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© Borgis - Nowa Stomatologia 4/2021, s. 129-141 | DOI: 10.25121/NS.2021.26.4.129
Angelika Kobylińska1, Marcin Studnicki2, *Dorota Olczak-Kowalczyk1
Prevalence of labial and lingual frena attachments in pediatric patients in Warsaw agglomeration – a cross-sectional study
Przyczepy wędzidełek warg i języka w różnych typach uzębienia u pacjentów w wieku rozwojowym w aglomeracji warszawskiej – badanie przekrojowe
1Department of Pediatric Dentistry, Medical University of Warsaw, Poland
Head of Department: Professor Dorota Olczak-Kowalczyk, MD, PhD
2Department of Biometry, Warsaw University of Life Sciences, Poland
Head of Department: Elżbieta Wójcik-Gront, Professor SGGW, PhD, DSc
Streszczenie
Wstęp. Nieprawidłowym przyczepom wędzidełek mogą towarzyszyć diastema, utrudnione oczyszczanie, ograniczona ruchomość języka.
Cel pracy. Określenie częstości występowania rodzajów przyczepów wędzidełek warg i języka w poszczególnych typach uzębienia oraz ustalenie istnienia tendencji do zmiany położenia przyczepu.
Materiał i metody. W badaniu klinicznym pacjentów w wieku do 19. r.ż. w warunkach gabinetu stomatologicznego określono rodzaj przyczepu wędzidełek warg oraz języka według Plačka, typ uzębienia, występowanie wędzideł dodatkowych, szparowatości uzębienia, ograniczonej ruchomości języka, zaburzeń wymowy, urazów mechanicznych tkanek miękkich i przebytych zabiegów frenulotomii/frenuloplastyki. Analiza statystyczna: test chi-kwadrat, U Manna-Whitneya, korelacja rang Spearmana, iloraz szans OR (poziom istotności p < 0,05).
Wyniki. Wśród 305 pacjentów w wieku 1,52-18,08 roku (średnia wieku [± SD]: uzębienie mleczne – 4,25 [± 1,31] roku, mieszane – 8,35 [± 1,75] i stałe – 14,56 [± 2,44]) najczęściej obserwowano przyczep dziąsłowy wargi górnej – 41,97%. U 90,16% występował przyczep śluzówkowy wargi dolnej i języka – 99,02%. Stwierdzono istotną dodatnią korelację między wiekiem a przyczepem śluzówkowym warg. Uzębienie szparowate dotyczyło 19,67% badanych.
Wnioski. Częstość występowania poszczególnych rodzajów przyczepów wędzidełka warg różni się w typach uzębienia. Istnieje tendencja do obniżania się przyczepu – częściej obserwuje się przyczepy śluzówkowy i dziąsłowy wargi górnej u starszych dzieci, a brodawkowy i penetrujący brodawkę u młodszych.
Summary
Introduction. Incorrect labial and lingual frena attachments may be accompanied by diastema, difficult cleaning, and tongue mobility.
Aim. To determine the frequency of lip and tongue frena attachments in relation to the types of dentition and the existence of a tendency to a pical movement of the frena attachment.
Material and methods. Clinical evaluation of labial and lingual frena attachment type according to Plaček classification was carried out in dental office settings in patients up to 19 years of age. Type of dentition, additional frena presence, spacing of dentition, restricted tongue mobility, speech disturbance, soft tissue trauma and frenulotomy/frenuloplasty in history were noted. Statistical analysis: chi-squared test, Mann-Whitney U, Spearmans correlation, odds ratios OR (p < 0.05).
Results. Among 305 patients aged 1.52-18.08 years (mean age [± SD] in years: primary dentition – 4.25 [± 1.31], mixed – 8.35 [± 1.75] and permanent – 14.56 [± 2.44]) the most frequent was gingival frenum attachment of upper lip – 41.97%. Mucosal frenum attachment of lower lip was noted in 90.16% and lingual frenum attachment in 99.02%. There was a positive correlation of age and mucosal frenum attachment of upper lip. In 19.67% spacing of dentition was present.
Conclusions. The frequency of labial frenum attachment location differs in relation to dentition type. There was a tendency to apical movement of frenum attachment of upper lip – mucosal and gingival location of frenum attachment was more frequent in older patients, papillary and penetrating in younger ones.



