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The International Online Seminar Series on Periodontology in conjunction with

KnE Medicine Scientific Seminar
Volume 2022

Research article

Perio-Aesthetic Treatment With Frenectomy

and Crown Lengthening: A Case Report
Muhammad Yusuf1 and Sri Pramesti Lastianny2 *
1
Periodontics Specialist, Dentist Education Program
2
Department of Periodontics, Faculty of Dentistry, Gadjah Mada University Denta Street No.1,
Sleman, Yogyakarta, Indonesia
ORCID
Sri Pramesti Lastianny: https://orcid.org/0000-0003-2991-6584

Abstract.
Background: High frenum attachment has a detrimental effect on periodontal tissue and
esthetics. High adhesion to the frenulum can lead to gingivitis and central diastema,
which are indications for frenectomy. A better oral aesthetic appearance improves the
overall appearance and personality and self-confidence when smiling. Short clinical
crown is often a patient complaint, one of the causes being altered passive eruption.
Objective: To describe the correction of high frenulum with frenectomy and correction
Corresponding Author: Sri
of altered passive eruption with crown-lengthening surgery with ostectomy.
Pramesti Lastianny; email:
Case Report: A 23-year-old patient presented to the periodontics clinic of Dental and
sri.pramestri@ugm.ac.id
Oral Hospitals Gadjah Mada University (RSGM UGM), with complaints of short front teeth
Published: 25 April 2022 and difficulty in cleaning the teeth in the maxillary anterior region. The management of
high frenulum was done by frenectomy, followed by crown lengthening using a scalpel.
Publishing services provided by
Results: The four-week control showed corrected altered passive eruption and coral
Knowledge E
pink gingiva.
Muhammad Yusuf and Sri Conclusion: Frenectomy is an action to overcome high frenulum which aims to prevent
Pramesti Lastianny. This article is periodontal disease. Crown lengthening is a treatment for correction of functional and
distributed under the terms of aesthetic disturbances associated with altered passive eruption.
the Creative Commons
Attribution License, which Keywords: frenectomy, altered passive eruption, crown lengthening
permits unrestricted use and
redistribution provided that the
original author and source are
credited. 1. Introduction
Selection and Peer-review under
the responsibility of the NaSSiP
A harmonious smile is considered as a symbol of beauty in modern society [1]. The
6 Conference Committee. importance of a better oral aesthetic appearance will improve appearance and per-
sonality and self-confidence when smiling. A wide smile is associated with a variety
of factors; harmonization of the shape, location, and size of teeth in relation to the
alveolar bone and gingival tissue. The attachment of the frenulum in the oral cavity is
an important factor that influences the appearance of a smile, because it determines the
shape of the lips and the fit of the teeth [2]. When a person smiles, the entire maxillary
incisor crown and 1 mm of attached gingiva are visible. An open gingiva of 2-3 mm is
esthetically acceptable [3].

How to cite this article: Muhammad Yusuf and Sri Pramesti Lastianny *, (2022), “Perio-Aesthetic Treatment With Frenectomy and Crown Lengthening:
A Case Report” in The International Online Seminar Series on Periodontology in conjunction with Scientific Seminar, KnE Medicine, pages 302–312. Page 302
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The frenulum is a small fold of mucous membrane, fibrous tissue, and muscle fibers
that attaches the inner lip or cheek to the alveolar processes, gingiva and periosteum.
It stabilizes the movement of the lips or cheeks and tongue [2]. The attachment of the
high frenulum to the upper lip occurs on the labial surface between the maxillary central
incisors, this attachment results in gingivitis and central diastema. The attachment of
the high frenulum in the maxillary central incisor area is more incense than the mandible
on both the labial and lingual sides [4].
Blanch test is the most commonly used method for the diagnosis of high frenum
attachment. It works by pulling the upper lip to observe the movement of the papillary
margin, in which the upper lip is lifted and held until the area becomes ischemic [5].
Based on the extension of the fiber attachment, the frenulum is classified as follows: 1.
Mucosa, when the fibers of the frenulum are attached to the mucogingival junction; 2.
Gingiva, when the frenulum fibers are attached to the attached gingiva; 3. Papillae, when
the frenum fibers of their attachment extend to the interdental papillae; 5. Penetration of
the papilla, when the frenulum fibers pass through the alveoli and extend to the palatal
papilla [6].
Frenectomy is a surgery procedure that aims to remove excess interdental tissue
and reduce tension in the gingival margin tissue. Several methods have been used
for surgical excision of the frenulum, including; scalpel, electrosurgery, and laser [7].
The utilization of a scalpel in frenectomy is the most commonly used technique in
dentistry, but it has several disadvantages, including bleeding. Bleeding in frenectomy
can be minimized with the use of electrosurgery or can be done by modifying the
existing incision technique, namely the Incision below the Clamp (IBC) modified incision
technique [4].
A short clinical crown that affects the patient’s confidence is characterized by overex-
posure of the maxillary gingiva when smiling or speaking. [1,8] Common causes of short
clinical crowns include caries, erosion, dental malformations, fractures, attrition, exces-
sive tooth reduction, eruption disharmony, exostosis, and genetic variation. Therefore,
this clinical crown length deficiency should be increased when the caries margin or
fracture margin is placed in subgingival, the crown is too short for restoration retention,
there is excess gingiva, and the anatomical crown is partially erupted [9].
Altered passive eruption can occurs in all or some of the maxillary anterior teeth
that causes gummy smile. Such patients are often unaware that they have short teeth.
Normally, the anterior teeth length are 11 mm, 9 mm, and 10.5 mm for the upper central
incisors, lateral incisors and canines [10]. There are various techniques used to perform

