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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 11  |  Issue : 2  |  Page : 77-80

Management of ankyloglossia


Department of Periodontology, MGV'S KBH Dental College and Hospital, Nashik, Maharashtra, India

Date of Submission13-Feb-2019
Date of Acceptance24-Feb-2019
Date of Web Publication15-Jul-2019

Correspondence Address:
Aishwarya Madhukar Kale
Flat No. 1, Sancheti Towers, Opposite Milind College of Science, Aurangabad, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_7_19

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  Abstract 


Tongue tie which is also known as Ankyloglossia originated from Greek word “agkilos” which means curved and glossa which mean tongue. Ankyloglossia is usually associated with difficulty in speech articulation and breast feeding as it causes limited tongue movement. There are different modalities available to manage Ankylossia. A twenty-three year old male with ankyloglossia and a chief complaint of difficulty with speech underwent lingual frenectomy under local anaesthesia using a standard surgical technique using scalpel and blade that was followed with speech therapy. Two month follow up showed marked improvement in tongue movements with no signs of recurrence. Early diagnosis and proper surgical intervention is key to help the patient to avoid problem associated with Ankylossia 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. J Oral Res Rev 2019;11:77-80

How to cite this URL:
Kale AM, Sethi KS, Karde PA, Mamajiwala AS. Management of ankyloglossia. J Oral Res Rev [serial online] 2019 [cited 2019 Dec 12];11:77-80. Available from: http://www.jorr.org/text.asp?2019/11/2/77/262764




  Introduction Top


The most common developmental anomaly of the tongue is ankyloglossia which is characterized by a short, thick lingual frenum resulting in the limitation of tongue movement, speech problems, and feeding problems in neonates. Wallace[1] 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.[2] 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 the following 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%–10.7%) to be higher than in children, adolescents, or adults (0.1%–2.08%).[3] Ankyloglossia leads to inability to extend the tip of the 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[4] observation, ankyloglossia can be of the following 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:[5]

  • 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 to 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 Top


A 23-year-old male patient reported to the department of periodontics with the chief complaint of difficulty in speaking and bleeding gums. Careful intraoral examination was done, and it was found that the patient had short lingual frenum [Figure 1], 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 the lower anteriors. Difficulty in tongue protrusion was observed. No dentofacial deformities were found. According to Kotlow's assessment, this type of ankyloglossia is diagnosed as Type IV. Blood investigation report was evaluated which was found to be within the 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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Surgical procedure

The patient was advised to rinse the mouth with 10-ml 0.2% chlorhexidine mouthwash before the commencement of surgical procedure. Xylocaine with 1:80,000 adrenaline was used for local infiltration anesthesia. 0.5–1 ml of the solution was deposited bilaterally at the base of the tongue, floor of the mouth, and toward the geniod tubercle on the lingual aspect of the mandible. A retraction suture 3-0 silk[6] 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 a scalpel [Figure 2]. Protrusive tongue movement was checked to access the complete elimination of frenum. Using a #15 scalpel blade, incisions were placed from the base of the tongue toward the floor of the 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.
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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Postoperative care

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.[6]

Other specific exercises[7] to be done were as follows:

  1. Stretching of the tongue toward the nose and then downward
  2. Open the mouth widely, and try to touch the upper front teeth with mouth still wide open
  3. Licking of the upper lip from one side to other, and vice versa
  4. Repeat the same on your lower lip
  5. Close the mouth and poke both the cheeks as far as you can.


Outcome

The primary closure of the wound resulted in an uneventful healing with the primary intention after 1 week [Figure 3]. Thereafter, the patient was advised to initiate speech therapy. There was no postoperative complication associated with the procedure such as infection, bruising on floor of the mouth, submandibular gland swelling, lingual par aesthesia, and numbness of the tongue-tip during the next week of the surgery.
Figure 3: Follow-up after 1 week

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  Results Top


After surgery, the patient was revaluated [Figure 4]. Changes were observed in the frenulum and in tongue mobility. Protrusion, lateralization, and elevation of the tongue were improved in different degrees. The best results were for tongue protrusion, whereas the worst were for tongue elevation. Shape of the tip of the tongue altered after the surgery. Speech was improved after the surgery. Speech became more efficient due to improvement in tongue mobility and wider mouth opening. The patient reported improvement in their oral communication.
Figure 4: Follow-up after 2 months (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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  Discussion Top


The lingual frenum, a fibro-mucosal fold, connects the ventral surface of the tongue and the mucosa of the oral pavement.[4]

