Case Report: Clinical Guidelines and Management of Ankyloglossia With 1-Year Followup: Report of 3 Cases
Case Report: Clinical Guidelines and Management of Ankyloglossia With 1-Year Followup: Report of 3 Cases
Case Report: Clinical Guidelines and Management of Ankyloglossia With 1-Year Followup: Report of 3 Cases
Case Report
Clinical Guidelines and Management of Ankyloglossia with
1-Year Followup: Report of 3 Cases
Copyright © 2013 Mayur S. Bhattad et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
e tongue is an important oral structure that affects speech, position of teeth, periodontal tissue, nutrition, swallowing, nursing,
and certain social activities. Ankyloglossia (tongue tie) is a congenital anomaly characterized by an abnormally short, thick lingual
frenulum which affects movement of tongue. ough the effect of ankyloglossia in general appears to be a minor condition,
but a major difference exists concerning the guidelines for tongue-tie division. ere are no accepted practical criteria for the
management of such condition, and hence this paper aims at bringing all the compilation in examination, diagnosis, treatment,
and management of tongue tie together for better clinical approach.
3. Clinical Assessment
F 2: Preoperative photograph (Case 2). All the 3 cases were assessed clinically by Kotlow’s criteria
(Table 1) in which normal range of motion of the tongue was
assessed [1], Hazelbaker’s assessment tool (Table 2) to observe
the functional movement and appearance of the tongue [13],
the chief complaint of pain in lower right and le posterior and speech analysis to identify and rectify defective speech
region. Oral examination of the patient revealed not only [3, 14].
multiple decayed teeth in lower arch but also an ankyloglossia Upon diagnosis of an ankyloglossia, the patient’s parents
with thick, short frenulum, restricted tongue protrusion, and were informed about the nature of the lesion, its functional
liing of the tip of the tongue (Figure 1). implications, and the variety of surgical approaches. e
patient’s family and medical history were noncontributory.
Case Number 2. An 8-year-old male patient reported to the Patient’s height and weight were appropriate for their age.
Department of Pedodontics and Preventive Dentistry with ��T and general physical examination revealed insigni�cant
the chief complaint of pain in upper right posterior region. �ndings. Hematologic examination of the patients was within
Aer clinical examination, decayed tooth and ankyloglossia normal range. Aer obtaining informed consent, the follow-
with restricted tongue movements were also observed. A bi�d ing procedures were carried out for correction of lingual
or heart shape of the anterior tip of the tongue was seen upon frenum.
attempted extension (Figure 2).
4. Clinical Management
Case Number 3. An 11-year-old male patient reported to
Department of Pedodontics and Preventive Dentistry with In the �rst and second case (cases number 1 and 2), frenum
the chief complaint of improper speech, and his parents also attachment was revised by conventional frenectomy. A top-
reported that he was not able to chew solid foods. Clinical ical anesthetic was applied to the underside of the tongue
examination revealed that patient had ankyloglossia with following which block anesthesia was given. Aer achieving
thick frenum, restricted tongue movements like protrusion, objective symptoms, a suture was passed at the middle of the
and liing of the tip of the tongue and a bi�d or heart shape tongue to control its movements, and two hemostat was used
of the anterior tip of the tongue, was observed. To assess to clamp the frenum: one at the under surface of the tongue
the extent of limitation of tongue movement, the mouth and another at the �oor of the mouth avoiding salivary gland
was carefully inspected under adequate illumination with a duct. Incision was placed above and below the hemostats
tongue depressor (Figure 3). to release the complete frenum. On achieving homeostasis,
Case Reports in Dentistry 3
T 2: Hazel baker’s Assessment tool for appearance and function of the tongue.
Appearance Function
Appearance of tongue when lied Lateralization
2: Round or square 2: Complete
1: Slight cle in tip apparent 1: Body or tongue but no tongue tip
0: Heart or V-shaped 0: None
Elasticity of frenulum Li of tongue
2: Very elastic 2: Tip to mid-mouth
1: Moderately elastic 1: Only edges to mid-mouth
0: Little or no elasticity 0: Tip stays at lower alveolar ridge or rises
to mid-mouth only with jaw closure
Length of lingual frenulum when tongue
Extension of tongue
lied
2: >1 cm 2: Tip over lower lip
1: Tip over lower gum only
1: 1 cm
0: Neither of the above, or anterior or
0: <1 cm mid-tongue humps
Attachment of lingual frenulum to tongue Spread of anterior tongue
2: Posterior to tip 2: Complete
1: At tip 1: Moderate of partial
0: Notched tip 0: Little or none
Attachment of lingual frenulum to
Cupping
inferior alveolar ridge
2: Attached to �oor of mouth or well 2: Entire edge, �rm cup
below ridge
1: Attached just below ridge 1: Side edges only, moderate cup
0: Attached at ridge 0: Poor or no cup
Peristalsis
2: Complete, anterior or posterior
1: Partial, originating posterior to tip
0: None or reverse
14 = Perfect score, 11 = Acceptable if appearance item score is 10. Frenectomy is necessary if function score is <11 and appearance score is <8.
5. Results
Using the Kotlow’s criteria and Hazelbaker’s assessment tool,
preoperative and postoperative scores were recorded. Aer 14, and 15 mm (Table 3), respectively, and functional score of
1-year followup, signi�cant improvement in prognosis of 9, 10, and 10 and appearance score of 6, 6, and 7 were changed
symptoms of ankyloglossia was observed (Figures 7, 8, and 9). to 14, 13, 12, and 9, 9, and 10 (Table 4), respectively. Speech
Free tongue movement increased from 7, 9, and 8 mm to 13, in case number 3 also signi�cantly improved (Table 5).
