See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/326293216

Z‑plasty: An Esthetic Eraser for Labial Frenum

Article · January 2016

DOI: 10.4103/2249-9725.174963

CITATIONS READS
0 171

2 authors, including:

Varshal J Barot

11 PUBLICATIONS   14 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Z-plasty: An Esthetic Eraser for Labial Frenum View project

All content following this page was uploaded by Varshal J Barot on 10 July 2018.

The user has requested enhancement of the downloaded file.

[Downloaded free from http://www.urjd.org on Wednesday, January 27, 2016, IP: 117.222.93.107]

CASE REPORT

Z‑plasty: An Esthetic Eraser for Labial Frenum

Varshal J. Barot, Jayesh M. Brahmbhatt1
Department of Periodontics and Implantology, M.P. Dental College and Hospital, Vadodara, Department of Plastic Surgery, Government Medical
1

College and Hospital, Surat, Gujarat, India

ABSTRACT
Maxillary labial frenum is capable of creating diastema and recession, affecting esthetics by compromising the orthodontic
result in the midline diastema cases, thus causing a recurrence after the treatment. This case report demonstrates the
removal of the abnormal labial frenum attachment with midline diastema in a 28‑year‑old male through the technique of
basic Z‑plasty. Z‑plasty is a common procedure in plastic surgery, but not so common in the field of dentistry. It appears
complex, but is really rather simple, safe, and reliable. The main aim is to promote the use of this surgical technique; which
helps to release scar contracture, relieve soft‑tissue tension, and facilitates healing by primary intention. Frenectomies
commonly fail due to a high risk of re‑occurrence and hypertrophic scarring with other techniques that can be reduced by
the use of Z‑plasty. Moreover, it is cost‑effective and results in better functional and esthetic appearance.

KEY WORDS: Diastema, esthetics, frenum, labial frenectomy, Z‑plasty

INTRODUCTION classified as papillary frenum [Figures 1a and b and 2]

Z‑plasty is a plastic surgery technique used to improve the
functional and cosmetic appearance of scars. It involves
a central incision and creation of two triangular flaps of
equal dimension that are then transposed around each
other.[1] It breaks up the surgical band into a longer line
which runs in zig‑zag fashion, so that the tissue tensions
are distributed in different directions which relieves the
pull on the wound, mitigates against wound disruption,
and allows for better healing. The principle of Z‑plasty
was first described by Denonvilliers in 1856 for the release
of an eyelid scar and is now utilized in every part of the
body.
CASE REPORT
A case of 28‑year‑old healthy male reported with the
problem of a midline diastema between the maxillary central
incisors. Clinically, intraoral examination using tension
test showed blanching of the tissue on applying tension
over the frenum to see the movement of the papillary tip,
which was suggestive of an abnormal frenal attachment,
according to Mirko et al.[2] Radiographic examination,
intra‑oral periapical radiograph [Figure 3] showed “v”
shaped notch between the two central incisors, suggesting
of deep fibrous frenal attachment in the bone, and presence
of any other pathology/unerupted mesiodens was ruled
out. After the informed consent, labial frenectomy was
planned by basic Z‑plasty technique.
Frenum was anesthetized by giving bilateral local
infiltration on the labial aspect and on the palatal aspect
near the base of the papilla. The Frenum was assessed,
and one central incision and two lateral incisions at an
angle of 60° were marked using marking pencil [Figure 4],
creating two triangular flaps of equal size and shape.
Two initial incisions on either side of the central fibrous
band [Figures 5 and 6] were made with a bard parker (B.P)
blade number 11. Two lateral incisions at an angle of
Address for Correspondence:
Dr. Varshal J. Barot,
E‑2/5, Professors Quarters’, New Civil Hospital Campus, Majura Gate,
Surat ‑ 395 001, Gujarat, India.
E‑mail: varshalb@gmail.com

This is an open access article distributed under the terms of the Creative Commons
Access this article online Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix,
Quick Response Code tweak, and build upon the work non‑commercially, as long as the author is credited
Website: and the new creations are licensed under the identical terms.
www.urjd.org
For reprints contact: reprints@medknow.com

DOI:
10.4103/2249-9725.174963 How to cite this article: Barot VJ, Brahmbhatt JM. Z-plasty: An esthetic
eraser for labial frenum. Univ Res J Dent 2016;6:48-52.

