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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2010  |  Volume : 28  |  Issue : 2  |  Page : 130-133
 

Monopolar diathermy used for correction of ankyloglossia


1 Assistant professor, Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Sundernagar, District Mandi, Himachal Pradesh-175002, India
2 Assistant professor Department of Periodontics, Himachal Dental College, Sundernagar, District Mandi, Himachal Pradesh-175002, India

Date of Web Publication24-Jul-2010

Correspondence Address:
A Tuli
Assistant professor, Department of Pedodontics & Preventive Dentistry, Himachal Dental College, Sundernagar, District Mandi, Himachal Pradesh-175 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.66757

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   Abstract 

Tongue tie, also known as ankyloglossia or ankyloglossia inferior, is a relatively common finding in pediatric surgical outpatient clinics. It occurs as a result of a short, tight, lingual frenum causing tethering of the tongue tip. It is a common oral finding in infants and children, which is often neglected. Although most cases resolve or are asymptomatic, some patients develop articulation problems and other concerns related to poor tongue-tip mobility. In this article, we report on a 5-year old girl with a tongue tie, who underwent frenectomy using monopolar diathermy under local anesthesia without any postoperative complication.


Keywords: Ankyloglossia, frenectomy, monopolar diathermy


How to cite this article:
Tuli A, Singh A. Monopolar diathermy used for correction of ankyloglossia. J Indian Soc Pedod Prev Dent 2010;28:130-3

How to cite this URL:
Tuli A, Singh A. Monopolar diathermy used for correction of ankyloglossia. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2019 Dec 6];28:130-3. Available from: http://www.jisppd.com/text.asp?2010/28/2/130/66757



   Introduction Top


Congenital oral adhesions may pose both esthetic and functional disturbing ailments to children. Most of them are benign, easily cured and may be treated as soon as possible in the dental office. [1] The tongue being an important oral structure affects speech, position of teeth, periodontal tissue, swallowing and nutrition. [2] Ankyloglossia, or tongue tie, is an uncommon congenital oral anomaly characterized by an abnormally short lingual frenum which may restrict tongue-tip mobility and may subsequently lead to a range of problems such as difficulties in breastfeeding during infancy, inability to chew age-appropriate solid foods, speech impediments, poor oral hygiene, behavior problems, and being embarrassed by peers during childhood and adolescence. [3]

Epidemiology

It is very difficult to assess the actual incidence because of a wide spectrum of its presentation ranging from very thin band to fully developed ankyloglossia. According to Lalakea and Messner, [4] incidence figures reported in literature vary from 2 to 4.8%. Tongue tie occurs more commonly in males with a male to female ratio of 3 to1 and shows no racial predilection. Ankyloglossia may occur in conjunction with various syndromes like Pierre Robin syndrome, Opitz syndrome and Orodigitofacial syndrome. [3],[5]

Clinical features and diagnosis

Tongue tie can vary from a thin elastic membrane to a thickened, white nonelastic tissue. Dealing with a variety of solid foods of different textures during childhood may also prove difficult. Habitual gagging, coughing, choking or vomiting is frequently caused by inadequate tongue mobility and coordination while eating. Such children often continue to be slow picky eaters or fast untidy eaters who chew inadequately, prefer soft foods or suffer the results of aerophagia - swallowing air while they eat. [3] Speech problems may occur which are difficult to correct by conventional means because they cannot memorize the correct movements of speech or be sure of always achieving them. Salivary profusion due to inadequate coordination of swallowing during speech becomes both visually and auditorily obvious. Habits of mouth breathing and forward tongue position become entrenched, and are easily noticed and less excused in the teenager or adult person. [3]

The cumulative effect of these barriers in the way of normal development often has negative repercussions on self-esteem and confidence, and emotional or behavioral problems soon follow, complicating the diagnosis, especially in children. [6] Lactation consultants may use the Hazelbaker Assessment tool for Lingual Frenulum Function [7] or rely on their judgment of appearance and any sucking problems experienced. Checking for speech impediments at the age of 3 years may also help in the diagnosis, as the child may have difficulty pronouncing the following sounds: d, l, n, r, s, sh, t, th and z. [6]

There is a wide difference of opinion regarding its clinical significance and optimal management. In many children, ankyloglossia is asymptomatic; the condition may resolve spontaneously, or affected children may learn to compensate adequately for their decreased lingual mobility. Some children, however, benefit from surgical intervention for their tongue tie. [2] Parents should be educated about the possible long-term effects of tongue tie so that they may make an informed choice regarding possible therapy. [1],[4] Some surgeons perform the division exclusively in the operating room under general anesthesia, [8] whereas some divide it as an outpatient procedure without anesthesia in small infants. [9]

There are four surgical interventions available, i.e., snipping the frenum (sometimes referred to as 'frenotomy') of neonates, surgical revision of the frenum (sometimes referred to as 'frenectomy', 'frenulectomy' or 'frenuloplasty') under a general anesthetic at or after 6 months of age, revision of the frenum by laser without a general anesthetic and/or revision by electrocautery or monopolar diathermy using a local anesthetic. [2],[4],[10],[11]


