Buccinator muscle repositioning.

Anatomical aberrations and abnormalities are frequently associated with functional, psychosocial, and emotional problems. One such aberration is crestal attachment of frenum or muscle on the alveolar processes of the jaws. Crestal attachment of buccinator muscle is a rare phenomenon, which may pose various problems in routine oral exercises/functions or restoring the edentulous area. A case of abnormal buccinator muscle attachment is presented here, which was relocated apically by surgical means using an acrylic stent. The healing was uneventful and significant apical repositioning was observed. A fixed bridge was fabricated and the long-term results of the restorative therapy were assured because the patient could maintain the oral hygiene well after the muscle repositioning operation.

INTRODUCTION

A healthy periodontal complex is the one which is capable of withstanding the stress of mastication, tooth brushing, trauma from foreign objects, tooth preparation associated with crown and bridge, subgingival restorations, orthodontics, inflammation, and frenulum pull.[1] A frenum is a small band or fold of mucosal membrane that attaches the lips and cheeks to the alveolar process and that limits their movements.[1] Similarly, muscle attachments near the crest of the alveolar bone in edentulous areas or near the marginal tissues in dentate areas may create problems mimicking those of high frenal attachments.

Cohen[1] suggested that the frenulum must always be removed when it is so thick and wide that it may interfere with tooth brushing. For the same reason and also for the purposes of appropriate prosthodontic management, coronally attached muscles may require apical repositioning; if not resection.

The buccinator muscle may pose problems similar to thick, wide, and crestally attached freni in the region of molars near its origin over the jaw bones. The buccinator muscle is a plain, square-shaped bilateral mimic muscle, which composes the mobile and adaptable portion of the cheek. It is frequently referred to as an accessory muscle of mastication because of its role on chewing food and swallowing and compressing the cheeks against the molars as well as its use for whistling, sucking, and blowing.[2]

The orbicularis oris, buccinator, and superior constrictor muscles functionally perform as a unit in the acts of swallowing, blowing, sucking, pronouncing vowels, chewing, and coughing. The buccinator and orbicularis oris play a definite role in beginning the swallow by producing a peristaltic-like wave of contraction originating in the oral cavity and passing pharyngeally. The buccinator usually initiated the sequence followed quickly by the orbicularis oris.[3] Also Kang et al.[4] have described a tentative physiological role, suggesting that they act as a dilator of the parotid duct, as the buccinator muscle fibers extends to the terminal portion of the duct.

Buccinator muscle arises from the molar portion of the alveolar process of the maxilla, the buccinator crest of the mandible and the pterygomandibular raphe of the bucco-pharyngeal fascia. The fiber bundles of the muscle are divisible into four sets all of which insert into the orbicularis oris. The pterygomandibular raphe connects the anterior portion of the superior constrictor muscle of the pharynx with the posterior portion of the buccinator. From the two bone origins, {buccal alveolar bone of maxillary and mandibular molars [Figure 1] and from the pterygomandibular raphe, the fibers of the buccinator muscle run anteriorly, forming the musculature of the cheek.[2]

Figure 1

Normal attachments of buccinator muscle on jaw bones

Not infrequently abnormal buccinator muscle attachment may cause problems in the form of oral hygiene maintenance, proper prosthodontic management, restricted lip and cheek movement, and difficulties in mastication and phonation. One such case with high buccinator muscle attachment causing difficulties in local oral hygiene maintenance and fixed bridge therapy is reported here. Because of various important functions, the muscle cannot be resected, like frenectomy, but can be repositioned apically.

CASE REPORT

A 30-year-old female patient was referred from the Dept. of Prosthetic Dentistry for consideration and management of a mandibular partial edentulous area having high muscle attachment. The patient was being considered for a fixed bridge for missing mandibular left first and second permanent molars (# 36, 37). The high muscle attachment was considered to be an impediment for proper prosthetic management and difficult to control oral hygiene. The patients′ main concerns were difficulty in chewing food because of absence of teeth and ′restricted′ movements of the cheek in the concerned area.

Examination

On examination, the patient was a well-built, adequately nourished, and mentally sound adult. The medical history was non-contributory and no extra-oral abnormalities were noted. The patient was non-alcoholic and had no tobacco habits.

Intraoral examination showed acceptable oral hygiene. Teeth # 36 and 37 were missing as they were extracted due to decay. The height and width of the ridge was nearly maintained. On retracting the cheek, we observed a frenum-like band of soft tissue attached at the crest of the edentulous ridge. Closure examination, anatomic reference points and nature of attached tissue revealed that it is the buccinator muscle whose attachment was abnormal. The attachment (origin) was on the crest of the alveolar ridge. The vestibular fornix (depth) was almost non-existent in that area [Figures 2 and 3].

