyay and Ghimire, Nadar, Pandiyan and Hedge, Joshi et al. also found papillary penetrating type was the least among all.19,25,26,35 It is mostly associated with midline diastema and can be considered a pathological etiology.
CONCLUSION
The most prevalent type of morphology, according to Sewerin’s classification, is simple frenum in the present study. The most prevalent type of attachment, according to Placek et al.’s classification, is the mucosal type of attachment in primary and permanent dentition, whereas it is gingival in mixed dentition. There is a strong correlation between midline diastema with the papillary penetrating type of attachment and persistent tectolabial type of morphology. As a child grows through the different phases of dentition, the frenal attachment may shift to a more apical position, and morphology, too, tends to change, and it is essential to correlate each of them. Thus, age is highly crucial in determining treatment options for frenum in children to avoid unneeded surgical operations, especially during the developmental phase.
Limitations
A larger sample size could have been included in the study, which would have helped in finding a more prominent result in variations in morphology and attachment of labial frenum in the three dentitions.
Future Prospect
A longitudinal study can be conducted to check for frenum change in primary, mixed, and permanent dentition.
ORCID
Anshula N Deshpande https://orcid.org/0000-0003-3467-2123
Acknowledgments
We would like to thank all the participants for their contributions to the study. We are also grateful to Dr Medha Kalyan for her help in statistical analysis.
REFERENCES
1. Dasgupta P, Kamath G, Hs S, et al. Morphological variations of median maxillary labial frenum: a clinical study. J Stomatol Oral Maxillofac Surg 2017;118(6):337–341. DOI: 10.1016/j.jormas.2017.06.018
2. Gkantidis N, Kolokitha OE, Topouzelis N. Management of maxillary midline diastema with emphasis on etiology. J Clin Pediatr Dent 2008;32(4):265–272. DOI: 10.17796/jcpd.32.4.j087t33221771387
3. Breslin WW. Excision of the abnormal frenum. J Can Dent Assoc 1949;15(1):20. PMID: 18109035.
4. Fischer TJ, Psaltis GL. The diastema and the abnormal frenum. ASDC J Dent Child 1981;48(4):264–268. PMID: 6944323.
5. Christabel SL, Gurunathan D. Prevalence of type of frenal attachment and morphology of frenum in children, Chennai, Tamil Nadu. World J Dent 2015;6(4):203–207. DOI: 10.5005/jp-journals-10015-1343
6. Dewel BF. The normal and the abnormal labial frenum; clinical differentiation. J Am Dent Assoc 1946;33(5):318–329. DOI: 10.14219/jada.archive.1946.0261
7. Edwards JG. The diastema, the frenum, the frenectomy: a clinical study. Am J Orthod 1977;71(5):489–508. DOI: 10.1016/0002-9416(77)90001-x
8. Kotlow LA. The influence of the maxillary frenum on the development and pattern of dental caries on anterior teeth in breastfeeding infants: prevention, diagnosis, and treatment. J Hum Lact 2010;26(3):304–308. DOI: 10.1177/0890334410362520
9. Huang WJ, Creath CJ. The midline diastema: a review of its etiology and treatment. Pediatr Dent 1995;17(3):171–179. PMID: 7617490.
10. Curran M. Superior labial frenotomy. J Am Dent Assoc 1950;41(4):419–422. DOI: 10.14219/jada.archive.1950.0198
11. Noyes HJ. The anatomy of the frenum labia in newborn infants. Angle Orthod 1935;1:3–8.
12. Sewerin I. Prevalence of variations and anomalies of the upper labial frenum. Acta Odontol Scand 1971;29(4):487–496. DOI: 10.3109/00016357109026535
13. Mirko P, Miroslav S, Lubor M. Significance of the labial frenum attachment in periodontal disease in man. Part I. Classification and epidemiology of the labial frenum attachment. J Periodontol 1974;45(12):891–894. DOI: 10.1902/jop.1974.45.12.891
14. Tadros S, Ben-Dov T, Catháin ÉÓ, et al. Association between superior labial frenum and maxillary midline diastema - a systematic review. Int J Pediatr Otorhinolaryngol 2022;156:111063. DOI: 10.1016/j.ijporl.2022.111063
15. Yamane T. Statistics: An Introductory Analysis, 2nd edition. New York: Harper and Row; 1967.
16. Díaz-Pizán ME, Lagravère MO, Villena R. Midline diastema and frenum morphology in the primary dentition. J Dent Child (Chic) 2006;73(1):11–14. PMID: 16734307.
