Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2012  |  Volume : 30  |  Issue : 2  |  Page : 183--185

Presurgical management of a child with missing lower lip using a new design of fixed lower tongue crib

S Safeena1, M Najmuddin2, K Reddy1,  
1 Department of Orthodontics, Al-Badar Rural Dental College and Hospital, Gulbarga, India
2 Department of Oral Medicine and Radiology, AME's Dental College, Raichur, India

Correspondence Address:
S Safeena
Department of Orthodontics, Al-Badar Rural Dental College and Hospital, Gulbarga


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. A new clinical experience for lower lip missing cases in children are added, as these cases are rare.

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;30:183-185

How to cite this URL:
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 [serial online] 2012 [cited 2022 May 20 ];30:183-185
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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. Patient's 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 1]a. 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 [Figure 1]c and d. {Figure 1}

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 1]b 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.


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 archwire on the left side. Initially a 0.016² NiTi wire was used for alignment and the retraction was done using 0.016² 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]{Figure 2}


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 sub-Sahara 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 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.


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.


1Proffit WR. Contemporary Orthodontics, The etiology of orthodontic problems. 3 rd ed. Missouri: Mosby 2000; p-128.
2Nthumba P, Carter L. Visor flap for total upper and lower lip reconstruction: A case report. J Med Case Reports 2009;3:7312 p1-5
3Moss JP. Soft tissue environment of teeth and jaws: An experimental and clinical study: Part 1. Br J Orthod 1980;7:127- 37.
4Cooke MS. A lower fixed lingual tongue crib and lip toning exercises: Report of an unusual case. Br J Orthod 1977;4:143-8.