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Welcome to the University of Michigan Dentistry Podcast Series promoting oral health care
We have with us this morning Lynn Warren who is 14 years of age and she has a problem of
a diastema. Lynn will you open your mouth a little for us. You can see the space between
her central incisor teeth and beneath her upper lip she has an extensive frenum. You
can see the attachment and this is a particularly wide frenum and we'll get back to it in just
a moment. This young lady will be with us today for a little while and therefore we
thought it wise to pre-medicate her and we'll do that now intravenously. We'll have her
drop her arm down to her side and make a tight fist of her hand. Apply a small tourniquet
here and utilize some pre-medication or some psycho-sedation. We have then a vein that's
dilated and we'll use an alcohol sponge to prepare the skin and I don't know whether
we have that… that's surprisingly good for the little light that's here. Skin again is
penetrated small stick here.
Okay. Off tourniquet. You can see the rapidity with which the skin, with which the syringe
fills. Now injecting slowly. You can relax your hand a little bit Lynn. That's good.
And so I'm watching the site of the needle penetration as we administer 10 milligrams
of diazepam or ***. If we turn back to the patient for the moment as we're administering
this quite slowly. We should see that she will develop some degree of relaxation some
tendency for less concern and a little more tranquil state.
You can see the relatively wide insertion of the labial frenum toward the… toward
the lip. I am going to infiltrate a little bit on the palatal side as well because our
incision must go through the palatal area in order to completely eliminate that tissue.
Now then Lynn I would like you to open widely please tip your head back a little bit. We'll
go right in at the base of the papilla. There will be a small pin stick in here. Open widely.
That's a good girl. Small pin stick here on the arm. That's good. That's good. Keep open
as widely as you can. I'll give you a little more appreciation for the angulation of the
teeth in question and the residual space that's here.
I have gone now into the base of the papilla and a little bit into the nasal palatine area.
We're going to also infiltrate a little bit laterally because of some of soft tissue manipulation
we're going to carry out here. And note that there is a space between the central incisors.
We'll note that actually in the midline there appears to be a suture, a dark linear structure
that contains fibrous tissue and this fibrous tissue serves as sort of a bumper and a resistance
to the remedial migration of the centrals and it's the removal of that fibrous tissue
and of the mucosa and the excess fibrous tissue that is across the alveolar crest that we'll
be modifying this morning. Oh we'll extend, we'll want to remove this tissue that's in
between the teeth and in a diamond shaped excision we'll proceed to do that. A little
pressure here, Lynn.
I'm standing just as close to the epithelial attachment or these centrals as possible and
on the palatal side I'm going to also then going to complete that diamond-shaped incision.
Now we'll get some of that tissue that we've been speaking about.
And we'll attempt to dissect that. I'll use a straight curette for a part of that.
Eliminating the attachment to this fibrous and perhaps we can put a mosquito hemostat
on that and dissect it out of there.
We will write down to fibrous tissue. I'll put a small snap on that and we'll use some
scissors and I'll complete this cut.
Okay. Then we can see we've gained some space there.
And you'll observe that the hemostasis is really quite good. It's been gained from the
preliminary injection in this field. There really is not a lot of problem with the escape
of any bleeding. So we've cleared the interproximal then of any soft tissue barriers. Now we'll
extend the exposure slightly, superiorly so that I can get at the bone area before we
apply the wire to close this diastema. The small drill. We want to place it here underneath
the flap. Now a little vibration then. You're doing fine. That's carried. I'm sorry. Maybe
I can catch it from underneath and you'll see it a little better. Yes, okay.
I'm removing the interradicular bone. After the removal of this bone we'll save time by
simply putting a temporary wire on these teeth and bring them partially together before doing
the Z-plasty on the large frenum.
Our overall length here of incision will probably go to this point. Where you see the blue dot.
Our lower point will be down here at the junction of these attached gingival areas. Down here.
So we'll have an overall length then between those two dots in a vertical direction.
We're going to simulate for this Z. And the reason for doing the Z is the amount of tissue
that's involved here to simulate an angle of about 45 degrees and our length of the
members of the components to this Z will be about three-quarters the length of the central
member. So that will be out about there. So that in configuration if this becomes the
central portion of the Z and the midline, I can get a little more ink on the subject.
Then this member will be one of the elements of the Z, now here… in this manner. And
the other one will be from that… wind up like that. So that will be the sign of Zorro
if any of you are that old. So remember that symbolism and we'll resize the central member…
…in the midline, trying to stabilize it.
We could have some suction. It will probably be needed.
There then is the central excision. Now with very simple webs that do not involve much
tissue. Excision is all that's necessary. It's only when they involve considerably more
basal tissue that we resort to this management of this basal tissue by transposition of flaps.
Now soft tissue tends to run away from us. Now the hook, please. Skin hook.
That's it thank you. So we'll stabilize it in this manner. Hold back. Thusly I'm going
to need to widen the angles of these flaps in order to have them adequate. They won't
quite conform to our original markings but they will be shorter than the original designation
and we'll carry this one out and try to match it out here.
