Periodontics

Localized
severe chronic
periodontitis with
Abstract
frenal pull and || Brief Background

ankyloglossia: A A frenum is a naturally occurring muscle attachment, normally

seen between the upper and lower front teeth. It connects the

case report
inner aspect of the lip to the gum tissue around the teeth. There
is also a frenum between the tongue and gum tissue. A fre-
num becomes a problem if the attachment is too close to the
marginal gingiva. Tension on the frenum may pull the gingi-
val margin away from the tooth. This condition is conducive to
plaque accumulation, inhibits proper toothbrushing and can re-
sult in gingival recession and loss of attachment. An excessively
large frenum may also result in diastema formation. Here, we
report a case of localized chronic periodontitis with frenal pull
and tongue tie which was treated by a free gingival graft and
lingual frenectomy.

|| Materials and Methods

Intraoral examination revealed localised severe chronic peri-
odontitis associated with secondary trauma from occlusion, fre-
nal pull and ankyloglossia. After scaling and root planing the
frenal pull was relieved by incision and vestibuloplasty with a
free gingival graft was performed.

|| Discussion
The importance of gingival health, optimizing function and aes-
thetics through soft tissue grafting procedures, the treatment
modalities and gains achieved, association of ankyloglossia with
Dr. Khaled Ben Salah both midline diastema and gingival recession, in addition to a
Lecturer mild speech impairment; techniques to manage ankyloglossia
and factors responsible for diastema were the matters discussed.
Correspondence Address
Dr. Rohit Radhakrishnan || Key Words
Department of Periodontics
Faculty of Dentistry, Benghazi University, Libya Periodontitis, frenal pull, ankyloglossia, free gingival graft.

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 || Introduction On intraoral examination, we found:
A frenum is a naturally occurring muscle attachment, 1. Miller's Class III recession with 31 and 41 (Fig.1).
normally seen between the upper and lower front 2. Multiple frena exerting pull on the gingiva on the
teeth. It connects the inner aspect of the lip to facial aspect of 31 and 41 (Fig.2).
gum tissue around the teeth. There is also a frenum
3. Associated with shallow vestibule and inadequate
between the tongue and gum tissue. A frenum
width of attached gingiva in the 31- 41 region
becomes a problem if the attachment is too close
(Fig.2).
to the marginal gingiva. Tension on the frenum may
4. Supra and subgingival calculus (Fig.1, Fig.2).
pull the gingival margin away from the tooth. This
condition is conducive to plaque accumulation and 5. Loss of attachment and Grade 2 mobility with 31
inhibits proper toothbrushing.1 The frenal pull upon and 41.
the tissue can lead to continuation of the lesion2 6. Positive fremitus test.
and loss of attachment. High muscle attachment 7. Pathological migration with 31 and 41 with a 5mm
and frenal pull have been associated with gingival diastema between them (Fig.1).
tissue recession.3 Tongue tie or ankyloglossia is an
8. Class II ankyloglossia (8 to 11mm) with lingual
abnormal condition affecting the lingual frenum.
frenal pull (Fig.3).
The frenum may be attached at or near the tip of the
tongue and hold it close to the gingival margins of
the lower anterior teeth.4 Rarely, it extends across the
floor of the mouth and attaches onto the mandibular
alveolus.5 Normally, the lingual frenum does not create
a diastema between the mandibular central incisors.
Ankyloglossia can cause tension in the floor of the
mouth, resulting in pulling of the tissue behind the
mandibular incisors or the development of a diastema
between the mandibular central incisors.6 Here, we
report a case of localised chronic periodontitis with
labial frenal pull and tongue tie, which was treated by
a free gingival graft and lingual frenectomy.
Fig.1: Chronic periodontitis and diastema formation with
miller's class iii gingival recession in relation to 31 and 41
|| Case Report
A male patient, 28 years of age, from Benghazi
presented with a chief complaint of elongation,
looseness and spacing between his teeth in the lower
anterior region since two years. He initially noticed
bleeding, increase in the size of the gingiva and a
slight amount of spacing between the lower central
incisor teeth. With time, he noticed that the teeth
were getting elongated, with an increase in the space
between them and also mobility of the teeth. There
was nothing of significance in his medical, dental
or family history other than an amalgam filling with
upper left 6 and extraction of lower left 7 due to
caries. The patient was married with two children. He
was a non - smoker.
There was nothing of significance in the extraoral Fig.2: Frenal pull on the gingiva in relation to 31 and 41,
examination. coupled with shallow vestibule and inadequate width of
attached gingiva

