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Authors : Dr. Adil Gandevivala .

Abstract:

Frenum is a fold of tissue or muscle connecting the lips, cheek, or tongue to the jawbone. It is also known as frenulum,frenulums, frenula, frenums, or frena. Ankyloglossia, commonly known as tongue tie, is a congenital anomaly characterizedby an abnormally short/tight lingual frenulum, which restricts mobility of the tongue tip.

Though the ankyloglossia or tonguetie is not a serious manifestation, it may lead to a host of problems including infant feeding difficulties, speech disorders, andvarious mechanical and social issues related to the inability of the tongue to protrude. Lingual frenectomy is advised for themanagement of ankyloglossia. The present paper discusses one case of successful management of ankyloglossia or tongue tiewith Four-Flap Z-Frenuloplastytechnique.

Introduction:

Wollance defined tongue -tie as “a condition in which thetip of the tongue cannot be protruded beyond the lowerincisor because of short lingual frenum.1 The term Ankyloglossia originates from the Greek word “Agkilos” (curved)and “glossa” (tongue).2

The ankyloglossia can be classified into four classes based on Kotlow’s assessment as follows: Class I, mild ankyloglossia 12-16 mm; class II, moderate ankyloglossia 8-11 mm; class III, severe ankyloglossia 3-7 mm; and class IV, complete ankyloglossia <3 mm.3 Ankyloglossia can affect feeding, oral hygiene as well as some mechanical/social effects.

Case Report:

A 26 year old male reported to our department with a complain of difficulty in speech and protrusion of tongue since birth. He had undergone a surgical treatment for the same 1 year ago but since 2-3 months complains of difficulty in speech. On intraoral examination , it was found that the individual had some degree of ankyloglossia , there was no malocclusion and recession present lingual to mandibular incisors. Given the possibility of post treatment scarring and recurrence of the ankyloglossia following the first surgery surgical correction of the ankyloglossia, treatment was planned with four-flap Z-frenuloplasty, so as to minimize contracture from scar tissue and increase the length of the frenum.

The patient wasplaced supine and a midline 2-0 silk suture was placed to retract the tongue, with the tongue tip elevated for maximum exposure and tension on the frenulum. The vertical midline was marked with a marker from the connections of the frenulum to the tongue, to the alveolus.The lateral lines were marked as 90 degrees at the superior and the inferior margins of the vertical line on alternate sides, with 45 degrees division to each of these angles. These flaps are 1-1.2 times the length of the frenulum.

After anesthetizing the frenulum and the ventral surface of the tongue, the incisions were made along the lines through the mucosa and the flaps were developed bluntly.Any submucosal connective tissue within the frenulum wasdivided, and the flaps were rotated from an “ABCD” configuration to a “CADB” configuration and sutured into place with interrupted 4-0 Vicryl sutures. Post operatively patient showed improvement in speech, frenulum length and tongue protrusion gained.
 
 


Discussion:

Ankyloglossia is an uncommon congenital oral anomaly that can cause difficulty with breastfeeding, speech articulation.3 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.

Surgical techniques for the therapy of tongue-ties can be classified into three procedures.4 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 favour any one of the three main techniques. 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 tonguetie so that they may make an informed choice regarding possible therapy.3,5

Conclusion:

Overall the Z-Frenuloplasty procedure is considered to be safe, cost effective and results in better functional and aesthetic appearance. This procedure allows for tissue healing by primary intentions; increasing recovery and reducing the risk of tissue contractures.6 Four-Flap Z-Frenuloplasty is an excellent technique specially in cases of post treatment scarring and recurrence of the ankyloglossia.7 However due to the limited evidence currently available on this procedure, further research is proposed in the field to compare the different surgical frenectomy procedures.

References:
  1. WallaceAF.Tonguetie.Lancet1963;2:377-78.
  2. Suter VGA, Bornstein MM. Ankyloglossia: Facts and MythsinDiagnosis and Treatment. JPeriodontol 2009;80: 1204-19.
  3. Kotlow L. Ankyloglossia (tongue‑tie): A diagnostic and treatment quandary. Quintessence Int 1999;30:259‑62.
  4. ChaubalTV, Dixit B.Ankyloglossia and itsmanagement. J IndianSocPeriodontol2011Jul;15(3):270-72.
  5. Ayer FJ, Hilton LM. Treatment of ankyloglossia: Report of a case. ASDC J Dent Child. 1977;44:69-71.
  6. Suter VG, Bornstein MM (2009) Ankyloglossia: facts and myths in diagnosis and treatment. J Periodontol 80(8): 1204-1219.
  7. Aaron R,Michele M. Surgical Treatment of ankyloglossia.Operative TechniquesinOtolaryngology(2015)26,28–32.

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