Ankyloglossia: case report

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Ankyloglossia: case report
ISSN:
Printed version: 1806-7727
Electronic version: 1984-5685
RSBO. 2011 Jan-Mar;8(1):93-8
Case Report Article
Ankyloglossia: case report
Norma Suely Falcão de Oliveira Melo1
Antonio Adilson Soares de Lima1
Ângela Fernandes1
Regina Paula Guimarães V. Cavalcanti da Silva1
Corresponding author:
Norma Suely Falcão de Oliveira Melo
2915/14, Martin Afonso St.– Bigorrilho – Curitiba – PR
E-mail: [email protected]
1
Dentistry School, Federal University of Paraná – Curitiba – Paraná – Brazil
Received for publication: August 10, 2009. Accepted for publication: June 28, 2010.
Keywords: lingual
frenum; surgery;
abnormalities.
Abstract
Introduction: The lingual frenulum is an anatomic structure that
plays an important role in the act of suction, speech and feeding. A
short and adhered lingual frenulum obstructs the tongue movement.
This can impair the diverse functions of this structure. This alteration
is called ankyloglossia. Objective and case report: The aim of this
article is to relate a case of ankyloglossia in a female child of two-years
old who was examined in the Clinic of Child Care of the Department
of Pediatrics, Federal University of Paraná. The child was diagnosed
with type II ankyloglossia and treated by frenectomy. Conclusion: The
routine examination of the lingual frenulum permits the identification
of insertion abnormalities and enables the establishment of preventive
measures for complications during the period of breastfeeding.
Introduction
The lingual frenulum, or tongue’s frenulum,
connects the tongue to the mouth floor, allowing
tongue’s free movement. The frenulum is not a
muscular tissue. It is a median fold of mucosa tunic
that joints the tongue’s posterior-inferior surface and
gingival tissue, covering the lingual surface of the
anterior alveolar ridge. Lingual frenulum is formed
by a dense fibrous conjunctive tissue and, often,
by superior fibers of the genioglossus muscle. As
there is bone development and growth with tongue
projection and dental eruption, the lingual frenulum
migrates towards a central position up to occupy
its definitive position after the tooth eruption. It is
classified as short lingual frenulum, with anterior
fixation and short with anterior fixation [5, 6, 7,
17, 18]. Madeira (1993) [19] described the frenulum
as part of oral mucosa forming a corrugated fold
resulting in a fringy fold. This structure covers the
deep vein of the tongue and the anterior lingual
gland close to apex.
Histologically, the lingual frenulum is composed
of a conjunctive tissue rich in collagen and elastic
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Melo et al.
Ankyloglossia: case report
fibers, with some muscular fibers, blood vessels,
and fat cells, covered by a stratified pavimentous
epithelium [14].
Ankyloglossia, so-called tongue-tie, constitutes
a development a l a noma ly cha racter i zed by
a lterat ion in tongue’s frenulum result ing in
limitations of this structure’s movements, leading
to speech and deglutition changes. The change
of the insertion occurs in the tongue’s tip up
to the lingual alveolar ridge, being visible at
birt h [6]. Its definit ion ra nges from since a
vague description of “tongue functioning with
the activity extension lower than normal” up to
the description of a “short, thick, muscular or
fibrous frenulum” [17].
The joint of the mouth floor with the tongue
is a rare condition; partial ankyloglossia is more
common. This abnormality makes the tongue’s
movements difficult, mainly the pronunciation of
certain consonants and labial-dental diphthongs
[21]. Although it is a very much known clinical
entity, ankyloglossia affecting children younger
than 1 year-old represents a challenge for dentists
regarding to its diagnosis [17]. Moreover, it interferes
in toothbrushing process, consequently, favoring the
risk of plaque accumulation, tissue inflammation
onset, and gingival recession [33].
The lingual frenulum examination should
consider the clinical and functional aspects of the
tongue. Ballard and Kroury (2002) [3] cited the
lingual frenulum evaluation according to Hazelbaker
(table I) for frenectomy indication when the child
is presenting difficulty during breastfeeding with
pain in the mother’s nipple.
