16 Dental Hypotheses Jan-Mar 2014 / Vol 5 | Issue 1

Proposed classification of medial maxillary labial

frenum based on morphology
Ranjana Mohan, Pankaj Kumar Soni, Munagala Karthik Krishna, Mohan Gundappa
1
Departments of Periodontology, and
1
Consertive Dentistry and Endodontics, Teerthanker Mahaveer Dental College and Research Centre,
Moradabad, Utar Pradesh, India
Introduction
Frenum can be defined as a fibrous band of tissue
attached to the bone of the mandible and maxillae,
and is frequently superficial to muscle attachments.
[1]

The frenii of the oral cavity are categorized into
different types: Frenulum linguae, under the tongue;
the frenulum labii superioris, inside the upper lip;
the frenulum labii inferioris, inside the lower lip;
and the buccal frena which connect the cheeks to the
gingiva.
[2]
The frenulum labii superioris or median
maxillary labial frenum (MMLF) is found on the
underside of the center of the upper lip that connects
to the midline of the attached gingiva between the
central incisors. The origin is often wide but the tissue
of the frenum itself narrows in width and is inserted
in the midline into the outer layer of periosteum, and
into the connective tissue of the intermaxillary suture
and the alveolar process.
[3]
A normal frenum attaches
apically to the free gingival margin so as not to exert
a pull on the zone of the attached gingiva and usually
terminating at the mucogingival junction. However, its
level may vary from the height of vestibule to the crest
of the alveolar ridge and even to the incisal papilla
area in the anterior maxilla.
[3,4]
Several classifications
for frena based on morphology have been proposed,
the Modified Sewerins Topology being the most
cited one.
[5,6]
However, this classification may not
be adequate, especially in the aspect of the MMLF,
as several variations in its morphology have been
observed which have not been classified till date.
Many dentists are not aware of the variations of MMLF,
misinterpreting them as pathological entities. Certain
degree of confusion exists in classifying frena types,
leading to difficulties in diagnosis and treatment
planning. Aberrant frena often cause problems such
as loss of papilla, recession, diastema, difficulty
in brushing, alignment of teeth, and psychological
A B S T R A C T
Objectives: To propose a new classification of median maxillary labial frenum (MMLF) based on the morphology in permanent
dentition, conducting a cross-sectional survey. Materials and Methods: Unicentric study was conducted on 2,400 adults (1,414
males, 986 females), aged between 18 and 76 years, with mean age = 38.62, standard deviation (SD) = 12.53. Male mean age =
38.533 years and male SD = 12.498. Female mean age = 38.71 and female SD = 12.5750 for a period of 6 months at Teerthanker
Mahaveer University, Moradabad, Northern India. The frenum morphology was determined by using the direct visual method
under natural light and categorized. Results: Diverse frenum morphologies were observed. Several variations found in the study
have not been documented in the past literature and were named and classified according to their morphology. Discussion: The
MMLF presents a diverse array of morphological variations. Several other undocumented types of frena were observed and revised,
detailed classification has been proposed based on cross-sectional survey.
Key words: Appendix, bifid, classification, frenum, median maxillary labial, nodule, tectolabial, trifid
Corresponding Author: Dr. Ranjana Mohan, Department of Periodontology, Teerthanker Mahaveer Dental College & Research Centre,
Moradabad - 244 001, Utar Pradesh, India. E-mail: ranjanamohan162@gmail.com
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DOI:
10.4103/2155-8213.128108
ORIGINAL RESEARCH
Mohan, et al.: Proposed classifcation of MMLF
17 Dental Hypotheses Jan-Mar 2014 / Vol 5 | Issue 1
disturbances.
[5]
Morphological variations of MMLF
need to be addressed, differentiating them from
abnormal ones during various dental procedures. The
present study aims to propose a detailed and revised
classification of normal MMLF based on morphology.
Materials and Methods
A prospective, cross-sectional unicentric study was
undertaken for a period of 6 months at the Campus of
Teerthanker Mahaveer University, Moradabad, Uttar
Pradesh, one of the most populous states of Northern
India, where pupils hail from all over the country with
all religions, income groups, married and unmarried,
and with different languages. Since the study did not
involve any treatment and was mainly based on mere
examination of frenum, convenience sampling was
used for sampling methodology. Probabilistic sampling
does not seem to be providing any improvement in
observations or the accuracy of the study. The subjects
included anyone from students, to staff members,
and even patients attending the Dental Outpatient
Department and the Department of Periodontology at
Teerthanker Mahaveer University campus, Moradabad,
India, who were willing to participate. There was no limit
on the sample size, and hence the data was considered
in such a way that the number of observations are to
the nearest hundred digit. Study population included
2400 adults (1,414 males and 986 females) who were
willing to participate in cross-sectional survey.
