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170]
Case Report
Ankyloglossia and its management
Tanay V. Chaubal, Mala Baburaj Dixit
Department of Abstract:
Periodontics, Nair Ankyloglossia or tongue-tie is the result of a short, tight, lingual frenulum causing difficulty in speech articulation
Hospital Dental College, due to limitation in tongue movement. In this article, we have reported a 24-year-old male with tongue-tie who
Mumbai, Maharashtra, complained of difficulty in speech following which he underwent frenectomy procedure under local anesthesia
India without any complications. Finally, he was given speech therapy sessions.
Key words:
Ankyloglossia, frenectomy, Kotlow
INTRODUCTION
E tymologically, ankyloglossia originates
from the Greek words agkilos (curved)
and glossa (tongue). The same term is used
for very different clinical situations: When
the tongue is fused to the floor of the mouth,
but also if the lingual frenulum is only short
Access this article online and thick with slight impairment of tongue
mobility. The first use of the term ankyloglossia
Website:
www.jisponline.com in the medical literature dates back to the
1960s, when Wallace [1] defined tongue-tie as
DOI:
10.4103/0972-124X.85673 a condition in which the tip of the tongue
cannot be protruded beyond the lower incisor
Quick Response Code:
teeth because of a short frenulum linguae, often
containing scar tissue.
CASE REPORT
A 24-year-old male was reported in the
department of Periodontics with difficulty
in speech since birth. The ENT and general
physical examination was normal. On intraoral
examination, it was found that the individual
had ankyloglossia (tongue-tie) and was
classified as Class III by utilizing Kotlows
assessment [Figure 1] and was able to protrude
the tongue up to the lower lip [Figure 2]. There
were no malocclusion and recession present
lingual to mandibular incisors. The patient
was undertaken for a frenectomy procedure
under local anesthesia with 2% lignocaine
hydrochloride and 1:80,000 adrenaline by using
Address for a scalpel method; first a curved hemostat was
correspondence: inserted to the bottom of the lingual frenum
Dr. Tanay V. Chaubal, at the depth of the vestibule and clamped into
6/Jagruti, Sudarshan position followed by giving two incisions at the
Colony, Thane (East), superior and the inferior aspect of the hemostat.
Maharashtra, India.
This way, we removed the intervening frenum
E-mail: tanayvc@gmail.
com and got a diamond shaped wound. Then with
the help of the same hemostat, we released
Submission: 01-05-2010 the muscle fibers so as to achieve a good
Accepted: 09-08-2011 tension free closure of the wound edges
270 Journal of Indian Society of Periodontology - Vol 15, Issue 3, Jul-Sep 2011
[Figures 3 and 4] after which the wound edges
were approximated with (4-0) black braided
silk sutures [Figure 5] for the tissues to heal
by primary intention thereby minimizing
the scar tissue formation, antibiotic Cap.
Amoxicillin (500mg) thrice a day for 3 days
and non-steroidal anti-inflammatory drug
Tab. Ketorolac DT (10mg) thrice a day for 3
days was prescribed to prevent post-operative
infection and pain. The post-operative period
was uneventful with no delayed hemo-
rrhage. Sutures were removed after 1 week
[Figure 6] which showed no scar tissue
formation following which the patient was sent
for speech therapy sessions. After a follow-up
of 6 months, the tongue showed good healing
[Figure 7], protrusion several mm beyond the
lower lip [Figure 8], and normal speech.
DISCUSSION
Ankyloglossia is an uncommon congenital oral
anomaly that can cause difficulty with breast-
feeding, speech articulation.[2] For many years, the
subject of ankyloglossia has been controversial
with practitioners of many specialties having
widely different views regarding its significance
and management. In many individuals,
ankyloglossia is asymptomatic; the condition may
resolve spontaneously or affected individuals
may learn to compensate adequately for their
decreased lingual mobility. Some individuals,
however, benefit from surgical intervention
frenotomy, frenectomy or frenuloplasty for
their tongue-tie. Patients should be educated
about the possible long-term effects of tongue-
tie so that they may make an informed choice
regarding possible therapy.[2,3] The prevalence
of ankyloglossia reported in the literature varies
from 0.1% to 10.7%. The prevalence is also higher
in studies[4] investigating neonates (1.72% to
10.7%) than in studies[5] investigating children,
adolescents, or adults (0.1% to 2.08%). It can
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Chaubal and Dixit: Ankyloglossia

Figure 1: Pre-operative view showing ankyloglossia Figure 2: Pre-operative view showing extension of tongue

Figure 3: Frenectomy incision using scalpel Figure 4: Completion of frenectomy

Figure 5: Sutures Figure 6: Post-operative view 1 week

Figure 7: Post-operative view 6 months Figure 8: Post-operative view 6 months showing adequate extension of tongue