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Fig.3: Class II ankyloglossia with lingual frenal pull and gingival
recession with 31 and 41
This was an interesting finding because the patient was
not aware of the tongue tie and believed that he was
normal in this respect, even though he had difficulty
in pronouncing some words. When the patient was
asked to protrude his tongue, the movement was
limited and the lingual frenum got wedged between
the two central incisors, contributing to the diastema
formation (Fig.4).
9. Gingival recession on the lingual aspects of 31 and
41.
Fig.4: Lingual frenum protruding between 31 and 41
IOPA x-rays of the lower anterior region were taken.
An OPG was also made to screen other areas for
any pathology. The x-rays revealed severe angular
bone loss between 41-42 and between 31-41, with
moderate horizontal bone loss between 31 and 32
(Fig.5). Widening of the periodontal ligament space
was noticed with 31 and 41. Pulp vitality testing
showed that 31 and 41 were vital. Upper and lower
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alginate impressions were taken and study casts were
fabricated in dental stone.
Fig.5: IOPA x-ray showing bone loss in relation to 31,32,41 and
42.
Diagnosis
Localised severe chronic periodontitis associated with
secondary trauma from occlusion, frenal pull and
ankyloglossia.
Treatment
A comprehensive treatment plan was discussed with
the patient, and was approved by him. Here, we
will be reporting only the periodontal part of the
treatment plan. Scaling and root planing was carried
out under local anaesthesia with both ultrasonic and
hand instruments. Premature contacts were identified
using articulating paper and coronoplasty was done.
OHI were reinforced and chlorhexidine mouthwash
was prescribed for 10 days. He was recalled after 4
weeks for re-evaluation with reports of a routine
blood investigation. At the recall visit, the tissue was
deemed suitable to begin the surgical phase. The
blood investigation reports were found to be normal.
The following surgical procedures were carried out.
Surgical procedure 1: Labial frenectomy with free
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 gingival graft
A vacuum formed surgical stent, which was fabricated
on the study model of the maxillary arch (Fig.6),
was tried in the patient's mouth and was found to
fit satisfactorily. The donor and recipient sites were
anaesthetized by infiltration with lignocaine 1:80,000.
A free gingival graft of the required dimensions was
harvested from the palate using a No.15 blade (Fig.7).
The graft was trimmed to correct thickness (Fig.8) and
immersed in saline.
Fig.6: Vacuum – formed surgical stent to protect the palatal
donor site
Fig.7: Free gingival graft being harvested
The donor site was sutured with 3-0 black silk sutures
to aid haemostasis (Fig.9) and covered by the surgical
stent. The recipient site was prepared concomitant
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with a vestibuloplasty in relation to the lower anterior
teeth (Fig.10). The free gingival graft was placed at
the recipient site extending over the 31, 32, 41 and
42 region (Fig.11). It was sutured in place with 3-0
black silk sutures (Fig.12). A tinfoil strip was cut to the
appropriate dimensions and placed over the grafted
area. A periodontal pack was then placed over the
surgical site (Fig.13). Antibiotics and analgesics were
prescribed for 3 days and a twice – daily chlorhexidine
rinse for 7 days.
Fig.8: Free gingival graft ready for placement
Fig.9: Donor site sutured to aid hemostasis
Surgical procedure 2: Lingual frenectomy
This procedure was carried out 2 weeks after the
previous procedure, at the patient's request. The
tongue and floor of the mouth were anaesthetized by
infiltration with lignocaine 1:80,000. A 3-0 black silk
stay suture was passed through the tongue (Fig.16) to
aid manipulation. Using a No. 15 blade and surgical
scissors, the aberrant lingual frenum was excised
(Fig.17).