Figure 2

Clinical view showing the fan‑shaped buccinator attachment‑ occlusal view

Figure 3

Clinical view showing the fan‑shaped buccinator attachment‑ buccal view

Although the muscle was impeding the placement of the toothbrush, the patient had acceptable oral hygiene. But fixed restoration without relaxation of the crestal attachment would have furthered the existing problem. Also, the attachment would have definitely created a space problem for the pontics and an area of food impaction, further deteriorating the situation. A decision to reposition the attachment apically was undertaken. Treatment options like fenestration operation, apical repositioning with free gingival grafts, ‘frenectomy’ plus free gingival grafts, and apical repositioning with acrylic stent were discussed with the patient. The patient agreed for the last option and gave a written consent.

Investigations

The hematological investigations were carried out and were within normal limits. Intra-oral periapical radiographs showed completely healed extraction sockets and absence of any osseous pathology. Radiographically adjacent teeth showed no periapical pathology.

Treatment

An irreversible hydrocolloid (alginate) impression of the lower arch was taken and a cast made in gypsum. A decision to make a surgical acrylic stent was taken as periodontal pack would have been difficult to stay and rigid stent would counteract the forces created by muscle activity. The cast was marked and scored approximately, to accommodate the acrylic stent in close homogenous contact to the ridge [Figure 4], for the loss of tissue going to occur because of the surgical procedure. A passive fit of the stent was checked in patient's mouth and final adjustments were done [Figure 5]. The stent was finished and polished adequately to prevent plaque accumulation.

Figure 4

Surgical stent made in clear acrylic with retention clasps

Figure 5

Checking the fit of surgical stent

Surgery was performed under lignocain with adrenalin (2% lignocain with 1:80,000 adrenalin) where in a crestal incision was placed keeping the incision slightly buccally. The incision was extended anteriorly two to three teeth and posteriorly distal to the last molar. The muscle attachment was detached from the crest and dissection was continued inferiorly for about 1.5-2.0 cm. Deeper to that the dissection continued apically but keeping the periosteum intact (split-thickness). The achieved vestibular depth and muscle repositioning was checked by retracting the cheek [Figure 6]. After adequate depth was achieved, the area was irrigated, hemorrhage controlled and the surgical stent stabilized in place [Figure 7].

Figure 6

Surgical detachment of buccinator and vestibular extension

Figure 7

Post‑surgical stent placement

Written postoperative instructions were provided and a course of amoxicillin 500 mg tds and paracetamol 625 mg tds was given for 5 days. The stent was kept for 15 days to allow complete healing with regular povidone iodine irrigations and oral hygiene instructions. The patient was also asked to gargle with 0.2% chlorhexidine mouthrinse 10 ml each twice daily for 15 days. Povidone iodine was used as wound irrigant and chlorhexidine as anti-plaque mouthwash. As the surgical site was treated as open wound which will heal by secondary intention, prevention of infection was our concern. We used povidone iodine irrigations once every 2 or 3 days till stent removal as it has been demonstrated to be effective at killing a broad range of pathogens generally associated with wound infection. Also povidone-iodine solution appears to be a relatively safe treatment for small acute wounds. Chlorhexidine mouthwash was prescribed for twice daily use mainly as an anti-plaque agent. As chlorhexidine has been recommended to aid/ replace mechanical toothbrushing when this is not possible after oral or periodontal surgery and during the healing period. The area was healed uneventfully without much swelling and pain, but the patient experienced some discomfort while eating for first two to three days. After two months of healing [Figure 8], it was observed that there was significant gain in vestibular depth and the muscle was relocated to an apical position allowing the toothbrush head to be positioned properly for maintaining the hygiene. The final fixed prosthesis was delivered after three months of healing.

Figure 8

2‑month post‑operative result

DISCUSSION

Various reasons have been attributed but the three common conditions necessitating vestibular alterations are;[5]

Abnormal frenal or muscle attachments approximating the marginal gingiva or alveolar crest,

Gingival margin situated at or near mucogingival junction, following a gingivectomy or gingival recession, and

Deep periodontal pockets ending at or apical to mucogingival junction.

