Pacific Coast Society of Orthodontists Bulletin Spring 2021 - 33

Let's Talk About That

Clinical Practice

Patrick Turley Interviews Dr. Cate
Quas Regarding the Lingual Frenum

Dr. Patrick Turley
PCSO Bulletin Section Editor

Dr. Cate Quas
Bend, OR

In orthodontics, the influence of a maladaptive
tongue plays a role in treatment decisions for
open bites or maxillary constriction. In the finishing stages of treatment, it may become apparent
that there are influences from the tongue that
are habitually preventing ideal completion of the
case. A patient may have a maladaptive tongue
because of parafunctional habits such as clenching, or it could be due to a volume issue (eg, the
tongue is large, the oral cavity is small); it might
be an anatomical issue, such as tethered by the
frenum; or it could be due to discoordination of a
muscle within the tongue itself. This is not an exhaustive list but merely a sample of some factors
to consider when attempting to diagnose the etiology of the influence of the tongue on the bite.
Dr. Cate Quas, pediatric dentist and orthodontist,
begins to shed light on the implications of tongue
malfunction common in our orthodontic patients.
Brief Bio: Dr. Catherine Quas' dental training was
completed at the University of Pittsburgh School
of Dental Medicine. After dental school, she completed two residencies, one in pediatric dentistry
and the other in orthodontics at the University of
California, Los Angeles School of Dental Medicine.
She returned to central Oregon to open Bluefish
Dental in 2004. In addition to private practice,
she has been intimately involved in community
efforts to improve oral health in children.
The Lingual Frenum: An Overview of Impact,
Form, and Function
According to Merriam-Webster's dictionary
definition:
fren·u·lum (plural: frenula) - a connecting fold of
membrane serving to support or restrain a part
(such as the tongue)1
It has also been defined2 as a small fold of tissue
that secures the motion of a mobile organ in the
body. Frenums of consideration in the oral cavity
include those on the labial and buccal aspects of
the upper and lower lips and the ventral surface
of the tongue. Tongue-tie or ankyloglossia is a

Spring 2021    PCSO Bulletin	

condition where the frenum is restrictive and
therefore limits tongue mobility.
The consequence of reduced tongue mobility deposits us at the entrance of the lingual wormhole.
Bienvenido!
Patrick Turley (PT): How did the frenum get on
your radar as a clinician?
Cate Quas (CQ): My attention to the presence
and significance of the lingual frenum came
over time. In my orthodontic residency, I had
the privilege to conduct my research under Dr.
Eung-Kwon Pae, who was doing some of the
early work on airway and sleep apnea. Since my
early years in practice, the initial assessment of
all patients includes an evaluation of airway,
noting facial morphology, tonsils, frenums, and
arch form along with classical examination of
occlusion, dentition, and caries risk. The influence
of a maladaptive tongue can have quite a serious
sequelae and is a concern that emerges at birth.
As the tongue plays a significant role in successful breastfeeding, concerns can develop such
as a failure to thrive, lack of weight gain, reflux,
labored nursing, infant exhaustion, pain on
nursing (mastitis, bleeding, cracking of nipples),
and choking.
Historically, it was assumed that the tongue
extracted milk from the breast through peristaltic-like movement. Through the work of Geddes
et al3, the mechanism of transfer was found to be
through the creation of suction by the mid-portion of the tongue, which creates a seal against
the palate rather than a peristaltic wave. When
the tongue has restricted mobility, it cannot reach
the palate to create a seal, and feeding dysfunction results. As a pediatric dentist, I am brought
into the team to offer frenum releases of lips
and tongues of infants when deemed necessary
to facilitate breastfeeding. We are well aware of
the myriad of benefits of breastfeeding for both
infants and mothers. That fact is no more evident
than in the 2014 law established in Brazil, which

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Pacific Coast Society of Orthodontists Bulletin Spring 2021

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