BJS 16-3.pdf | Tooth Enamel | Epithelium

BALKAN OF

JOURNAL

STOMATOLOGY 

Official publication of the BALKAN STOMATOLOGICAL SOCIETY 

 Volume  V olume 16

No 3

ISSN 1107 - 1141

November 2012

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ISSN 1107 - 1141

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Ljubomir TODOROVIĆ, DDS, MSc, PhD Faculty of Dentistry University of Belgrade Dr Subotića 8 11000 Belgrade

Editor-in-Chief 

Serbia

 Editorial board  ROMANIA

ALBANIA

Ruzhdie QAFMOLLA - Editor Emil KUV KUVARA ARATI TI Besnik GA GAV VAZI

Address: Dental University Clinic Tirana, Albania

Alexandru-Andrei Alexandru-And rei ILIESCU - Editor

Address:

Victor NAMIGEAN

Faculty of Dentistry

Cinel MALITA

Calea Plevnei 19, sect. 1 70754 Bucuresti, Romania

BOSNIA AND HERZEGOVINA

Maida GANIBEGOVIĆ - Editor  Naida HADŽIABDIĆ Mihael STANOJEVIĆ

Address: Faculty of Dentistry Bolnička 4a

SERBIA

Dejan MARKOVIĆ - Editor Slavoljub ŽIVKOVIĆ Zoran STAJČIĆ

71000 Sarajevo, BIH BULGARIA

 Nikolai POPOV POPOV - Editor Editor

Address:

 Nikola ATANASSOV  Nikolai SHARKOV

Faculty of Dentistry G. Sofiiski str. str. 1 1431 Sofia, Bulgaria

TURKEY

FYROM

Julijana GJORGOV GJORGOVA A - Editor

Address:

Ana STA STAVREVSK VREVSKA A Ljuben GUGUČ GUGUČEVSKI EVSKI

Faculty of Dentistr Dentistryy Vodnjanska 17, Skopje Republika Makedonija

Address: Faculty of Dentistry Dr Subotića 8 11000 Beograd, Serbia

Ender KAZAZOGLU - Editor

Address:

Pinar KURSOGLU Arzu CIVELEK

Yeditepe University Faculty of Dentistry Bagdat Cad. No 238 Göztepe 81006 Istanbul, Turkey

GREECE

CYPRUS

Anastasios MARKOPOUL MARKOPOULOS OS - Editor Address: Haralambos PETRIDIS Aristotle University Lambros ZOULOUMIS Dental School Thessaloniki, Greece

George PANTELAS - Editor Huseyn BIÇAK

Address: Gen. Hospital Nicosia

Aikaterine KOSTEA

No 10 Pallados St.

Nicosia, Cyprus

 International Editorial (Advisory) (Advisory) Board 

Christoph HÄMMERLE - Switzerland Barrie KENNEY

George SANDOR

- USA

- Canada

Ario SANTINI

- Great Britain

Predrag Charles LEKIC - Canada

Riita SUURONEN

- Finland

Kyösti OIKARINEN

Michael WEINLAENDER - Austria

- Finland

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Council:

President: Past President: President Elect: Vice President: Secretary General: Treasurer: Editor-in-Chief:

 Members:

Prof. H. Bostanci Prof. P. Koidis Prof. N. Sharkov Prof. D. Stamenković Prof. A.L. Pissiotis Prof. S. Dalampiras Prof. Lj.Todorović

R. Qafmolla P. Kongo Ko ngo M. Ganibegović S. Kostadinović

A. Adžić M. Djuričković

A. Filchev D. Stancheva Zaburkova

M. Carčev

M. Carević M. Barjaktarević E. Kazazoglu

A. Minovska T. Lambrianidis S. Dalambiras

M. Akkaya G. Pantelas S. Solyali

N. Forna A. Bucur 

The whole issue is available on-line at the web address of the BaSS (www.e-bass.org) (www.e-bass.org)

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ISSN 1107 - 1141

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Ljubomir TODOROVIĆ, DDS, MSc, PhD Faculty of Dentistry University of Belgrade Dr Subotića 8 11000 Belgrade

Editor-in-Chief 

Serbia

 Editorial board  ROMANIA

ALBANIA

Ruzhdie QAFMOLLA - Editor Emil KUV KUVARA ARATI TI Besnik GA GAV VAZI

Address: Dental University Clinic Tirana, Albania

Alexandru-Andrei Alexandru-And rei ILIESCU - Editor

Address:

Victor NAMIGEAN

Faculty of Dentistry

Cinel MALITA

Calea Plevnei 19, sect. 1 70754 Bucuresti, Romania

BOSNIA AND HERZEGOVINA

Maida GANIBEGOVIĆ - Editor  Naida HADŽIABDIĆ Mihael STANOJEVIĆ

Address: Faculty of Dentistry Bolnička 4a

SERBIA

Dejan MARKOVIĆ - Editor Slavoljub ŽIVKOVIĆ Zoran STAJČIĆ

71000 Sarajevo, BIH BULGARIA

 Nikolai POPOV POPOV - Editor Editor

Address:

 Nikola ATANASSOV  Nikolai SHARKOV

Faculty of Dentistry G. Sofiiski str. str. 1 1431 Sofia, Bulgaria

TURKEY

FYROM

Julijana GJORGOV GJORGOVA A - Editor

Address:

Ana STA STAVREVSK VREVSKA A Ljuben GUGUČ GUGUČEVSKI EVSKI

Faculty of Dentistr Dentistryy Vodnjanska 17, Skopje Republika Makedonija

Address: Faculty of Dentistry Dr Subotića 8 11000 Beograd, Serbia

Ender KAZAZOGLU - Editor

Address:

Pinar KURSOGLU Arzu CIVELEK

Yeditepe University Faculty of Dentistry Bagdat Cad. No 238 Göztepe 81006 Istanbul, Turkey

GREECE

CYPRUS

Anastasios MARKOPOUL MARKOPOULOS OS - Editor Address: Haralambos PETRIDIS Aristotle University Lambros ZOULOUMIS Dental School Thessaloniki, Greece

George PANTELAS - Editor Huseyn BIÇAK

Address: Gen. Hospital Nicosia

Aikaterine KOSTEA

No 10 Pallados St.

Nicosia, Cyprus

 International Editorial (Advisory) (Advisory) Board 

Christoph HÄMMERLE - Switzerland Barrie KENNEY

George SANDOR

- USA

- Canada

Ario SANTINI

- Great Britain

Predrag Charles LEKIC - Canada

Riita SUURONEN

- Finland

Kyösti OIKARINEN

Michael WEINLAENDER - Austria

- Finland

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Council:

President: Past President: President Elect: Vice President: Secretary General: Treasurer: Editor-in-Chief:

 Members:

Prof. H. Bostanci Prof. P. Koidis Prof. N. Sharkov Prof. D. Stamenković Prof. A.L. Pissiotis Prof. S. Dalampiras Prof. Lj.Todorović

R. Qafmolla P. Kongo Ko ngo M. Ganibegović S. Kostadinović

A. Adžić M. Djuričković

A. Filchev D. Stancheva Zaburkova

M. Carčev

M. Carević M. Barjaktarević E. Kazazoglu

A. Minovska T. Lambrianidis S. Dalambiras

M. Akkaya G. Pantelas S. Solyali

N. Forna A. Bucur 

The whole issue is available on-line at the web address of the BaSS (www.e-bass.org) (www.e-bass.org)