In our case, negligible vestibular depth along with no attached gingiva on buccal aspect and almost crestal positioning of mucogingival junction precluded proper positioning of toothbrush. Gingival augmentation would have been another option as the American Academy of Periodontology[6] recommends that gingival-augmentation procedures should be performed to prevent soft tissue damage in the presence of alveolar bone dehiscence during natural or orthodontic tooth eruption, to halt progressive recession of the gingival margin, to improve plaque control and patient comfort around teeth and implants, and to increase the insufficient dimension of gingiva in conjunction with fixed or removable prosthetic dentistry.

Vestibular alterations in the mandibular molar area because of abnormal buccinator attachment may be sometimes required for proper oral hygiene maintenance or for prosthetic reasons.

Frequently in the region of mandibular buccinator attachment in the premolar and molar area, the alveolar process is short and the mucobuccal fold is high. A frenectomy will result in the formation of a shallow vestibule. The procedure of choice in these cases is a combination of frenectomy and vestibular extension.[5]

It was not clear that the coronal attachment was pre-extraction (because of shallow vestibule due to high external oblique ridge) or developed after the extraction of the involved teeth. If it had developed after extraction then following would be the possible reasons:

Loss of vertical ridge height during traumatic extractions as some amount of alveolar remodeling is expected after every tooth extraction,

Loss of soft tissue and improper suturing (coronal pulling) during extraction,

Horizontal loss of alveolar ridge due to periodontal diseases compounded by bone loss during extraction,

Disuse atrophy because of loss of functional stimulation, and

Combination of the above.

Various differing results have been observed by many authors who worked on vestibular extensions. Bohannan HM[7-9] reported shallowing out of the vestibule in all cases for vestibular extensions regardless of the technique employed. Ochsenbein[10] reported that vestibular fornix cannot be increased in depth on a predictable basis. Corn′s[11] observations were more positive, he reported greatly increased zone of attached gingiva and the mucogingival junction was positioned more apically. The greatest permanent increase in depth of the fornix followed complete denudation of the fibrous periosteum from the alveolar margin to the base of the deepened vestibule.

Although Ainamo et al.[12] proposed a genetically determined position for mucogingival junction (MGJ), various long term studies[13-16] have shown little changes in positioning of the junction after augmentation procedures and maintained keratinized tissue (KT) width for as long as 10 to 27 years. Agudio et al.[13] further reiterated that although there is some tendency towards coronal migration of MGJ, the amount of KT, could last for >10 years in a well-controlled and properly motivated patient population. A recent systematic review[17] also revealed that with respect to increasing the width of keratinized tissue or attached gingiva around teeth, APF/V (apically positioned flap/ vestibuloplasty) procedures are successful treatment concepts, and the addition of autogenous tissue statistically significantly increases the width of attached gingiva.

In this case, the site for vestibular extensions is a difficult area as Bradin[18] had explained that ′any area which forms broad shelf-like projections in the mandible on the labial or buccal surfaces hinders the amount of attached gingiva and vestibular extension, unless extensive bony reshaping is done. The most common site is the external oblique ridge area about the second and third molar and next commonly the midline of the mandible. In these areas, one has to be content with a shallow vestibule and about 1 or 2 mm of attached gingiva’.

Various techniques have been proposed till date with the aim to create adequate vestibular depth and limit the traction of fiber and muscle attachments. In recent years, vestibuloplasty using free gingival or split thickness skin grafts (as denture base) has become the preferred procedure because of its effective increase of vestibular depth and quantity of stable tissue obtained. Secondary epithelialization techniques were found to be less effective because the postoperative vestibular depth often decreased over time as a result of wound contraction. To minimize loss of vestibular depth obtained during surgery, a surgical acrylic stent is used in this case for long term retention and proper stabilization. As Bradin[18] reported, ‘for vestibular extensions to be successful, pack should be in position for at least three weeks. Many cases fail because packs cannot be maintained. The pack should go down to the area of depth required and be maintained. Packs are frequently displaced in an incisal direction while they are still setting and this will interfere with desired result. Aids in pack retention such as wire ligature, copper bands, or stents can be employed at various times.’

CONCLUSION

Alterations of the vestibule and mucobuccal fold are valuable adjuncts in periodontal-prosthetic management. Appreciation, understanding, and proper utilization of recommended procedures will definitely contribute towards more favorable and lasting results. Apical repositioning of an aberrant muscle attachment will preserve all important functions of the muscle as well. Instead of restoring sub-optimal edentulous areas which may complicate future hygiene maintenance, pre-prosthetic surgeries should be considered to achieve appropriate ridges for restorations.