CLINICAL REPORT

aProfessor, BbProfessor, ScAssistant Pr

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Frenectomy with anterior lingual sulcoplasty for animplant-supported overdenture: A clinical report

Paulo Sergio Perri de Carvalho, DDS, PhD,a Luiz Antonio Janjacomo, DDS,b and Daniela Ponzoni, DDS, PhDc

ABSTRACTThis clinical report describes the deepening of a patient’s anterior mandibular lingual sulcus incombination with frenectomy and the use of an acrylic resin guiding device fixed to an osseoin-tegrated dental implant to maintain the patency of the new sulcular depth. (J Prosthet Dent2016;115:406-408)

After the loss of the mandib-ular teeth and bone resorptionof the alveolar process, thefloor of the mouth and thelingual frenulum often becomeraised to the level of the bone

ridge during normal functional movements, especiallyduring speech and swallowing. This situation makes thestabilization of a conventional complete dental prosthesisdifficult, because it becomes nearly impossible to providea lingual flange, and frequent ulceration of the lingualfrenulum may occur in osseointegrated implant-retainedoverdentures.1,2 Frenectomy and anterior lingual sulco-plasty are indicated for these situations.

Cooley3 proposed lingual frenectomy and the trans-position of the superficial fibers of the genioglossus andgeniohyoid muscles to deepen the lingual sulcus. Thisprocedure is often associated with osteoplasty of themental spine.

CLINICAL REPORT

A72-year-oldmanwhowas unable to use his overdentureprosthesis because of pain and frequent ulcerations in theanterior mandible region was referred by Oral Rehabili-tation Clinic (Araçatuba, São Paulo, Brazil). He presentedwith 2 osseointegrated implants with abutments in theanterior mandible region and the lingual frenulum close tothe crest of the ridge with absence of depth of the anteriorlingual sulcus. The insertion position of the lingualmusculature was palpated near the crest of the ridge(Fig. 1). Initially, the replacement of the overdenturewith a

auru School of Dentistry, University of São Paulo (USP), Brazil.pecialization Course on Implant Dentistry at NEC Araçatuba School of Denofessor, Department of Surgery and Integrated Clinic, Araçatuba School of

fixed prosthesis was proposed after additional mandibularimplant placement. However, this option was declinedbecause the patient’s lack of motor coordination mighthave prevented adequate hygiene of a fixed prosthesis.Thus, frenectomy and anterior lingual sulcoplasty weresuggested.

A mandibular impression was made with a polyvinylsiloxane material (Express; 3M ESPE) and an acrylic resinguiding device was designed and fabricated so that itcould be retained by the dental implants. The followingprocedure was performed under local anesthesia. Thetongue was extended, and hemostats were placed on thelingual frenulum as determined by the single hemostatfrenectomy technique4 (Fig. 2). After excising the fren-ulum with a scalpel, a diamond-shaped wound wasformed (Fig. 3). Then, only the superior and lateral fibersof the genioglossus and geniohyoid muscles were excisedfrom the mandible. The removed mandibular fibers weresutured directly around the muscle and connecting tis-sue. The lingual mandible side remained covered by theperiosteum; the sublingual region was sutured withsimple interrupted stitches.

The acrylic resin guiding device was extended toattain the desired depth, internally coated with a surgicalcement (COE-PAK; GC America Inc), and finally stabi-lized with screws to the 2 implants (Figs. 4, 5). The

tistry (UNESP), São Paulo, Brazil.Dentistry (UNESP), São Paulo, Brazil.

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Figure 1. Initial clinical presentation: lack of lingual sulcus depth. Figure 2. Single hemostat frenectomy technique.

Figure 3. After frenectomy. Figure 4. Acrylic resin guide positioned and fixed on osseointegratedimplants.

Figure 5. Acrylic resin guide positioned with surgical cement.

