Ankyloglossia (Tongue-tie): A Series of 2 Case Reports

Headnote

Abstract

Ankyloglossia or tongue tie is a congenital anomaly which results in a short, tight, lingual frenum. The main difficulty with this anomaly is nipple pain and trauma, difficulty in the baby attaching to the breast, and uncoordinated sucking. These problems results in earlier termination of breast feeding, slows weight gain and results in hypernatramic dehydration in young children. In older children it may cause difficulty in speech. This is mainly because of limited tongue movement. In this article we report 2 cases of 8 and 15-year-old patient with complaint of difficulty in speech due to tongue-tie, for which they underwent lingual frenectomy procedure under local anesthesia.

Keywords: Ankyloglossia; tongue-tie; frenectomy.

Introduction

Wollance defined tongue-tie as "a condition in which the tip of the tongue cannot be protruded beyond the lower incisor because of short lingual frenum.1 The term Ankyloglossia originates from the Greek word' Agkilos" (curved) and "glossa" (tongue).2 In older children it may cause difficulty in speech articulation due to limited tongue movement. Ankyloglossia can affect feeding, oral hygiene as well as some mechanical/social effects. Insertion of lingual frenum in the area of papilla had highest association with gingival recession Surgical techniques for the therapy of tongue-ties can be classified into three procedures. Frenot-omy is a simple cutting of the frenum. Frenectomy is defined as complete excision, ie., removal of the whole frenum. Frenuloplasty involves various methods to release the tongue-tie and correct the anatomic situation.3 In this article in both cases surgical frenectomy was planned after thorough oral examination.

Case report

Case 1

An 8-year-old male child reported to the Department of Pedodontics with difficulty in speech since birth. The ENT and general physical examination was normal. On intraoral examination, it was found that the child had ankyloglossia (tongue-tie) (Figure 1). After obtaining informed consent, topical anesthetic was applied to the underside of the tongue and local anesthetic infiltration was administered into the frenum area. After anesthesia was found to be effective, ahaemostatwasusedtoclampthe frenum, andthe frenum was surgically released along the sides of the haemostat (Figure 2). After release of the lingual frenum, the margins of the incision were sutured with 3-0 silk suture (Figure 3). The favorable outcome of the procedure was apparent immediately and the extent of release could be assessed durin-g the intervention itself (Figure 4).

Postsurgical instructions were given along with a course of non steroidal anti-inflammatory drugs for 3 days. The sutures were removed after a week following the procedure (Figure 5). The post-operative period was uneventful. The following exercises were advised: i) Stretch the tongue up towards the nose, then down towards the chin and repeat, ii) Open the mouth widely and touch the big front teeth with the tongue with mouth still open, iii) Shut the mouth and poke it into leftand right cheek to make a lump for 3 to 5 minute bursts, once or twice daily for 3 or 4 weeks postoperatively. The routine follow-up at 3 weeks showed an extremely satisfied patient with improved tongue protrusion andnormal speech (Figure 6).

Case 2

A 15-year-old male was reported in the Department of Pedodontics with difficulty in speech since birth. The ENT and general physical examination was normal. On intraoral examination, it was found that the individual had ankyloglossia (tongue-tie) and was not able to protrude the tongue up to the lower lip (Figure 7). There were no malocclusion and recession present lingual to mandibular incisors. The patient was undertaken for a frenectomy procedure under local anesthesia with 2% lignocaine hydrochloride and 1:80,000 adrenaline by using a scalpel method; first a curved hemostat was inserted to the bottom of the lingual frenum at the depth of the vestibule and clamped into position (Figure 8) followed by giving two incisions at the superior and the inferior aspect of the hemostat (Figure 9). This way, we removed the intervening frenum and a diamond shaped wound was formed. Then with the help of the same hemostat, the muscle fibers were released so as to achieve a good tension free closure of the wound edges (Figure 10). After which the wound edges were approximated with3-0 black braided silk sutures (Figure 11). Forthe tissues to heal by primary intention thereby minimizing the scar tissue formation, antibiotic Cap Amoxicillin (500mg) thriceadayfor3daysandnon-steroidalanti-inflammatory drug Tab Ketorolac DT (lOmg) thrice a day for 3 days was prescribed to prevent post-operative infection and pain. The post-operative period was uneventful with no delayed hemorrhage. Sutures were removed after 1 week which showed no scar tissue formation following which the patient was sent for speech therapy sessions. After a 3 month follow-up, the tongue showed good healing, protrusion several mm beyond the lower lip, and normal speech (Figure 12).

Discussion

Ankyloglossia is an developmental anomaly causing difficulty in speech articulation.4 The ankyloglossia is classified into 4 classes based on Kotlow's assessment as follows; Class I: Mild ankyloglossia: 12-16mm, Class II: Moderate ankyloglossia: 8-11mm, Class III: Severe ankyloglossia: 3-7mm Class IV: Complete ankyloglossia: Less thanSmm. In Class III and IV tongue movement is severely restricted so surgical approach is needed.

The etiology of ankyloglossia is unknown. Ankyloglossia can be a part of certain rare syndromes such as X-linked cleftpalate and van der Woude syndrome.6'7 Most often ankyloglossia is seen as an isolated finding in an otherwise normal child. Maternal cocaine use is reported to increase the risk of ankyloglossia to more than threefold.8 The incidence of ankyloglossia is from 0.02% to as high as 4.8% of term newborns as reported in the literature.2

Post-operative exercises following tongue-tie surgery intended to develop new muscle movements, particularly those involving4gue-tip elevation andprotnjsion, inside andoutsideoffhemouth,increasekinestheticawarenessof the full range of movements the tongue and lips can perforin, Encourage tongue movements related to cleaning the oral cavity, including sweeping the insides of the cheeks, fronts and backs of the teeth, and licking right around both lips.10

Conclusion

Tongue-tie (ankyloglosssia) is a developmental anomaly which can cause speech defect. Short lingual frenum should be identified during developing stage of child and should be corrected immediately. Negligence of early correction can result in to permanent speech defect. It is the role of a pediatric dentist to identify the defect and create awareness.

References

References

1. Wallace AF. Tongue tie. Lancet 1963;2:377-78.

2. Suter VGA, Bornstein MM. Ankyloglossia: Facts and Myths in Diagnosis and Treatment. J Periodontal 2009;80: 1204-19.

3. Chaubal TV, Dixit B. Ankyloglossia and its management. J rndianSocPeriodontol2011 Jul;15(3):270-72.

4. Morowati S, Yasini M, Ranjbar R, Peivandi AA, Ghadami M. Familial Ankyloglossia (Tongue-tie): A Case Report. ActaMedicaIranica2010;48:123-24.

5. Kotlow LA. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Quintessence Intl 1999;30:259-62.

6. Moore GE, Ivens A, Chambers J, Farrall M, Williamson R, Page DC, et al. Linkage of an X-chromosome cleftpalate gene.Nature 1987;326:91-92.

7. Burdick AB, Ma LA, Dai ZH, Gao NN. Van Der Woude syndrome in two families in China. J Craniofac Genet Dev Biol 1987;7:413-18.

8. Harris EF, Friend GW, Tolley EA. Enhanced prevalence of ankyloglossia with maternal cocaine use. CleftPalate Craniofac J 1992;29:72-76.

9. Babu HM. Surgical Management of Ankyloglossia-A Case Report. IntJContDent2010Nov;l(2)58-61.