Frenulum Tear

Get CMETorn FrenulumHave you ever been told that something “isn’t a big deal” only to later find out that it was? Of course, any one who is in a significant relationship with another person has experienced this phenomenon. I, myself, may be at fault (once in a blue moon). Often, when I evaluate intra-oral injuries I will tell families that the mouth heals very well and seldom requires primary repair (ex, Tongue Lacerations). Naturally, there are other intra-oral injuries that do warrant more contemplation and concern (ex, Tonsillar Injuries). A lip frenulum tear, however, is “no big deal.” Right? Well… let us just remain vigilant.

 

Frenulum Tear

  • The upper lip has the Superior Labial Frenulum and lower lip has the Inferior Labial Frenulum.
    • Also referred to as a Frenum.
    • These are folds of mucous membrane that are midline and extend from the gingiva to the lips.
  • They can be easily torn when the mouth is hit or the lip is pulled/stretched.
  • Often bleeds “a lot” (as many injuries to the face/mouth do), but usually will spontaneously stop bleeding.

 

Frenulum Tear: Management

  • This is easy… management is reassurance that it will heal fine on its own! 🙂
    • Let families know that they may bleed intermittently if people keep pulling open the lip to see the injury.
    • Simple pressure on outside of lip usually is enough to stop bleeding.
    • May want to advocate for a soft mechanical diet for a few days to help avoid reopening the wound with sharp crackers and chips (the typical diet of most American kids).
  • Does not typically require specific closure or intervention.
    • Heals well on its own without primary closure.
    • If the tear is more than the frenulum, extending to the surrounding gingiva, repair may be necessary – be sure to use absorbable sutures!

 

Frenulum Tear: It is Trauma!

  • Unfortunately, another consideration needs to cross your mind: Non-Accidental Trauma / Abuse.
    • A frenulum tear is NOT pathognomonic for abuse, but intra-oral injuries are seen in a significant number of abuse cases. [Maguire, 2007]
    • The history, obviously, plays an important role in helping to raise concern for abuse.
      • Knowing the developmental milestones can help determine whether an reported cause of injury would be reasonable.
        • A 2 month old would not have caused her/his own frenulum tear by falling.
        • An 18 month old may have fallen an hit the lips on a table edge.
        • Non-ambulatory children with facial injuries should raise your level of concern for abuse. [Starr, 2015; Thackeray, 2007]
      • The most frequently reported abusive injury to the mouth is injury to the lips, but a frenulum tear in isolation does not equate to abuse. [Maguire, 2007; Thackeray, 2007]
    • Several abusive mechanisms have been proposed to cause a frenulum tear: [Maguire, 2007]
      • Forceful feeding
      • Forceful placement of a pacifier
      • Gagging
      • Gripping or stretching of the lip
      • Vigorous rubbing of the lip
      • Direct forceful blow to lip

 

Moral of the Morsel

  • A frenulum tear can be managed with simple, non-surgical interventions.
  • A frenulum tear is intra-oral trauma. Remain vigilant and evaluate for other trauma.
  • Undress the child and look for other trauma. I know it is tempting to just look in the mouth… but be thorough and look for other signs of non-accidental trauma.
  • A frenulum tear is not pathognomonic for abuse, but make sure the story and developmental milestones make sense.

 

References

Starr M1, Klein EJ, Sugar N. A Perplexing Case of Child Abuse: Oral Injuries in Abuse and Physician Reporting Responsibilities. Pediatr Emerg Care. 2015 Aug;31(8):581-3. PMID: 25426684. [PubMed] [Read by QxMD]

Maguire S1, Hunter B, Hunter L, Sibert JR, Mann M, Kemp AM; Welsh Child Protection Systematic Review Group. Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries. Arch Dis Child. 2007 Dec;92(12):1113-7. PMID: 17468129. [PubMed] [Read by QxMD]

Thackeray JD1. Frena tears and abusive head injury: a cautionary tale. Pediatr Emerg Care. 2007 Oct;23(10):735-7. PMID: 18090110. [PubMed] [Read by QxMD]

Naidoo S1. A profile of the oro-facial injuries in child physical abuse at a children’s hospital. Child Abuse Negl. 2000 Apr;24(4):521-34. PMID: 10798841. [PubMed] [Read by QxMD]

da Fonseca MA1, Feigal RJ, ten Bensel RW. Dental aspects of 1248 cases of child maltreatment on file at a major county hospital. Pediatr Dent. 1992 May-Jun;14(3):152-7. PMID: 1528783. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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