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crown lengtening procedures on anterior teeth, one of which is the Chu’s aesthetic
gauges technique [11].
Crown lengthening is a surgical procedure by exposing more tooth structure either
around one tooth or a group of teeth [12]. The reason for crown lengthening is to
restore the biologic width to a more apical position to avoid breaches that could
result in bone resorption, gingival recession, inflammation or hypertrophy [13]. Bone
sounding is used to determine the thickness of the soft tissue layer and the proximity
of the alveolar bone during the planning stages of various surgical procedures [14].
Ostectomy consists of removing the supporting bone, and the amount of bone resected
is determined by the degree of crown lengthening required [13]. Crown lengthening
with bone correction requires flap access. However, in several cases this treatment
can generate black triangle. The success of this technique is influenced by diagnosis,
determination of indications and appropriate action. In the case of altered passive
eruption, the proportions of the face, lips and all aspects must be observed, because
crown lengthening has different techniques and not all of them have to involve bone
reduction [15].
This case report aims to describe the correction of cases of high labial frenulum with
IBC technique and cases of altered passive eruption with crown lengthening surgery
with osteoctomy to improve function and aesthetics.

2. Case

A 23-year-old male patient came to the periodontics clinic of the RSGM UGM, with a
complaint that his gums looked excessive so that his teeth looked short and looked
thicker when smiling. There was no history of systemic disease. Extraoral examination
revealed no abnormalities. Intraoral examination revealed adequate attached gingiva
in the maxillary anterior region, scalloped gingival shape, asymmetrical and reddish
gingival margins, short clinical crown, spongy consistency, unstippling texture, and
probing depth of about 3-4 mm and a base of width and height frenulum extends
to the interdental area of the maxillary anterior region. Dental hygiene status (OHI) was
good with minimal plaque and calculus index.
After the initial phase in the form of scaling and root planing was carried out, an
examination of the ideal proportion of the crown of the tooth was applied by using
a chu’s gauge. Based on clinical examination, the determined clinical diagnosis was
altered passive eruption. On clinical examination of the frenulum, a blanch test was

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performed by lifting the upper lip and holding it until the area became ischemic and a
positive blanch test was obtained.
Based on the patient’s complaints and the clinical examination that has been carried
out, a treatment plan is carried out, namely initial treatment by removing plaque and
calculus and then surgical treatment; labialis frenectomy procedure with IBC technique,
then crown lengthening procedure with gingivectomy begins with an internal bevel
incision accompanied by an ostectomy procedure. The procedure to be carried out
has been informed and explained to the patient, and the patient agrees with all the
treatment plans that will be carried out and the patient has signed an informed consent
as a sign of approval for surgery.

Figure 1: A short clinical crown (left) and clinical examination of a high frenulum (right) are seen.

Figure 2: Labial infiltration of local anesthetics.