BALKAN OF

JOURNAL

STOMATOLOGY 

Official publication of the BALKAN STOMATOLOGICAL SOCIETY 

 Volume  V olume 16

No 3

ISSN 1107 - 1141

November 2012

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BALKAN JOURNAL OF STOMATOLOGY

ISSN 1107 - 1141

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VOLUME 16

NUMBER 3

NOVEMBER 2012

PAGES 129-184

Contents

LR

I. Markou A. Kana A. Arhakis

Natal and Neonatal Teeth: Teeth: A Review of the Literature

132

LR

E. Lioliou A. Kostas L. Zouloumis

The Maxillary Labial Fraenum A Controversy Controversy of Oral Surgeons vs. Orthodontists

141

OP

L. Kanurkova J. Gjorgova B. Dzipunova  N. Toseska Toseska A. Dorakovska M. Popovska M. Pandilova

Association between Condylar Position and Tilt of  Frontal Occlusal Plane in Patients with Transversal and Vertical Dentofacial Discrepancy

147

OP

E. Kongo Xh. Mulo

Cephalometric Features of Class III Malocclusion among Albanian Patients Seeking Orthodontic Treatment

154

OP

E. Zabokova-Bilbilova A. Sotirovska-Ivkovska B. Evrosimovska L. Kanurkova

Effect of Fluoride Varnish Varnish on Demineralization Adjacent to Orthodontic Brackets

157

OP

M. Carcev B. Getova O. Sarakinova H. Petanovski S. Carceva-Shalja

Sealing of Fissures and Pits of First Permanent Molar at Children with High Caries Risk 

161

OP

S. Georgieva M. Pandilova L. Zendeli-Bedzeti

Use of Topical Bio-stimulative Laser Therapy among Individuals with Glossopyrosis and Hypochromic Anaemia

165

 Balk J Stom, Vol Vol 16, 2012

131

OP

J. Nikolovska D. Petrovski

Oral Health-Related Quality of Life (OHRQoL) Before and After Prosthodontic Treatment with Full Removable Dentures

169

OP

A. Uludamar  F. Ayke Aykent nt

Bond Strength of Resin Cements to Zirconia Ceramics with Different Surface Treatments Treatments

173

CR

U. Cılasun E.AlperSınanoglu S.Yılmaz E.Guzeldemır  G.Alnıacık 

An Unusual Laryngeal Complication Following Inferior Alveolar Nerve Block 

179

CR

N. Güler 

Surgical Planning of Bilaterally Impacted Maxillary Third Molars by Using Cone Beam Computed Tomography

181

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 Natal and Neonatal Teeth: A Review of the Literature

SUMMARY

I. Markou, A. Kana, A. Arhakis

 Normal eruption of primary teeth into the oral cavity begins at about 6  months of child’s age. Teeth that erupt prematurely have occasionally been reported in the medical and dental literature and have been referred to as congenital teeth, foetal teeth, pre-deciduous teeth and dentitio praecox. The most affected teeth are lower central incisors and only 1-10% of them are  supernumerary teeth. The incidence of natal and neonatal teeth ranges from 1:2000 to 1:3500. The exact etiology has not been proved yet, but there is a correlation between natal teeth and hereditary, environmental factors and some syndromes. The management of the case depends on clinical  characteristics of the natal or neonatal teeth, as well as on complications they might cause. The aim of this text is to present a literature review on important  aspects of natal and neonatal teeth concerning prevalence, etiology, clinical  and histological characteristics, differential diagnosis, complications and  management. Keywords: Natal Teeth; Neonatal Teeth

Introduction Typical eruption of primary teeth begins at about 6 months of age. Teeth observed at birth are considered as natal teeth, while teeth observed within the first 30 days as neonatal teeth, based on the classification given  by Massler and Savara in 1950 according to the time of  eruption78. In 1966, Spouge and Feasby categorized these teeth based on clinical features as mature and immature 110. Mature are those which are fully developed in shape and comparable in morphology to the deciduous teeth; immature are the teeth whose structure and development are incomplete. Finally, Hebling in 1997 presented 4 clinical categories 44: - Shell-shaped crown loosely attached to the alveolus by gingival tissue and absence of a root; - Solid crown loosely attached to the alveolus by gingival tissue and little or no root; - Eruption of the incisal margin of the crown through gingival tissue; - Mucosal swelling with the tooth non-erupted but  palpable.

Aristotle University of Thessaloniki School of Dentistry Thessaloniki, Greece

LITERATURE REVIEW (LR) Balk J Stom, 2012; 16:132-140

The rare occurrence of natal and neonatal teeth was associated in the past with superstition and folklore. Today this phenomenon creates great interest and concern, not only to parents but to clinicians as well. This is due to their clinical characteristics (small size, conical shape, and great mobility) which are the cause of certain complications (laceration of mother’s breasts, sublingual ulceration, and danger of aspiration of the teeth).

History The rare occurrence of natal and neonatal teeth has led to association with superstition and folklore. Some cultures have believed that children born with teeth were favoured, particularly in Western Europe and Malaysia, whereas other considered natal teeth as an ill omen. In England it was believed that natal teeth showed that the children would grow into famous soldiers, in France and Italy that they ‘would get on in the world’ and in Sweden that they could cure an injured finger if it were placed in

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Natal and Neonatal Teeth 133

their mouth. In many places like Poland India and Africa superstition still prevails considering these children to be monsters or evil children 14. Among several native African tribes, such as in urban Bariba in Benin West Africa, one of the most dangerous signs suggesting a witch child is to be born with teeth and if that happened the child was either abandoned or killed. Precautions in the form of a  purification ritual are still taken today in such cases, and sometimes the teeth will be extracted 101. In China a child  born with teeth suggests misfortune for the family: if the child is male then the father will die and if it is a female the mother. Many historic personalities, like Hannibal, Cardinal Richelieu, Broca, Zoroaster, Napoleon, English King Richard the III and King Louis XIV of France are said to be born with teeth. Also many proverbs and apothegms are made up for natal teeth, such as ‘The one

whose teeth grow early, will early sink into the grave’ 14. Due to these superstitions it is suggested that a transcultural approach be adopted in managing cases in which the parents feel particularly anxious and uncomfortable about prematurely erupted teeth in order to cater for the social well-being of the child and family 88.

Prevalence Many authors have reviewed the incidence of natal and neonatal teeth (Table 1). The estimated prevalence ranges from 1:10 to 1:30.000. It is accepted by many authors that the ratio of natal and neonatal teeth is somewhere between 1:2000 and 1:3500 14,23,24,78,110,123.

