Management of ankyloglossia by functional frenuloplasty using diode laser Cherian D, Saeed R, Anusha K, Rag B, Peter T

CASE REPORT

Year : 2023 | Volume : 12 | Issue : 1 | Page : 23

Management of ankyloglossia by functional frenuloplasty using diode laser

Deepthi Cherian¹, Raed Saeed², K Anusha³, Bimal Rag¹, Tim Peter⁴
¹ Department of Pedodontics, Sree Anjaneya Institute of Dental Science, Modakallur, Kerala, India
² Department of Orthodontics, Zaindent Dental Clinics, Calicut, Kerala, India
³ Department of Periodontics, Smile Art Dental Clinics, Kannur, Kerala, India
⁴ Department of Oral Medicine and Radiology, KMCT Dental College, Calicut, Kerala, India

Date of Submission	15-Mar-2022
Date of Decision	18-Apr-2022
Date of Acceptance	29-Apr-2022
Date of Web Publication	18-Mar-2023

Correspondence Address:
Deepthi Cherian
Department of Periodontics, Sree Anjaneya Institute of Dental Science, Modakallur, Kerala - 673017
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jos.jos_20_22

Abstract

Ankyloglossia or tongue-tie is a condition present since birth that results in restricted movement of the tongue due to the attachment of the lingual frenulum. The condition affects breastfeeding, speaking, swallowing, occlusion, and proper tongue posture. Tongue ties vary in degree of severity from mild cases of mucus membrane bands to complete tongue ties where the tongue adheres to the floor of the mouth. Treatment options such as speech therapy, frenotomy,frenectomyhave all been suggested in the literature. Surgical correction often causes, bleeding,chances of infection, swelling, and relapse.A systemically healthy 23-year-old male patient who experienced difficulty in speech since childhood was referred for treatment to the dental clinic in September 2020. He was diagnosed with Kotlows class III tongue tie and angles class 3 malocclusion. Orthodontic correction and Functional frenuloplasty using a diode laser was carried out.In conjunction with it,orofacial myofunctional therapy was advised. Follow-up: The surgical procedure was uneventful. The patient was reviewed post-operatively at regular intervals every 3 months to check for relapse. This paper elaborates on the newer modes of diagnosis, orofacial myofunctional therapy, and lingual frenuloplasty with diode laser. This technique will help to overcome all the challenges of conventional tongue-tie treatments providing long-term excellent results.

Keywords: Ankyloglossia, diode laser, functional frenuloplasty, tongue-tie

How to cite this article:
Cherian D, Saeed R, Anusha K, Rag B, Peter T. Management of ankyloglossia by functional frenuloplasty using diode laser. J Orthodont Sci 2023;12:23

How to cite this URL:
Cherian D, Saeed R, Anusha K, Rag B, Peter T. Management of ankyloglossia by functional frenuloplasty using diode laser. J Orthodont Sci [serial online] 2023 [cited 2023 Apr 2];12:23. Available from: https://www.jorthodsci.org/text.asp?2023/12/1/23/371960

Introduction

The tongue is an important organ, which helps a person in speech and mastication. Proper positioning of the lingual frenum enables the tongue to carry out its functions.^[1] The development of the lingual frenum is guided by a fibrous band of tissue located in the center of the mouth before birth. As the growth progresses, the lingual frenum usually recedes and becomes thin.

There are reports of lingual frenum which does not recede as the growth advances and leads to tongue immobility.^[2],[3] This causes ankyloglossia (AG) or tongue-tie. AG can be an isolated finding in routine clinical examinations in children. There are reports of a few syndromes associated with AG like Ehler–Danlos syndrome, Beckwith–Wiedemann syndrome, Simosa syndrome, X-linked cleft palate, and Orofacial digital syndrome.^[4] There are also reports stating that the use of maternal cocaine increases the risk of AG more than three times.^[5] AG may cause functional issues like:

Lingual hypomobility could lead to difficulty in breastfeeding. The inability of a nursing infant to squeeze the nipple against the hard palate can be a potential problem during breastfeeding. The lateral margins of the tongue are raised to form a U-shaped channel that covers the nipple to avoid the leakage of milk to the vestibule of the oral cavity.
Swallowing is a natural function that involves extremely complex neuromuscular activity. It occurs with a progressive push of the tongue apex into the retroincisal-palatal spot. It is then followed by the posterior area of the tongue pressing on the hard palate first and soft palate later, and culminating on the wall of the pharynx. Anyone with AG will have difficulty swallowing, as it will be impossible to perform the movements described above.
Speech impediment for the correct pronunciation of dento-lingual-labial phonetics due to reduced lingual mobility.^[6]