Table I – Lingual frenulum evaluation according to Hazelbaker
Clinical aspects
Function
Tongue’s aspect when elevated
2: Round or square
1: Mild apparent cleft in the tip
0: Shape of “heart” or “V”
Lateralization
2: Complete
1: Tongue’s body, without the tip
0: None
Frenulum elasticity
2: Very elastic
1: Mild elastic
0: Little or no elasticity
Tongue’s elevation
2: Tongue tip in the middle of the mouth
1: Only the tip in the middle of the mouth
0: The tip is below the inferior alveolar ridge or it
is only elevated when the mandible is closed
Frenulum length when the tongue is elevated
2: Greater than 1 cm
1: 1 cm
0: Lesser than 1 cm
Frenulum insertion into tongue
2: Posterior to tip
1: Tip
0: Tip in “V” shape
Frenulum insertion into inferior alveolar ridge
2: Insertion into mouth’s floor or very below the
ridge
1: Insertion very below the ridge
0: Insertion into the ridge
Tongue’s extension
2: Tip on inferior lip
1: Tip only on gingiva
0: None of the previous alternatives;
Body’s tongue depression
2: Complete
1: Moderate
0: Little or none
Peristaltism
2: Complete
1: Moderate or partial
0: Little or none
Abrupt tongue’s movement
2: None
1: Periodical
0: Frequent or in each suction
RSBO. 2011 Jan-Mar;8(1):93-8 The baby’s mouth presents a small membrane
that extends from tongue to mandible’s inner surface.
Such membrane maintains the tongue in correct
position during breastfeeding. After some days of
child’s development, this membrane is transformed
into the lingual frenulum, modifying its insertion.
Therefore, the child will be able of stretching the
tongue forward. In some cases, this membrane
becomes thicker and shorter and the tongue’s tip
is confined, causing ankyloglossia [20, 29, 32].
Tongue plays an important role in deglutition.
During breastfeeding, the mother’s nipple is
compressed and flattened by the baby’s tongue
against the palatine papilla. The child apprehends
the nipple with the lips and tongue, performing a
sealing composed by the upper lip, above, and by
the tongue’s tip and lower lip, below [1]. Occasionally,
newborn and nursing babies show atypical oral
movements of the tongue that are capable of
interfering in breastfeeding. These oral disturbances
may be transitory alterations of the oral function
or individual anatomical features. Tongue’s correct
movement favors the proper fit between the baby’s
mouth and the mother’s breast. Oral dysfunctions,
when present, result in little weight gain or early
ablactation. The breastfeeding of children showing
ankyloglossia is frequently inappropriate, being
uncomfortable and painful for the mothers [27,
30]. If these alterations are not corrected, they will
result in breastfeeding impairment [24].
Frenectomy provides the lingual mobility return
because no adherence is formed after the horizontal
incision of the frenulum (with scissors and under
local anesthesia). In some cases, the surgical
procedure is repeated for successfully obtaining
tongue articulation mobility [11, 13, 22]. According
to Santos et al. (2007) [25], the frenectomy should
be executed, as early as possible, or as soon as it is
diagnosed. The protocol aims to prevent or reduce
the implications related to poor tooth positioning
and muscle development, which are damaged.
Besides the surgical procedure, treatment should
be completed by a speech therapist, in order to
reestablish the normal deglutition and speech
physiology. The authors emphasized that if the
frenectomy is delayed, patient’s psychological and
social well-being will be compromised.
A st udy on t he determi nat ion of t he
frenectomy effectivit y in children presenting
breastfeeding difficulty, through submentual
ultrasonography, revealed that there was less
compression of the mother’s nipple by the baby’s
tongue after frenectomy, which resulted in small
discomfort during breastfeeding, according to
the mothers [12].
95
Baldini et al. (2001) [2] performed a study on the
prevalence of the oral alterations in children aging
from 0 to 2 years-old. The incidence of ankyloglossia
in children aging from 0 to 3 months-old and
from 4 to 12 months-old was 1.59% and 1.49%,
respectively. The anomaly was more recurrent in
girls. According to Vieira (2004) [31], the occurrence
of ankyloglossia is about 1 subject to 300 births.
However, a similar study performed in Mexico, with
newborn babies, demonstrated that ankyloglossia
in the studied population was approximately 1%
[10]. This same investigation pointed out that the
abnormality occurred more in male than in female
subjects (male:female ratio = 1.5:1).
In a population of 621 children aging from 0
to 6 months-old, the most prevalent oral alterations
were inclusion cysts, comprising Bohn’s nodules,
Epstein’s pearls, and dental lamina cysts; there
was no case of ankyloglossia [26].