Table 1. Prevalence of natal and neonatal teeth  Natal and neonatal teeth

Author(s)

Location of study

Magicot (1883) 71

Paris, France

3

17.578

1:6.000

Howkins (1932) 48

Birmingham, England

1

10.000

1:10.000

Massler and Savara (1950) 78

Chicago, USA

7

9.400

1:2.000

Allwright (1958)3

Hong Kong, China

2

6.817

1:3.400

Mayhall (1967) 80

Juneau, Alaska (Tlinget Indians)

8

90

Gordon and Langley (1970) 41

Oklahoma, USA (American Indian)

4

407

Jarvis and Gorlin (1972) 50

Alaska, USA (Eskimo)

Anderson (1982) 5

Columbia, USA

Kates et al (1984)

52

16

Total births

1.571

Prevalence

1:11.25 1:100 1:98 1:800

Boston, USA

13

18.155

1:3.667

Leung (1989) 67

Alberta, Canada

15

50.892

1:3.392

King and Lee (1989) 57

Hong Kong, China

17

22.500

1:1.324

Gladen et al (1990) 39

Taiwan

13

Rusmah (1991) 100

Kuala Lumpur, Malaysia

To (1991)117

128

1:10

4

9.600

1:2.325

Hong Kong, China

48

53.678

1:1.118

Diaz-Romero et al (1991) 30

Mexico

31

1.200

De Almeida and Gomide (1995) 27

Brazil

47*

Alaluusua et al (2002) 2

Finland

34

Liu and Huang (2004) 70

Taipei, Taiwan

Freudenberger et al (2008) 36

Mexico

1019** 34.457

1:38,7 1:22 1:1.013

2

420

1:140

50

2182

2.3:100

* 14 with complete unilateral cleft lip and palate and 33 with bilateral cleft lip and palate **692 with complete unilateral cleft lip and palate and 327 with bilateral cleft lip and palate

134 I. Markou et al.

Balk J Stom, Vol 16, 2012

The prevalence of occurrence of natal and neonatal teeth in males and females is controversial, with some authors giving a higher ratio for females 3,5,23, 36, 52, 65,78, Kates et al 54 reporting a 66% proportion for females against a 31% proportion for males, and others suggesting that there isn’t any correlation with gender 14,25,106.  Natal teeth are more common than neonatal teeth14,23,33,57,78,110.

Etiology The exact etiology of natal and neonatal teeth has not  been elucidated yet. Many theories have been expressed regarding the cause of the occurrence of these teeth. One of them includes dietary deficiencies 3 or hypovitaminosis due to poor maternal health, endocrine disturbances and

 pyelitis during pregnancy15. Another theory refers to hormonal stimulation, meaning the excessive secretion of pituitary, thyroid or gonads 78. It is also significant to mention that congenital syphilis seems to have varying effect; in some cases premature eruption was noticed, while in others the eruption was retarded 15. Moreover, febrile states can affect the normal eruption of teeth, for  example fever and exanthemata during pregnancy can cause premature eruption 78. The hereditary factor is assumed a possible cause of  natal teeth. Zhu and King (1995) 123 have reported natal teeth as a familiar trait in 8-62% of cases. Bondenhoff and Gorlin (1963) 14 reported family association in 14.5% of  cases, while Kates et al (1984) 52 found a positive family history in 7 out of 38 cases of natal and neonatal teeth. A hereditary transmission of an autosomal dominant gene has also been suggested 24,49.

Table 2. Syndromes and developmental disturbances related to natal and neonatal teeth Syndromes and developmental disturbances

Author(s)

Ellis-Van Creveld syndrome

Himelhoch(1988) 47; Kurian et al(2007) 64

Hallerman-Streiff syndrome

Fonseca and Mueller(1995) 35; Oshihi et al (1986) 87

Patent ductus arrteriosus and intestinal pseudo-obstruction

Harris et al (1976) 43

Opitz (G/BBB) syndrome

Shaw et al (2006)103

Van der Woude syndrome

Hersh and Verdi (1992) 46

 Pachyonychia congenital (Jadasshon- Lewandawsky syndrome)

Feinstein et al (1988) 34

Steatocystoma multiplex

King and Lee (1987) 56 Pivnick et al (2000), Arboleda (1997); Byung-Duk and Jung-Wook (2006); Castiñeyra et al (1992), Korniszewski et al (2001) 91,7,18,22,62 Alvarez et al (1993) 4

Wiedermann-Rautenstrauch neonatal progeria Pfeiffer syndrome type 3 Walker Warburg syndrome (Congenital hydrocephalus with congenital glaucoma)

Mandal et al (2002)73

Hyper IgE syndrome

Roshan et al (2009) 98

Rubinstein-Taybi syndrome

Hennekam and Van Doorne (1990) 45

Bifid tongue and profound sensorineural hearing loss

Darwish, Sastry and Ruprecht (1987) 26

Cyclopia

Boyd and Miles (1951) 16

Transient Pseudohypoparathyroidism

Koklu and Kurtoglu (2007) 61

Pierre Robin syndrome

Kharbanda et al (1985) 54

Down syndrome

Ndiokwelu et al (2004) [85]

Short rib-polydactyly syndrome type II (Saldino-Noonan syndrome )

Strømme Koppang, Boman and Hoel (1983) 113

Soto’s syndrome

Callanan, Anand and Sheehy (2009) 20

Adrenogenital syndrome

Leung (1989) 67

Epidermolysis bullosa simplex

Liu, Chen and Miles (1998) 69

Cleft lip-palate

Cabate et al (2000)19

Odonto-Tricho-Ungual-Digital-Palmar Syndrome

Mendoza and Valiente (1997) 81

Bloch-Sulzberger syndrome (incontinentia pigmenti)

Wolf (2007) 122

Goltz syndrome

Dias et al (2010) 28

Teebi hypertelorism syndrome

Koenig (2003) 59

Clouston syndrome

Reynolds, Gold and Scriver (1971) 96

Finlay-Marks Syndrome

Taniai et al (2004) 114

Beare-Stevenson Syndrome

Tao et al (2010) 115

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Natal and Neonatal Teeth 135

