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Abstract

Background: Although individual studies have investigated the clinical significance of frenal attachments, no recent systematic review has comprehensively synthesized the evidence regarding the association between frenal attachment morphology, orthodontic treatment considerations, and esthetic outcomes. Therefore, this systematic review was conducted to address this knowledge gap.
Methods: Electronic database searches were conducted through December 31, 2025, and studies published between January 2014 and December 2025 were eligible for inclusion.Eligible observational and clinical studies reporting orthodontic or esthetic outcomes associated with frenal attachment morphology were included. Study selection, data extraction, and CASP-based quality assessments were performed independently by two reviewers. Twelve studies involving 17,911 participants were included in the qualitative synthesis. Because of methodological heterogeneity, the findings were synthesized narratively. The review protocol was prospectively registered in PROSPERO (CRD42024553792).
Results: Twelve studies involving 17,911 participants were included. Most studies reported an association between papillary or papilla-penetrating frenal attachments and maxillary midline diastemas. The included studies demonstrate a correlation between frenal morphology and both demographic and periodontal variables. Although the existing literature on the relationship between frenectomies, esthetics, and orthodontic outcomes is limited, there is a consensus that favorable outcomes are likely following frenectomy. A substantial body of literature links abnormal frenal attachment patterns to orthodontically significant conditions; however, the observational nature of many of these studies makes it difficult to establish a causal link.
Conclusion: Frenal morphology (especially papillary and papilla-penetrating types) appears to be associated with orthodontically significant conditions, such as midline diastemas, which can influence treatment planning and esthetic outcomes. Because many of the reviewed studies were observational, establishing causality is challenging.Further well-designed prospective studies are required to better clarify these associations.

Pages

214

DOI

10.65844/2503-0825.1505

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