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CASE REPORT to Treat - A Perio-prosthetic Venture

Divya Bhat1 and Suchetha A2

ABSTRACT: Department of Periodontics, D.A.P.M. R.V. Dental College, Ankyloglossia, or -tie as it is more commonly known, is said to exist when the inferior frenulum attaches to the bottom of the Bangalore, Karnataka, India tongue and subsequently restricts free movement of the tongue. The implication of an abnormal frenum is that it could it can indirectly produce malpositioning of the teeth, cause Sr. Lecturer1 abnormalities in speech, lead to periodontal problems such as 2 recession and interfere with the construction of the mandibular Professor denture. Such cases necessitate lingual frenectomy as a pre- prosthetic procedure. The lingual frenum is interposed between a highly mobile tongue, a richly vascular floor of mouth and ducts of the submandibular glands. Therefore, certain precautions need to be taken while performing a lingual frenectomy. This article emphasizes on the finer aspects of lingual frenectomy procedure. Article Info This is a case report describing the procedure of lingual Received: April 18, 2010 frenectomy to aid in prosthetic rehabilitation of a 65 year old, Review Completed: May 18, 2010 edentulous, male patient, with an abnormal lingual frenal Accepted: June 15, 2010 attachment. Available Online: July, 2010 Key words: Ankyloglossia, tongue - tie, edentulous patient, pre- © NAD, 2010 - All rights reserved prosthetic procedure, lingual frenectomy.

INTRODUCTION rupture after mild accidents. Many others continue The frenulum of tongue (or lingual frenulum) is to cause problems throughout life, unless corrected.1 a small fold of extending from Normally, ankyloglossia occurs in approximately the floor of mouth to the midline of underside of the 1.7% of all neonates without preference for either tongue. 1 This usually consists of mucosa, dense gender and is reported to be transitory. With growth fibrous connective tissue, and occasionally, superior the frenum lengthens and normal function is fibers of the genioglossus muscle. 2 established. 3 Initially the frenum is attached close to the tip Persisting ankyloglossia associated with the of the tongue. As the tongue continues to develop, absence of the inferior labial and lingual frenulum frenulum cells undergo apoptosis, retracting away was found to be associated with classical and from the tip of the tongue, and increasing the hypermobility types of Ehlers-Danlos syndrome. 1 tongue’s mobility. During early gestation (as early as An abnormally short lingual frenum results in 4 weeks) the lingual frenulum serves as a guide for speech difficulties, development of recession, and forward growth of the tongue. After birth, the tip of interferes with the stability of mandibular denture. 4 the tongue continues to elongate, giving the In the anterior lingual region many impression that the frenulums of some previously prosthodontists extend the flange of the lower tongue-tied infants stretch with age and growth. In denture to the sublingual folds and utilize the reality the tongue often just grows beyond the inherent elastic recoil of the soft tissues in the area frenulum, although some do also stretch and/or to develop positive retention upon the anterior part Email for correspondence: of the denture base. The presence of a short lingual [email protected] frenum may render impossible this use of the anterior