Another theory explaining the premature eruption is they occur in pairs 65,123. The eruption of more than 2 teeth is rare. Despite that, Masatomi et al 77 in 1991 reported an considered to be the abnormal position of the germ during its development in the alveolar bone 8,97. Furthermore, 18-month-old Japanese boy with 14 natal teeth, Gonçalves Clergueau-Guerithault proposed that the eruption of natal et al40 in 1998 presented the case of a newborn with 12 natal teeth and Portela et al 92 in 2004 reported a newborn and neonatal teeth could be dependent on osteoblastic with 11 natal teeth. activity within the area of the tooth germ 102.  Natal teeth are described as conical or normal in As far as environmental factors are concerned, some environmental toxins are considered to be size and shape, yellowish, with hypoplastic enamel and 37,100,123. causative factors. Gladden et al (1990) 39 reported that dentin, and poor or absent root development 13 of 128 newborns, whose mothers where exposed to The hypoplastic enamel might be related to gingival 52 and has a tendency to discolour. The  polychlorinated binephyls and dibenzofurans during the covering Yusheng environmental accident in Taiwan, had natal incomplete root formation is the reason for the great teeth. Also, 2 out of 12 live-borns from parents poisoned mobility of the natal and neonatal teeth. As far as histological characteristics are concerned,  by PCBs in Kyushu, Japan were reported to have natal 82 2 despite the normal basic structure of the natal teeth, teeth . Another report by Alaluusua et al (2002) supports that there is no association between milk levels early eruption is associated with hypo-mineralization of  52 of polychlorinated binephyls, and dibenzofurans and the the enamel, which is usually described as dysplastic , occurrence of natal teeth. They suggest that the prevailing reduced in thickness and covering only the two thirds of  6,42 111 levels of polychlorinated binephyls and dibenzofurans are the crown , but has a normal ultrastructure . Complete 3,78 likely below the threshold to cause prenatal eruptions of  absence of enamel is noted rarely . The enamel for  the age of the child is normal but since the tooth erupts teeth. Moreover, the presence of natal and neonatal  prematurely the matrix of the non-calcified enamel wears teeth has been associated with many syndromes and off in time and this is probably the reason why their  developmental disturbances but there is no conclusive crowns look small in size and appear yellow brown in colour 52. The dentino-enamel junction seems irregular 42. evidence of a correlation with these systemic conditions 25. Dentin and predentin appear normal coronally, The conditions that are related with the appearance of   but become irregular and with reduced number of  natal teeth are shown in the table 2. dentinal tubules and large inter-globular spaces with  Natal and neonatal teeth have also been reported in 14,16,42 cervically and bonelike cutis gyratum and acanthosis nigricans 10, Turnpenny abnormal cell inclusions apically resembling osteodentin, which is attributed to ectodermal dysplasia 119, in association with primary stimulation by movement of the teeth. It has been further  congenital glaucoma 72, in a case of an anencephalic suggested that the mobility may cause degeneration of  infant with cleft palate 74, in association with giant Hertwig’s sheath, thus preventing root development and congenital nevocellular nevus 53, in a case of restrictive stabilization109. Increased mobility causes histological dermopathy79, in a case of multiple joint dislocations with changes in the cervical dentin and cementum 6,42,109. metaphyseal dysplasia90, in a case of multiple anomalies: Cementum is either absent 14 or, if present, shows variation natal teeth, palatal cyst, bilateral lymphangiomas of the in thickness covers the cervical third of the crown and alveolar ridge and median alveolar notch 21, in a case of  is usually acellurar 42. The pulp tissue has a normal complex craniofacial anomalies 112, in Mohr syndrome 9 appearance but the pulp cavity and the radicular canals are and in association with syringomas and oligodontia 83. wider 6,42,110. It is suggested that tooth abnormalities are dysmorphic In neonatal teeth the differences from normal markers of earlier developmental abnormalities, and could  primary dentition are less pronounced due to their more give warning signs in a syndrome diagnosis 13. mature state at the time of eruption 6. Root formation in natal and neonatal teeth is grossly deficient 14.

Clinical and Histological Characteristics

Differential Diagnosis

Regarding clinical characteristics, the most affected Most of the teeth that occur in the oral cavity at birth teeth are the lower primary central incisors (85%), or during the first days of life represent the early eruption followed by the maxillary incisors (11%), mandibular  of the normal primary deciduous dentition 44,65. The canines and molars (3%) and maxillary canines and  prevalence of supernumerary teeth has been suggested molars (1%)123. Another characteristic of natal teeth is that to range from 1-10% 17,37,123. At this point, it is important

136 I. Markou et al. to mention the need of radiographic examination, in order to differentiate the premature eruption of a primary deciduous tooth from a supernumerary tooth 15,25,65. Moreover, radiographic verification reveals the root development of the tooth, adjacent structures and the existence of a relative germ in the primary dentition. There are also 3 types of inclusion cysts that might  be confused with natal teeth: Epstein’s pearls, Bohn’s nodules and dental lamina cysts. Epstein’s pearls are located along the mid-palatine raphe in the line of fusion of embryonic palatal processes. They are true cysts derived from residual ectodermal cells covering these  processes. The cysts are lined by stratified squamous epithelium and the lumen contains keratin 24. Bohn’s nodules are usually multiple and located along the buccal and lingual aspects of the mandibular and maxillary ridges68. They represent remnants of minor mucous salivary glands. They are true cysts comprised of stratified squamous epithelium lining a dense fibrous connective tissue wall that contains mucous acinar cells and wellformed ducts. The clinical appearance of Epstein’s pearls and Bohn’s nodules is similar. They are both small white-gray, raised nodules, 0.5-3 mm in diameter and no treatment is necessary 24. The third type of cyst is dental lamina cyst which appears as single or multiple swellings on the maxillary or mandibular ridges. These cysts, also known as gingival cysts of the newborn, are lined by thin epithelium and show a lumen usually filled with desquamated keratin, occasionally containing inflammatory cells. It is believed that they are created by fragments of dental lamina that remain within the alveolar ridge mucosa after tooth formation. Most of them degenerate and involute or  rupture into the oral cavity within two weeks to five months of postnatal life63. Furthermore, natal teeth should be discriminated from epulis and odontogenic hamartomas. Epulis are tumour-like growths of the gum that might be either  sessile or pedunculated, and are reactive rather than neoplastic lesions 68. Odontogenic hamartomas are tumour-like lesions, without the growth characteristics of  a neoplasm, and develop during the time dental structures remain capable of further development and maturation 38.

Complications Problems that arise from the presence of natal and neonatal teeth include interruption in breastfeeding 93 either by pain on suckling or by ulceration of the mother’s nipples, but the infant’s tongue usually overlies the lower incisors while nursing and any trauma will be to the infants tongue rather than mother’s

Balk J Stom, Vol 16, 2012  breast106, inflammation of the surrounding tissues, pain associated with mobility, which all may lead to refusal to nurse52. Although no case is reported, there is usually a concern about aspiration or swallowing of the teeth due to excessive mobility or spontaneous exfoliation 95. Furthermore there can be teething symptoms just as with eruption of the primary teeth 52 or even infantile diarrhea, drooling and malaise106,110 . The development of an abscess, probably due to the loss of attachment, has also  been reported32,51. A complication that is common with natal teeth is ulceration of the tip or the ventral surface of the tongue, known as Riga-Fede disease. The ulceration occurs after repetitive tongue thrusting not only in newborns  but also to elder infants with the eruption of the primary mandibular central incisors and in children with familiar  dysanatomia107. There has also been a report of prenatal ulceration of the tongue due to natal teeth 58. The lesion  begins as an ulcerated area and with repeated trauma it may progress to an enlarged fibrous mass with the appearance of a granuloma. The pain occurring from the ulceration often results on dehydration, feeding difficulties and discomfort. It also may lead to bleeding and in a child with other medical problems a potential of  infection is added to the concerns 107. Periapical abscess is  possible because enamel breakdown may lead to carries 52. Another complication in children with cleft lip-palate is the potential interference in naso-alveolar moulding 124. There have also been reported a case of reactive fibrous hyperplasia by a natal tooth 106, hypoplasia of   primary and permanent teeth following osteitis due to infection by neonatal tooth 55 and also microdontic teeth succedaneous to natal teeth, suggesting that there might be some unknown developmental influence common to the occurrence of natal teeth and abnormally small (mesiodistal dimension) permanent successors 75 and in neonatal orthopaedics31.

