Fractured genial tubercles William M. Goebel, D.D.S., M.S.D.* University of California, School of Dentistry, Los Angeles, Calif.
The genial tubercles are a group of bony extensions that surround the lingual foramen. 1 They are located bilaterally on the lingual surface of the mandible, situated midway between the superior and inferior borders, z These extensions, also referred to as mental spines, n u m b e r from two to four and serve as part of the origin of the genioglossus and geniohyoid muscles. These muscles are derived further from roughened depressions on the mandible lateral to the lingual foramen, 3 and, according to Maw and Lindsay, 4 in the anterior floor of the mouth. The genial tubercles are normally quite small, although on occasion they m a y be increased in size and extend significantly inward from the lingual surface of the mandible. If their size is excessive they may interfere with successful wearing of a mandibular prosthesis. This process of enlargement commonly is referred to as dystrophic calcification of the genioglossus ligament, although another possible reason for this increased size m a y be a process similar to the one observed with the styloid process as described by Stafne? H e suggests that ossification of normal embryonal cartilage results in large processes rather than degenerative calcification of the ligament. Regardless of terminology or origin, the fact remains that large genial tubercles m a y be a source of interference to mandibular dentures. T R E A T M E N T FOR F R A C T U R E D GENIAL TUBERCLES A review of the modern medical and dental literature revealed two previous reports of fracture of genial tubercles 6, 7 and one article advocating conservative management of tubercle fractures.' Interference of large genial tubercles with prosthetic flanges is not uncommon and is readily recognized, but fracture is a rare occurrence. Surgical intervention
*Chairperson, Section of Oral Diagnosis, Oral Medicine, Oral Pathology. 0022-3913/78/0639-0603500.20/0 9 1978 The C. V. Mosby Co.
usually is unnecessary. T h e genioglossus and geniohyoid origins apparently are not completely severed in most fractures, as no immediate or permanent loss of function has been noted. Normal function would be expected to continue and should be minimal, as the origin of these muscles is not limited solely to the tubercles but extends laterally on the lingual surface of the mandible, and in the case of the genioglossus into the floor of the mouth. I m m e d i a t e loss of function could be explained partly by pain from movement of the tongue and its associated muscular attachments. In the patient reported on by Reifman, G immediate surgical intervention removed the fractured segment. In treatment of an earlier patient reported on by Smyd, 7 surgical removal of the fractured portion was not employed, and the patient had an unremarkable recovery with satisfactory glossal mobility. M a w and Lindsay' reported five genial tubercle fractures from combat injuries with concomitant symphysis fractures. No surgery was done on the tubercles. None of these patients experienced loss of tongue function after healing. Patient history. A 65-year-old white edentulous man complained of denture irritation in the anterior floor of the mouth. The history indicated that 4 days before he had experienced a sharp, severe pain in the region while eating. No cracking or noise was experienced at the time of the incident, but the area had been quite tender since. The patient had been edentulous for 24 years, and new complete dentures had been constructed 6 months previously, with the oral examination at the time of denture fabrication indicating a "hypertrophied genial tubercle." Interference with the proposed denture flange was not expected. On examination a 1.5 • 1.5 cm irregular area of bluepurple discoloration which was moderately edematous and extremely tender to p a l p a t i o n was noted around the openings of Wharton's duets (Fig. 1). A prominent, hard, slightly movable mass was THE JOURNAL OF PROSTHETIC DENTISTRY
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Fig. 1. Arrow indicates discolored tissue surrounding the submaxillary caruncles.
