Ankyloglossia with Phonetic Disorders: From Diagnosis to Treatment about a Clinical Case Report

The lingual frenulum recedes as a natural process of the child’s growth and development that occurs during the first 6 months to 6 years of life [1]. A short lingual frenulum will limit the movements of the tongue and cause a tongue-tie. This is reflected externally by a more or less forked tongue at protraction, and an inability to stick the tip of the tongue to the palate [2,3]. Ankylossia, or tongue tie, can be observed in neonates, children, or adults [4,5].

Several studies establish diagnostic criteria based on the length of the lingual frenulum [6,7], amplitude of tongue movement [8], heart-shaped look when the tongue is protruded and thickness of the fibrous membrane [9].

The severity of ankyloglossia varies from an absence of clinical significance to a completely fixed tongue to the floor of the mouth. The clinical consequences of ankyloglossia include difficulties during infant feeding and swallowing, speech problems, orthodontic and orthopedic anomalies, and social problems [10,11].

The main indication of frenectomy is connected with the suction-swallowing disorders having an anatomical impact. Correction of an alveolar protrusion or a gap is achievable by current orthodontic means, but the stability of these results will be challenged by the lingual dysfunction [12]. A myotherapy of the tongue is absolutely necessary immediately after the procedure. The obtained physiological mobility shall restore a physiological tongue posture during all mandibular praxis [13]. Here we report a case of ankyloglossia with phonetic disorders, which was successfully treated by surgical excision and speech therapy sessions.

7-year-old male child was reported in the department of Pediatric Dentistry at Mohamed V Military Hospital of Rabat (Morocco), with difficulty in speech since birth. Familial, medical and dental history was noncontributory. On intraoral examination, it was found that the child had ankyloglossia (short frenulum with restricted tongue movements). A bifid or heart shape of the anterior tip of the tongue was seen upon attempted extension (Figure 1). There were no malocclusion and recession present lingual to mandibular incisors (Figure 2).

Figure 1:Intraoral view: A normal occlusion.

Figure 2:Intraoral view: Severe ankyloglossia, with a bifid aspect of the tongue.

The patient was diagnosed as having severe ankyloglossia (class III) according to the classification given by Ruffoli et al. [13]. This ankyloglossia has caused the phonation disorders, frenectomy is the therapy of choice in this case. After obtaining informed consent, topical anesthetic was applied to the underside of the tongue and local anesthetic infiltration was administered in to the frenum area. After anesthesia was found to be effective, a haemostat was used to clamp the frenum, and the frenum was surgically released along the sides of the haemostat (Figure 3) followed by a detachment of the mucosa and disinsertion of the fibers (Figure 3). The margins of the incision were sutured with 3-0 silk suture (Figure 4).

Figure 3:Horizontal incision and detachment of the mucosa and disinsertion of the fibers.

Figure 4:Sutures.

Postsurgical instructions were given, 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 nonsteroidal anti-inflammatory drug Tab. Ketorolac DT (10mg) thrice a day for 3 days was prescribed to prevent post-operative infection and pain.

The sutures were removed after two weeks following the procedure. This therapy allows the release of lingual movements after rehabilitation sessions (Figure 5). The routine follow-up for 8 weeks showed an extremely satisfied patient with improved tongue protrusion several mm beyond the lower lip and normal speech.

Figure 5:Intraoral view: liberation of the tongue.

Etymologically, “Ankyloglossia” originates from the Greek words “ankilos” (curved) and “glossa” (tongue). The English synonym is “tongue-tie”. The first use of the term ankyloglossia in medical literature dates back to the 1960s, when Wallace defined tongue-tie as “a condition in which the tip of the tongue cannot be protruded beyond the lower incisor teeth because of a short frenulum linguae, often containing scar tissue” [14].

Ankyloglossia may occur in infants, children or adults. The exact incidence of ankyloglossia is unknown. Figures reported in literature vary, ranging from 2% to 5% [15]. This variation in reported incidence may be attributed in part to the lack of uniform definition and objective grading system of tongue-tie. Also, some of the variations may reflect age related differences, as some cases are postulated to resolve spontaneously with age [16]. The embryonic mechanism of ankyloglossia is still under investigation. Studies in humans and knock-out animal models concluded that ankyloglossia may result from mutations in T-box genes or exposure to teratogenic substances during pregnancy [17].

Its early detection is provided in maternity wards because of induced lactation disorders, or later by pediatric dentists, orthodontists, speech therapists and finally by general dentists [18]. A procedure called a frenectomy is performed to eliminate the restrictions of both the tongue and the tethered attachments extending into the muco-periosteal insertion and the alveolar process. Eliminating this “tie” increases mobility and improves function, provided it is followed by tongue rehabilitation [18]. Patients should be asked to pronounce certain words which start from “I,” “th,” “s,” “d,” and “t” to check the accuracy of the word pronunciations. If a defective speech is observed, after postoperative wound healing, referral to a speech therapist is mandatory for speech modification.

Postoperative tongue muscle exercises like licking the upper lip, touching hard palate with the tip of tongue, and side to- side movements should be explained to the patient for enhanced tongue movements [19]. In our case, the indication of frenectomy is due to phonation disorders. This procedure was followed by lingual rehabilitation and speech therapy [20].

A thorough intraoral exam should be performed on the infant. Inspection of the tongue and its function should be part of the routine first dental visit. Parents should be advised regarding the presence and severity of ankyloglossia. 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. Resection of the lingual frenulum is a simple procedure that restores the normal functions of the tongue associated with lingual rehabilitation and speech therapy.

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