Management The treatment plan for natal and neonatal teeth has many factors to consider. If the tooth is not interfering with the nutrient intake of the child and is otherwise asymptomatic no intervention should be made 78. Although it is difficult to determine initially whether root formation will occur in natal or neonatal teeth 104 those teeth that are stable beyond 4 months have a good prognosis 52. The retention of a natal tooth, which is part of the normal  primary dentition, is suggested because of possible space loss, although the opinions differ 23,32,38. If the tooth is supernumerary or has an excessive mobility, if it is poorly developed or is associated with soft tissue growth 106 or if 

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Natal and Neonatal Teeth 137 

it interferes with naso-alveolar moulding 124 or presents Paediatric dentists should educate parents 32,51,52 an abscess, the treatment of choice is extraction . and medical community about the preferred treatment and should conduct any necessary extraction in order  Before extraction, a dental radiograph should be obtained in order to inform the parents of possible complications to prevent trauma. The child should be re-evaluated and to get their consent. It is suggested to leave the tooth  periodically to ensure oral health. Management of natal and neonatal teeth should consist of concern to avoid in the mouth as long as possible in order to decrease the  possibility of removing permanent tooth buds with the any complication, to make early diagnosis and provide natal tooth or risk defecting them 76. The possibility of  adequate treatment. hypoprothrombinaemia should be taken into consideration as the commensal flora of the intestine might not have  been established until the child is 10 days old. Since Conclusion vitamin K is essential for the production of prothrombin in the liver it should be administered before extraction  Natal and neonatal teeth are rare conditions (0.5-1.0 mg, intramuscularly) if the routine postnatal in infancy. Most commonly involved teeth are the injection is not given 32. Also, haemophilia should be mandibular central incisors. Despite the fact that the investigated38. The extraction is usually done under local exact etiology is still unknown, superficial position of  anaesthesia but can also be done without anaesthesia the tooth germ with association of hereditary factors is depending on the gingival attachment, with the use of  the most accepted possibility. Many complications may gauze as a pharyngeal guard 32. After the extraction, it is occur with the nursing problem most commonly reviewed. advised to curette the socket to prevent the cells of the Treatment and periodic follow-up should be conducted by dental papillae from continuing to develop and erupting as a paediatric dentist. odontogenic remnants 11,25,108. If curettage is to become the routine treatment, then the injection of local anaesthetic to provide adequate anaesthesia would be required 32. Residual natal teeth have been reported with a risk of  References formatting without curettage about 9.1% 32, 86, myxoid 1.  Agostini M, León JE, Kellermann MG, Valiati R, Graner  calcified hamartoma 1, pulp polyp as erupted remnants 121,  E, de Almeida OP . Myxoid calcified hamartoma and natal  pyogenic granuloma due to trauma during extraction 84 and teeth: A case report.  Int J Pediatr Otorhinolaryngol , 2008;  peripheral ossifying fibroma 60. 72(12):1879-1883. 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 JC . A four generation hidrotic ectodermal dysplasia family: an allelic variant of Clouston syndrome? Clin Dysmorphol , 1995; 4(4):324-333. 120. Uzamis M, Olmez S, Ozturk H, Celik H . Clinical and ultrastructural study of natal and neonatal teeth.  J Clin

 Pediatr Dent , 1999; 23(3):173-177. 121. Vergotine R, Hodgson B, Lambert L. Pulp polyp associated with a natal tooth: Case report.  J Clin Pediatr Dent , 2009; 34(2):161-163. 122. Wolf N . Dental anomalies in neuropediatric disorders.

 Medizinische Genetik , 2007; 19(4):414-417. 123. Zhu J, King D. Natal and neonatal teeth.  ASDC J Dent  Child , 1995; 62(2):123-128. 124. Ziai MN, Bock DJ, Da Silveira A, Daw JL . Natal teeth: A  potential impediment to nasoalveolar molding in infants with cleft lip and palate.  J Craniofac Surg , 2005; 16(2):262-266.

Correspondence and request for offprints to: Arhakis Aristidis Ermou 73 54623 Thessaloniki, Greece E-mail: [email protected]

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The Maxillary Labial Fraenum A Controversy of Oral Surgeons vs. Orthodontists SUMMARY

The maxillary labial fraenum is a normal anatomic structure in the oral cavity, formed by mucous membrane and connective tissue. Although it  is a normal structure, its presence has been associated with some unpleasant  and even pathological situations. Specifically, a thick, hypertrophic or broad   fibrous fraenum has been accused of causing a maxillary midline diastema, interfering with plaque removal, causing tension and gingival recession.  A surgical removal of the fraenum is indicated in order to prevent these  situations or facilitate orthodontic closure of the diastema. Frenectomy is the complete removal of the fraenum, including its attachment to the underlying  bone. As shown in the literature there has been a controversy among  researchers regarding the need of frenectomy and the time of the surgery. The purpose of this study was to demonstrate the controversy of  researchers regarding the removal of the maxillary labial fraenum, as a result of the study of the literature. Additionally, there has been an attempt to suggest the appropriate therapeutic strategy and indications for   frenectomy, counting the medical experience and the patient’s needs. At the beginning of the study, it was important to cite the characteristics of normal  and abnormal fraenum and consequences that presence of a pathological   fraenum causes. Finally, there is a brief description of the most important   surgical techniques for removal of the maxillary labial fraenum. Keywords: Maxillary Labial Fraenum; Frenectomy, controversy

Introduction The maxillary labial fraenum is a normal anatomic structure in the oral cavity, usually triangular in shape, extending from the maxillary midline area of the gingiva into the vestibule and mid-portion of the upper lip 16. It consists of epithelium, collagen fibres, blood vessels, nerves and sometimes few elements of minor salivary glands and isolated stratified muscle fibers 19,42. The fraenum is a dynamic and changeable structure, which tends to have variations in size, shape, and position of attachment during the different stages of growth and development 12. It is found to be smaller in length, thicker and more inferiorly attached in children 12,34. The eruption of primary incisors, the development of the maxillary sinus and vertical growth of the alveolar process make that insertion of the fraenum moves apically 28. In

Eva Lioliou, Apostolos Kostas, Lampros Zouloumis

Department of Oral and Maxillofacial Surgery, Aristotle University, School of Dentistry, Thessaloniki, Greece

LITERATURE REVIEW (LR) Balk J Stom, 2012; 16:141-146

some of the cases a variation may lead to an “abnormal fraenum”; a fraenum which appears inordinately large or is attached especially close to the gingival margin 16. Henry et al25, in their histological study, concluded that there are also elastic fibres which extend sometimes to the whole length of the fraenum, even perforating the  periosteum. Those authors considered that the harmful effect of the fraenum is due to the presence of the elastic and collagen fibres, while no evidence of substantial differences in composition of normal and abnormal fraena were identified. Miller characterized as “pathological” a fraenum which is uncommonly wide, when there is insufficient attached gingival zone in the midline, and when the interdental papilla moves by stretch of the fraenum35. An abnormal labial fraenum has been implicated in functional and aesthetic problems, such as a maxillary

