Over the past few years, the frequency of frenectomies has increased. Many clinicians have touted the procedure as a surgical remedy for a variety of conditions, including sleep apnea, bruxism (teeth grinding), abnormal oral motor function in infants (inability to latch during breastfeeding), and malocclusion (ill-positioned teeth). However, caveat emptor: let the buyer beware. A frenectomy is not a simple snip-tuck. It is a surgical procedure with benefits and risks. As such, patients should research both the procedure and the provider prior to any frenectomy surgery.
What is a Frenulum?
A frenulum (or frenum, plural: frenula or frena) is defined as folds of tissue that stabilize a mobile body part. Frenula are located in various areas of the body: the brain, digestive tract, oral cavity, and external genitalia. In the oral cavity, the three most visible frenula are the two that attach the maxillary (upper) and mandibular (lower) lips to the respective arch and the one that attaches the tongue to the floor of the mouth. This blog will focus primarily on the lingual frenula.
Histology
According to a July 2020 study, Understanding the Lingual Frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery, published in the Journal of Otolaryngology, the lingual frenulum is not a cord or a band [1]. The frenulum is a complex structure and is formed by a midline fold of the floor of the mouth (FOM) fascia (connective tissue) and the overlying FOM mucosa. The study found that the comprising fascia is not only complex; it is also variable. In fact, the study found “significant individual variability in the histological composition and microanatomical structure of the FOM fascia (connective tissue)” [1].
Implications
Frenectomies are like any other surgical procedure, and clinicians should never take a one-size-fits-all approach. In fact, clinicians who perform this or any other surgical procedure should possess a thorough understanding of both the anatomical and histological composition of a potential surgical site. It is imperative that clinicians who perform frenectomies not simply view the frenulum as a band of tissue but view it as a complexed fascial matrix. During surgical preparation, clinicians should also allow for and anticipate the existence of anatomical anomalies. Additionally, it is important that clinicians consider and understand the location and vulnerability of the surrounding vital structures.
Anatomical Considerations
The Lingual and Hypoglossal Nerves:
According to the aforementioned study, lingual nerve branches are located “superficially on the ventral (underside) tongue surface, immediately beneath the fascial layer.” [1]. This location renders the lingual nerve vulnerable during frenotomy surgery. Furthermore, surgical instruments that generate thermal energy also pose an increased risk to the nerve and the underlying tissue. These instruments can transmit heat to the underlying tissues and nerves. The study also states that “direct neural connections have been shown between lingual nerve (sensory) branches and hypoglossal nerve (motor) branches, creating a direct link for sensation to stimulate intrinsic muscles to alter dorsal tongue contour. Dorsal tongue contouring around the nipple has been shown to be critical for creating the intraoral vacuum required for milk extraction during breastfeeding” [1]. In other words, damage to the lingual nerve (sensory) could impact the hypoglossal nerve (motor), which could then impact dorsal tongue contour (the ability to contour the top of the tongue around the nipple during breastfeeding) [1]. Therefore, clinicians who use heat-generating instruments to treat neonatal tongue-ties could inadvertently exacerbate the problem they are attempting to remedy.
Salivary Glands and Ducts
Salivary glands (sublingual and submandibular) and salivary ducts are located under the floor of the mouth. Damage to these structures could lead to temporary or permanent damage, including dry mouth, swelling, infection, cavities, and pain. Again, in order to avoid damage to these vital structures when performing a frenectomy, clinicians must exercise extreme caution when working in this area.
Other Anatomical Considerations
Other anatomical considerations include the surrounding veins, arteries, and muscles. Damage to any of these can have deleterious implications.
Preoperative Considerations
Oral surgery is surgery. Oral surgical candidates should be screened using the same measures as medical surgical candidates. In fact, a thorough preoperative screening should include a review of medical history and systems, a comprehensive metabolic panel, and any other necessary adjunctive tests. Without appropriate screening, potential risk factors could go undetected. In many cases, performing a comprehensive assessment could reduce or even prevent untoward outcomes.
Instrumentation
There are many ways to achieve a desired surgical outcome. However, like with all facets of medicine and dentistry, there is no one-size-fits-all solution. With surgery, not all instruments and equipment are suitable for all patients or all providers. Prior to performing a surgical procedure, clinicians should: know their patients; understand the anatomy; comprehend the procedure; and master the utilization of all necessary instruments and equipment.
There is no infallible device in medicine or dentistry. Clinicians should familiarize themselves with the indications, contraindications AND the limitations of all their instruments and equipment. Clinicians should also learn their own limitations.
An instrument’s efficacy is not inherent. An operator’s skill, not armamentarium, will determine a positive surgical outcome. In fact, there could be significant outcome variance between clinicians who utilize the same equipment. Additionally, outcome variance could also exist within the same clinician. For example, a clinician might be proficient at using a scalpel to perform a frenectomy. However, he or she could fail to master the use of the laser. As such, clinicians should critically assess and evaluate their skill set. This self-assessment requires a certain intellectual honesty and humility. However, it is necessary for the safety of the community.
Patient Consideration
Clinicians should brief patients about all surgical considerations, including pre- and post-surgical recommendations and requirements. They should also inform patients about what to expect during the surgery. However, clinicians should not solely bear the burden of preparation. Patients should perform their due diligence prior to treatment. This includes inquiring about surgical modalities, office and surgical protocols, pre- and post-operative requirements, and post-operative complication management.
Post-Operative Complications
The possibility of deleterious surgical outcomes can evoke a sense of fear in many patients. Consequentially, some patients and clinicians may broach the topic of post-operative complications with trepidation. However, failure to appropriately identify potential complications could negatively impact both patients and clinicians. Ill- or misinformed patients lack the necessary information to make appropriate treatment decisions, which include the decision to decline or defer treatment.
Clinicians should always assess their ability to manage any potential surgical complications. Complication management requires a combination of proficiency (required skill set), appropriate armamentarium, and facility preparedness. If any of these factors are missing, the clinician should refer the procedure to another clinician or facility. Clinicians who fail to consider potential post-operative complications have done their patients and community a great disservice.
Post-Operative Care
Careful surgical planning includes a post-surgical needs assessment. An appropriate post-operative protocol should include the provision of any recommended medications and an explanation of any post-operative regimens, such as dietary instructions and restrictions, a hygiene protocol, stretches and exercises, and/or professional therapy. Clinicians should provide patients with both written and oral instructions. The office should schedule patients for any follow-up examinations or additional treatment. If warranted, clinicians should also provide patients with any needed specialty referrals.
Conclusion
Mutual trust should be the cornerstone of the doctor-patient relationship. Clinicians should be confident that patients will be forthright when providing their medical history and their history of present illness. Additionally, patients should also be confident that their healthcare or dental care providers are equipped to provide the best possible patient outcome. Working together will almost always provide the best possible treatment outcome.
Frenectomies: The Truth Behind Surgical Intervention (Podcast)
References:
- Nikki Mills, Donna T. Geddes, Satya Amirapu, S. Ali Mirjalili, “Understanding the Lingual Frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery”, International Journal of Otolaryngology, vol. 2020, Article ID 1820978, 12 Pages, 2020. https://doi.org/10.1155/2020/1820978