|Year : 2019 | Volume
| Issue : 3 | Page : 206-209
Management of ankyloglossia
Aishwarya Madhukar Kale, Kunal Sunder Sethi, Prerna Ashok Karde, Alefiya Shabbir Mamajiwala
Department of Periodontics, MGV's KBH Dental College and Hospital, Nashik, Maharashtra, India
|Date of Submission||03-Feb-2019|
|Date of Decision||13-Feb-2019|
|Date of Acceptance||11-Apr-2019|
|Date of Web Publication||10-Sep-2019|
Dr. Aishwarya Madhukar Kale
Flat No. 1, Sancheti Towers, Opposite Milind College of Science, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
Tongue-tie which is also known as ankyloglossia originated from the Greek word “agkilos” which means curved and glossa which means tongue. Ankyloglossia is usually associated with difficulty in speech articulation and breastfeeding as it causes limited tongue movement. There are different modalities available to manage ankyloglossia. A 23-year-old male with ankyloglossia and a chief complaint of difficulty with speech underwent lingual frenectomy under local anesthesia using a standard surgical technique using scalpel and blade that was followed with speech therapy. One-month follow-up showed marked improvement in tongue movements with no signs of recurrence. Early diagnosis and proper surgical intervention are key to help the patient to avoid problems associated with ankyloglossia and lead a better life.
Keywords: Ankyloglossia, frenectomy, tongue-tie
|How to cite this article:|
Kale AM, Sethi KS, Karde PA, Mamajiwala AS. Management of ankyloglossia. Biomed Biotechnol Res J 2019;3:206-9
| Introduction|| |
The most common developmental anomaly of the tongue is ankyloglossia which is characterized by a short, thick lingual frenum, resulting in limitation of tongue movement, speech problems, and feeding problems in neonates. Wallace defined tongue-tie as “a condition in which the tip of the tongue cannot be protruded beyond the lower incisor teeth because of a short frenulum linguae, often containing scar tissue.” Ankyloglossia, or tongue-tie, can be observed in neonates, children, or adults.
Academy of breastfeeding medicine recommended Hazelbaker Assessment Tool for Lingual Frenulum Function to evaluate the severity of tongue-ties in newborns. It was a method of assessing ankyloglossia. It includes the tongue's appearance (five items) and functional aspects (seven items) and uses a scoring system to classify babies' tongues into one of three categories: functionally impaired, acceptable, or perfect.
The prevalence of ankyloglossia varies from 0.1% to 10.7%. Literature reports the prevalence in neonates (1.72% to 10.7%) to be higher than in children, adolescents, or adults (0.1% to 2.08%). Ankyloglossia leads to inability to extend the tip of tongue beyond the vermillion border of the lips or a line joining the lip commissures, along with speech impairment, midline diastema, oral motor dysfunction, and mandibular lingual gingival recession.
Kotlow's classification of ankyloglossia
According to Kotlow's observation, ankyloglossia can be of four types depending on clinically available free tongue (protrusion of tongue):
- Class I – mild ankyloglossia: 12–16 mm
- Class II – moderate ankyloglossia: 8–11 mm
- Class III – severe ankyloglossia: 3–7 mm
- Class IV – complete ankyloglossia: <3 mm.
Different levels of gravity of the anomalies of the lingual frenum on the basis of the type of lingual insertion are as follows:
- Level F0 – the frenum is absent
- Level F1 – the frenum goes from sublingual caruncle to the lower portion of the tongue, with an insertion at the lingual tip
- Level F2 – the frenum goes from sublingual caruncle a half the distance between the plane of the lips and the plane of the tongue, that is, not far from the lingual tip
- Level F3 – the frenum has marginal alveolar insertion and lingual connection to the median raphe of the tongue away from the tip of the tongue itself.
| Case Report|| |
A 23-year-old male patient reported to the Department of Periodontics with the chief complaint of difficulty in speaking and bleeding gums. The patients consent form were obtained. Careful intraoral examination was done, and it was found that the patient had short lingual frenum, with limited tongue movements along with poor oral hygiene. Limited tongue movement may be the cause of the patient's inability to maintain oral hygiene in lower anteriors. Difficulty in tongue protrusion was observed. [Figure 1], [Figure 2], [Figure 3], [Figure 4]. According to the Kotlow's assessment, this type of ankyloglossia is diagnosed as Type IV. Blood investigation report was evaluated and was found to be within normal limits.
|Figure 1: Postoperative (a) occlusal view, (b) labial view, (c) length of frenum – labial view, (d) length of frenum – lateral view, (e) on tongue protrusion – frontal view, (f) on tongue protrusion – lateral view|
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|Figure 2: Surgical procedure (a) holding suture, (b) incision using 15# surgical blade, (c) diamond-shaped wound seen after lingual frenum excision, (d) suturing|
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|Figure 4: Follow-up after 1 month (a) occlusal view, (b) length of frenum – labial view, (c) on tongue protrusion – frontal view, (d) on tongue protrusion – lateral view|
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The patient was advised to rinse the mouth with 10 ml 0.2% chlorhexidine mouthwash beforethe commencement of surgical procedure. Xylocaine with 1:80,000 adrenaline was used for local infiltration anesthesia. 0.5–1 ml of solution was deposited bilaterally at the base of the tongue, floor of the mouth, and toward the glenoid tubercle on the lingual aspect of mandible. A retraction suture 3–0 silk was placed at the tip of the tongue to facilitate retraction and visibility in the area of the operating field, and frenectomy was initiated using scalpel. Protrusive tongue movement was checked to access complete elimination of frenum. Using a #15 scalpel blade, incisions were placed from the base of tongue toward floor of mouth. Then, the intervening frenum was removed, and a diamond-shaped wound was obtained. Persisting muscle fibers were removed to achieve a good tension-free primary closure of the wound and minimize scar tissue formation. Wound edges were approximated with 3–0 silk suture.