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 Fig.13: Tinfoil placed covered by periodontal pack

Fig.10: Vestibuloplasty and preparation of the recipient site

Fig.14: Three weeks post surgery. Note the absence of frenal

pull, deepening of the vestibule and increase in the width
of attached gingiva
Fig.11: Placement of the free gingival graft onto the recipient
site

Fig.15: Donor site showing satisfactory healing 3 weeks post

Fig.12: Graft sutured in place surgery

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 The wound was closed with 3-0 black silk sutures
(Fig.18). Analgesics were prescribed for 3 days and a
twice – daily chlorhexidine rinse for 7 days.

Results
Healing after both the surgical procedures was
uneventful. After 3 weeks, absence of frenum pull, an
increase in the vestibular depth and an increase in the
width of attached gingiva were clearly noted (Fig.14)
on the facial aspect of 31,32, 41 and 42. On, the
palate, the donor site was almost completely healed
(Fig.15). Lingually, the ankyloglossia was relieved
(Fig.19), with tongue movements noticeably better
than before the surgery.
Fig.16: Stay suture passed through the tongue

Fig.19: Three weeks post surgery: ankyloglossia relieved with

Fig.17: Excision of the aberrant lingual frenum satisfactory healing

Fig.18: Surgical site sutured Fig.20: Ankyloglossia was also observed in the patient's son.

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 || Discussion
Gingival health can be maintained with as little as 1
or 2 mm of attached gingiva.7,8,9 However, soft tissue
grafting procedures are often indicated to optimize
function and aesthetics. Grafting is indicated in areas
of minimal or no attached gingiva where the movable
alveolar mucosal margins interfere with plaque control.
These areas become chronically inflamed and may be
further compromised by a frenum pull and shallow
vestibule10,11 Bjorn, in 1963, was the first to report
a free gingival graft for enhancing vestibule height,
eliminating frenum and creating attached keratinized
gingiva.12 Since then, gingival grafts were performed
to gain keratinized gingiva around teeth13,14, to
deepen shallow vestibules and to release frenum and/
or muscle tension.15,16,17
In our case, we relieved the frenal pull by incision and
performed a vestibuloplasty with a free gingival graft.
By this procedure, we achieved a stable deepening
of the vestibule and an increase in the width of
attached gingiva. Vestibuloplasty techniques without
the use of free gingival gtafts, with healing by second
intention show a 50% of vestibule width loss within
3-5 years.18 In ankyloglossia, the tongue is bound to
the floor of the mouth, restricting its extension.19,20
Due to restricted movement, patients exhibit speech
difficulties in pronunciation of certain consonants.20
Ankyloglossia has also been associated with midline
diastema.21,22 In our case, ankyloglossia was associated
|| References
1. Newman, Takei, Klokkevold, Carranza. Carranza’s
Clinical Periodontology, ed. 10. Saunders 2006, 1023.
2. Park J. Correcting the frenal pull and increasing the width
of keratinised mucosa around endosseous implants using
denudation procedure. Indian J Dent Res 2008; 19: 362-
5.
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with both, midline diastema and gingival recession, in
addition to a mild speech impairment.
Pioneers in the field of periodontics and oral and
maxillofacial surgery have suggested many techniques
to manage cases with ankyloglossia. These include
the use of a surgical blade23, bipolar diathermy24 and
lasers25. We decided to perform the lingual frenectomy
by a surgical blade as it was the only option available to
us at the time. The technique described by Hall23gives
predictable results, but may result in complications like
submandibular swelling due to blockage of Wharton's
duct, numbness in the tongue tip due to damage to
the lingual nerve and secondary infection.26 None of
these complications arose in our case. Two factors were
responsible for the creation of the diastema between
31 and 41: (1) the abnormal lingual frenum pushing
between these teeth and (2) pathological migration
secondary to chronic periodontitis aggravated by
trauma from occlusion.27 The traumatic occlusion was
corrected by coronoplasty28 before the start of the
surgical phase of treatment.
|| Conclusion
Thus, the periodontal management of this interesting
case was completely successful and the patient was
referred to an orthodontist and a speech therapist
for further treatment. A surprising finding was that
ankyloglossia was also observed in the patient’s son
(Fig.20).
Co-authors
Dr. Rohit Radhakrishnan Dr. Bhanu Prakash
Lecturer Lecturer
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