4 Case Reports in Dentistry
Pre-operative Post-operative,
Case
free tongue Diagnosis free tongue Diagnosis
number
movement movement
1 7 mm Class III 13 mm Class I
2 9 mm Class II 14 mm Class I
3 8 mm Class II 15 mm Class I
6. Discussion
Anatomical de�nition of ankyloglossia consists of descrip-
tions as well as absolute measurements. Descriptions include
the attachment of the frenulum to the tongue, the attachment
of the frenulum to the inferior alveolar ridge, the elasticity
of the lingual frenulum, and the appearance of the tongue
when lied. Absolute measurements include the length of the
lingual frenulum when the tongue is lied as well as the free
F 7: Postoperative photograph aer 1 year (Case 1).
tongue length [15].
According to �allace, functional de�nition includes it
as a condition in which the tip of the tongue cannot be
protruded beyond the lower incisor teeth because of a short
frenulum. On the other hand, tongue movement is more
complex than simple protrusion, and as a result functional
assessments criteria have included tongue lateralization,
tongue li, tongue spread, tongue cupping, and tongue snap
back [15].
Ankyloglossia can be divided into partial or complete
ankyloglossia. e academy of Breastfeeding Medicine Pro-
tocol de�nes partial ankyloglossia as the presence of a sublin-
gual frenulum which changes the appearance and/or function
of the infant’s tongue because of its decreased length, lack of
elasticity or attachment too distal beneath the tongue or too
close to or onto the gingival ridge. Complete ankyloglossia is
a condition in which there is extensive fusion of the tongue
F 8: Postoperative photograph aer 1 year (Case 2). to the �oor of the mouth which is extremely rare [16].
Case Reports in Dentistry 5
T 4: Pre-operative and post-operative assessment of functional and appearance score of all the 3 cases by using Hazel-Baker’s assessment
tool.
Pre-operative Pre-operative Post-operative Post-operative
Case number
function score appearance score function score appearance score
1 9 6 14 9
2 10 6 13 9
3 10 7 12 10
T 5: Pre-operative and post-operative assessment of speech in which should be determined by using Kotlow’s criteria [1]
all the 3 cases. in which classi�cation ranges from class I to class I�. e
Case Pre-operative associated Post-operative tip of the tongue should able to protrude outside the mouth
number problem associated problem without cleing and should be able to sweep the upper
and lower lips easily, without straining. When the tongue
1 No speech abnormality —
is retruded, it should not blanch the tissue lingual to the
2 No speech abnormality — anterior teeth and should not put excessive forces on the
3 Defective speech Improvement of speech mandibular anterior teeth. e lingual frenum should not
create a diastema between the mandibular central incisor, and
the frenum should not prevent an infant from attaching to the
mother’s nipple during nursing.
7. Consequences of Not Treating the Tongue Tie e functional movement and appearance of the tongue
could be determined by using Hazelbakers assessment tool
Appearance of the tongue could be abnormal in some [15]. In this tool, scores are given to each movement of the
individuals. Improper chewing and swallowing of food could tongue and appearance of the tongue. If the functional and
increase the gastric distress and bloating, and snoring and bed appearance score is below 11 and 8, then surgical invention
wetting at sleep are common among tongue tied children. should be considered.
It also affects children who want to participate in routine Patients should be asked to pronounce certain words
play which involves tongue movements, gestures, and speech. which start from “I,” “th,” “s,” “d,” and “t” to check the
Dental caries could occur due to food debris not being accuracy of the word pronunciations. If a defective speech
removed by the tongue’s action of sweeping the teeth and is observed, aer postoperative wound healing, referral to
spreading of saliva. Malocclusion like open bite due to thrust a speech therapist is mandatory for speech modi�cation.
created by being tongue tied, spreading of lower incisors with Postoperative tongue muscle exercises like licking the upper
periodontitis, and tooth mobility due to long-term tongue lip, touching hard palate with the tip of tongue, and side-
thrust are associated problems. It also affects self-esteem to-side movements should be explained to the patient for
because it has been noted clinically that occasionally an older enhanced tongue movements.
child or adult will be self-conscious or embarrassed about
their tongue tie that they may be teased by their classmates for
their anomaly. In infant feeding problem may be experienced 9. Conclusion
due to latching on to the nipple which may compress the
nipple against the gum resulting in nipple pain in mothers, Tongue tie affects a considerable number of infants and chil-
and due to this the mothers may oen try to shi the baby to dren. It is perhaps interesting that such a simple condition can
a bottle [3, 16–18]. cause such controversy and diversity of opinions. However, it
is important that accurate information and guidance is given
to parents with regard to the indications and potential bene-
8. Clinical Guidelines for �ts of tongue-tie revision, and that appropriate provisions are
Management of Ankyloglossia in place for those infants and children who require revision.
ese case reports offer guidelines which can be used by
ere is a wide difference of opinion regarding its clinical general and pediatric dentists for diagnosis and treatment of
signi�cance and optimal management. In many children, a tongue restriction resulting from ankyloglossia.
ankyloglossia is asymptomatic, and the condition may resolve
spontaneously, or affected children may learn to compen-
sate adequately for their decreased lingual mobility. Some References
children, however, bene�t from surgical intervention of their
tongue tie. Parents should be educated about the possible [1] L. A. Kotlow, “Ankyloglossia (tongue-tie): a diagnostic and
long-term effects of tongue tie, so that they may make an treatment quandary,” Quintessence International, vol. 30, no. 4,
pp. 259–262, 1999.
informed choice regarding possible therapy.
For effective management proper clinical guidelines are [2] Entnet.org [Internet] American Association of otolaryngolo-
mandatory. In ankyloglossia, the most important factor to gist: head and neck surgery: fact sheet, 2012, http://entnet
be considered is the normal range of motion of the tongue .org/HealthInformation/Ankyloglossia.cfm.
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