3. Treatment

Initial treatment was plaque and calculus removal and oral hygiene instructions. Control
1 was carried out a week later after scaling with OHI = 1.67 (Good), PCR = 9.8% and GI
= 0.96 (mild). Then surgical treatment was carried out, including frenectomy and crown
lengthening procedures with ostectomy.

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Extraoral and intraoral asepsis were employed with betadine solution 10%. The first
step was a frenectomy procedure. Local infiltration anesthesia was performed in the
vestibule area on the right and left lateral frenulum followed by the palatine area near
the incisive foramen. After being anesthetized, the clamp is placed parallel and attached
to the lip, the incision is made by using a scalpel number 15 on the bottom and parallel
to the clamp from the incisal direction to the base of the vestibule. Suturing was done
with interrupted sutures with silk no. 5-0 immediately after incision in the most apical
area of the incision. Followed by cleaning and taking the connective tissue that makes
up the frenulum. Subsequently, a second surgical procedure was performed, namely
crown lengthening.
Infiltration anesthesia was performed in the labial and palatal regions 13-23 and chu’s
gauge were used when performing crown lengthening. Chu’s gauge is used to measure
ideal tooth and gingival proportions as well as measurement of bone height. Making a
bleeding point with a pocket marker from teeth 13-23 as a guide and limit for excess
gingival gingivectomy. Gingivectomy with an internal bevel incision was performed using
a number 15 scalpel following the bleeding point. Excess gingiva that has been excised
with granulation tissue and remaining calculus or necrotic cementum was removed with
a curette resulting a smooth and clean surface.
The ideal size of Dento Gingival Complex according to Bhuvaneswaran, et al. (2010)
is less than 3 mm. If the distance is less than ideal, it is necessary to reduce the alveolar
bone [16]. After gingivectomy was performed, ostectomy also was performed by making
a flap with a full thickness incision from the distal tooth 13 to the mesial to tooth 23
with a sulcular incision. The flap was opened using a raspatorium to obtain a sufficient
field of view to prevent the gum touched by the bur during alveolar bone reduction.
A 10 mm round diamond bur was utilized. Then the gum was sutured with interrupted
5-0 silk sutures on the interdental papillae adequately so that primary wound healing
is expected. The rough surface was dried and covered with a periodontal pack in the
area where the frenectomy and crown lengthening were performed.
After surgery, the patient was given the following drugs: antibiotics (amoxicillin 500
mg, 3x daily for 5 days), analgesics (mefenamic acid 500 mg, 3x daily for 5 days), and
mouthwash (minosep gargle 2x daily for 1 week). Post- operative instructions are given
to the patient, namely to take medication regularly; maintain oral hygiene by brushing
the teeth regularly and avoiding the operating area; avoiding hot, spicy, hard, sour and
sticky foods; and don’t rinse too hard.
The patient returned for a 1 week control, the patient did not complain of pain and
the periodontal pack was still attached. The periodontal pack was opened, the gingival

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margins and gingival color were still hyperemic and edematous, so the patient was
instructed to continue the Minosep Gargle mouthwash for one week and maintain oral
hygiene. The patient returned for a second control at week 4 for evaluation and removal
of the sutures, the healing seemed complete, marked by complete re-epithelialization
and keratinization, namely the gingival margin and gingival color appeared coral pink,
there was stipling, no pain complaints. , and the sensitivity of the teeth. After frenectomy,
a marked shift of the frenum attachment was seen at the mucogingival junction and a
scar that healed without fibrous tissue.

Figure 3: Maxillary labial frenectomy procedure.

Figure 4: Gingivectomy procedure accompanied by osteectomy: a. gingivectomy with internal bevel

incision, b. excessive gingival tissue, c. ostectomy, d. sutures with interrupted sutures, and e. installation of
periodontal packs.

4. Discussion
4.1. Frenectomy

Abnormal attachment of the frenulum leads to the development and persistence of a

central diastema, gingival recession, and speech problems [5]. Abnormal attachment

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Figure 5: Control 1 week there is still redness on the gingiva.

