When the lip is pulled upwards, a fibrous band between the inner surface of the upper lip and the crest of the maxillary alveolar ridge can be palpated just underneath the mucosa. An incision is made around the fibrous band and the fraenal attachment on the ridge. The incision is superficial on the lip and fraenum but extends down to bone between the central incisors. The fraenum is grasped with forceps and detached by sharp dissection from the lip. The fibres entering the bone are detached with a small excavator or curette. Some operators mill the crestal bone surface with a bur.
When the fraenum has been removed, further dissection is required to recontour the sulcus. A Z-plasty can be performed but this can cause excessive swelling. It is simpler and kinder to hitch the midline of the incision to the periosteum overlying the anterior nasal spine with a resorbable suture. The fatty tissue on the anterior aspect of the alveolus is mobilised by inserting scissors superficial to the periosteum and opening the blades. This allows the bulky tissue to be displaced laterally so that a good sulcus depth can be achieved when the suture is placed. The incision is then closed with interrupted sutures. A Whitehead's varnish pack may be placed between the incisors and this will also cover the adjacent small defect in the alveolar mucosa, but this is often unnecessary.
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