17. Ray S, Golden WC, Walsh J. Anatomic distribution of the morphologic variation of the upper lip frenulum among healthy newborns. JAMA Otolaryngology Head Neck Surg 2019;145(10):931–938. DOI: 10.1001/jamaoto.2019.2302
18. Rajagopalan RE, Padmaprabha BP. An insight into the role of the maxillary labial frenum in the growth of the maxilla: a systematic review. J Indian Orthod Soc 2019;53(4):232–243. DOI: 10.1177/0301574219877728
19. Upadhyay S, Ghimire N. Attachment of maxillary labial frenum in Nepalese children. Orthod J Nepal 2012;2(1):38–31. DOI: 10.3126/ojn.v2i1.9291
20. Popovich F, Thompson GW, Main PA. The maxillary interincisal diastema and its relationship to the superior labial frenum and intermaxillary suture. Angle Orthod 1977;47(4):265–271. DOI: 10.1043/0003-3219(1977)047<0265:TMIDAI>2.0.CO;2
21. Boutsi EA, Tatakis DN. Maxillary labial frenum attachment in children. Int J Paediatr Dent 2011;21(4):284–288. DOI: 10.1111/j.1365-263X.2011.01121.x
22. Manjunath N, George AM, Neethi M, et al. The frenum and the diastema: a clinical observational study. Int J Innov Sci 2018;3(9):560–566. https://ijisrt.com/the-frenum-and-the-diastema-a-clinical-observational-study
23. Sękowska A, Chałas R. Diastema size and type of upper lip midline frenulum attachment. Folia Morphol (Warsz) 2017;76(3):501–505. DOI: 10.5603/FM.a2016.0079
24. Ceremello PJ. The superior labial frenum and the midline diastema and their relation to growth and development of the oral structures. Am J Orthod 1953;39(2):120–139. DOI: 10.1016/0002-9416(53)90016-5
25. Pandiyan NJ, Hedge A. Clinical assessment of frenum morphology and attachment in Malaysian children. Pesquisa Bras Odontopediatria Clín Integr 2018;18(1):1-9. DOI: 10.4034/pboci.2018.181.20.
26. Joshi U, Pradhan M, Lawaju N, et al. Variations in maxillary frenal morphology in a sample of Newari Children of Bhaktapur. J Nep Soc Periodontol Oral Implantol 2021;5(1):34–38. DOI: 10.3126/jnspoi.v5i1.38181
27. Thosar N, Murarka P, Baliga S, et al. Assessment of maxillary labial frenum morphology in primary, mixed, and permanent dentitions in Wardha district. Eur J Gen Dent 2017;6(1):14–17. DOI: 10.4103/2278-9626.198601
28. Nagaveni NB, Umashankara KV. Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Maxillofac Surg 2014;3:5–10. DOI: 10.4103/2278-9588.130430
29. Biradar SM, Patil AY, Kotnoor SS, et al. Assessment of diverse frenal morphology in primary, mixed, and permanent dentition: a prevalence study. J Contemp Dent Pract 2020;21(5):562–567. PMID: 32690841.
30. Vierci VR, Marin AP, Gini AM, et al. Malocclusions, gingivitis, upper labial frenum and diastemas in students of Itá (Paraguay). Rev Odontol Circ Odontol Parag 1974;20:79–87. PMID: 4535777.
31. dos Santos VI, Korytnicki D, Ando T, et al. Prevalence of different types of upper labial frenum in the deciduous dentition. Rev Fac Odontol Sao Paulo 1985;23(2):129–135. PMID: 3880305.
32. Kaimenyi JT. Occurrence of midline diastema and frenum attachments amongst school children in Nairobi, Kenya. Indian J Dent Res 1998;9(2):67–71. PMID: 10530193.
33. Lindsey D. The upper mid-line space and its relation to the labial fraenum in children and in adults. A statistical evaluation. Br Dent J 1977;143(10):327–332. DOI: 10.1038/sj.bdj.4804003
34. Bergese F. Research on the development of the labial frenum in children of age 9-12. Minerva Stomatol 1966;15(10):672–676. PMID: 5225222.
35. Nadar S. Maxillary labial frenum attachment in children of different age groups. Int J Curr Res 2017;9(5):50367–50369. https://www.journalcra.com/sites/default/files/issue-pdf/20873.pdf
36. Zakirulla M, Alshahrani NA, Alqarni LS, et al. Maxillary midline frenum morphology and its variations in Saudi Children. J Res Med Dent Sci 2021,9(1):174–178.
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