Fig. 3. The opacity is not related to the ducts. T h e p a t i e n t was advised of the findings. N o specific t h e r a p y was r e c o m m e n d e d o t h e r t h a n restricted w e a r i n g o f the m a n d i b u l a r d e n t u r e until discomfort subsided. N o p o s t - t r a u m a l i m i t a t i o n of f u n c t i o n has been noted. A 2 m o n t h follow-up revealed resolution of the h e m a t o m a , c o m p l e t e s y m p t o m a t i c recovery, a n d no loss of n o r m a l m o b i l ity. R a d i o g r a p h s revealed the f r a c t u r e d p o r t i o n of the tubercles in the s a m e relative position as i m m e d i a t e l y after the incident. SUMMARY
Fig. 2. Note the radiopaque mass posterior to the symphysis of the mandible. felt easily b e n e a t h the site of the discoloration; however, the presence or absence of a t t a c h m e n t to the m a n d i b l e could n o t be discerned easily. T o n g u e m o b i l i t y was not restricted n o t i c e a b l y e v e n t h o u g h the p a t i e n t experienced p a i n d u r i n g function. Both W h a r t o n ' s ducts were f o u n d to be p a t e n t , with saliva flowing free of debris. T h e right a n d left ducts were p r o b e d w i t h a 000 l a c r i m a l p r o b e a n d found to be u n o b s t r u c t e d . Occlusal r a d i o g r a p h s revealed a n irregular 6 • 7 m m r a d i o p a q u e mass in the a n t e r i o r floor of the m o u t h (Fig. 2). Differential diagnosis: h e m a t o m a , sialolith, a n d f r a c t u r e d genial tubercles. A d u c t s i a l o g r a m was d o n e 2 d a y s later. A n occlusal f i l m of the opacified d u c t showed the catheters a n d ducts well to the p e r i p h e r y of the o p a c i t y (Fig. 3). D i s c h a r g e diagnosis: h e m a t o m a a n d fractured genial tubercles. 604
It is a p p a r e n t from these reports t h a t fractures of genial tubercles occur p e r i o d i c a l l y a n d t h a t surgical t r e a t m e n t for most fractures is not necessary. This type of p a t i e n t is q u i t e likely to seek d e n t a l care because a d e n t u r e m a y seem to be the obvious source of irritation. Review of all a v a i l a b l e i n f o r m a t i o n indicates t h a t conservative m a n a g e m e n t is the treatm e n t of choice for fractures of genial tubercles. REFERENCES 1. Wood, N. K., and Goaz, P. W.: Differential Diagnosis of Oral Lesions. St. Louis, 1975, The C: V. Mosby Company, p 478. 2. Stafne, E. C.: Oral Radiographic Diagnosis. Philadelphia, 1976, W. B. Saunders Company, p 9. 3. Sicher, H.: Oral Anatomy. St. Louis, 1965, The C. V. Mosby Company, p 68. 4. Maw, R. B., and Lindsay, J. S.: Conservative management of genial tubercle fractures. Oral Surg 30:445, 1970. 5. Stafne, E. C.: Oral Radiographic Diagnosis. Philadelphia, 1969, W. B. Saunders Company, p 13. 6. Reifman, S.: Genial tubercle fracture. Report of a case. Oral Surg 27:595, 1969. 7. Smyd, E. S.: Fracture of the genial tubercles. J Am Dent Assoc 55:136, 1957. Reprint requests to:
DR. WILLIAMM. GOEBEL UNIVERSITY OF CALIFORNIA SCHOOL OF DENTISTRY
Los ANGELES,CALIF.90024 JUNE 1978
VOLUME39
NUMBER6
The genial tubercles are a group of bony extensions that surround the lingual foramen. 1 They are located bilaterally on the lingual surface of the mandible, situated midway between the superior and inferior borders, z These extensions, also referred to as mental spines, n u m b e r from two to four and serve as part of the origin of the genioglossus and geniohyoid muscles. These muscles are derived further from roughened depressions on the mandible lateral to the lingual foramen, 3 and, according to Maw and Lindsay, 4 in the anterior floor of the mouth. The genial tubercles are normally quite small, although on occasion they m a y be increased in size and extend significantly inward from the lingual surface of the mandible. If their size is excessive they may interfere with successful wearing of a mandibular prosthesis. This process of enlargement commonly is referred to as dystrophic calcification of the genioglossus ligament, although another possible reason for this increased size m a y be a process similar to the one observed with the styloid process as described by Stafne? H e suggests that ossification of normal embryonal cartilage results in large processes rather than degenerative calcification of the ligament. Regardless of terminology or origin, the fact remains that large genial tubercles m a y be a source of interference to mandibular dentures. T R E A T M E N T FOR F R A C T U R E D GENIAL TUBERCLES A review of the modern medical and dental literature revealed two previous reports of fracture of genial tubercles 6, 7 and one article advocating conservative management of tubercle fractures.' Interference of large genial tubercles with prosthetic flanges is not uncommon and is readily recognized, but fracture is a rare occurrence. Surgical intervention
*Chairperson, Section of Oral Diagnosis, Oral Medicine, Oral Pathology. 0022-3913/78/0639-0603500.20/0 9 1978 The C. V. Mosby Co.
