Prevalence of type of maxillary labial frenal attachment among 18-30 years: A retrospective study

Jitesh S1, Arvina Rajasekar*1, Madhulaxmi M2 1Department of Periodontics, Saveetha Dental College & Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 77, Tamil Nadu, India 2Department of Oral and Maxillofacial Surgery, Saveetha Dental College & Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 77, Tamil Nadu, India


INTRODUCTION
Labial frenum is a vertical band of oral mucosa that attaches the cheeks and lips to the alveolar mucosa of the mandibular and maxillary arches, limiting the movement of the lips and cheeks (Parker, 1937;Thamaraiselvan et al., 2015). Maxillary labial frenum has ibrous tissue which runs in the anterior-posterior direction and it ends by merging to the submucosal ibers of the lips (Dewel, 1946;Kavarthapu and Thamaraiselvan, 2018). The frenum has its origin from the remnant of central cells of vestibular lamina which predominantly has connective tissue and least amount of muscle ibers. The maxillary labial frenum is also said to be the posteruptive remnant of tecto labial bands (Dewel, 1946;Varghese et al., 2015).
Frenal attachments are at different levels at various stages of growth and development (Ceremello, 1953). Frenal attachments are classi ied as four types by Placek et al (Mirko et al., 1974). Mucosal -when the frenal ibers are attached upto mucogingival junction; Gingival -when ibers are inserted within attached gingiva; Papillary -when ibers are extending into interdental papilla; Papilla penetrating -when the frenal ibers cross the alveolar process and extend up to palatine papilla.
Papillary and papillary penetrating type of frenal attachments are said to be pathological beyond mixed dentition. As the pull of the abnormal frenal attachment is greater than normal, it produces a constant force on the attached gingiva leading to localized gingival recession and requires treatment (Arvina and Kumar, 2019;Khalid et al., 2016;Mootha et al., 2016). It may also lead to midline diastema, which leads to laring of the two upper central incisors due to the presence of thick bands of the frenum, which is not self correcting and it requires minor surgical correction (Avinash et al., 2017;Panda et al., 2014).
Clinically, papillary and papilla penetrating frenum have been found to be associated with loss of papilla, recession, diastema, dif iculty in brushing, malalignment of teeth and it may also prejudice the denture it or retention leading to psychological disturbances to the individual (Mootha et al., 2016;Janarthanan et al., 2019).
The type of the maxillary labial frenal attachment and its morphology in Chennai has not been studied extensively. The purpose of this retrospective study was to determine the prevalence of the type of maxillary frenal attachment among 18-30 years.

MATERIALS AND METHODS
This retrospective study was undertaken using a convenience sample of patients aged 18 to 30 years reported to a private institution in Chennai from June 2019 to March 2020. The study consisted of a total of 100 patients, including 61 males and 39 females. Data regarding the type of frenum was collected and categorized based on the classi ication by Placek et al. and the prevalence was assessed. Ethical approval for the study was obtained from Saveetha University Ethical Review Board (SDC/SIHEC/2020/DIASDATA/0619-0320).

RESULTS AND DISCUSSION
Data collected were entered in SPSS version 20 and was subjected to statistical analysis. Results were tabulated and represented graphically. Out of 100 patients, 61% were males and 39% were females. (Figure 1) Also, regarding the type of frenal attachment, 41% had a gingival type, 27% had a mucosal and papillary type, 5% had the papillary penetrating type of maxillary labial frenal attachment (Figure 2). The association between the type of frenal attachment among males and females. X axis repre-sents the gender and Y axis represents the percentage distribution of the subjects. Association tested by Pearson Chi-Square test -1.105, df-3, p value -0.776(>0.05); statistically not signi icant. (Figure 3) Gingival type of frenal attachment (green) is more likely to occur in males and females. However, there was no signi icant association between gender and type of frenal attachment.
The maxillary labial frenum is in a passive relationship with the maxillary alveolar process and its pattern of development is dependent on alveolar growth (Khalid, 2017;Khalid et al., 2016). In this present study, the prevalence of the type of maxillary labial frenal attachment among Chennai population was assessed. In this present study, we followed Placek et al. classi ication of frenal attachments, as this classi ication is extensively used among children and adults in numerous studies (Janczuk and Banach, 1980;Addy et al., 1987;Boutsi and Tatakis, 2011).
If the papillary penetrating type of frenal attachments persists even after mixed dentition, it may lead to several consequences, such as midline diastema and dental caries (Ramesh et al., 2016(Ramesh et al., , 2017Kavarthapu and Thamaraiselvan, 2018). The treatment of midline diastema is most commonly frenectomy followed by orthodontic treatment to correct a malalignment. Abnormal frenal attachment may also lead to speech abnormality, poor oral hygiene maintenance (Priyanka, 2017). In this study, there was no signi icant association of frenal type with gender. Both males and females had more or less equal distribution which is in accordance with a study done in Greece (Boutsi and Tatakis, 2011;Ravi et al., 2017;Ramamurthy and Visha, 2018).
In the present study, the most common type of frenal attachment was found to be gingival. Similarly, Boutsi et al., (Boutsi and Tatakis, 2011) Addy et al., (Addy et al., 1987) Kaimenyi, (Kaimenyi, 1998 in their studies showed the most prevailing type of frenal attachment was gingival. However, Placek et al. (Mirko et al., 1974) and Janczuk and Banach (Janczuk and Banach, 1980;Ramesh et al., 2016) had found the mucosal type of frenal attachment to be common in Czech and Polish teens.
The limitation of this study is its smaller sample size. A similar study should be conducted on a larger scale involving a large number of samples for more reliable results (Ramamurthy and Visha, 2018;Ramesh et al., 2019). Therefore, extensive studies need to be conducted to assess the type of frenal attachment and associated complications.

CONCLUSIONS
Within the limits of the present study, the most prevalent type of maxillary labial frenal attachment among 18-30 years was found to be gingival type (41%) and the least prevalent type was papillary penetrating (5%). Also, there was no signi icant association between gender and type of frenal attachment.