From Volume 42, Issue 2, March 2015 | Pages 142-143
Whilst transient effects of orthodontic appliances on the oral mucosa are well recognized, chronic lesions, persisting post therapy are unusual. We describe a persistent lingual mucosal defect related to a transpalatal arch (TPA) in a healthy 19-year-old female. The asymptomatic lesion is presently being monitored, however, surgical revision in the future may be requested by the patient if the area fails to remodel.
A transpalatal arch is a fixed orthodontic appliance used to reinforce posterior anchorage during orthodontic treatment. It consists of bands cemented to the upper first permanent molars and 1.0 mm stainless steel wire lying over the hard palate and separated from the soft tissue by 0.5–1mm (Figure 1).
A 19-year-old female had a history of attending both her general medical and dental practitioners regarding an asymptomatic tongue lesion. The patient first became aware of an ulcerated lesion on her tongue during orthodontic treatment, which was completed at the age of 16. During the course of the orthodontic treatment, she remembered that a transpalatal arch was fitted. The advice from her orthodontist was that the lesion would disappear once the transpalatal arch was removed. Three years post-treatment, however, the lesion was still present and the patient was concerned about its appearance. The area was occasionally uncomfortable and she reported a history of ulceration when traumatized.
Extra-oral examination did not reveal any lymphadenopathy.
Intra-oral examination revealed an irregular lesion approximately 25 mm in length, running transversely across the dorsum of the tongue. The lesion had the appearance of a mucosal flap with two distinct arms about 1 mm wide (Figure 2). On palpation, it was soft with a rubbery margin. A provisional diagnosis of fibrous hyperplasia secondary to the use of TPA during orthodontic treatment was made.
The patient was referred to the Oral Medicine department, where it was decided, in the first instance, to monitor the lesion with serial photography before proceeding to excision. The problem was chiefly an aesthetic consideration, giving little discomfort, so the patient was only likely, in time, to opt for excision on aesthetic grounds.
Orthodontic patients are at risk of iatrogenic damage to the soft tissues as a result of orthodontic appliances. In a study by Kvam et al, the incidence of oral ulceration reported by patients was 93%, with only four people in the study of 79 patients never experiencing an ulcer. Oral ulceration was found to be the most irritating part of orthodontic treatment in 46.8% of adults and 28.7% of young patients.1
Minimizing the risk of oral ulceration is essential to ensure improved comfort during treatment and good patient compliance.
Clinically, the clinician should ensure the following when fitting a transpalatal arch:
If patients experience discomfort, including traumatic ulceration, they should be reassured as to the traumatic nature of the lesion and advised to use orthodontic wax to cover the wire. The use of chlorohexidine mouthwash may be appropriate to prevent any mucosal infection and, in severe cases, the removal of the TPA may be required.
In the majority of cases, any soft tissue irritation caused by a transpalatal arch disappears rapidly following removal of the appliance. Where severe ulceration of the tongue occurs, its early removal may be advocated.2 As prevention is always better than cure, a good design and a well-fitting transpalatal arch is the key to ensuring that soft tissue trauma is minimized.