Amoxicillin (500 mg) twice daily for 5 days and nonsteroidal anti-inflammatory drug ketorolac DT (10 mg) thrice a day for 5 days were prescribed. Pain and swelling were present for the first 3 postoperative days but eventually subsided thereafter with the continuation of medications. Tongue exercises were started after 1 week. Complete healing was noted at 1 month postoperatively. To achieve significant speech improvement, oral kinesthesis (ability to feel the part and how they are moving) and diadochokinesis (the ability to perform rapid, alternatively movements) were started without which no significant improvement of speech can be achieved.
Other specific exercises to be done were:
- Stretching of the tongue toward the nose and then downward
- Open the mouth widely and try to touch the upper front teeth with mouth still wide open
- Licking of the upper lip from one side to other and vice versa
- Repeat the same on your lower lip
- Close the mouth and poke both the cheeks as far as you can.
The primary closure of the wound resulted in an uneventful healing with the primary intention after 1 week. Thereafter, the patient was advised to initiate speech therapy. There was no postoperative complication associated with the procedures such as infection, bruising on floor of the mouth, submandibular gland swelling, lingual paraesthesia, and numbness tongue tip during the next week of surgery.
| Discussion|| |
The lingual frenum, a fibromucosal fold, connects the ventral surface of the tongue and the mucosa of the oral pavement.
Ankyloglossia is a congenital oral anomaly, possibly genetically transmissible, although it is unknown which genetic component regulates the phenotype and penetrates in the affected patient. Ankyloglossia is associated with a few rare syndromes such as Kindler syndrome, Van der Woude syndrome, X-linked cleft palate syndrome, and Opitz syndrome; however, the majority of the affected individuals do not suffer from any of these congenital anomalies.
Tuerk and Lubit proposed two dental deformities as a consequence of ankyloglossia which are open-bite deformity and mandibular prognathism. The inability to raise the tongue to the roof of the palate encourages the continuation of the infantile swallow, prevents development of the adult swallow, and leads to an open-bite deformity. The lack of a free upward and backward movement of the tongue may result in an exaggerated anterior thrusting of the tongue against the anterior body of the mandible and produce mandibular prognathism. Horton et al. reported that the prominent lower frenulum may lead to repeated lower denture plates dislodgment when the tongue is elevated. The above possibility was also noted by other authors. Speech problems are evident because of limited tongue mobility, especially in the articulation of consonants such as t, z, s, d, l, ch, j, zh, th, and d.
There are several conservative as well as surgical options for the management of tongue-tie which includes observation, speech therapy, otolaryngotherapy, frenotomy, frenectomy, Z-plasty, and laser frenectomy. If intervention of speech and otolaryngotherapist fails to resolve speech and tongue-related problems, then it may be appropriate to consider surgical protocol. The literature suggests that surgical interventions are absolutely safe at any age including infants, toddlers, and adults but strictly requires postsurgical speech therapy to achieve pleasing results.
Structural guidelines are given by Kotlow to determine the need for surgical management of the lingual frenulum; it includes:
- If the tip of the tongue cleft during the act of protrusion
- If the tip of the tongue is not able to sweep the upper and lower lips easily, without straining
- If retrusion of tongue blanches the tissue lingual to anterior teeth
- If tongue places excessive forces on mandibular anterior teeth
- If the frenum interferes with normal deglutition process
- If lingual frenum creates diastema between mandibular central incisors
- If child experiences speech difficulty due to limited tongue movements
- If infants show abrasion at underside of the tongue
- If the frenum prevents infant from attaching to mother's nipple during nursing.
Timely surgical intervention (frenotomy or frenectomy) to correct ankyloglossia at early age reduces long-term complications. Frenotomy involves relocation of the lingual frenulum. Frenectomy is complete excision of the frenum. Frenuloplasty, on the other hand, involves any of the various methods used to free the tongue and correct the anatomic situation. However, the literature lacks sufficient information to favor any of these three main techniques.
A frenectomy, as performed in this patient, is a more invasive and difficult procedure to be performed on younger children, although the results are more predictable and there is a lower recurrence rate. Literature lacks conclusive parameters in regard to the timing of a frenectomy. However, ideal time for surgery to be performed is before the development of abnormal speech and swallowing patterns. When performed on older individuals, referral to a speech therapist is necessary to help establish normal tongue functions.
| Conclusion|| |
If severe/complete ankyloglossia is present, there is usually a limitation of tongue protrusion, elevation, and problems with speech. Early diagnosis and prompt surgical intervention generally help the patient to avoid long-term effects of these problems.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]