Volume 39, Issue 11 , Pages 1130-1132, November 2010
Surgical treatment of ankyloglossia in babies—case report
Article Outline
Abstract
Ankyloglossia is an anomaly that is characterized by the abnormal insertion of the lingual frenulum that hinders protrusion and elevation of the tongue towards the palate, due to the short and thick composition of the frenulum. In babies it can cause inefficient nursing at the mother's breast, inadequate transfer of milk and pain in the mother's breast, resulting in early weaning and weight loss. An 8-month-old baby boy was brought to the clinic by his mother because he found it difficult to suck and consequently avoiding breast feeding, and was apparently losing weight. During the clinical exam it was observed that the patient presented little mobility of the tongue. Owing to the degree of ankyloglossia and the features of malnutrition present, it was decided to carry out complete removal of the frenulum under general anesthesia. Although this procedure might increase the risk of morbidity, the possibility of recurrence and the need to perform further procedures are avoided; the main advantage is reducing aggravation of the clinical problems.
Keywords: ankyloglossia, frenectomy, general anesthesia
Ankyloglossia is an oral anomaly characterized by the abnormal insertion of the lingual frenulum, which compresses the mucosa, dense connective tissue, and occasionally, superior fibers of the genioglossus muscle. In this case, protrusion and elevation of tongue in the direction of the palate was hindered by the tension on the short frenulum8. This pathology, diagnosed at birth, can persist until late childhood or even adulthood, and presents different patterns of insertion from the tip of the tongue to the lingual alveolar ridge4.
The prevalence of ankyloglossia described in the literature ranges between 0.1% and 10.7%1, 4. The main reason for this wide variation is the lack of definition among researchers when making diagnosing ankyloglossia. In observational epidemiologic studies of oral mucosa in general, the prevalence of ankyloglossia is generally lower (0.1–4%) than in studies related only to the prevalence of ankyloglossia (4–11%). The prevalence is also higher in studies that investigate newborns (2–11%) compared with studies reporting on children and adults (0.1–2%)3.
There are asymptomatic cases of this abnormality, but disorders of language development can be noted, as a result of limitation of tongue tip movement9, as well as mandibular development alterations, affecting facial development and dental treatment7. Ankyloglossia in infants is associated with a 25–60% incidence of difficulty with breastfeeding, such as failure to thrive, maternal nipple damage, maternal breast pain, poor milk supply, breast engorgement, and refusing the breast1, 4, 8. These symptoms have been associated with ankyloglossia, so it should be considered a contributing factor when assessing women with breastfeeding difficulties. Infants with restrictive ankyloglossia cannot extend their tongues over the lower gum line to form a proper seal and must use their jaws to keep the breast in the mouth1, 8. In infants with ankyloglossia, this deficiency might require surgical correction9.
Ankyloglossia can be diagnosed using the following criteria: impossibility of touching palate with tongue tip when the mouth is open; bifid tongue during protrusion; curvature of the intermediate part of the tongue, preventing it from moving forward out of the oral cavity; and reduced sublingual space7, 10.
The treatment options for ankyloglossia involve observation, language articulation therapy and three possible surgical techniques: frenotomy, which consists of simply cutting the frenulum; frenectomy, complete excision of the frenulum; and frenuloplasty, which involves freeing the tongue and correcting its anatomy3, 7, 10. Depending on the consequences of the abnormality, radical and urgent treatment may be required.
Case report
An 8-month-old boy was brought in by his mother, who related the baby's inability to generate and maintain suction during breast or bottle feeding, rejecting the bottle when it was offered. She also reported painful breastfeeding and the baby's weight loss.
During the initial clinical examination poor tongue mobility was observed, especially when attempting to elevate the tongue (Fig. 1). The severity was defined using the Hazelbaker Lingual Assessment Tool for Lingual Frenulum Function5, which was developed to evaluate the severity of ankyloglossia in newborns, and is recommended by the Academy of Breastfeeding Medicine as a method of evaluating ankyloglossia. The method is based on appearance (five items) and functional aspects (seven items) and uses a score system to classify the tongue into three categories: functionally compromised, acceptable or perfect. The items related to appearance are: the appearance of the tongue when it is raised, elasticity of the lingual frenulum, length of the frenulum when the tongue is raised, fixation of the lingual frenulum and tongue, and fixation of the frenulum to the inferior crest. The items evaluated regarding function are: lateralization, tongue elevation, tongue extension, anterior spread of the tongue, peristaltism and snapback. Each item has a score: significant ankyloglossia is defined as a function of the score (0, 1 or 2) according to the characteristics of the tongue. A tongue with a score of 14 (irrespective of the item appearance) is classified as perfect. A score of 11 is considered acceptable. A score under 11 characterizes a functionally compromised tongue. A score below 8 determines the need for surgical treatment. Examination gave this baby a score of 7 determining a functionally compromised tongue in of surgical intervention. Oral and maxillofacial surgeons and anesthesiologists planned the treatment in conjunction with a specialist in pediatric dentistry. Owing to the degree of ankyloglossia present, complete removal of the frenulum with muscle dissection, performed under general anesthesia was chosen.