Frenectomy: It is important to release the high frenal attachment. The lingual frenum is neither a vascular nor a sensitive structure. Hence severing the tissue is easy but the presence of vital structures makes it technique-sensitive. The bilateral lingual vessels and veins take their course on the ventral aspect of the tongue. It traverses laterally through the midline location of the frenulum, deep to the intrinsic musculature. Adequate care has to be taken to safeguard the lingual nerve and vessels to preserve the sensation of the tongue and complications of hemorrhage during the surgical intervention. Also, the genioglossus muscle runs from the symphysis of the mandible to the tongue, inferiorly to the lingual frenulum. Bilateral Wharton's duct can be visible in the proximity to the lingual frenulum. Care must also be taken to preserve the salivary gland ductal openings during the surgical intervention as it could lead to dysphagia, stricture of ducts, and sialocele formation.^[4],[5] It is important to diagnose and assess certain tongue parameters before surgical intervention.

Newer modes of diagnosis

There are five dimensions of tongue-tie diagnosis.^[7]

Kottlow's free tongue measurement (<16 mm): Sticking out the tongue is the first dimension of tongue-tie assessment. Stick out your tongue forward and to the maximum. The distance from the tongue tip to the insertion of the frenal attachment is measured. The frenulum attaches the undersurface of the tongue to the floor of the oral cavity. If the measurement is more than 16 mm, there is no tongue-tie. It is usually done in the age group of 18 months to 14 years.

Class I: Mild AG: 12–16 mm
Class II: Moderate AG: 8–11 mm
Class III: Severe AG: 3–7 mm
Class IV: Complete AG: <3 mm

Tongue to incisive papilla (TIP): The second dimension is to lift the tongue. The mouth should be open wide and the tongue has to be lifted and held on to the incisive papilla. It can be measured as compared to the maximum mouth opening. Lift the TIP and this is the measurement of anterior tongue mobility.
Lingual palatal suction (LPS): It is the assessment of LPS. It is used to assess posterior tongue mobility. It is the assessment of functional AG.
The floor of mouth/neck compensations: Present or absent: It is to assess posterior tongue-tie. The floor of the mouth is compressed with the help of an instrument to check for compensation in the tongue movements.
Tension: Present or absent: To check if the muscles of the tongue tense on stretching.

The Assessment Tool for Lingual Frenulum Function by Hazelbaker:^[8]

A. Function items

I. Lateralization

2 = complete

1 = body of the tongue, but not tongue tip

0 = none.

II. Lift of tongue

2 = tip to mid-mouth

1 = only edges to mid-mouth

0 = tip stays at alveolar ridge or tip rise only to mid-mouth with jaw closure

III. Extension of tongue

2 = tip over the lower lip

1 = tip over lower gum only

0 = neither of the above or anterior or mid-tongue humps

IV. Spread of anterior tongue

2 = complete

1 = moderate or partial

0 = little or none

V. Cupping of tongue

2 = entire edge, firm cup

1 = side edges only, moderate cup

0 = poor or no cup

VI. Peristalsis

2 = complete anterior to posterior (originates at the tip)

1 = partial: originating posterior to the tip

0 = none or reverse peristalsis

VII. Snap-back

2 = none

1 = periodic

0 = frequent or with each suck

B. Appearance items

I. The appearance of the tongue when lifted

2 = round or square

1 = slight cleft in the tip apparent

0 = heart-shaped

II. Elasticity of frenulum

2 = very elastic

1 = moderately elastic

0 = little or no elasticity

III. Length of lingual frenulum when tongue was lifted

2 = >1 cm or embedded in the tongue

1 = 1 cm

0 = <1 cm

IV. Attachment of lingual frenulum to tongue

2 = posterior to tip

1 = at tip

0 = notched

V. Attachment of lingual frenulum to the inferior alveolar ridge

2 = attached to the floor of the mouth or well below the ridge

1 = attached just below the ridge

0 = attached at ridge

Scoring

14 = perfect score (regardless of appearance item score)

Surgical intervention is necessary if the function score is <11 and the appearance score is <8.