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surgical guide was unscrewed and removed 5 weekslater. Epithelialization of the lingual surface wasobserved, and deepening of the lingual sulcus was ach-ieved (Fig. 6). The overdenture prosthesis retained on the2 osseointegrated implants was installed without theformation of ulcerations on the lingual side of themandible (Fig. 7).

DISCUSSION

Owing to alveolar process resorption that follows toothloss, the lingual frenulum and the genioglossus andgeniohyoid muscles may become shallow with respect tothe ridge crest, making it difficult to stabilize conven-tional or overdenture-type removable prostheses.2,3 Inthis patient, discomfort could have been resolved bysubstituting the removable system with a fixed pros-thesis. However, considering the patient’s inability tocarry out prosthesis hygiene, he opted for the implant-based removable prosthesis.

On palpation, good positioning of the mental spinewas found; this allowed the deepening of the lingual

Perri de Carvalho et al

sulcus by removing a part of the superior and lateralmuscle fibers without spine osteoplasty. If all the gen-ioglossus and geniohyoid muscle fibers were removedfrom the bone, the whole muscle mass would retractposteriorly under the patient’s tongue, resulting in

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Figure 6. Thirty days after procedure. Figure 7. Definitive overdenture prosthesis.

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postoperative speech and swallowing problems.5,6 Byscrewing the acrylic resin device on to the implants thelingual tissues were preserved in place during scarring,and sutures transfixed on the lingual region of themandible and anchored to the menton region wereunnecessary; moreover, as proposed by Cooley, thistechnique also avoided the use of steel sutures transfixedon the anterior mandible and twisted on the vestibularside.1

This technique increased the patient’s comfort duringthe postoperative phase. The treatment provided stabilityof and prevented ulcerations on the lingual side of themandible during the use of the overdenture prosthesisretained on the 2 osseointegrated implants.

SUMMARY

The technique of deepening the lingual sulcus in theanterior mandibular region is used in patients withatrophy of the alveolar ridge and uplifting of themouth floor. Both situations make prosthetic rehabil-itation difficult. A modified technique can be usedwith a surgical guide supported by the dental implantsduring the healing phase. Thus, the procedure be-comes straightforward, comfortable, and less traumaticfor the patient, enabling adequate prosthetic rehabil-itation of the area.

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CONCLUSION

This clinical report described the specific application of alocalized anterior mandibular sulcoplasty and lingualfrenectomy, together with accompanying surgical-guidestabilization with dental implants to ensure the surgicalprocedure’s efficacy.

REFERENCES

1. von Wowern N, Hjørting-Hansen E. The mandibular bone mineral content inrelation to vestibulolingual sulcoplasty. A 2-year follow-up. J Prosthet Dent1991;65:804-8.

2. Kwakman JM, Voorsmit RA, Freihofer HP. Treatment of the edentulousmandible with a vestibuloplasty combined with Intramobil Zylinder implants:a 5-year follow-up. Br J Oral Maxillofac Surg 1998;36:296-300.

3. Cooley DO. Method for deepening the mandibular and maxillary sulci tocorrect deficient edentulous ridges. J Oral Surg 1952;10:279-89.

4. Archer H. Oral surgery for dental prosthesis. In: Oral and maxillofacial surgery.5th ed. Philadelphia: Saunders; 1975. p. 135-210.

5. Watson CJ. Changes to the lower third facial profile following mandibularsulcoplasty with free skin grafting. Br J Oral Maxillofac Surg 1987;25:465-73.

6. Berg RW, Goldman BM, Kurtz K, Schweitzer K, Kraut RA. Prosthodonticmanagement of sulcoplasty and sialodochoplasty with a conforming surgicalstent. J Prosthodont 2008;17:52-4.

Corresponding author:Dr Daniela PonzoniDepartment of Surgery and Integrated ClinicAraçatuba School of Dentistry (UNESP)Rua José Bonifácio, 1193 CEP 16015-050BRAZILEmail: dponzoni@foa.unesp.br

Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

Perri de Carvalho et al