Management of ankyloglossia (tongue tie)-A Case Series

Introduction

Ankyloglossia, commonly referred to as tongue-tie, is an uncommon congenital condition characterized by a thick, short, and fibrosed lingual frenulum, which restricts tongue function and affects speech. Wallace (1960) described tongue-tie as a condition in which a small frenulum linguae prevents the tip of the tongue from protruding beyond the lower incisor teeth.¹ Histological studies by Young and Knox revealed the presence of both muscle and elastic fibers (Orbicularis oris, comprising horizontal and oblique bands) in the frenulum.² However, Levin, Henry, and Tsaknis identified an abundance of collagenous tissue and elastic fibers but found no muscle fibers in the frenulum.³

The tongue plays a crucial role in various functions, and when affected by ankyloglossia, some of these functions become limited. Disorders that restrict the tongue’s free movement, preventing it from touching the anterior palate, can disrupt the development of a mature swallow pattern and may result in open bite deformities.⁴ The diagnostic and treatment criteria for ankyloglossia remain subjects of ongoing debate.⁵

In children, ankyloglossia may lead to bullying, poor oral hygiene, difficulty nursing, and speech problems during childhood and adolescence.⁶ In teenagers and young adults, speech-related issues associated with ankyloglossia can negatively impact academic performance, social interactions, and overall quality of life. Individuals in this age group are often acutely aware of the challenges posed by their condition.⁷

Various techniques have been utilized to treat tongue-tie, including electrosurgery, lasers, and scalpels. Kotlow (1999) introduced the concept of "free tongue," which refers to the distance between the tip of the tongue and its ventral base, as a criterion to classify the severity of ankyloglossia.⁴

This case series focuses on the management of children with ankyloglossia using surgical excision with a scalpel. It discusses clinical findings, specific indications, methodology, and the outcomes of frenectomy procedures.

Case Series

This case series highlights three cases of ankyloglossia that were managed at the Department of Paediatric and Preventive Dentistry, Oxford Dental College, Bangalore. Following an accurate diagnosis, treatment plans were formulated using a conventional surgical technique. Informed and written consent was obtained from the guardians before proceeding with the procedures.

Case 1

A male patient, aged 11 years, presented with complaints of difficulty in tongue movements, particularly lateral movements and protrusion. On clinical examination, the free tongue length was measured as 7 mm, indicative of severe ankyloglossia (Kotlow’s Class III) (Figure 1a). The patient and guardians were unaware of relevant treatment options, and no prior interventions had been attempted. Based on the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLLF), frenectomy was deemed necessary.

Figures 1a to 1d illustrate the pre-operative findings, tongue mobility limitations, and the surgical approach undertaken for the frenectomy. The treatment outcomes demonstrated significant improvement in tongue mobility and functionality at follow-up visits.

Hazelbaker Assessment Tool for Lingual Frenulum Function

Function Form                       Score

Lateralization                      1 (body of tongue only)

Lift of tongue                      2 (tip to mid mouth)

Extension of tongue            2 (tip over lower lip)

Spread of anterior tongue   2 (complete)

Cupping of tongue              1 (moderate cup)

Peristalsis                             1 (partial)

Snap-back                            0 (frequent)

Appearance Items                                             Score

Appearance of tongue when lifted                  1 (slight cleft)

Elasticity of frenulum                                        2 (very elastic)

Length of lingual frenulum                               2 (>1 cm)

Attachment to tongue                                      2 (posterior to tip)

Attachment to alveolar ridge                            0 (attached at ridge)

Total Function Score: 9

Total Appearance Score: 7

Frenectomy indicated if Function Score <11 and Appearance Score <8.

Case 2

An 11-year-old patient presented to the Preventive Dentistry and Pediatric Department at Oxford Dental College with a primary complaint of difficulty in pronouncing and speaking words ending with "r," "t," and "s." A speech evaluation was conducted, and the results were documented. The patient had not undergone any previous treatment due to a lack of awareness about the condition.

On clinical examination, the length of the tongue was measured at 9 mm, indicative of moderate ankylo-glossia (Kotlow’s Class II). Evaluation using the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLLF) yielded a total appearance score of 7 and a functional score of 8, confirming the need for frenectomy. Additionally, the Marchesan Lingual Frenulum Protocol was applied, with the general test scoring 4 and the functional tests scoring 26, further indicating alteration of the lingual frenulum and the necessity for surgical intervention. Presurgical photographs documenting the condition are presented in figures 2a to 2e.