Introduction
The frenulum is the fold of mucous membrane that attaches the lip and cheek or tongue with the alveolar mucosa, the gingiva, and the underlying periosteum. The oral cavity involves the upper and lower labial frenula and the tongue; there may also be additional frenulum. The labial frena attachment is a thin fold of mucous membrane with muscle fibers that originate from the orbicularis oris muscle of the upper lip which attaches to the mucosa of the crestal bone and underlying the periosteum. The primary function of the frenulum is to ensure stability to the upper and lower lips and tongue. Depending upon the extension of attachment of fibers, four types of frenulum attachments are classified (1):
– mucosal attachment – the frenal fibers are attached to the mucogingival junction,
– gingival attachment – the fibers penetrate the attached gingiva,
– papillary attachment – the fibers extend into the interdental papilla,
– papilla penetrating attachment – the fibers cross the alveolar process and reach the palatal papilla.
Clinically, the papillary attachment and papilla penetrating attachment are considered as pathological (2). Improper frenulum attachment can lead to pull syndrome and widening of the gingival groove, which promotes plaque accumulation and an increase in the depth of the periodontal pockets. It may also worsen the stabilization conditions for removable dentures. Furthermore, it plays a vital role in the etiology of diastema and may cause gingival recession (3). Low frenal attachment can lead to difficulty in brushing, leading to plaque formation (4). A torn labial frenum in developmental age patients may indicate child abuse (5). Thus, evaluation of the frenulum in the oral cavity and the type of attachment represent an important element of intraoral examination, especially in pediatric patients.
Pathological frenum attachment of lower lip may result in a reduction in the vertical dimension of the oral vestibule and limitation of lower lip mobility, thus impairing its competence in the scope of speech participation, and cause occlusal abnormalities. Similar observations concern incorrect attachment of the lingual frenulum, whose limited mobility may lead to incorrect speech development or occlusal conditions. The available literature lacks classification dedicated to the assessment of the position of the lower lip and lingual frena attachments; therefore, in the discussed study we used Plaček classification (1), which we adapted to the mandibular anatomy.
Given the dynamic development of dentition and the stomatognathic system in pediatric patients, it is worth paying attention to the influence of changes taking place during patients growth, also in terms of the frena attachment site.
Aim
The objective of the work was to determine the prevalence of types of frena attachments in the upper and lower lip and tongue in pediatric patients, in individual types of dentition, and to determine the tendency of upper and lower lip frena attachments to change position as the dentition develops.
Material and methods
Study population
The cross-sectional study included patients aged < 19 years old who reported to the Department of Pediatric Dentistry of the Medical University of Warsaw.
Inclusion criteria:
– written permision of the patient and/or legal guardian to participate in the study,
– complete dentition within the maxillary and mandibular incisors,
– age < 19 years old.
Exclusion criteria:
– plastic surgery of the frenum of the upper lip or tongue,
– tooth missing from the anterior section of the arch.
Clinical examination
In each subject we determined the type of frenal attachment of the upper lip, lower lip and tongue according to Plaček (1), type of dentition (primary, mixed, permanent), gaps in the anterior region. Abundant dental plaque visible to the unaided eye in the anterior segment, additional frenum, reduced tongue mobility, speech impairments, mechanical soft tissue trauma caused by difficult access to the tooth surface resulting from improper frenulum attachment, and past frenulotomy or frenuloplasty were noted.
Statistical analysis
The collected data was initially subjected to descriptive statistical analysis (frequencies, percentages, mean, and standard deviation) and detailed analysis using chi-squared test, Mann-Whitney U test, Spearmans rank correlation coefficients, and the odds ratio (OR). The level of significance was set at p < 0.05. The analyses were carried out in Statistica 10, Statsoft.
Ethical aspects
The consent of the bioethics committee of the Medical University of Warsaw (KB/48/2014) and the written consent of patients/patients parents/legal guardians were obtained.
Results
Sample characteristics
The study included 310 patients. The statistical analysis covered 305 middle-aged subjects 8.96 (± 4.42) – 133 girls and 172 middle-aged boys, 8.83 (± 4.23) and 9.06 (± 4.58) years, respectively, who met the inclusion criteria. Three patients had a history of a surgical undercut or plastic surgery of the labial frenum, and two patients – of the lingual frenulum.
Three dentition groups were distinguished – primary, mixed, and permanent (tab. 1). There were no differences in age between girls and boys in individual dentition types or in the entire study group (Mann-Whitney U test, p = 0.711).
Tab. 1. The mean age in years in individual dental groups, broken down by gender
Dentition type (n)Mean age (years [± SD])Gender (n)Mean age (years [± SD])Mann-Whitney U test; *p < 0.05
Primary (n = 91)4.25 (± 1.31)girls (n = 41)4.51 (± 1.13)0.198
boys (n = 50)4.04 (± 1.41)
Mixed (n = 124)8.35 (± 1.75)girls (n = 54)8.30 (± 1.71)0.992
boys (n = 70)8.39 (± 1.79)
Permanent (n = 90)14.56 (± 2.44)girls (n = 38)14.26 (± 2.62)0.38
boys (n = 52)14.78 (± 2.31)
Additional frenulum was observed in 32 (10.49%) patients. Speech abnormalities were found in 2 (0.66%) patients, and in 3 (0.98%) cases, the soft tissues had suffered mechanical trauma during hygienic procedures as a result of improper frenulum attachment. Abundant plaque in the anterior portion of the mandible, caused by difficult access for hygienic procedures, was observed in 21 (6.89%) subjects. Restricted tongue mobility was not found in the study group.
Labial frenum

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Piśmiennictwo
1. Plaček M, Miroslav S, Mrklas L: Significance of the labial frenal attachment in periodontal disease in man. Part 1; Classification and epidemiology of the labial frenum attachment. J Periodontol 1974; 45: 891-894.
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3. Priyanka M, Sruthi R, Ramakrishnan T et al.: An overview of frenal attachments. J Indian Soc Periodontol 2013; 17(1): 12-15.
4. Divater V, Bali P, Nawab A et al.: Frenal attachment and its association with oral hygiene status among adolescents in Dakshina Kannada population: Across-sectional study. J Family Med Prim Care 2019; 8: 3664-3667.
5. Maguire S, Hunter B, Hunter L et al.: Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries. Arch Dis Child 2007; 92: 1113-1117.
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11. Kotian N, Jeevanandan G: Maxillary labial frenum morphology in children in chennai population: A cross-sectional study. Drug Invent Today 2020; 14(5): 769-71.
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otrzymano: 2021-11-09
zaakceptowano do druku: 2021-11-30

Adres do korespondencji:
*Dorota Olczak-Kowalczyk
Zakład Stomatologii Dziecięcej Warszawski Uniwersytet Medyczny
ul. Binieckiego 6, 02-097 Warszawa
tel.: +48 (22) 116-64-24
pedodoncja@wum.edu.pl

Nowa Stomatologia 4/2021
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