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midline diastema. Regarding the maxillary midline 6. When a maxillary labial fraenum prevents the diastema, two ways were suggested in which the fraenum installation of a removable denture; may cause it. In the first way, the bulk of the fraenum 7. In rare occasions, for aesthetic reasons. fibres, retaining their embryological connection with the incisive papilla, will physically prevent approximation of central incisors2,15,22. Alternatively, these fibres will interrupt the fibres of the periodontal ligament between The Fraenum by the central incisors and produce a weak link in the chain Orthodontic Approach of fibres that join the teeth from one end of the arch to the other 1,5,13. The presence of the maxillary labial fraenum has a High fraenum insertion can lead to gingival recession great significance for the orthodontic community, since due to the tension which is applied on the tissues during it is considered to be the commonest causative factor for  normal functions, such as speaking, chewing, and a maxillary midline diastema. An abnormal fraenum has laughing4,21,24,37,44. Moreover, a fraenum that encroaches also been accused of being a great danger for relapse after  on the gingival margin and prevents the closure of space orthodontically treated diastema. Consequently, maxillary  between the maxillary central incisors creates an area labial frenectomy was considered for many years as the for food impaction and difficulty in plaque removal 24,37. indicated treatment for maxillary midline diastema 9,14,34,37. The poor oral hygiene, due to difficulty in tooth brushing There has been a controversy even among results in inflammatory periodontal destruction 33. orthodontists concerning the need at all, and the timing Aesthetics could be affected as well in cases of a high for a frenectomy. Some orthodontists support a viewpoint smile line4,44. Finally, a big and high attached fraenum that there is a need for an early removal of the fraenum, could eliminate lip movement 4. so as to prevent any obstacles to complete diastema Over the years, the relationship between the closure. Other orthodontists propose to close the diastema maxillary midline diastema and the labial fraenum has first, and then carry out frenectomy in the hope that the  been the subject of much controversy and confusion. resultant scar tissue will hold together the teeth in close In the 1939, Hirschfield advocated frenectomy as a apposition. A third body of clinicians rarely, if ever, mucogingival procedure to eliminate the aforementioned considers surgical removal of the fraenum. They prefer to  pathologic situations caused by an abnormal fraenum attachment44. There is still a controversy among combat the undeniably increased relapse potential when a researchers concerning the need for it at all, as well as the diastema is closed, by using bonded retainers on the two central incisors 6,31,37. right time for frenectomy. Literature offers a great variety of opinions during Many orthodontists support the idea that even in years and it is obvious that they differ a lot concerning cases of an abnormal fraenum we should wait the eruption of all 6 permanent anterior teeth first. If the eruption of  the etiology of a persisting diastema, such as to the all 6 permanent teeth has failed to close the diastema,  possibility of promoting closure of a diastema by means 9 frenectomy has a clinical validity only in conjunction of frenectomy . At the beginning it was thought that the labial with orthodontic treatment 16,27. They also state that the relapse of orthodontically treated diastema caused by an fraenum interfered with the closure of the midline abnormal fraenum, which had not been excised, is a rare diastema. This belief resulted in misdiagnosis and 13,14.  phenomenon3,5,16. On the other hand, surgeons accuse unnecessary surgical intervention of the fraenum Adams1 suggested that there is a specific type of fraenum a hyperplastic type of fraenum, usually with a fanlike which interrupts the continuity of interdental fibre, forms attachment, of causing a diastema and enhancing the  possibilities of a relapse. A frenectomy could als o prevent the factor that inducts the reaction for the development the other unpleasant situations cited previously, such as of the diastema. Although, he stated that there is a need of presence of other causative factors. Campbell et al 11 gingival recession4,9,23,24,28,33,37. 43 There are some clinical situations in which a stated the same. Shashua and Artun found that there is a relationship between abnormal fraenum and the width maxillary labial frenectomy is indicated 4,24,37,49: of the maxillary midline diastema. Edwards 16 supported 1. To avoid a relapse of an orthodontically treated the presence of a strong but not absolute correlation maxillary diastema; 2. In cases with a too short labial fraenum, which creates  between the fraenum and the upper midline diastema. Gardiner 18 made a survey of 1000 children 5-15 years old.  problems in upper lip movement, speech etc; 80% of the cases with midline diastema were associated 3. To avoid gingival recession due to tension created with a prominent fraenum. He took this finding as an during the normal oral function; evidence to support the opinion that the fraenum is often a 4. To facilitate lip lengthening procedure; contributory cause of midline diastema. Angle 2 concluded 5. To allow effective tooth brushing in the area of the fraenum; that the presence of an abnormal fraenum is a cause for 

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midline diastema. James 29 used a sample of 10 girls 12-22 In case of a diastema, a hyperplastic type of fraenum, years old with medial diastema. A year after frenectomy, with a fanlike attachment, can inhibit the closure of the a reduction was noted in 8 cases. He assumed that diastema or even lead to a relapse of an orthodontically frenectomy leads to a reduction of the diastema. By the corrected diastema. Studies reveal that a midline diastema time researchers rejected this statement and proved that has closed earlier in operated cases. Thus, the result there is no evidence to establish a relationship between the implies that frenectomy is indicated, if early closure of the different types of fraenum and diastema. diastema is considered desirable, especially if patient finds 46 Tait stated that the fraenum has no effect to the it very unsightly9. maxillary central incisors. Ceremelo 12 concluded that The advantage of an early excision prior to the fraenum is not related to the presence or the width orthodontic treatment is the ease of surgical access 33,37. of the diastema. Bergstorm et al 9 stated that the long Access to the surgical procedure is more limited after  term potential for spontaneous diastema closure, in orthodontic closure and it will not be possible to remove  patients with abnormal fraenum, has no difference even all the residual fibrous tissue thoroughly from the if there has been a frenectomy, or not. Popovich et al 40,41 interdental suture area 37. suggested that the presence of the diastema leads to the In guides of paediatric, oral surgery treatment is abnormal fraenum, and not the adverse. suggested when attachment exerts a traumatic force on the Since there is no quite evidence concerning the fact gingiva, causing the papilla to blanch when the upper lip that the maxillary labial fraenum is the main causative is pulled, or if it causes a diastema to remain after eruption factor for a midline diastema, some orthodontists propose of permanent canines 23. the following therapeutic methodology 37,45: Initially, it Interference with oral hygiene measures, aesthetics is necessary for the dentist to make a diagnostic trial, in and psychological reasons are contributing factors that order to find out whether the fraenum is implicated in the relate the treatment of the maxillary fraenum 23.  pathogenecity of the diastema. Also, elimination of the maxillary labial fraenum is 1. Positive “blanch test” of the incisal papilla, when often indicated in edentulous or partial edentulous patients  pulling the lips forward. By pulling the upper lip and to allow denture flange extension in this area 49. exerting pressure on the fraenum, if there is a blanching, (ischemia in the papilla) it is safe to predict that the fraenum will unfavourably influence the development of  The Fraenum by the anterior occlusion; 2. With the use of a periapical radiograph, in the Periodontal Approach area of central incisors we can discover: a presence of a mesiodens, an odontoma in the middle line; a presence The labial frenectomy must be examined by the of residual suture of alveolar bone. If we find out that the aspect of periodontists as well. In 1950, Friedman was diastema in our case is related to the fraenum, a maxillary the first to introduce the term “mucogingival surgery”, labial frenectomy is indicated. in order to describe techniques that aim to preserve the It is important to emphasize on the fact that attached gingiva, remove aberrant fraenum or muscle frenectomy has clinical validity only after the eruption attachment and increase the depth of the vestibule 36. of all 6 permanent teeth if it failed to close the diastema, For years, clinicians targeted in removing the fraenum and then only in conjunction with orthodontic treatment. or deepening the vestibule 17; today, it is approved that So after the eruption of all 6 permanent teeth, orthodontic the presence of an adequate zone of attached gingiva appliances are used to close the diastema. A frenectomy is the basic factor. When there is an adequate zone of  is carried out, so as the scar tissue will hold the teeth attached gingiva, even a high fraenum attachment does together 16,20,27,33,37,39,48. not constitute dangerous factor for the beginning and the During the primary dentition phase, surgical  process of periodontal disease. On the other hand, in the intervention of the labial fraenum is not recommended 7. case of inadequate zone of the attached gingiva, the draw of the fraenum and muscle attachment cannot be balanced, there is inability of good and atraumatic oral hygiene, and this is a fact that usually leads to gingival recession 32,36. The Fraenum by Consequently, there exist anatomic (not adequate zone of  attached gingiva), biologic (inflammation, inability for  Oral Surgery Approach good oral hygiene) and functional (inability for protection Oral surgeons accused an abnormal fraenum of  during chewing procedure) factors that lead to the causing unpleasant situations, such as maxillary midline decision of frenectomy 32. The maxillary labial fraenum diastema and consequently suggested the operation of  may present the aesthetic problem as well, compromise an maxillary labial frenectomy 20,36. orthodontic result or create traumatic problems in tissues

