Management of ankyloglossia in a six-year-old child after cleft lip and palate surgery: about a case

Ankyloglossia or tongue is caused by an excessively short and thick lingual frenulum that limits the normal movements and functions of the tongue. Its prevalence is higher in infants than in children and adults. In this case, a six-year-old boy came with his parents with a chief complaint of slurred speech. His medical history revealed that he had a congenital cleft lip and cleft palate, for which he underwent surgery shortly after birth. He was classified by the Kotlow classification in class II (moderate ankyloglossia). Under local anesthesia, diode laser surgery was planned to treat the tongue tie. The patient showed excellent healing after one week of follow-up. An increase in tongue movements was noted and the patient was referred to a speech therapist.

Introduction

Tongue tie, also known as ankyloglossia, is a birth defect marked by a small lingual frenulum that can limit tongue movement and negatively affect function. [1]. Ankyloglossia derives from the Greek words “agkilos” (curved) and “glossa” (tongue). Ankyloglossia is the inability of the tip of the tongue to stick out due to a small lingual frenulum [2].

The tongue muscle is the only organ in the body with one end attached and the other free. [3]. Ankyloglossia affects 0.1% to 10.7% of the population. According to reports, neonates have a higher prevalence (1.72%-10.7%) than children, adolescents or adults (0.1%-2.08%). [4]. A male to female ratio of ankyloglossia is 2.5:1. The anomaly appears to be more common in males for unspecified reasons [5]. Some rare syndromes, such as van der Woude syndrome, Opitz syndrome, and X-linked cleft palate syndrome, are associated with tongue tie [3].

According to the Kotlow classification of ankyloglossia [6], we note that ankyloglossia can be one of the following four types depending on the clinically visible free tongue: Class I – Mild ankyloglossia with a clinically visible free tongue of 12 to 16 mm. Class II – Moderate ankyloglossia with free tongue 8-11 mm. Class III – Severe ankyloglossia with free tongue 3 to 7 mm. Class IV – Complete ankyloglossia.

Presentation of the case

A six-year-old child presented to pediatric and preventive dentistry with speech and pronunciation difficulties as his chief complaint. His medical history revealed that he had congenital cleft lip and cleft palate, for which he underwent surgery immediately after birth. On intraoral examination, the patient had secondary fistula formation in the palate and a thick lower lingual frenulum attached 8 mm from the tip of the tongue (Figure 1).

Restricted tongue movements have been noted, including protrusion, sideways movements, and an inability to touch the palate with the tip of the tongue. The child was classified according to the Kotlow classification as having class II or moderate ankyloglossia.

A lingual frenectomy was planned using a diode laser set at 980 nm in continuous mode at 1.8 Watts (W). For local anesthesia, a cartridge containing 2% lidocaine with 1/80,000 epinephrine was used. Operator and child received appropriate eye protection and care. The lingual frenulum was dissected after immobilization of the tip of the tongue. Densely integrated muscle fibers have been detached from the floor of the mouth to allow sufficient and proper tongue movement (Figure 2).

After surgery, sutures were made (Figure 3), and the child was recalled after a week. There was no delay in bleeding and the site healed satisfactorily after one week (Figure 4).

Discussion

Specific speech disorders are caused in some children by ankyloglossia, whether partial or complete. Interference with articulation is consistent with our scenario although it does not delay or prevent onset of speech [7]. Some sounds in the language, such as “t”, “d”, “l”, “th”, and “s”, are difficult to pronounce. Improper chewing and swallowing of food in children with a tongue tie can increase the risk of stomach distress and bloating, bedwetting, and snoring while they sleep. [8].

According to Lamba et al. [9], the management of ankyloglossia depends on the location, the severity of the tongue mobility restriction and the associated functional restrictions in addition to the patient’s age. Kara et al. [10] and Adelaimi and Mahmood [11] reported that using a surgical laser instead of a scalpel or blade is an excellent and reliable choice for pediatric frenectomies. Therefore, in the present case, instead of scalpel or blade, diode laser was preferred for surgery.

Diode lasers have an easy-to-use beam delivery technology that uses a flexible fiber optic handpiece. The laser is strongly absorbed by hemoglobin and weakly absorbed by water. Diode lasers can effectively seal capillaries by causing protein denaturation and activating clotting factor VII (stable factor) synthesis. Additionally, these lasers have antimicrobial qualities and are recommended for soft tissue oral procedures with minimal bleeding near dental structures. Water cooling is essential as they can rapidly increase in temperature if applied for an extended period to irradiated tissue [12]. In our case, laser surgery was chosen to cut the tissue and preserve it as much as possible to avoid scarring of the tongue. The laser leads to faster and safer healing. It also helps to minimize postoperative bleeding.

In cases of cleft palate with ankyloglossia (CPX), expression of the TBX22 (transcription factor T-box) gene is evident in the palatal plates, where it is prominent before being elevated to a horizontal position above the palate. language. Additionally, TBX22 mRNA was found near the frenulum at the base of the tongue, which is where ankyloglossia is present in CPX patients. [13]. in the present case, there was a history of cleft lip and palate with ankyloglossia, possibly associated with the TBX22 gene. After surgical correction of the tongue tie, the patient was referred for speech articulation to a speech therapist.

conclusion

Depending on the degree of lingual adhesion, ankyloglossia that can lead to oral problems can be easily corrected with frenectomy. Many children with ankyloglossia may not express discomfort with the difficulties it causes. Therefore, it is crucial to provide counseling to the patient or parent so that newborns and children can receive the right care at the right time. Compared to conventional scalpel/blade methods, lingual frenectomy as a management treatment for ankyloglossia, via laser surgery, offers a better outcome for both the young patient and the pediatric dental professional. However, after surgical repair, the patient should be referred to a speech therapist.

Christine E. Phillips