Case Report

A systemically healthy 23-year-old male patient, a nonsmoker, was referred to the Clinic of Periodontics in September 2020. The patient consulted because he experienced difficulty in speech [Figure 1] and [Figure 2].

Figure 1: Kotlows grade 3 tonur tie (7 mm)

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Figure 2: Angles class 3 mal occlusion

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Upon examination, the following was observed:

Angles class III malocclusion.
AG – TIP –7 mm. The floor of mouth compensation: absent.

Tension: present/LPS: absent

Kotows class III

Scoring according to Hazelbaker classification is 9.

We explained the diagnosis and suggested the treatment plan in detail to the patient: Orthodontic correction and functional frenuloplasty. The patient started orthodontic correction in April 2020. In April 2021, the patient reported for correction of AG. Three months before the surgical procedure preoperative orofacial myofunctional therapy (OMT) was started.

Preop exercises

These exercises help thin out the frenulum, increase range of motion, and push back nerves and blood vessels.^[9],[10]

Tongue around the world:

Move the tongue in a circle along with the teeth. Keep the lips closed. Do not move the jaw. Begin with smaller circles around and build up to larger circles as the tongue gets stronger. Five times in each direction (building up to 10 in each direction), twice a day.
Lip lickers:

Lick the lips in a full circle, as if you are trying to lick off something sticky. Ten times in each direction, twice a day.
Tongue clicks:

Suction the tongue to the roof of the mouth, smile, and click the tongue down. Try not to move the jaw; 30 loud ones, twice a day.
Peanut butter scrapes:

Open the mouth wide. Place the tip of the tongue behind the top front teeth. Scrape backward as far as possible, toward the throat. Ten times, twice a day.
Tongue push-ups

Hold the lower jaw in place with one hand. Do not let it come forward. Open the mouth and extend the tongue out to a tongue depressor (or back of a spoon). Push as hard as possible. Hold for 3–10 s, 15 times, twice a day.^[10]

Surgical procedure

The tongue is lifted gently with sterile gauze. Local anesthesia (1:100,000 adrenaline) was injected into the undersurface of the tongue and a sling suture is placed at the tip of the tongue to help retract it upward toward the palate exposing the frenum. The frenum is then divided with a laser using vertical strokes after the tip was initiated [Figure 3].

Figure 3: Angles class 3 malocclusion

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Diode laser (Zolar, WA) with a 0.5 mm focal spot was utilized, delivering 1.8 watts in continuous contact mode. Deeper cuts were placed. A curved hemostat is inserted into the wound to detach any deeper underlying fibers [Figure 4]. Care is taken not to incise any vascular tissue. There is usually no risk of severe bleeding from smaller vasculature as it is efficiently coagulated by the 810 nm laser wavelength. The patient is asked to lift, extend the tongue, and put it in the “suction-cup” position to assess the extent. Linear wound helps to achieve a good tension-free closure of the wound edges. Over the wound, 4-0 non-absorbable silk sutures are placed^[11] [Figure 5].

Figure 4: Blunt dissection to release the deep fibres.genioglossus muscle is visible

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Figure 5: Post operative sutures placed

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Analgesic is prescribed for 48 h after the frenum release. During this time, the patient is advised to maintain a soft diet and to abstain from hot and spicy food or drink. Postsurgical exercises are to be resumed 72 h after treatment.

Postoperative exercises^[9],[11]

These exercises increase the efficiency of the treatment done. It has to be done from the first week after the surgery to three months to achieve good postop healing and range of motion.

Snake exercise:

Make a point with your tongue. Extend the pointed tongue out of your mouth and pull it back in. Make sure that the tip of the tongue does not touch the lip. The process has to be repeated 25 times.
Waggle flap:

Place the tip of your tongue on your upper and lower lips. Move the tip of your tongue up and down. The process has to be repeated ten times.
Jawbreaker:

With the lips closed, point the tongue out into the left cheek. It should look like a jawbreaker on the side of your cheek. Hold it for 10 s and proceed with the same exercise on the contralateral side.
Peanut butter rub: (same as preop)
Spoon hold: Stick your tongue out and make a point. Push a spoon against your pointy tongue. Resist with the tongue for a count of 5 s.