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during oral hygiene actions. These situations also need and periosteum exposed 3. After that, some modifications surgical intervention 32. include the addition of horizontal relaxing incisions and The initial approach was to remove the fraenum the mucogingival junction, and the lateral underlying with simultaneous deepening of the vestibule. Later, this of the labial attached gingiva adjacent to the excision technique was replaced by plastic surgery, which aimed area. Disagreements have been expressed because of  to cover the root of the tooth. Another technique was a the increased possibility for creating hematoma and frenectomy with a gingival augmentation procedure, using concerning the need for a dressing over the wound 16. a pedicle graft 36. Another procedure that was described called “the Edwards16 used a sample of 308 patients, who prior  z-plasty technique”. In this technique, the fraenum is to orthodontic treatment demonstrated either diastema not removed but it is intended to relax the pull of the an abnormal fraenum or a combination of both. In his fraenum on the interdental soft tissue 16,20. By the aspect of  technique he noticed the aesthetic maintenance of the  periodontists, there has been described a frenotomy with interdental papilla between the central incisors. Miller  no excision of the marginal papilla, and “the curtain type” chose a surgical technique in which he avoided removal of  of gingivotomy of the palatal tissue behind 4 incisors the entire fraenum, but emphasized in orthodontic stability (Frisch, Jones, Bhaskar)16. Other clinicians combined the without aesthetic sacrifice. His technique seemed to be classic frenectomy with a lateral pedicle graft, free papilla similar, but Edwards thought that the transeptal fibres of  graft and free gingival graft taken from the papilla 4,20. A the fraenum should be destroyed, whereas Miller made lateral pedicle graft does not offer a complete coverage no effort to destroy transeptal fibres 35,36. Regarding the of the wound and has aesthetic problems creating an interdental papilla, it proved that it should be maintained, unsatisfactory colour match 4. A technique known as even though clinically it may appear to be a part of the “Archer incision” is a simple frenectomy that is made 36 labial fraenum . with a V-shaped incision 3. The disadvantage of this Periodontists do not tend to use the classical technique is that it leaves a longitudinal surgical incision frenectomy, in which interdental tissue and palatine and scarring, which may lead to periodontal problems and  papilla are completely excised. Today, we use frenectomy an non-aesthetic appearance 4. in which we have a partial removal of the fraenum and Recently a new frenectomy technique has been relocate it to a more apically position. This technique  proposed by Bagga et al 4, which provides a good aesthetic leads to an acceptable solution of the problem and to the result. In this technique, a V-shaped full-thickness incision 16,44 movement of the fraenum more apically . was placed at the gingival base of the fraenum attachment. In case of a diastema, the ideal time for this After the excision of a fraenum, a V-shaped defect on the technique is after the beginning of orthodontic treatment gingiva side has remained. An oblique partial thickness and about 6 weeks before the appliances are removed. incision is placed on adjacent attached gingiva extending That allows healing, tissue maturation and does not  beyond the mucogingival junction. A partial-thickness  prolong orthodontic treatment36. dissection of the attached gingiva is formed in an apicocoronal direction. Then we have a triangular pedicle of the attached gingiva with free apex and the base continuous with the alveolar mucosa. Finally, a bilateral triangular   pedicle is sutured at the centre, covering the underlying Surgical Techniques defect4. Various surgical techniques have been described for the management of the abnormal upper labial fraenum8,20,30. It is important to refer that there is a distraction between the terms “frenectomy” and Discussion “frenotomy”. Frenectomy is the complete removal of the fraenum including its attachment to underlying bone; The study of the literature reveals that the presence frenotomy is the partial removal of the fraenum and is of the maxillary labial fraenum has been associated used extensively for periodontal purposes to relocate the with many pathological situations in the oral cavity; fraenum attachment, so as to create an increased zone of  the most common of them is the maxillary midline the attached gingiva between the gingival margin and the diastema. Consequently, for decades there has been a fraenum16,24,37. tendency from every part of the dental community, to 2 main ways for the removal of the fraenum are remove the fraenum at an early age in order to achieve the conventional technique with scalpels or periodontal the diastema closure. 13 Many researchers dealt with this knives and the technique with the use of soft tissue issue and many research papers have been published. laser 24,47. Archer described the classic frenectomy The therapeutic approach gradually changed into a more technique in which the fraenum, interdental tissues and conservative management and a controversy among  palatine papilla are completely excised, leaving bone researchers started, existing until nowadays.

 Balk J Stom, Vol 16, 2012 In the orthodontic community there is unanimity on this issue37. Orthodontists support that the fraenum should be maintained until the age of the eruption of all 6 permanent anterior teeth. After that, and only if the diastema remains the same, a frenectomy is indicated, with subsequent orthodontic closure of the diastema 9,16. Periodontists concentrate on the issue of the adequate zone of the attached gingiva. In case of inadequate zone of  the attached gingiva, the increased tension causes gingival recession and a frenectomy is recommended 24,32,36. Oral surgeons suggest that in case of a maxillary midline diastema, a small intervention of the fraenum is useful. In this way, the closure of the diastema is facilitated and the orthodontic treatment is not affected 9,20. In cases that the fraenum causes problems in periodontal tissues, such as gingival recession, the removal of the fraenum should be direct 24,44. Moreover, it is quite clear that when the presence of the maxillary labial fraenum interrupts the installation of a removable denture, the removal of the fraenum is imperative49. Today, the belief that the presence of a maxillary midline diastema does not prompt an early frenectomy  predominates. We must wait for a short period, specifically until the eruption of all 6 permanent anterior  teeth9,14,16,20,34,36,37. Yet, this is acceptable if the fraenum is not responsible for other pathological situations in the oral cavity. On the other hand, it is important to remember that the final decision is taken by patients. The duration and the cost of the treatment are 2 basic factors. Patients rarely compromise with expensive and long-term procedures, especially if these include orthodontic treatment which affects aesthetics8,9.

References 8.  Adams CP . The relation of spacing of the upper central incisors to abnormal labial fraenum and other features of the dento-facial complex.  Dent Prac Dent Rec, 1954; 74:72-86. 9.  Angle EH . Malocclusion of the teeth. 7 th ed. Philadelphia: White dental manufacturing, 1907. 10.  Archer WH . Oral surgery for dental prosthesis. In: Archer  WH (Ed). Oral and maxillofacial surgery. Philadelphia: Saunders, 1975; pp 135-210. 11.  Bagga S, Bhat KM, Bhat GS, Thomas BS . Esthetic management of the upper labial fraenum: a novel frenectomy technique. Quintessence, 2006; 37:819-823. 12.  Baum AT . The midline diastema.  J Oral Med , 1966; 21:3039. 13.  Beasley WK, Maskeroni AJ, Moon MG, Keating GV,  Maxwell AW . The orthodontic and restorative treatment of a large diastema: a case report. Gen Dent , 2004; 52:37-41. 14.  Bedell WR. Nonsurgical reduction of the labial fraenum with and without orthodontic treatment.  J Am Dent Assoc , 1951; 42:510-515.