The end of the flap well then try to pick up. Identify a corner and dissect back. When
we get this elevated high enough. I'll go underneath the peripheral mucosa undermining
with scissors. If I could have those in just a moment. The scissors end please. You can
see that these flaps containing mucosa tend to shrink down and that's one of the behaviors
of the elasticity of mucosa. Now I'm going to dissect under here and spread slightly
the scissors. In that manner you see the undermining of the triangular flap. Here's the other one
up here kinda shriveled up but it's there and it will give us what we need in a moment.
Okay. A very small accessory salivary gland so it won't be missed. I have to proceed next
to explore with another periosteal elevator the bone in the area of the diastema and our
previous removal of it as you recall was from the interproximal. I'm going to see that that
bone removal is complete. We'll look at the base of this frenectomy first of all, and
see about establishing that closure. And then the rotation of the flaps. Could I have the
silk suture please 4-O silk?
Thank you. 4-O silk suture and pick up. We'll go through first the base of this frenectomy
with several sutures. And we'll try to pick those needles up as we go.
This then is the base of that frenum if we could sponge it please. Sponge the flap up
into position. One on the right side. That's better. Thank you.
So we'll close this vertical component on the attached gingiva. You might use a wet
sponge there. Thank you.
So we'll have this vertical flap to bring together. I'm also going to put a secondary wire in
there that I think you'll find we'll give us just what we need in the final nudge of
those incisors so that the centrals are together. Right now there's some force working on them.
We'll now look at our components of this Z. See what we can identify.
In these mucosal flaps I think at this stage of the game then you can see the incision,
you can see this Z and this was originally up on this side and this one which was down
here. So those are the two flaps that will be transposed. This one going over this side,
this one going over here. As we try to rotate this one, there'll be some residual retention
here that may be just from the retractor. I'd like to undermine that a little more though
if I could have the scissors please. Scissors please. Thank you.
So the base of the flap does migrate a little. Alright now we'll secure those into position.
First of all, moving… this one out to its new pore.
Probably not quite so much lotto retraction here [mumbling].
This will change the long access scar into a more horizontal component than it had before.
And you begin to see the position of the Z.
Well the flaps have been transposed then. So that the Z is pretty well consummated.
There's need for one more suture up at the base up in here and that should be the last
one. I'd like a smaller, smaller, wire now. A segment of slightly smaller gauge wire if
you can find it.
Then we'll cut and sponge again.
Now we're come off the retractors please.
We will now apply an alternative method to the temporary wire that has been removed.
I have a double-ended wire there… that we'll use just around the centrals. We'll use it
First of these…
Periosteal elevator please.
Work it well up on the… lingual.
Trying to get equal attention on this. We'll soon have this together.
I'd like wire twister
and another small piece of double wire.
Okay another piece of double wire. Thank you.
This is just a double back loop then on this. We'll continue to feed it through.
Fine. Then we'll even this.
Perhaps you can twist that up and knot with a little tension, please.
That's good. Now take a little on this side and we'll have one more small piece of double
in a moment.
Now if you'll give that a little bit more over there.
And we'll take another piece of that double wire. And we have the Z reflected above.
The free cut ends of wire will be turned into the embrasure as we conclude the procedure.
Lynn has returned to us today. She is now 10 days post-op. Three days ago she had her
sutures removed and the periodontal pack removed from the midline where part of the fibrous
frenum was removed. We now have an opportunity to see uh, somewhat the post-operative results
although we do recognize for full maturation of soft tissue healing of the scar, maturation,
a period of about six months or so will have to elapse before we can see the ultimate final
result. Nevertheless if we can get an intraoral view we'll try and demonstrate to you first
of all the configuration of the Z-plasty which I think you can see quite readily. There is
some irregularity of margins but this is completely normal at this stage as maturation continues
to occur the irregularities will blend in and the mucus membrane will again become quite
smooth. Also the scar itself as well the months go by soft and become much more flexible.
Secondly I would like to direct your attention to the incisors. We can see now that the diastema
is very nicely closed. The ligation wires will remain in place another week before they're
removed and at that time her treatment will be completed. We'll continue to follow her
periodically in three months from now … to be sure that everything remain the way
we would like it to. We would like thank Lynn today for returning to us to allow us for
this post-op observation period.
Fifteen year old Ms. Lynn Warren returns for her three month check up following the excision
of the labial frenum that was associated with the diastema between her teeth. You'll recall
that last time we had wires that were attempting to close this space in part. Those have been
removed. In addition to that wire action this particular age is selected as a time for the
excision of the frenum tissue between the central incisors because of the action of
the erupting canines. The cuspids are coming in and more crown space is being required.
That means there are some menial tendency to bring the two teeth together. They are
nicely in contact. Just close now Lynn. Bite down. And functionally A-satisfactory. There
is a cross-bite malocclusion in the left canine that needs orthodontic consultation. The release
of the frenum, just close your teeth again. Release of the frenum has been complete and
we see that the vestibule is now established and clear and the maturation of the scar is
Okay, can you smile for us Lynn? That's good.
So we would conclude that the frenectomy for diastema should be properly timed, that either
orthodontic treatment should be active or the growth and development phase should be
bringing the centrals together at the time that the incision is carried out and the release
of the frenum by Z-plasty where there is a wide quantity of tissue involved is a useful
measure to release that band and adhesion. We anticipate that this should go on to satisfactory
and complete stabilization and that the diastema is eliminated completely.
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