The study protocol was approved by the Teerthanker
Mahaveer University Ethical Committee which is in
accordance with Helsinki Declaration. Written consent
was obtained from patients before enrolling them for the
study. Patients with cleft lip/palate, congenital anomalies,
or with a history of traumatic injuries to the labial frenum
were excluded from the study. The frenum morphology
was determined by using the direct visual method under
natural light by reflecting the upper lip with index finger
and thumb of both hands. To maintain consistency, all
examinations were carried out by a single dentist.
Various morphological types of MMLF were observed in
the study subjects based on which they were categorized
into different types as follows: Simple frenum: Single
[Figure 1a], double [Figure 1b], and triple [Figure 1c];
tectolabial frenum: Simple [Figure 2a], with nodule
[Figure 2b], and with appendix [Figure 2c]; frenum with
nodule: Labial third [Figure 3a], middle third [Figure 3b],
alveolar third [Figure 3c], and multiple [Figure 3d];
frenum with appendix: Labial third [Figure 4a], middle
third [Figure 4b], and alveolar third [Figure 4c]; frenum
with nichum [Figure 5a], inverted Y frenum [Figure 5b],
bifid frenum [Figure 5c] and trifid frenum [Figure 5d].
The actual and percentage-wise distribution of
MMMF types was calculated. The obtained data was
subclassified based on gender prevalence.
Figure 1: Simple frena: (a) Single, (b) double, and (c) triple
a b
c
Figure 2: Tectolabial frenum: (a) Simple, (b) with nodule, and (c) with
appendix
a b
c
Figure 3: Frenum with nodule: (a) Labial third, (b) middle third, (c) alveolar
third, and (d) multiple
a b
c d
Mohan, et al.: Proposed classifcation of MMLF
18 Dental Hypotheses Jan-Mar 2014 / Vol 5 | Issue 1
On comparison of the distribution patterns of MMLF
types based on sex, the tectolabial frenum with
nodule and inverted Y frenum showed a significantly
higher prevalence in male patients; whereas, the bifid
frenum showed higher prevalence in female patients.
No significant differences in sex distribution were
found in the other types of MMLF as depicted in
Table 2.
Based on the morphological variations observed, a
revised classification of MMLF has been proposed as
mentioned in Table 3.
Discussion
MMLF appears as a fold of mucous membrane extending
from the mucous lining of the mucous membrane of the
Table 1: Overall distribution and percentage values of
median maxillary labial frenum (MMLF) types
Type of MMLF No. observed (Percentage)
Simple frenum 1,589 (66.21)
Simple single frenum 1,531 (63.79)
Simple double frenum 25 (1.04)
Simple triple frenum 33 (1.3)
Frenum with nodule 478 (19.92)
At labial 1/3 186 (7.75)
At middle 1/3 193 (8.04)
At alveolar 1/3 61 (2.54)
Multiple nodules 38 (1.58)
Frenum with appendix 153 (6.38)
At labial 1/3 67 (2.79)
At middle 1/3 55 (2.29)
At alveolar 1/3 31 (1.29)
Tectolabial frenum 135 (5.63)
Simple tectolabial 125 (5.2)
Tectolabial with lateral appendix 3 (0.12)
Tectolabial with nodule 7 (0.29)
Inverted Y frenum 7 (0.29)
Frenum with nichum 12 (0.50)
Bifd frenum 12 (0.50)
Trifd frenum 14 (0.58)
Results
Study population included 2,400 adults (1,414 males,
986 females) with all religions, income groups, and
languages who were willing to participate in cross-
sectional survey at the campus of Teerthanker Mahaveer
University, Uttar Pradesh, one of the most populous states
of India. The study included only the examination of
Frenum morphology based on convenience sampling. A
total of 2,536 individuals were approached, out of which
2,400 agreed to participate in the study and aged between
18 and 76 years with mean age = 38.62 years, standard
deviation (SD) = 12.53. Male mean age = 38.533 years
and male SD = 12.498. Female mean age = 38.71 years
and female SD = 12.5750. The most common type of
MMLF observed was the simple single frenum (63.79%)
followed by frenum with nodule (19.92%) and frenum
with appendix (6.38%). Among the frena with nodule,
majority of them had the nodule at middle one-third
position (8.04%) and in the case of frena with appendix,
majority of appendices were found at labial one-third
position (2.79%). Simple tectolabial frena were observed
in 5.2% of the patients. Other types of MMMF observed
based on the Modified Sewerins Typology
[5]
were the
frenum with nichum (0.5%) and bifid frenum (0.5%).