Fig. 1.
Infant's tongue movement is restricted by an abnormal lingual frenulum.
After evaluation by the pediatrician and anesthesiologist, the patient underwent general anesthesia, followed by local infiltration of 0.9
ml of 4% articaine with 1:200,000. A 5-0 simple catgut suture thread placed in an atraumatic needle was used to immobilize the tongue in its position. This thread was passed through the tongue tip and fixed with Halsted forceps. This surgical instrument was used to provide tongue traction and facilitate the surgical procedures. Resection of the lingual frenulum was performed with a No. 15 surgical scalpel fitted to a No. 3 handle. A pair of Metzenbaum scissors was used to perform muscle dissection until normal tongue mobility for an 8-month-old infant was achieved. The surgical wound was sutured with 5-0 simple catgut.. Immediately after surgery it was noted that tissue mobility had been re-established (Fig. 2).
Fig. 2.
Clinical photograph taken after surgery. Note that proper tissue mobility is achieved immediately after surgery.
The patient was discharged on the same day and his mother was instructed to encourage him to suck in order to exercise the tongue.
At the 1 week follow-up, the baby's mother reported that he had no postoperative complaints and his ability to suck had improved. 30 days after surgery, the patient showed movement and strength consistent with his age, and had no difficulty with breastfeeding.
Discussion
Ankyloglossia is the most frequent developmental abnormality of the tongue, occurring in 0.2–20% of patients1. There are various consequences of this abnormality, ranging from a mild reduction in tongue movement to a mandibular growth deficiency. In breastfed infants it can cause poor sucking at the breast, inadequate transfer of milk and make the mother's nipples painful, resulting in early weaning4, 6, and weight loss in the baby. Marmet et al.8 confirmed that a short lingual frenulum prevents the normal movements of breastfeeding, because it is impossible for the baby to compress the mother's breast, resulting in regurgitation, and in extreme cases, inanition, because the movements required for sucking are inhibited.
Depending on the consequences of the abnormality, early treatment is essential and radical measures must be taken. Although frenotomy is a more conservative procedure, it offers the undesirable possibility of fibers becoming reattached, requiring complementary procedures to release the tongue satisfactorily, such as section of superficial genioglossus muscle fibers, dissection of the lateral edge of the incision and gingivectomy. Frenectomy is a more invasive procedure and more difficult to perform in very young children, in an ambulatory environment, but its results are more predictable, decreasing the recurrence rate7. Berg2 reported that frenectomy is normally performed in 1–3-year-old children, under general anesthesia, in most cases. It should be performed as soon as possible, because if performed later, the child might have incorrect swallowing and disturbed speech muscle movement patterns. There are no conclusive parameters about the age for performing the surgical technique in the literature9. Randomized clinical trials, prospective studies and long-term follow-up studies are necessary to determine the optimum age for surgery.
In situations in which the newborn presents difficulty with breastfeeding associated with weight loss, frenectomy is the treatment option, and must be performed as quickly as possible to prevent conditions of malnutrition or problems with physical and/or motor development. The main treatment options for ankyloglossia are frenectomy and frenotomy, but because of the limited quantity and quality of available data it is impossible to determine the best surgical treatment and ideal age for therapy10.
In conclusion, this study describes the case of a baby with ankyloglossia who had started to reject breastfeeding and had lost weight; a typical situation for the indication of a radical treatment such as frenectomy, even though it needs to be performed under general anesthesia.
Funding
None.
Competing interests
None declared.
Ethical approval
Not required.
References
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PII: S0901-5027(10)00282-1
doi:10.1016/j.ijom.2010.06.007
© 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Volume 39, Issue 11 , Pages 1130-1132, November 2010