48 © 2016 Universal Research Journal of Dentistry | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.urjd.org on Wednesday, January 27, 2016, IP: 117.222.93.107]

Barot and Brahmbhatt: Z-plasty - An esthetic eraser

a b
Figure 1: (a) Abnormal labial frenum: Papillary, front view.
(b) Abnormal labial frenum: Papillary, right side view

Figure 2: Abnormal labial frenum: Papillary, occlusal view

Figure 3: Intra-oral periapical radiograph of 11 and 21 showing

“v” shaped notch

Figure 4: Z-shaped incision line marked using a marking pencil

Figure 5: Two incisions on either side of thick central fibrous band

using B.P blade number 11

60° were made with a B.P blade number 15. Adequate

undermining of surrounding tissues was performed to
achieve proper mobilization of the flaps and minimize
the distortion of the underlying structures. The two flaps
were then transposed to the opposite side of the apex of
each flap and stabilized by giving anchoring sutures at
Figure 6: Immediately after the removal of thick central fibrous
band of frenum
two flap tips [Figure 7] by 5‑0 absorbable (vicryl) suture.
Additional simple interrupted sutures were placed to close
the diagonal lines and secure the flaps [Figure 8].

Universal Research Journal of Dentistry · January-April 2016 · Vol 6 · Issue 1 49

