Abstract

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Tongue is the vital oral structure in the oral cavity that is responsible for speech articulation, deglutition and positioningof teeth. Ankyloglossia or tongue tie is the result of unusually short, tight, lingual frenum causing difficulty in breast feeding among neonates, malocclusion and gingival recession. This article reports  two cases of ankyloglossia which was treated one case surgically and other case with diode laser , with uneventful healing and excellent patient satisfaction.

Introduction

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Etymologically the term ankyloglossia developed from a greek word ankylos- "crooked", glossia - "tongue". This term is used first in medical literature in 1960s. Wallace defined tongue as a"condition in which the tip of tongue can not be protruded ahead of the lower incisor teeth because of a short frenulum linguae, often containing scar tissue."¹   It can be categorized  in to two types-  Total ankyloglossia , which is a rare condition and Partial ankyloglossia. The ankyloglossia classification  based on Kotlow's assessment as ²

 1. Clinically acceptable, normal range of free tongue: greater than 16 mm

2. Class I: Mild ankyloglossia: 12 to 16 mm

3. Class II: Moderate ankyloglossia: 8 to 11 mm

4. Class III: Severe an kyloglossia: 3 to 7 mm

5. Class IV: Complete ankyloglossia: less than 3 mm

Surgical correction for ankyloglossia can be 3 types depending on severity of problem, frenotomy, frenectomy and frenuloplasty.³

Case 1

A 27-year-old male was reported to the department of Periodontics, with difficulty in speech, diastema in the lower central incisors and class I gingival recession in relation to 31 and 41. The general physical examination was normal. On intraoral examination, the individual found to have short lingual frenum with restricted tongue movements, Class III ankyloglossia by utilizing Kotlow's assessment.( Figure 1, 2).Surgical frenectomy of the lingual frenum was planned. The patient was informed about the treatment procedure and informed consent was obtained.

 Treatment :

The lingual frenectomy was undertaken under local anesthesia with 2% lignocaine and l: 80000 adrenaline. After anesthesia was found to be effective, a suture was used at the tip of the tongue to stabilize it. A curved hemostat was inserted to the bottom of the lingual frenum at the depth of the vestibule and clamped in position.   With the help of No 15 blade incisions made in the superior and inferior aspect of the hemostat and the frenum was removed.

The wound edges were approximated with (4-0) black braided silk sutures for the tissues to heal by primary intention thereby minimizing the scar tissue formation (Figure 3).

CASE 2 

A 24 year old male patient reported in the Department of Periodontics, with a complaint of difficulty in speech. On intraoral examination, it was found that the individual had partial ankyloglossia and was classified as class III according to Kotlow's assessment and was able to protrude the tongue up to the lower lip. Lingual frenectomy with DIODE laser ( PICASO 810 nm)was planned and patient was informed about the procedure (Figure 4).

Treatment

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After application of topical anesthesia, few drops of lignocaine were injected in the frenum. After stripping the fiber?optic wire tip, the tip was initiated by firing it into a piece of cork at 1.5 Watt in a continuous mode. (Figure 5)  The diode laser was applied in a contact mode with focused beam for excision of the tissue. The tip of the laser was moved from the apex of the frenum to the base in a brushing stroke cutting the frenum. The ablated tissue was continuously mopped using wet gauze piece. No suturing was done.

Results

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The conventional blade surgical patient was prescribed 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 hemorrhage. Sutures were removed after 1 week. The laser surgical patient was prescribed only analgesics and mouth rinse. One week postoperative showed good healing in both cases. (Figure 6)

Both the patients were given post-surgical instructions. The following exercises were advised: 1) Extend the tongue up towards the nose, then down towards the chin 2) Open the mouth widely and touch the front teeth with the tongue when the  mouth is still wide open, 3) Close the mouth and poke the tongue into the left and right cheek to make a lump: for 3 to 5 minute bursts, once or twice daily for 3 or 4 weeks post-operatively.⁴

Discussion

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In many individuals, ankyloglossia is asymptomatic; the condition may resolve spontaneous, but in some individuals, it may require surgical intervention frenotomy, frenectomy or frenuloplasty for their tongue-tie.  The prevalence of ankyloglossia reported in the literature varies from 0.02% to 4.8%.⁵  The etiology of ankyloglossia is unknown, can be part of some unusual syndromes such as X-linked cleft palate syndrome and van der Woude syndrome.³

Speech problems can arise when there is restricted mobility of the tongue due to ankyloglossia. The difficulties in articulation are evident for consonants and sounds like “s, , l, j, z, t, d, zh, ch, th” and it is especially difficult to roll an “r”.⁶  

The problems during blade surgical procedures are close proximity to the ducts of the submandibular glands, coupled with a richly vascular floor of mouth and hypermobility of the tongue.⁷

Diode lasers are compact and portable in design, withefficient and reliable benefits for use in soft tissue oralsurgical procedure. Treatment of ankyloglossia using diode laser is more efficient, innovative, gentle, less traumatic, as well as precsion.⁸ The thermal effect of laser seals the capillariesand lymphatics, which also reduce the post operativebleeding and edema. In addition, sterilization of woundby laser reduces the need for post operative care andantibiotics. The advantages of lasersurgery over scalpel is the dry surgical field and bettervisualization, tissue surface sterilization and reduction inbacteremia,  lesser immediate post operative complications like decreased swelling, edema, decreased pain,faster healing response, and increased patient acceptance.⁹

Conclusion

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Treatment of ankyloglossia is safe procedure and it provides benefit to patient in terms of speech and tongue movements. Laser is always safe and better option for treating ankyloglossia when compare to surgical treatment

References

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1. Tanay V. Chaubal, Dixit MB. Ankyloglossia and its management. Journal of Indian Society of Periodontol 2011;  15( 3): 270-272
2. Lawrence A. Kotlow. Ankyloglossia (tongue-tie):A diagnostic and treatment quandary. Ouintessence International 1999;30:259-262.
3. Ankyloglossia (Tongue –tie): a series of 2 case Reports. Kumaraswamy, Nitin Sharma, Subhash chander, Shamsher singh, Prashant  babaji. Indian  J Stomatol 2012;3(3):205-07.
4. Gohil Meera, Padhiyar Navneet, Gohil Ankit. Surgical Management of Ankyloglossia. Journal of Research in Medical and Dental Science | Vol. 1(2):77-79
5. Sulter VGA, Bomstein MM. Ankyloglossia: Facts and myths in Diagnosis and Treatment. J Periodontol 2009;80:1204-19.
6. Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg 2002; 127:539-45.
7. Butchibabu k, Uppada UK, Koppulu P, Mishra A, Chandhra CR, Pandey R. Management of ankyloglossia : Have lasers taken the sheen away from scalpel. J of Dental Lasers 2014; 2(4):56-60.
8. Magid KS, Srauss RA. Laser use for esthetic soft tissue modification. Dent Clin North Am 2007; 51(2): 525-545
9. Cobb CM.  Lasers in periodontics. A review of the literature. J Periodontal 2006 ; 77:545–5640.

Source(s) of Funding

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None

Competing Interests

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None