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Case Report

Presurgical management of a child with

missing lower lip using a new design of fixed
lower tongue crib
Abstract
Missing of any perioral structure can result in imbalance of
muscular forces leading to loss of structure and function along
with esthetics especially in a growing individual and can result
in permanent damage. Rehabilitation of such children is a
challenge and requires an integrated multidisciplinary approach
not only to correct the defect, but also to ensure normal
development with minimal handicap. Here is a case report
of a 10-year-old child with missing lower lip due to childhood
infection and its presurgical management using a new design of
fixed lower tongue crib used to limit tongue pressure, improve
tongue position, and facilitate lower incisor retraction.

Safeena S, Najmuddin M1, Reddy K

Department of Orthodontics, Al-Badar Rural Dental College

and Hospital, Gulbarga, 1Department of Oral Medicine and
Radiology, AMEs Dental College, Raichur, India
Correspondence:
Dr. Safeena S, Department of Orthodontics,
Al-Badar Rural Dental College and Hospital, Gulbarga.
E-mail: aksafe@yahoo.com
Access this article online
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Website:
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DOI:
10.4103/0970-4388.100019

A new clinical experience for lower lip missing cases in children

are added, as these cases are rare.

PMID:
***

Key words
Fixed tongue crib, incisor retraction, missing lip, Top of page

Introduction
Equilibrium theory states that an object subjected to
unequal forces will be accelerated and thereby move
to different positions in space. Equilibrium effects
on dentition are governed by masticatory forces and
pressure from the lips, cheek, and tongue. The pressures
from the soft tissues are much lighter than the forces
of mastication, but much greater in duration. Injury to
the lip leading to scarring and contracture will lead to
the incisors being tipped lingually and if the pressure
from the lip or cheek are removed, unopposed pressure
from the tongue will lead to outward movement of the
teeth.[1] We report a case of missing lower lip due to
infection and scarring leading to proclination of lower
incisors and its early management in a child using a
fixed lower tongue crib and fixed orthodontic appliance.

Case Report
A 10-year-old male patient was referred from the
department of oral surgery with a chief complaint
of proclined lower incisors and a missing lower lip.
Patients father gave a history of infection of the lower
lip with purulent discharge when the child was 4-year
old that healed with scarring and lead to loss of the
lower lip.
On examination, it was found that 2/3rd of the lower lip
was missing and there was scar tissue in the chin area,
fused to the lower alveolus. Upper and lower central
incisors and first molars were erupted except the lower
right central incisor. Lower incisors were severely
proclined with the tongue resting on the lower incisors
[Figure 1a]. He had missing lower right deciduous
molars and upper deciduous first molars due to caries.
The remaining deciduous teeth also showed gingival
recession and mobility [Figures 1c and d].

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Safeena, et al.: Presurgical management of missing lower lip

Figure 2: (a) Fixed tongue crib and initial Niti wire for alignment.
(b)Post retraction intraoral view. (c) Occlusal view before retraction.
(d) Occlusal view post-retraction

Figure 1: (a, b) Extraoral view. (c) Lateral Cephalogram showing

severe proclination of lower incisors. (d) Extraoral left profile view

Cephalometric analysis showed a class II skeletal

pattern, hyperdivergent mandibular base with FMA 32
and lower incisor inclination to the mandibular plane
being 141 [Figure 1b] indicating severe proclination
of the lower incisors.
OPG examination revealed missing lower central
incisor and all other teeth present at different staged
of eruption.
Lingual pressure from the tongue had to be controlled
and lower incisors had to be retracted in order to
improve esthetics and function, and to facilitate a lip
reconstruction surgery.

Treatment
The lower incisors and the remaining deciduous
teeth were bonded with Begg appliance except the
lower left canine since it showed grade II mobility.
Since the tongue was resting on the lower incisors, it
was necessary to position the tongue away from the
incisors to facilitate retraction. A fixed lower tongue
crib was planned. The lower permanent molars were
banded and the tongue crib was soldered to the bands
with two metal extensions soldered on the right side.
Since the lower-left deciduous molars were lost, the
wire extensions would help support the long span of
184

archwire on the left side. Initially a 0.016 NiTi wire was

used for alignment and the retraction was done using
0.016 stainless steel wire and elastic thread.
At the end of retraction, the lower incisors were
positioned at 122 to the mandibular plane which was
141 pretreatment. After debonding the appliance and
removal of the tongue crib, the patient was referred
back to the department of oral surgery for the lip
reconstruction surgery. [Figure 2]

Discussion
Reported causes of loss of lower lip in children have
been due to neonatal oral infection (cancrum oris)
chemical, electrical burns, trauma, animal bites, cancer
and as a surgical complication, cancrum oris being the
most common cause seen especially in the African subSahara region, leading to facial deformities.[2]
Presurgically, these children need to be rehabilitated for
function and to prevent further malocclusion. Medical
management of such children for control of disease has
been reported.[3] Surgical reconstruction is required
in such children and presurgical management is also
essential.
Fixed tongue crib has been used for control of oral
habits such as tongue thrusting and thumb sucking
especially in noncompliant patients, which usually leads
to proclination of upper incisors in children. Tongue
crib is rarely given in the lower arch.[4] Here we have
devised a new design of tongue crib to be fixed to the

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Safeena, et al.: Presurgical management of missing lower lip

lower arch which not only prevents lingual forces of

the tongue on the lower incisors, but also helps support
the long span of archwire that may become too flexible
and distort if left unsupported.

Conclusion
The new design of fixed tongue crib given in the
mandibular arch is an efficient way of controlling the
unbalancing forces from the tongue especially when the
tongue position is low lying.

orthodontic problems. 3rd ed. Missouri: Mosby 2000; p-128.

2. Nthumba P, Carter L. Visor flap for total upper and lower
lip reconstruction: A case report. J Med Case Reports 2009;
3:7312 p1-5
3. Moss JP. Soft tissue environment of teeth and jaws:
An experimental and clinical study: Part 1. Br J Orthod
1980;7:127-37.
4. Cooke MS. A lower fixed lingual tongue crib and lip toning
exercises: Report of an unusual case. Br J Orthod 1977;
4:143-8.

References

How to cite this article: Safeena S, Najmuddin M, Reddy K.

Presurgical management of a child with missing lower lip using a
new design of fixed lower tongue crib. J Indian Soc Pedod Prev
Dent 2012;30:183-5.

1. Proffit WR. Contemporary Orthodontics, The etiology of

Source of Support: Nil, Conflict of Interest: None declared.

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