282 IJDA, 2(3), July-September, 2010 Lingual Frenectomy to Treat Ankyloglossia Divya Bhat & Suchetha lingual region for prosthetic purposes.5 Movement of A traction suture was placed at the tip of the the tongue can easily unseat the denture if the frenal tongue with which the tongue was firmly retracted. attachment to the lingual aspect of the mandible is (fig. 2) close to the crest. This can occur even with a frenum The first line of horizontal mattress sutures, using of relatively normal length. A frenectomy is indicated 3-0 silk suture, was placed just below the ventral when tension is seen in the frenum as the patient surface of the tongue. Three sutures were placed attempts to touch the with the tip of extending from the origin to the insertion of the the tongue while the mouth is partially open. 4 frenum on the ventral surface of the tongue. A second Case Report line of sutures was placed several millimeters below A 65 year old male patient came to the the first one. This second line of sutures was placed Department of Prosthodontics, KLE VK Institute of loosely and superficially through the mucosa. (fig. 3) Dental Sciences, Belgaum, wanting to get his missing The frenum was held with a hemostat. (fig. 4). A teeth replaced. Clinical examination revealed #15 blade was used to sever the frenal attachment edentulous maxillary and mandibular arches; and a by a transverse incision above and below the area high lingual frenum. The patient was referred to the held by the hemostat (fig. 5). Department of Periodontics to relieve this lingual As the area was pre-sutured there was minimal frenum as it would interfere with the mandibular bleeding. No dressing was placed. The patient was denture retention. (fig. 1) put on analgesics and antibiotics to manage pain and The treatment options included frenotomy and prevent infection. frenectomy. Frenectomy is complete removal of the Sutures were removed after 1 week, at which frenum, while frenotomy is incision of the frenum. 6 time healing was almost complete (fig. 6). Patient was Frenectomy was chosen over simple incision due referred back to the Department of Prosthodontics, to the following reasons: following complete healing after 1 month, for the construction of complete dentures. 1. In a classic paper in 1954, Gottsegen discussed the need for a broader intervention than a simple Discussion incision detaching the frenum in four situations. The diagnosis of ankyloglossia is given based Two of these criteria were fulfilled in this case: upon the observation of lingual mobility; no current specific indications for surgery are emphasized in - “Cases where a shallow vestibule exists when either the dental or the medical literature reviewed. the reflected folds of mucosa making up the 3 Hence, the indication of lingual frenectomy in frenum spread widely from its edge so that the dentulous patients is not clear cut. However, after the mucobuccal fold on either side of the frenum loss of teeth, this frenal attachment interferes with approaches the gingival side” denture stability. Each time the tongue is moved, the - “Cases where muscle is present in the frenum frenal attachment is tensed and the denture is and/ or adjacent attachments”. 7 During lingual dislodged. 2 Therefore, in these patients lingual frenectomy it is necessary to incise a portion of frenectomy is clearly indicated. the genioglossus muscles, since in many cases According to Laskin, the area can be the short frenum is really not the cause but the anesthetized by giving bilateral lingual nerve block effect of the diminished length of these plus infiltration for hemostasis or local infiltration 4 structures. alone. Hence, the area was anesthetized by local 2. Schuller and Schleuning, 1994, found that simple infiltration prior to surgery. A traction suture was incison of frenulum may result in the placed through the tip so that the tongue could be development of scar tissue and further restrict elevated to tense the frenum. 4 tongue movement. 3 Suturing was done prior to the incision for the Surgical procedure following reasons: Bilateral local infiltration was given in the lingual 1. Post operative suturing is difficult along the mucosa. An infiltration was also given into the ventral border of the tongue due to the presence substance of the tongue at the tip of the tongue. of the muscles of the tongue and at the floor of

IJDA, 2(3), July-September, 2010 283 Lingual Frenectomy to Treat Ankyloglossia Divya Bhat & Suchetha

the mouth due to the presence of loose CONCLUSION connective tissue which opens up exposing a Pre-prosthetic surgery is indicated in various large wound. situations such as inadequate vestibular depth, 2. To achieve adequate hemostasis. defects in ridge morphology and abnormal frenal 3. To mark the area of incision to avoid injury to attachment. the submandibular ducts and the blood vessels Lingual frenectomy procedures pose a special in the floor of the mouth. challenge when compared to labial frenectomy The second line of sutures was placed loosely to procedures due to the hypermobility of the tongue; prevent hematoma formation; and superficially and the proximity to the submandibular ducts and to prevent constriction of the Wharton’s ducts. 4 the richly vascular mucosa of the floor of the mouth. However, an adequately relieved lingual frenum Silk sutures were used as they have the best greatly aids in mandibular denture construction. handling properties; and knot easily and securely. The advantage of a transverse incision over a REFERENCES vertical incision is that the resulting scar is situated 1. http://en.wikipedia.org/wiki/Frenulum_of_tongue 2. Hupp JR, Ellis E, Jucker MR. Contemporary oral and on the undersurface of the tongue, well away from maxillofacial surgery, 5th edition. Mosby: 235-236. the area that concerns the prosthetists. 5 3. Shafer WG, Hine MK, Levy BM. Shafer’s textbook of oral th Periodontal dressing was not placed due to the pathology, 6 edition. Elsevier India Ltd, 2009: 27. 4. Laskin DM. Oral and Maxillofacial surgery, Volume 1. The CV following reasons: Mosby Company, 1989: 360. 1. Poor retention of the dressing at the site. 5. Howe GL. Minor Oral Surgery, 3rd edition. Wright, 1994: 278 - 279. 2. Loe and Silness, 1961, showed that a dressing has 6. Carranza FA, Takei HH, Newman HA, Kokkevold PR. Clinical little influence on healing provided the area is Carranza’s Clinical Periodontology, 10th edition. Saunders: kept clean. 1023. 3. Greensmith and Wade, 1974, found that the use 7. Hall WB. Pure Mucogingival Problems. Quintessence Publishing Co., Inc., 1984: 82. of a periodontal dressing caused more pain and 8. Sachs HA, Farnoush A, Checchi L, Joseph E. Current status of swelling. 8 periodontal dressing. JP 1984; 55: 689 – 696.

Figure 1: Abnormal lingual frenum Figure 2: Traction sutures at the tip of the Figure 3: Horizontal mattress sutures on the tongue ventral surface of tongue

Figure 4: Frenum held with a hemostat Figure 5: Transverse incision of frenum Figure 6: Healing 1 week Post operative

284 IJDA, 2(3), July-September, 2010