The patient was reviewed 2 weeks, 3 months, and 10 months postoperatively after surgery. Good healing was achieved and the patient did not experience any difficulty in speech. A good occlusal correction was also obtained.

Discussion

The adult functional laser frenuloplasty technique is a recently developed concept that helps to remove the deeper layers of the tight lingual frenum and helps to prevent re-epithelialization of the fibers. It also helps to establish the proper functioning of the tongue, lips, and mandible.

Functional frenuloplasty involves the following criteria as suggested by Melissa Mugno and Tara Erson:^[12]

Mandatory regular prefrenuloplasty OMT exercises are required to prepare and re-pattern tongue functions (to facilitate the release of the lingual frenulum).
Diode laser frenum release (frenuloplasty) and placing sutures, under local anesthesia, combined with tongue mobility is an effective assessment to assure the removal of restrictions for optimal oral function.
Mandatory postsurgical OMT program is unavoidable to attain long-standing functional results.

The surgical section involves severing the superficial fibers with lasers and separating the deeper fibers with the help of a hemostat. This helps to preserve vital structures. The placement of sutures helps in wound healing without re-epithelialization. OMT also plays an important role.

The goal of OMT is to primarily strengthen the tongue and orofacial musculature. OMT utilizes the association between muscular and behavioral forces. OMT aids in normalizing the adaptability of soft and hard orofacial tissues.

Preoperative exercises are required to ascertain help stretch the tongue muscles. It helps to re-educate the orofacial muscles. It also aids to create new neuromuscular patterns for proper oral function, including mastication, deglutition, speech, and breathing.

Postoperative exercises following tongue-tie surgery have multiple objectives. The primary objective is to strengthen the musculature. The supplementary objectives are:

To develop new muscle movements, particularly those involving tongue tip elevation and protrusion, inside and outside of the mouth,
To increase awareness of the full range of movements the tongue and lips can perform,
To 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.^[13]

For the surgical purpose diode laser was used because of its safe and easy use and the avoidance of any bleeding. There are different types of laser for this operation, CO₂ laser, diode laser, erbium:yttrium-aluminum-garnet (Er:YAG laser), and erbium, chromium:yttrium-scandium-gallium-garnet laser (Er, Cr:YSGG laser). If a diode laser is chosen for this approach, firms recommend 1, 5-3 watt, continuous wave, 810/940/980 nm with initiated tip, always in contact with the tissue.^[14] Sutures are to be placed, and antibiotics are not necessary.^[3]

Late postoperative complications after AG management are rare. Various complications include bleeding, blockage of Wharton's duct while suturing on the ventral surface of the tongue leading to retention cyst, and damage to the lingual nerve causing numbness of the tongue tip.^[11] However, in this procedure, the chances of complications are very rare.

There is no sufficient evidence in the literature concerning surgical treatment options for AG. A recent systematic review conducted by Bin-Nun et al.^[15] mentioned that the yearly number of AG-related articles has increased dramatically in the past few years without bringing interesting evidence. Earlier studies conducted by various authors state that surgical correction is more invasive and difficult to be performed in young children, whereas laser is safe, minimally invasive, bactericidal, and provides a bloodless operating field.^[16],[17] The newer concept of functional frenuloplasty using laser is yet to gain momentum. Further literature works like randomized controlled trials and systematic reviews should accumulate regarding functional frenuloplasty and OMT to make them more popular in the management of tongue-tie. This technique combines the advantages of surgical and laser frenectomy with long-term predictable results.

Conclusion

AG has a low prevalence and both genetic and environmental factors are implicated in its appearance. AG affects breastfeeding, oral hygiene, speech, swallowing as well as the development of occlusion. Physicians may often delay recommending treatment of a short lingual attachment unless there is obvious speech or nursing difficulties. Treatment options such as speech therapy, frenotomy, and frenectomy under general anesthesia have all been suggested in the literature. More recently, the concept of functional frenuloplasty has been introduced. To rebuild the necessary orofacial function in children and adult patients, an extensive tongue-tie frenal release with pre and postoperative myofunctional therapy is necessary, which is the core concept of functional frenuloplasty. Further studies are required to prove the long-term success of this technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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