Ankyloglossia and its management.

Ankyloglossia or tongue-tie is the result of a short, tight, lingual frenulum causing difficulty in speech articulation due to limitation in tongue movement. In this article, we have reported a 24-year-old male with tongue-tie who complained of difficulty in speech following which he underwent frenectomy procedure under local anesthesia without any complications. Finally, he was given speech therapy sessions.

INTRODUCTION

Etymologically, “ankyloglossia” originates from the Greek words “agkilos” (curved) and “glossa” (tongue). The same term is used for very different clinical situations: When the tongue is fused to the floor of the mouth, but also if the lingual frenulum is only short and thick with slight impairment of tongue mobility. The first use of the term ankyloglossia in the medical literature dates back to the 1960s, when 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.”

CASE REPORT

A 24-year-old male was reported in the department of Periodontics 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 classified as Class III by utilizing Kotlow's assessment [Figure 1] and was able to protrude the tongue up to the lower lip [Figure 2]. 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 followed by giving two incisions at the superior and the inferior aspect of the hemostat. This way, we removed the intervening frenum and got a diamond shaped wound. Then with the help of the same hemostat, we released the muscle fibers so as to achieve a good tension free closure of the wound edges [Figures 3 and 4] after which the wound edges were approximated with (4-0) black braided silk sutures [Figure 5] for the tissues to heal by primary intention thereby minimizing the scar tissue formation, antibiotic Cap. Amoxicillin (500 mg) thrice a day for 3 days and non-steroidal anti-inflammatory drug Tab. Ketorolac DT (10 mg) thrice a day for 3 days was prescribed to prevent post-operative infection and pain. The post-operative period was uneventful with no delayed hemo-rrhage. Sutures were removed after 1 week [Figure 6] which showed no scar tissue formation following which the patient was sent for speech therapy sessions. After a follow-up of 6 months, the tongue showed good healing [Figure 7], protrusion several mm beyond the lower lip [Figure 8], and normal speech.

Figure 1

Pre-operative view showing ankyloglossia

Figure 2

Pre-operative view showing extension of tongue

Figure 3

Frenectomy incision using scalpel

Figure 4

Completion of frenectomy

Figure 5

Sutures

Figure 6

Post-operative view 1 week

Figure 7

Post-operative view 6 months

Figure 8

Post-operative view 6 months showing adequate extension of tongue

DISCUSSION

Ankyloglossia is an uncommon congenital oral anomaly that can cause difficulty with breast-feeding, speech articulation.[2] For many years, the subject of ankyloglossia has been controversial with practitioners of many specialties having widely different views regarding its significance and management. In many individuals, ankyloglossia is asymptomatic; the condition may resolve spontaneously or affected individuals may learn to compensate adequately for their decreased lingual mobility. Some individuals, however, benefit from surgical intervention frenotomy, frenectomy or frenuloplasty for their tongue-tie. Patients should be educated about the possible long-term effects of tongue-tie so that they may make an informed choice regarding possible therapy.[23] The prevalence of ankyloglossia reported in the literature varies from 0.1% to 10.7%. The prevalence is also higher in studies[4] investigating neonates (1.72% to 10.7%) than in studies[5] investigating children, adolescents, or adults (0.1% to 2.08%). It can be speculated that some milder forms of ankyloglossia may resolve with growth, explaining this age-related difference. There is some evidence that ankyloglossia can be a genetically transmissible pathology. It is unknown which genetic components regulate the phenotype and penetrance in the patients affected. More basic research is needed to clarify the exact etiopathogenesis of ankyloglossia. Ankyloglossia was also found associated in cases with some rare syndromes such as X-linked cleft palate syndrome,[6] Kindler syndrome,[7] van der Woude syndrome,[8] and Opitz syndrome.[9] Nevertheless, most ankyloglossias are observed in persons without any other congenital anomalies or diseases. Speech problems can occur when there is limited mobility of the tongue due to ankyloglossia. The difficulties in articulation are evident for consonants and sounds like “s, z, t, d, l, j, zh, ch, th, dg”[10] and it is especially difficult to roll an “r”. Localization of the frenum insertion on the gingiva seemed to be of importance for gingival sequelae because insertion of the lingual frenulum in the area of the papilla had the highest association with gingival recession. The term free-tongue is defined as the length of tongue from the insertion of the lingual frenum into the base of the tongue to the tip of the tongue. Clinically acceptable, normal range of free tongue is greater than 16 mm. The ankyloglossia can be classified into 4 classes based on Kotlow's assessment as follows; Class I: Mild ankyloglossia: 12 to 16 mm, Class II: Moderate ankyloglossia: 8 to 11 mm, Class III: Severe ankyloglossia: 3 to 7 mm, Class IV: Complete ankyloglossia: Less than 3 mm.2 Class III and IV tongue-tie category should be given special consideration because they severely restrict the tongue's movement. A normal range of motion of the tongue is indicated by the following criteria: The tip of the tongue should be able to protrude outside the mouth; without clefting, the tip of the tongue should be able to sweep the upper and lower lips easily; without straining, when the tongue is retruded, it should not blanch the tissues lingual to the anterior teeth; and the lingual frenum should not create a diastema between the mandibular central incisors. Ankyloglossia limits the tongue's range of motion. Because of limited mobility of the tongue in patients with ankyloglossia, the tongue is in a low position and causes forward and downward pressure favoring the development of mandibular prognathism with maxillary hypo development. The above mentioned hypothesis that ankyloglossia leads to altered development of the jaws is mainly based on single observation and speculative interpretations and there is limited evidence that tongue-tie represents a co-factor in the development of malocclusions, especially Class III malocclusion. More studies, especially controlled clinical trials, are needed to establish a clear correlation between malocclusion and ankyloglossia. If there is no feeding difficulty in the infant, it would be best to have a wait-and-see approach since the frenulum naturally recedes during the process of an individual's growth between six months and six years of age. After completion of growth and also during infancy, if the individuals have a history of speech, feeding, or mechanical/social difficulties surgical intervention should be carried out. Therefore, surgery should be considered at any age depending on the patient's history of speech, feeding, or mechanical/social difficulties. Surgical techniques for the therapy of tongue-ties can be classified into three procedures. Frenotomy is a simple cutting of the frenulum. Frenectomy is defined as complete excision, i.e., removal of the whole frenulum. Frenuloplasty involves various methods to release the tongue-tie and correct the anatomic situation. There is no sufficient evidence in the literature concerning surgical treatment options for ankyloglossia to favor any one of the three main techniques.

CONCLUSION

To conclude, it is important to agree upon one examination method, definition and classification of tongue-ties to enable comparisons between future observational and intervention studies. If severe/complete ankyloglossia is present in an adult, there is usually an obvious limitation of the tongue protrusion, elevation and speech problems which can be improved following surgical intervention.