Frenum types not previously classified and observed in
the present study were the simple triple frenum (1.57%),
frenum with multiple nodules (1.58%), tectolabial
frenum with nodule (0.29%), tectolabial frenum with
appendix (0.12%), inverted Y frenum (0.29%) [Figure
5b], and trifid frenum (0.58%).
Two or more frenal variations and absence of frenal
attachment were not detected in the study subjects as
shown in [Table 1].
Figure 4: Frenum with appendix: (a) Labial third, (b) middle third, and (c)
alveolar third
a b
c
Figure 5: New frenal types: (a) With nichum, (b) inverted Y, (c) bifd, (d) trifd
a b
c d
Mohan, et al.: Proposed classifcation of MMLF
19 Dental Hypotheses Jan-Mar 2014 / Vol 5 | Issue 1
lips towards the crest of the residual ridge on the labial
surface.
[1]
Several morphological variations of MMLF
are being observed in day-to-day practice which is not
documented in the literature. Need of the hour is to
properly classify them in various categories in order to
address them while performing various dental procedures.
The present study was conducted on 2,400 adults ageing
18-76 years, in the campus of Teerthanker Mahaveer
University, Moradabad, Uttar Pradesh, one of the most
populous states of India, to determine the morphological
variations of MMLF. One-third of the subjects had
variations in the MMLF morphology other than the
simple single frenum suggesting that diverse variations
may occur commonly in general population and are
usually considered to be developmental in nature and
not pathological as previously believed.
[6]
However, the
presence of abnormal frena have been reported in the
literature as a feature of syndromic conditions such
as Ehlers-Danlos syndrome, infantile hypertrophic
pyloric stenosis, holoprosencephaly, Ellis-van Creveld
syndrome, and oro-facial-digital syndrome.
[7]
Within the limitation of the study, conducted at one
place, factors like different geographical regions,
races, etc., could not be considered. To overcome the
shortcoming, University campus having more than
10,000 adults residing in it hailing from every corner
of the country with all religions, income groups, and
languages was selected. Many other factors do not seem
to be influencing the morphology of frenum.
In the present study, most commonly observed MMLF
type was the simple single frenum (63.79%). Previous
studies conducted on the prevalence of frenal types have
reported a similar occurrence of simple single frenum.
[8,9]

Sewerin in Denmark, observed 60.2% of patients had
a simple frenum.
[8]
In a recent study conducted by
Townsend et al., on Caucasians and African-Americans,
the prevalence of simple single frenum was 6.86%.
[6]

Present study observed majority of the nodules in the
middle third of the frenum, whereas appendices were
most commonly found in the labial third. Similar
findings were reported in the studies by Sewerin and
Townsend et al. These observations suggest that despite
the differences in the ethnic and racial backgrounds,
the pattern of distribution of MMLF variations maybe
similar. Absence of frenum and two or more variations
of any type of frenum were not found by author in any of
the adults examined that is consistent with the previous
studies. However, Kakodkar et al., conducted study on
frenal attachments in 1,206 school going children; found
a single case of absent frenum in a female.
[9]
This
suggests that absent frenum is a very rare occurrence and
maybe related to developmental abnormality.
Various classifications of MMLF have been mentioned
in the literature based on its attachment and
morphology.
[5,6]
Based on the level of attachment,
frena have been classified as mucosal, gingival,
papillary, and papilla penetrating.
[10]
However, the
present study reveals several variations of MMLF
Table 2: Distribution pattern of median maxillary labial
frenum (MMLF) based on gender
MMLF type Total
patients
Male % Female %
Simple single 1,531 904 (63.93) 627 (63.59)
Simple double 25 15 (1.06) 10 (1.01)
Simple triple 33 24 (1.69) 9 (0.91)
Nodule at labial 1/3 186 101 (7.14) 85 (8.62)
Nodule at middle 1/3 193 121 (8.55) 72 (7.3)
Nodule at alveolar 1/3 61 33 (2.33) 28 (2. 83)
Multiple nodule 38 21 (1.48) 17 (1.72)
Appendix at labial 1/3 67 35 (2.47) 32 (3.24)
Appendix at middle 1/3 55 33 (2.33) 22 (2.23)
Appendix at alveolar 1/3 31 14 (0.99) 17 (1.72)
Simple tactolabial 125 80 (5.65) 45 (4.56)
Tactolabial with appendix 3 2 (0.14) 1 (0.1)
Tactolabial with nodule 7 6 (0.42) 1 (0.1)
Inverted Y 7 6 (0.42) 1 (0.1)
Nichum 12 8 (0.56) 4 (0.4)
Bifd 12 2 (0.14) 10 (1.01)
Trifd 14 9 (0.63) 5 (0.5)
Total 2,400 1,414 986
Table 3: Revised classifcation of median maxillary
labial frenum (MMLF) in comparison to Modifed
Sewerins Typology
Modifed Sewerins
Typology
Proposed classifcation
Simple frenum Simple frenum
Single
Double
Triple
Simple with nodule With nodule
At labial third
At middle third
At alveolar third
Simple with appendix With appendix
At labial third
At middle third
At alveolar third
Persistent tectolabial Tectolabial
Simple
With nodule
With appendix
Simple with nichum With nichum
Inverted Y
Bifd Bifd
Double Trifd
Two or more variations Two or more variations
Absent Absent
Mohan, et al.: Proposed classifcation of MMLF
20 Dental Hypotheses Jan-Mar 2014 / Vol 5 | Issue 1
that have not been reported till date. These include
the simple triple frenum, frenum with multiple
nodules, inverted Y frenum, and the trifid frenum.