Case 3

A 7.5-year-old male patient reported difficulty in freely moving his tongue. Upon clinical examination, an abnormal frenal attachment was identified, classified as severe ankyloglossia (Kotlow’s Class III, tongue length 3-7 mm). No previous treatment attempts had been made due to a lack of awareness about the condition.

The patient’s anatomical and functional scores were assessed using the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLLF). The functional score was 9, and the appearance score was 7, meeting the criteria for frenectomy (appearance score <8 and functional score <11). A surgical frenectomy was performed successfully. Presurgical and intraoperative images documenting the condition and the surgical procedure are shown in figures 3a to 3e.

Treatment

After obtaining written informed consent, the clinical procedure was carried out. Blood investigations were recommended prior to the procedure. Antisepsis was achieved using betadine, followed by the application of a topical local anesthetic gel on the bilateral areas of the tongue. A conventional surgical frenectomy was performed under local anesthesia using 2% lignocaine with 1:80,000 adrenaline. Local infiltration anesthesia was administered at the tip of the tongue and the frenulum area.

The tongue’s tip was anesthetized, and a 3-0 black braided silk suture was employed for tongue traction to enhance visibility. Two incisions were made using a #15 BP blade. A horizontal incision was created at the base of the frenulum with a 15c blade, forming a diamond-shaped wound, which was followed by blunt dissection. Remaining fibrous tissue was excised. The desired tongue movement and extension were confirmed, and thorough irrigation was performed using saline. A 3-0 non-absorbable silk suture was placed over the wound. Post-operative care included the prescription of analgesics and antibiotics for five days.

Post-Operative Care

The postoperative period was uneventful. The patient was recalled the next day for a 24-hour review, and sutures were removed after seven days. Further follow-ups were conducted at 15 days and one month. Wound healing was satisfactory, and the patient was instructed to perform post-operative tongue exercises three times a day for one month.

Post-Operative Exercises:

1. Open the mouth wide enough to touch the upper front teeth with the tongue.

2. Extend the tongue downward and then upward toward the nose.

3. Lick from side to side along the upper and lower lips.

4. Poke both cheeks as far as possible while keeping the mouth shut.

5. Perform tongue motions to cleanse the oral cavity, including the fronts, backs, and insides of the cheeks.

Additional Exercises to Improve Speech, Strength, and Flexibility:

• Whistling.

• Inward rolling of the tongue.

• Spinning the tongue clockwise and counterclockwise while holding fluid.

• Strengthening the tongue by moving it against opposing forces, such as pressing it with a tongue depressor or applying external pressure to the cheek with the thumb.

Outcome

On review after one month, significant improvement in tongue mobility and speech was observed. Variations in tongue motility and frenulum tension were noted, contributing to better oral communication. The patients reported enhanced speech quality and ease in oral movements.

Discussion

Ankyloglossia, commonly referred to as tongue-tie, is a developmental abnormality characterized by a short lingual frenulum attached to the tongue tip.⁶ The reported prevalence of ankyloglossia in the literature varies widely, ranging from 0.1% to 10.7%.⁶ While some studies suggest an equal prevalence or even an inverse association, males are generally more affected than females.⁶ 

Treatment approaches for ankyloglossia include:

• Frenotomy: A simple incision of the frenulum.

• Frenectomy: Complete excision of the frenulum.

• Frenuloplasty: A more advanced surgical procedure aimed at correcting the anatomical abnormality and restoring tongue mobility using varied techniques.⁶

In this case series, the conventional scalpel-based frenectomy technique was employed for all three cases. This method was chosen due to its efficacy in tissue manipulation, affordability, and better healing potential compared to other techniques such as diode laser and electrocautery. As reported by Bakutra et al. (2017), diode laser and electrocautery techniques are associated with slower recovery times than traditional scalpel frenectomy.⁷

Complications following procedures like frenectomy, frenotomy, and frenuloplasty are rare but may include bleeding, lingual nerve injury leading to numbness at the tongue tip, and retention cysts caused by obstruction of Wharton’s duct during suturing on the tongue’s ventral surface.⁶

This case series highlights the advantages of the conventional scalpel-based technique for the excision of the frenulum. Due to its superior healing potential, cost-effectiveness, and minimal complications, the conventional method remains a viable and practical choice for managing tongue-tie, particularly in patients from varied socio-economic backgrounds.

Source of Support

Nil

Conflict of Interest

Nil