Figure 6: 4 weeks control

of the labial frenulum is characterized by adhesions near the gingival margin or over
the interdental papillae and even extending to the palatal region. This condition causes
retraction of the gingival margins and is generally associated with difficulties in optimal
teeth cleaning, thereby causing gingivitis, stretching of the gingival sulcus, accelerating
plaque accumulation, and ultimately leading to a periodontal condition [2]. Frenectomy
is the complete removal of the frenulum including its attachment to the underlying bone
in order to prevent periodontal disease, esthetic improvement due to a central diastema,
limited lip movement, and slurred speech [4,6].
Frenectomy can be performed using a scalpel, electrosurgery, or laser technique.
Conventional frenectomy using a scalpel is the most common procedure because it is
simple, inexpensive and practical. However, there is a higher complication arising from
this procedure which is a larger incision wound, followed by excessive bleeding during
the operation and creating discomfort for the patient. Electrosurgery and laser in frenec-
tomy are proven to be effective in minimizing bleeding, not taking time, not needing
suturing, and minimal complications such as postoperative swelling and ultimately more
comfortable for the patient. However, electrosurgery and lasers require specialized
equipment and require highly skilled operators, and involve high-cost operations. Other

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than that, there are several disadvantages of electrosurgery and laser. They are risky
to harm the tissue around operating area. The site will be necrotic due to excessive
contact with the device, this procedure is contraindicated for patients with pacemakers,
and produces smoke that will be inhaled by the patient during the procedure. One of
the modified techniques that aims to reduce bleeding from open wounds that usually
occurs in conventional techniques is the IBC technique [2].
In this case report, a modified frenectomy technique with an IBC approach is used,;
first, the placement of the clamp parallel and attached to the cheek mucosa; Second,
make an incision under the clamp and continue with suturing immediately after the
incision in the mucolabial fold area. The results showed that the incision made under
the clamp did not cause a widening wound on the lip mucosa, this was due to the
lateral pull of the orbicularis oris muscle being restrained by the clamp, and the suturing
action performed immediately after the incision at the top of the incision would resist
the muscle pull after it was released. clamps. Sutures on the side are intended to
connect the cut tissue as well as to reduce bleeding due to an open wound. Similar
to frenectomy performed using electrosurgery, IBC technique is able to Minimize the
bleeding that occurs during surgery performance [4].

4.2. Crown lengthening

A short clinical crown was found which was the patient’s complaint. The short clinical
crown in this case was caused by altered passive eruption, in which the gingival margin
failed to migrate apically to reach the cementum enamel junction (CEJ), so that the
position of the gingival margin was incisal/occlusal [17]. The aim of the action in this
case is to form an ideally contoured gingival margin in proportion to the immediate
post-surgery [15].
Crown lengthening is one of the most common surgical procedures in periodontal
practice. The main indications for a crown lengthening surgical procedure include
treatment of subgingival caries, crown or root fracture, altered passive eruption, cervical
root resorption, and short clinical support. The aim of crown lengthening is to restore
the biologic width to a more apical position to avoid breaches that could result in bone
resorption, gingival recession, inflammation or hypertrophy [13].
After determining the problem, the number of soft tissue resections planned, the
extent to which bone resection may be required, and the surgical technique can
be determined. Soft tissue removal without any bone resection then there are two
options; gingivectomy or apically positioned flap. If the alveolar crest is less than 3

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mm from the anticipated gingival margin, then bone resection is required. Therefore it
needs a full-thickness flap [10]. In this case report, a crown lengthening surgery was
performed with a gingivectomy technique, an internal bevel incision was performed
with an ostectomy. Aesthetic crown lengthening requires a gingivectomy procedure to
expose the necessary additional tooth structure, therefore a minimum of 2 to 5 mm of
keratinized tissue is required to ensure gingival health [9].
In the ostectomy procedure, the first incision will be the same as for the apically
positioned flap, and the excess gingiva is removed before raising the full- thickness
flap to expose the alveolar bone. After lifting the full-thickness flap, bone resection
can be performed using a bur. Resection should be performed with saline irrigation to
prevent overheating of the bone and to rinse away the remnants. Fine sutures such
as the 5-0 suture are preferred to allow better healing and are less bothersome to
the patient for the next week until the sutures are removed. It is very important to give
proper instructions to the patient to avoid unwanted tissue movement during the healing
phase [10].

5. Conclusion

The frenectomy procedure at high frenum attachment using the IBC technique has the
advantage of reducing bleeding during surgery, providing comfort for the patient and
can be performed easily by the dentist. Short clinical crown due to altered passive
eruption is an aesthetic and functional disturbance that is often complained of by
patients. The crown lengthening procedure is an effective treatment for correcting
functional and aesthetic disturbances associated with altered passive eruption.

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