In addition, tectolabial frena were found with
appendices and nodules. Reports of frenal anamolies
causing difficulties in speech, mastication, esthetics,
and maintenance of oral hygiene have been well-
documented in the literature.
[11,12]
MMLF is considered
to be a complicating factor in denture construction.
Frenal variations with a broad base migrated near the
crest of the residual ridge; require early recognition
and surgical removal for a more satisfactory treatment
outcome with complete dentures. They also require
the placement of large or multiple notches in dentures
which have been considered responsible for fracture
of many dentures. In such cases, it is preferred to
fabricate a cast partial denture to prevent fracture.
[13]

Hence, proper identification of frenal variations and
subsequent modification of treatment procedures are
vital for a successful outcome of therapy.
The MMLF presents a diverse array of morphological
variations. Several types of frena other than those
documented in the published literature were observed
in the present study. Hence, the detailed and revised
classification of MMLF has been proposed based on
morphology.
References
1. Zarb GA, Bolender CL. Prosthodontic treatment for edentulous
patients, complete dentures and implant-supported prostheses,
12
th
ed. Amsterdam: Elsevier; 2004.
2. Williams PL. Textbook of Grays Anatomy, 38
th
ed. London:
Churchill Livingstone and Sons; 1995.
3. Hupp JR, Ellis E, Tucker MR. Contemporary oral and
maxillofacial surgery, 5
th
ed. Amsterdam: Elsevier; 2009.
4. McDonald RE, Avery DR, Dean JA. Mc Donald dentistry for the
child and adolescent, 8
th
ed. Amsterdam: Elsevier; 2004.
5. Diaz-Pizan ME, Lagravere MO, Villena R. Midline diastema and
frenum morphology in the primary dentition. J Dent Child (Chic)
2006;73:11-14.
6. Townsend JA, Brannon RB, Cheramie T, Hagan J. Prevalence
and variations of the median maxillary labial frenum in children,
adolescents, and adults in a diverse population. Gen Dent
2013;61:57-60.
7. Priyanka M, Sruthi R, Ramakrishnan T, Emmadi P, Ambalavanan
N. An overview of frenal attachments. J Indian Soc Periodontol
2013;17:12-5.
8. Sewerin I. Prevalence of variations and anomalies of the upper
labial frenum. Acta Odontol Scand 1971;29:487-96.
9. Kakodkar PV, Patel TN, Patel SV, Patel SH. Clinical assessment
of diverse frenum morphology in permanent dentition. Internet
J Dent Sci 2009;7.
10. Placek M, Skach M, Mrklas L. Problems with the lip frenulum
in periodontics. I. Classification and epidemiology of tendons
of the lip frenulum. Cesk Stomatol 1974;74:385-91.
11. Mirko P, Miroslav S, Lubor M. Significance of the labial
frenum attachment in periodontal disease in man. Part I.
Classification and epidemiology of the labial frenum attachment.
J Periodontol 1974;45:891-4.
12. Miller PD Jr. Frenectomy combined with a laterally positioned
pedicle graft; functional and aesthetic consideration.
J Periodontol 1985;56:102-6.
13. Al Jabbari YS. Frenectomy for improvement of a problematic
conventional maxillary complete denture in an elderly patient:
A case report. J Adv Prosthodont 2011;3:236-9.
Cite this article as: Mohan R, Soni PK, Krishna MK, Gundappa M. Proposed
classifcation of medial maxillary labial frenum based on morphology. Dent
Hypotheses 2014;5:16-20.
Source of Support: Nil, Confict of Interest: None declared.