usually is unnecessary. T h e genioglossus and geniohyoid origins apparently are not completely severed in most fractures, as no immediate or permanent loss of function has been noted. Normal function would be expected to continue and should be minimal, as the origin of these muscles is not limited solely to the tubercles but extends laterally on the lingual surface of the mandible, and in the case of the genioglossus into the floor of the mouth. I m m e d i a t e loss of function could be explained partly by pain from movement of the tongue and its associated muscular attachments. In the patient reported on by Reifman, G immediate surgical intervention removed the fractured segment. In treatment of an earlier patient reported on by Smyd, 7 surgical removal of the fractured portion was not employed, and the patient had an unremarkable recovery with satisfactory glossal mobility. M a w and Lindsay' reported five genial tubercle fractures from combat injuries with concomitant symphysis fractures. No surgery was done on the tubercles. None of these patients experienced loss of tongue function after healing. Patient history. A 65-year-old white edentulous man complained of denture irritation in the anterior floor of the mouth. The history indicated that 4 days before he had experienced a sharp, severe pain in the region while eating. No cracking or noise was experienced at the time of the incident, but the area had been quite tender since. The patient had been edentulous for 24 years, and new complete dentures had been constructed 6 months previously, with the oral examination at the time of denture fabrication indicating a "hypertrophied genial tubercle." Interference with the proposed denture flange was not expected. On examination a 1.5 • 1.5 cm irregular area of bluepurple discoloration which was moderately edematous and extremely tender to p a l p a t i o n was noted around the openings of Wharton's duets (Fig. 1). A prominent, hard, slightly movable mass was THE JOURNAL OF PROSTHETIC DENTISTRY
t503
GOEBEL
Fig. 1. Arrow indicates discolored tissue surrounding the submaxillary caruncles.
Fig. 3. The opacity is not related to the ducts. T h e p a t i e n t was advised of the findings. N o specific t h e r a p y was r e c o m m e n d e d o t h e r t h a n restricted w e a r i n g o f the m a n d i b u l a r d e n t u r e until discomfort subsided. N o p o s t - t r a u m a l i m i t a t i o n of f u n c t i o n has been noted. A 2 m o n t h follow-up revealed resolution of the h e m a t o m a , c o m p l e t e s y m p t o m a t i c recovery, a n d no loss of n o r m a l m o b i l ity. R a d i o g r a p h s revealed the f r a c t u r e d p o r t i o n of the tubercles in the s a m e relative position as i m m e d i a t e l y after the incident. SUMMARY
Fig. 2. Note the radiopaque mass posterior to the symphysis of the mandible. felt easily b e n e a t h the site of the discoloration; however, the presence or absence of a t t a c h m e n t to the m a n d i b l e could n o t be discerned easily. T o n g u e m o b i l i t y was not restricted n o t i c e a b l y e v e n t h o u g h the p a t i e n t experienced p a i n d u r i n g function. Both W h a r t o n ' s ducts were f o u n d to be p a t e n t , with saliva flowing free of debris. T h e right a n d left ducts were p r o b e d w i t h a 000 l a c r i m a l p r o b e a n d found to be u n o b s t r u c t e d . Occlusal r a d i o g r a p h s revealed a n irregular 6 • 7 m m r a d i o p a q u e mass in the a n t e r i o r floor of the m o u t h (Fig. 2). Differential diagnosis: h e m a t o m a , sialolith, a n d f r a c t u r e d genial tubercles. A d u c t s i a l o g r a m was d o n e 2 d a y s later. A n occlusal f i l m of the opacified d u c t showed the catheters a n d ducts well to the p e r i p h e r y of the o p a c i t y (Fig. 3). D i s c h a r g e diagnosis: h e m a t o m a a n d fractured genial tubercles. 604
It is a p p a r e n t from these reports t h a t fractures of genial tubercles occur p e r i o d i c a l l y a n d t h a t surgical t r e a t m e n t for most fractures is not necessary. This type of p a t i e n t is q u i t e likely to seek d e n t a l care because a d e n t u r e m a y seem to be the obvious source of irritation. Review of all a v a i l a b l e i n f o r m a t i o n indicates t h a t conservative m a n a g e m e n t is the treatm e n t of choice for fractures of genial tubercles. REFERENCES 1. Wood, N. K., and Goaz, P. W.: Differential Diagnosis of Oral Lesions. St. Louis, 1975, The C: V. Mosby Company, p 478. 2. Stafne, E. C.: Oral Radiographic Diagnosis. Philadelphia, 1976, W. B. Saunders Company, p 9. 3. Sicher, H.: Oral Anatomy. St. Louis, 1965, The C. V. Mosby Company, p 68. 4. Maw, R. B., and Lindsay, J. S.: Conservative management of genial tubercle fractures. Oral Surg 30:445, 1970. 5. Stafne, E. C.: Oral Radiographic Diagnosis. Philadelphia, 1969, W. B. Saunders Company, p 13. 6. Reifman, S.: Genial tubercle fracture. Report of a case. Oral Surg 27:595, 1969. 7. Smyd, E. S.: Fracture of the genial tubercles. J Am Dent Assoc 55:136, 1957. Reprint requests to:
DR. WILLIAMM. GOEBEL UNIVERSITY OF CALIFORNIA SCHOOL OF DENTISTRY
Los ANGELES,CALIF.90024 JUNE 1978
VOLUME39
NUMBER6