The Maxillary Labial Fraenum 145 15.  Bell WH . Surgical-orthodontic treatment of interincisal diastemas.  Am J Orthod , 1970; 57:158-163. 16.  Bergstrom K, Jensen R, Martensson B. The effect of  superior labial frenectomy in cases with midline diastema.  Am J Orthod , 1973; 63:633-638. 17. Campbell A, Kindelan J . Maxillary midline diastema: a case report involving a combined orthodontic/maxillofacial approach.  J Orthod , 2006; 33; 22-27. 18. Campbell PM, Moore JW, Matthews JL. Orthodontically corrected midline diastemas. A histologic study and surgical  procedure.  Am J Orthod , 1975; 67:139-158. 19. Ceremello PJ . The superior labial fraenum and the midline diastema and their relation to growth and development of  the oral structures.  Am J Orthod , 1953; 39:120-139. 20.  Dewel BF . The labial fraenum, midline diastema, and  palatine papilla: a clinical analysis.  Dent Clin North Am, 1966; pp 175-184. 21.  Diaz-Pizan ME, Lagravere MO, Villena R. Midline diastema and fraenum morphology in the primary dentition.  Journal  of dentistry for children, 2006; 73:11-14. 22.  Dickson GC . Orthodontics in general dental practice. London: Pitman, 1964. 23.  Edwards JG. The diastema, the fraenum, the frenectomy: A clinical study. Am J Orthod , 1977; 71:489-508. 24.  Friedman N . Mucogingival surgery. Texas Dent J , 1957; 75. 25. Gardiner JH . Midline spaces.  Dent Prac Dent Rec, 1967; 17:287-298. 26. Gartner LP, Schein D. The superior labial fraenum: a histologic observation. Quintessence Int , 1991; 22:443-445. 27. Gkantidis N, Topouzelis N, Zouloumis L . Differential diagnosis and combined treatment of maxillary midline diastema caused by the fraenum and/or intermaxillary suture. Balk J Stom, 2008; 12:81-88. 28. Gottsegen R. Fraenum position and vestibule depth in relation to gingival health. Oral Surg Oral Med Oral Pathol , 1954; 7:1069-1078. 29. Graber TM . Orthodontics: Principles and Practice. Philadelphia: Saunders, 1972. 30. Guideline on Pediatric Oral Surgery, American Academy of  Pediatric Surgery (AAPD). 2010; p 8. 31.  Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques.  J Periodontol , 2006; 77:18151819.  Henry SW, Levin MP, Tsaknis PJ . Histologic features of the 32. superior labial fraenum.  J Periodontol , 1976; 47:25-28.  Herremans EL. Anterior diastema: frenectomy.  Dent Surv, 33. 1971; 47:33-37. 34.  Huang SW, Creath CJ . The midline diastema: a review of its etiology and treatment.  Pediatr Dent , 1995; 17:171-179. 35.  Jacobs MH . The abnormal fraenum labii.  Dent Cosmos, 1932; 74:436-439. 36.  James GA. Clinical implication of a follow-up study after  frenectomy. Dent Pract , 1967; 17:299-305. 37.  Kahnberg KE . Fraenum surgery. A comparison of three surgical methods.  Int J Oral Surg , 1977; 6:328-333. 38.  Kinderknecht KE, Kupp LI . Aesthetic solution for large maxillary anterior diastemas and fraenum attachment.  Prac  Periodontics Aesthet Dent , 1996; 8:95-102. 39.  Konstantinidis A. Periodontology. Vol 1.Thessaloniki: Konstantinidis A, 2003; p 77.

146 Eva Lioliou et al. 40.  Koora K, Muthu MS, Rathna PV . Spontaneous closure of  midline diastema following frenectomy.  J Indian Soc Pedo  Prev Dent , 2007; 25:23-26. 41.  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; 143:327-332. 42.  Miller PD Jr . The frenectomy combined with a laterally  positioned pedicle graft. Functional and esthetic considerations.  J Periodontol , 1985; 56:102-106. 43.  Miller PD Jr . Regenerative and reconstructive periodontal  plastic surgery. Dent Clin North Am, 1988; 32:287-305. 44.  Mittal M . Maxillary labial fraenectomy: indications and technique.  Dent Update, 2011; 38:159-162. 45.  Munshi A, Munshi AK . Midline space closure in the mixed dentition: A case report.  J Indian Soc Pedo Prev Dent , 2001; 19:57-60. 46. Oesterele LJ, Shellhart WC . Maxillary midline diastema: a look at the causes.  J Am Dent Assoc, 1999; 130:85-94. 47.  Popovich F, Thompson GW, Main PA. The maxillary interincisal diastema and its relationship to the superior  labial fraenum and intermaxillary suture.  Angle Orthod , 1977; 47:265-271. 48.  Popovich F, Thompson GW, Main PA. Persisting maxillary diastema: differential diagnosis and treatment.  Dent J , 1977; 43:330-333. 49.  Ross RO, Brown FH, Houston GD . Histologic survey of the frena of the oral cavity. Quintessence Int , 1990; 21:233-237.

Balk J Stom, Vol 16, 2012 50. Shashua D, Artun J . Relapse after orthodontic correction of maxillary median diastema: a follow-up evaluation of  consecutive cases.  Angle Orthod , 1999; 69:257-263. 51. Sorrentino JM, Tarnow DP . The semilunar coronally repositioned flap combined with a frenectomy to obtain root coverage over the maxillary central incisors.  J Periodontol , 2009; 80:1013-1017. 52. Spiropoulou MN . Basic Principles of Orthodontic. Vol 2. 2006; pp 250-251. 53. Tait CW . The median fraenum of the upper lip and its influence on the spacing of the upper central incisor teeth.  Dent Cosmos, 1924; 76:991-992. 54. Takei HH, Azzi RA. Periodontal plastic and esthetic surgery. In:  Newman MG, Takei HH, Carranza FA (Eds). Carranza’s clinical periodontology. London: WB Saunders, 2002; pp 870-871. 55. Taylor JE  .Clinical observations relating to the normal and abnormal fraenum labii superiors.  Am J Orthod , 1939; 25:646-660. 56. Terry BC, Hillenbrand DG. Minor preprosthetic surgical  procedures. Dent Clin North Am, 1994; 38(2):193-216. Correspondence and request for offprints to: Prof. Lampros Zouloumis Ippodromiou Sq 17 54621, Thessaloniki,Greece E-mail: [email protected] 

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Association between Condylar Position and Tilt of  Frontal Occlusal Plane in Patients with Transversal and Vertical Dentofacial Discrepancy SUMMARY

 Asymmetric malocclusion is a common problem in children with transverse and vertical dental anomalies. These asymmetries can be skeletal, dental, functional or combination of these. The aim of this study was to determine condylar position and quantifying inclination of frontal occlusal   plane in patients with transversal and vertical dentofacial discrepancy. The study group consisted of 80 patients, 40 had unilateral posterior  cross-bite, and 40 had normal occlusion. The age of the patients ranged  between 13 and 18 years. In addition to transversal and vertical clinical  observation, Ricketts facial PA cephalometric analysis was made.  Radiographic analysis showed the relationship between the cant of the occlusal plane and mandibular position. The obtained results showed that there was a very high statistical   significance (p