The aim of this study was to report a case of
ankyloglossia in a child, emphasizing its clinical
features and the recommended treatment.
Case report
The parents of a female, Caucasian, two yearold child sought for the Clinic of Child Care of
the Department of Pediatrics, Federal University
of Paraná. The child’s mother reported the child’s
difficulty in feeding and pronouncing the labialdental diphthongs. Moreover, the mother was
concerned about the child’s learning at school.
During anamnesis, the mother reported difficulty
during the child’s breastfeeding due to tongue-tie,
which hindered the nipple’s apprehension.
Intraoral clinical examination showed a short
lingual frenulum limiting tongue’s movement
amplitude, with insertion close to tongue’s tip
(figure 1). The frenulum insertion into the tongue’s
tip and basis interfered in tongue’s protrusion
forward, resulting in tongue bending (figure 2). Such
condition did not allow a normal deglutition pattern.
The girl showed speech difficulties associated
with lingual movement limitation. Frenectomy was
recommended as treatment, under topical anesthesia
on tongue’s inferior surface. After anesthesia,
hemostatic pliers were used for apprehend the
frenulum, and an electric-surgical instrument was
used for its releasing. Surgical wound was sutured
with catgut suture 4/0. Following, post-operative
instructions comprising measurements for avoiding
hemorrhages and the use of non-narcotic painkillers
for controlling pain discomfort, were performed.
Seven days after the surgery, the surgical wound
was undergoing healing. At that moment, the
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Melo et al.
Ankyloglossia: case report
tongue’s function was evaluated, and there was
an improvement in the capacity of movimentation.
Such fact suggested an excellent prognosis for the
case.
Figure 1 – Clinical aspect of the tongue at rest
Figure 2 – Tongue protrusion impaired by
ankyloglossia
it caused morphofunctional modifications. The
child showed difficulty in speech in association
with limitation of tongue’s movements, besides an
abnormal pattern of deglutition due to a short lingual
frenulum that limited the amplitude of tongue’s
movements. The child also displayed difficulty in
articulating labial-dental words.
Babies with an altered lingual frenulum may
present problems in mother’s nipple apprehension,
complicating the removal of milk and interfering in
the weight gain. Surgical releasing of the frenulum,
when carefully indicated, promotes this function
improvement [28].
The ankyloglossia correction at early ages
reduces the risks of complications to nursing babies,
and frenectomy should be performed when there is
interference in deglutition and speech [6, 13, 16].
The pediatrist, pedodontist, and general dentist
are capable of detecting abnormalities in the mouth
of newborn and nursing babies, and children. On
one hand, the pediatrist is responsible for the
diagnosis of the manifestations present in the
baby’s mouth in the early life. On the other hand,
the pedodontist usually examines the children at
the moment of deciduous tooth eruption (about 6
months-old). With the advent of Dentistry for babies,
early attention prior to tooth eruption potentiates
the diagnosis of oral alterations, such as neonatal
and prenatal tooth, and ankyloglossia [7].
The evaluation of lingual frenulum problems
will enable the identification of abnormalities in its
insertion and prevention of alterations in deglutition
and speech function after the surgical correction
of ankyloglossia.
Conclusion
Discussion
Undoubtedly, any problem affecting the tongue’s
health may seriously ref lect in oral functions.
A nk ylog lossia is a congenit a l ora l a noma ly
characterized by a very short lingual frenulum
capable of resulting in variable degrees of lingual
mobility reduction.
The tongue plays an important role in food
transportation and deglutition [9, 23], as well
as in words articulation [4]. Also, it influences
tooth positioning and breastfeeding. A very short
lingual frenulum restricts the tongue movements’
amplitude, impairing the capacity of executing its
functions [17].
In the case reported here, a nkyloglossia
presented a social and clinical relevance, since
The routine examination of the lingual frenulum
enables to both find anomalies in its insertion and
plan preventive measurements for intercurrences
during breastfeeding. In this present case report,
the abnormal tongue insertion altered significantly
the deglutition function, tongue’s movements,
speech, and word’s articulation. Lingual frenulum
surgery returned the tongue’s functions to patient’s
stomatognathic system.
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How to cite this article:
Melo NSFO, Lima AAS, Fernandes A, Silva RPGVC. Ankyloglossia: case report. RSBO. 2011 JanMar;8(1):93-8.

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