[Downloaded free from http://www.urjd.org on Wednesday, January 27, 2016, IP: 117.222.93.107]
Barot and Brahmbhatt: Z-plasty - An esthetic eraser
Analgesics along with antimicrobial rinse (0.2%
chlorhexidine gluconate twice‑a‑day for 2 weeks) was
prescribed with routine wound care instructions. Patient
was recalled after 1‑week for follow‑up. Follow‑up at
1, 6, and 12 weeks [Figures 9‑11] showed uneventful
healing with more functional and esthetic results. With
the comparison of preoperative dimensions, there was
increase in the depth of labio‑buccal sulcus, and on the
mucosal side, normal height (length) of lip was achieved
with good oral sphincter control and function. Patient was
referred to an orthodontist for further treatment of midline
diastema closure [Figures 12 and 13].
DISCUSSION
A frenum is an anatomic structure formed by a
fold of mucous membrane and connective tissue
and sometimes muscle fibers that attach the lip and
Figure 7: Two triangular flaps after transposition and stabilization
by anchoring sutures at flap tips using 5-0 vicryl sutures
Figure 9: 1-week postoperative view showing uneventful healing
in progress
50
cheeks to the alveolar mucosa and/or gingiva and the
underlying periosteum. The primary function of frenum
is to provide stability of the upper and lower lip and
the tongue. Midline diastema is a common esthetic
problem in mixed and permanent dentition for which a
high frenum attachment is often the cause. Depending
upon the extension of attachment of fibers, frenum has
been classified as follows[2]
• Mucosal  ‑  When the fibers are attached up to
mucogingival junction
• Gingival  ‑  When fibers are inserted within attached
gingiva
• Papillary  ‑  When fibers are extended into interdental
papilla; and
• Papilla penetrating ‑ When the fibers cross the alveolar
process and extend up to the palatine papilla.
Clinically, papillary and papilla penetrating frenum are
considered as pathological and have been found to be
Figure 8: Simple interrupted sutures placed to close the diagonal
lines and secure the flaps
Figure 10: Six weeks postoperative view showing complete healing
Universal Research Journal of Dentistry · January-April 2016 · Vol 6 · Issue 1
[Downloaded free from http://www.urjd.org on Wednesday, January 27, 2016, IP: 117.222.93.107]
Barot and Brahmbhatt: Z-plasty - An esthetic eraser
Figure 11: Twelve weeks postoperative view showing more
functional and esthetic results
Figure 12: Immediately after application of orthodontic braces for
diastema closure
Figure 13: After diastema closure with orthodontic braces after
6 months
associated with loss of papilla, recession, diastema, and
plaque accumulation.[3,4] The abnormal frenum is detected
Universal Research Journal of Dentistry · January-April 2016 · Vol 6 · Issue 1
visually by applying tension over the frenum to see the
movement of the papillary tip or the blanch, which is
produced due to ischemia in the region.[5] In such cases,
it is necessary to perform a frenectomy for esthetic and
functional reasons.
Frenectomy is a complete removal of frenum, including
its attachment to the underlying bone, and may be
required in the correction of an abnormal diastema
between the maxillary central incisors. In the era of
periodontal plastic surgery, more conservative and
precise techniques are being adopted to create more
functional and esthetic results. The management of
aberrant frenum has traveled a long journey from
Archer’s and Kruger’s “classical techniques” of total
frenectomy to Edward’s more conservative approach.
In the present case, frenectomy was done through
Z‑plasty.
Basic Z‑plasty flaps are created using an angle of 60°
on each side. Classic 60° Z‑plasty lengthens scars by
75%, while 45° and 30° designs lengthen scars by 50%
and 25%, respectively.[6] The Z pattern is effective as it
promotes re‑distribution of tension on the skin and the
wound and helps in healing along the skin lines. It helps
in minimizing scar formation and has a camouflaging
effect. Angles which are smaller than 60° are easier to
transpose but results in less lengthening and realignment
of the scar to <90°. Angles larger than 60° should be
avoided because the force required to transpose the
flaps increases markedly, making closure of the wound
difficult. The length of each of the lateral limbs of the
Z‑plasty must be precisely equal to the central incision
over the original scar, or puckering at the corners will
occur,  and additional undermining and trimming of
the flaps will be necessary to obtain proper closure.
Precisely, equal lengths and angles of the lateral arms are
keys for obtaining proper flap closure after transposition
in Z‑plasty.
Frenectomy using basic Z‑plasty technique gives more
esthetic and functional outcome due to its inherent
properties of redirecting and lengthening effects on tissues
which are not possible with other techniques. It also
lengthens the scar in favorable way so that the labio‑buccal
sulcus depth and lip height are brought to the normal
dimension from original shallow one.
Complications of Z‑plasty may be flap necrosis, hematoma
formation, wound infection, sloughing of the flap caused
by high wound tension, and the trapdoor effect (elevation
of central tissue resulting from a downward contraction of
a surrounding scar). Most complications may be prevented
by meticulous attention to technique.[7] The trapdoor effect
51
[Downloaded free from http://www.urjd.org on Wednesday, January 27, 2016, IP: 117.222.93.107]
Barot and Brahmbhatt: Z-plasty - An esthetic eraser
may be avoided by employing sufficient undermining of
tissues surrounding the flap site.
CONCLUSION
Since the procedure of frenectomy was first proposed, a
number of modifications have been developed. In most
of the procedures, esthetic outcome in terms of attached
gingiva with color matching is not considered and results in
scar formation. The frenectomy technique using Z‑plasty
for the removal of the abnormal labial frenum attachment
is reliable, easy to perform, and provides excellent esthetic
results.
Financial support and sponsorship
Nil.
52
View publication stats
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Burke M. Z‑plasty. How, when and why. Aust Fam Physician
1997;26:1027‑9.
2. Mirko P, Miroslav S, Lubor M. Significance of the labial frenum
attachment in periodontal disease in man. Part II. An attempt to
determine the resistance of periodontium. J Periodontol 1974;45:895‑7.
3. Dewel BF. The labial frenum, midline diastema, and palatine papilla:
A clinical analysis. Dent Clin North Am 1966:175‑84.
4. Díaz‑Pizán ME, Lagravère MO, Villena  R. Midline diastema and
frenum morphology in the primary dentition. J Dent Child (Chic)
2006;73:11‑4.
5. Gottsegen R. Frenum position and vestibule depth in relation to gingival
health. Oral Surg Oral Med Oral Pathol 1954;7:1069‑78.
6. Aasi SZ. Z‑plasty made simple. Dermatol Res Pract 2010;2010:982623.
7. Rohrich  RJ, Zbar  RI. A  simplified algorithm for the use of Z‑plasty.
Plast Reconstr Surg 1999;103:1513‑7.
Universal Research Journal of Dentistry · January-April 2016 · Vol 6 · Issue 1