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,[8] Van der Woude syndrome,[9] X-linked cleft palate syndrome,[10] and Opitz syndrome;[11] 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 the development of the adult swallow, and leads to an open-bite deformity. The lack of a free upward and backward movement of the tongue which may result in an exaggerated anterior thrusting of the tongue against the anterior body of the mandible produces mandibular prognathism.[12] Horton et al. reported that the prominent lower frenulum may lead to repeated lower denture plate dislodgement when the tongue is elevated. The above possibility was also noted by other authors.[13] 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.[14]

Several conservative as well as surgical options exist for the management of tongue-tie which include observation, speech therapy, otolaryngotherapy, frenotomy, frenectomy, Z-plasty, and laser frenectomy. If the 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.[15]

The following structural guidelines are postulated by Kotlow[4] to determine the need for the surgical management of lingual frenulum:

  1. If the tip of the tongue clefts during the act of protrusion
  2. If the tip of the tongue cannot sweep the upper and lower lips easily, without straining
  3. If retrusion of tongue blanches the tissue lingual to the anterior teeth
  4. If the tongue places excessive forces on the mandibular anterior teeth
  5. If the frenum interferes with normal deglutition process
  6. If lingual frenum creates diastema between mandibular central incisors
  7. If the child experiences speech difficulty due to limited tongue movements
  8. If infants, it shows abrasion at the underside of the tongue, and
  9. If the frenum prevents infant from attaching to the mother's nipple during nursing.


Timely surgical intervention (frenotomy or frenectomy) to correct ankyloglossia at an early age reduces long-term complications. Frenotomy involves relocation of the lingual frenulum. Frenectomy is the 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.[16]

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.[7] Literature lacks conclusive parameters with regard to the timing of a frenectomy. However, ideal time for surgery to be performed is prior to 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 Top


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 helps the patient to avoid long-term effects of these problems.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent form. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wallace AF. Tongue tie. Lancet 1963;2:377-8.  Back to cited text no. 1
    
2.
Amir LH, James JP, Donath SM. Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum function. Int Breastfeed J 2006;1:3.  Back to cited text no. 2
    
3.
Suter VG, Bornstein MM. Ankyloglossia: Facts and myths in diagnosis and treatment. J Periodontol 2009;80:1204-19.  Back to cited text no. 3
    
4.
Kotlow LA. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Quintessence Int 1999;30:259-62.  Back to cited text no. 4
    
5.
Dezio M, Piras A, Gallottini L, Denotti G. Tongue-tie, from embriology to treatment: A literature review. Journal of Pediatric and Neonatal Individualized Medicine 2015;4:e040101.  Back to cited text no. 5
    
6.
Reddy NR, Marudhappan Y, Devi R, Narang S. Clipping the (tongue) tie. J Indian Soc Periodontol 2014;18:395-8.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Singh M. Management of ankyloglossia by frenectomy – A case report. British Journal of Medicine and Medical Research 2016;18:1-5.  Back to cited text no. 7
    
8.
Moore GE, Ivens A, Chambers J, Farrall M, Williamson R, Page DC, et al. Linkage of an X-chromosome cleft palate gene. Nature 1987;326:91-2.  Back to cited text no. 8
    
9.
Burdick AB, Ma LA, Dai ZH, Gao NN. Van der Woude syndrome in two families in China. J Craniofac Genet Dev Biol 1987;7:413-8.  Back to cited text no. 9
    
10.
Brooks JK, Leonard CO, Coccaro PJ Jr. Opitz (BBB/G) syndrome: Oral manifestations. Am J Med Genet 1992;43:595-601.  Back to cited text no. 10
    
11.
Hacham-Zadeh S, Garfunkel AA. Kindler syndrome in two related Kurdish families. Am J Med Genet 1985;20:43-8.  Back to cited text no. 11
    
12.
Tuerk M,' Lubit EC. Ankyloglossia. Plast Reconstr Surg Transplant Bull 1959;24:271-6.  Back to cited text no. 12
    
13.
Horton CE, Crawford HH, Adamson JE, Ashbell TS. Tongue-tie. Cleft Palate J 1969;6:8-23.  Back to cited text no. 13
    
14.
Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg 2002;127:539-45.  Back to cited text no. 14
    
15.
Junqueira MA, Cunha NN, Costa e Silva LL, Araújo LB, Moretti AB, Couto Filho CE, et al. Surgical techniques for the treatment of ankyloglossia in children: A case series. J Appl Oral Sci 2014;22:241-8.  Back to cited text no. 15
    
16.
Khairnar M, Pawar B, Khairnar D. A novel surgical pre-suturing technique for the management of ankyloglossia. J Surg Tech Case Rep 2014;6:49-54.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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