Journal of Indian Society of Periodontology - Vol 15, Issue 3, Jul-Sep 2011 271
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Chaubal and Dixit: Ankyloglossia
be speculated that some milder forms of ankyloglossia may
resolve with growth, explaining this age-related difference.
There is some evidence that ankyloglossia can be a genetically
transmissible pathology. It is unknown which genetic
components regulate the phenotype and penetrance in the
patients affected. More basic research is needed to clarify the
exact etiopathogenesis of ankyloglossia. Ankyloglossia was
also found associated in cases with some rare syndromes such
as X-linked cleft palate syndrome,[6] Kindler syndrome,[7] van
der Woude syndrome,[8] and Opitz syndrome.[9] Nevertheless,
most ankyloglossias are observed in persons without any
other congenital anomalies or diseases. Speech problems can
occur when there is limited mobility of the tongue due to
ankyloglossia. The difficulties in articulation are evident for
consonants and sounds like s, z, t, d, l, j, zh, ch, th, dg[10]
and it is especially difficult to roll an r. Localization of the
frenum insertion on the gingiva seemed to be of importance
for gingival sequelae because insertion of the lingual frenulum
in the area of the papilla had the highest association with
gingival recession. The term free-tongue is defined as the
length of tongue from the insertion of the lingual frenum
into the base of the tongue to the tip of the tongue. Clinically
acceptable, normal range of free tongue is greater than 16mm.
The ankyloglossia can be classified into 4 classes based on
Kotlows assessment as follows; Class I: Mild ankyloglossia:
12 to 16mm, Class II: Moderate ankyloglossia: 8 to 11mm,
Class III: Severe ankyloglossia: 3 to 7mm, Class IV: Complete
ankyloglossia: Less than 3mm.[2] Class III and IV tongue-tie
category should be given special consideration because they
severely restrict the tongues movement. A normal range of
motion of the tongue is indicated by the following criteria:
The tip of the tongue should be able to protrude outside the
mouth; without clefting, the tip of the tongue should be able
to sweep the upper and lower lips easily; without straining,
when the tongue is retruded, it should not blanch the tissues
lingual to the anterior teeth; and the lingual frenum should
not create a diastema between the mandibular central incisors.
Ankyloglossia limits the tongues range of motion. Because of
limited mobility of the tongue in patients with ankyloglossia,
the tongue is in a low position and causes forward and
downward pressure favoring the development of mandibular
prognathism with maxillary hypo development. The above
mentioned hypothesis that ankyloglossia leads to altered
development of the jaws is mainly based on single observation
and speculative interpretations and there is limited evidence
that tongue-tie represents a co-factor in the development of
malocclusions, especially Class III malocclusion. More studies,
especially controlled clinical trials, are needed to establish a
clear correlation between malocclusion and ankyloglossia. If
there is no feeding difficulty in the infant, it would be best to
have a wait-and-see approach since the frenulum naturally
recedes during the process of an individuals growth between
six months and six years of age. After completion of growth and
272 Journal of Indian Society of Periodontology - Vol 15, Issue 3, Jul-Sep 2011
also during infancy, if the individuals have a history of speech,
feeding, or mechanical/social difficulties surgical intervention
should be carried out. Therefore, surgery should be considered
at any age depending on the patients history of speech, feeding,
or mechanical/social difficulties. Surgical techniques for the
therapy of tongue-ties can be classified into three procedures.
Frenotomy is a simple cutting of the frenulum. Frenectomy
is defined as complete excision, i.e., removal of the whole
frenulum. Frenuloplasty involves various methods to release
the tongue-tie and correct the anatomic situation. There is
no sufficient evidence in the literature concerning surgical
treatment options for ankyloglossia to favor any one of the
three main techniques.
CONCLUSION
To conclude, it is important to agree upon one examination
method, definition and classification of tongue-ties to enable
comparisons between future observational and intervention
studies. If severe/complete ankyloglossia is present in an
adult, there is usually an obvious limitation of the tongue
protrusion, elevation and speech problems which can be
improved following surgical intervention.
REFERENCES
1. Wallace AF. Tongue tie. Lancet 1963;2:377-8.
2. Kotlow LA. Ankyloglossia (tongue-tie): A diagnostic and
treatment quandary. Quintessence Intl 1999;30:259-62.
3. Ayer FJ, Hilton LM. Treatment of ankyloglossia: Report of a case.
ASDC J Dent Child. 1977;44:69-71.
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incidence, and effect of frenuloplasty on the breastfeeding dyad.
Pediatrics 2002;110: e63.
5. Garca PMJ, Gonzlez GM, Garca MJM, Gallas M, Seoane Lestn
J. A study of pathology associated with short lingual frenum.
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6. Moore GE, Ivens A, Chambers J, Farrall M, Williamson R, Page
DC, et al. Linkage of an X-chromosome cleft palate gene. Nature
1987;326:91-2.
7. Hacham-Zadeh S, Garfunkel AA. Kindler syndrome in two related
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8. Burdick AB, Ma LA, Dai ZH, Gao NN. Van der Woude syndrome
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9. Brooks JK, Leonard CO, Coccaro PJ Jr. Opitz (BBB/G) syndrome:
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How to cite this article: Chaubal TV, Dixit MB. Ankyloglossia and
its management. J Indian Soc Periodontol 2011;15:270-2.
Source of Support: Nil, Conflict of Interest: None declared.