   Case Report Top


A 5-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry Subharti Dental College and Hospital, Meerut with the chief complaint of improper speech, i.e., her parents reported that she was not able to speak clearly and was unable to chew age-appropriate solid foods. Oral examination revealed mild to moderate ankyloglossia, thick and short frenulum and restricted tongue protrusion and lifting of the tip of the tongue. A bifid or heart shape of the anterior tip of the tongue was seen upon attempted extension [Figure 1]. To assess the extent of limitation of tongue movement, the mouth was carefully inspected under adequate illumination with a tongue depressor. Upon diagnosis of a tongue tie, the patients' parents were informed of the nature of the lesion, its functional implications and the variety of surgical approaches. The patient's family and medical history were non-contributory. Her height and weight were appropriate for her age. ENT and general physical examination revealed insignificant findings. Hematologic examination of the patient revealed normal findings. After obtaining informed consent, topical anaesthesia was administered followed by local anaesthesia. Topical anaesthetic was applied to the underside of the tongue and local infiltration was administered into the frenum area. There were no incidents of major or minor haemorrhage from the hyfrecation site. The only sites of bleeding were those of the needle puncture resulting from the anaesthetic needle. These were treated by local pressure. After anaesthesia was found to be effective, a haemostat was used to clamp the frenum, and after wiping away excess saliva by gauze pads, monopolar diathermy was used to release the frenum. This phase was very short but demanded rigorous caution not to damage the buccal mucosa or lips. Bleeding occurring during the procedure was controlled by electrocautery. After release of the lingual frenum, sutures were done with 3-0 mersilk [Figure 2]. The favourable outcome of the procedure was apparent immediately and the extent of release could be assessed during the intervention itself. The patient was discharged with postoperative instructions and was asked to treat discomfort with non-narcotic analgesics. When compared to other methods used for frenectomy, electrosurgical method has a better result regarding postoperative homeostasis.The patient was recalled for oral check-up and removal of sutures after a week. There were no reports of unexpected irritability after the procedure. The patient and her parents were satisfied with the results of the frenectomy. The postoperative period was uneventful. The routine follow-up at 1 week showed slight inflammation below the tongue [Figure 3]. After a month post-operatively normal tongue protrusion and normal speech was observed [Figure 4].


   Discussion Top


Ankyloglossia (tongue tie) limits the range of motion of the tongue, impairing its ability to fulfill its functions like speech, the position of teeth, swallowing, nursing and certain social activities [2] Newborns with tongue tie are often diagnosed and treated by paediatricians. Problems and surgical indications are mostly nutritional. Speech and articulation problems were by far the most common indications especially in preschool children. [12],[13] The effect of ankyloglossia on speech remains controversial. While some authors [14] in the literature have advocated repair in infancy and prior to the development of speech, others [15] advocate waiting until a speech problem is manifested, usually after the age of 4 years. Unfortunately, there is no method for predicting which patients with tongue tie are likely to become symptomatic and this complicates decision-making regarding surgical timing. Early operation on all patients may be unwarranted, but delay until the onset of symptoms may unnecessarily commit some patients to a period of rehabilitative speech therapy or social embarrassment. Revision by electrocautery does not require general anaesthesia and can be performed as an outpatient service with local anaesthetic. It is an economical and safe option in other forms of minor surgery [16] and can be used to revise mild tongue tie in paediatric patients.


   Conclusion Top


Optimal management of tongue tie including timely and appropriate surgical intervention, followed by speech therapy when indicated, has the capacity to deliver pleasing results, often in a shorter time than expected. It is being so increasingly accepted by disciplines associated with infants, children and adults with tongue tie that there is now no place for 'wait and see' policies when the frenum has been identified and diagnosed as abnormal, and early intervention is the optimal form of management. The correction of ankyloglossia at an early age reduces the risk of latent complications. In addition, the early correction will mitigate the feeding- and speech-related concerns of parents and doctors alike. Electrocautery is safe and can be performed easily in the dental office. Operative and postoperative bleeding with electrocautery is significantly less than conventional surgery. Office-based electrocautery dissection is an efficacious, economical and safe treatment for mild congenital oral adhesions. We, as pedodontists, can cause minimum pain and receive maximum smiles this way.

 
   References Top

1.Naimer SA, Biton A, Vardy D, Zvulunov A. Office treatment of congenital ankyloglossia. Med Sci Monit 2003;9:CR432-5.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Kotlow LA. Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Quintessence Int 1999;30:259-62.   Back to cited text no. 2  [PUBMED]    
3.Lalakea ML, Messner AH. Ankyloglossia: Does it matter? Pediatric Clin North Am 2003;50:381-97.  Back to cited text no. 3      
4.Messner AH, Lalakea ML. Ankyloglossia: Controversies in management. Int J Pediatr Otorhinolaryngol 2000;54:123-31.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Hall DM, Renfrew MJ. Perspectives on tongue tie. Arch Dis Child 2005;90:1211-5.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF): Use in a lactation consultant private practice. Thesis. Pasadena, Calif: Pacific Oaks College; 1993.  Back to cited text no. 6      
7.Wright JE. Tongue-tie. J Pediatr Child Health 1995;31:276-8.  Back to cited text no. 7      
8.Wallace H, Clarke S. Tongues tie division in infants with breast feeding difficulties. Int J Pediatr Otorhinolaryngol 2006;70:1257-61.   Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Warden PJ. Ankyloglossia: A review of the literature. Gen Dent 1991;39:252-6.  Back to cited text no. 9  [PUBMED]    
10.Velanovich V. The transverse-vertical frenuloplasty for ankyloglossia. Mil Med 1994;159:714-5.  Back to cited text no. 10  [PUBMED]    
11.Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Pediatric Child Health 2005;41:246-50.  Back to cited text no. 11      
12.Klockars T, Pitkaranta A. Familial ankyloglossia. Int J Pediatr Otorhinolaryngol 2007;71:1321-4.  Back to cited text no. 12      
13.Nicholson WL. Tongue-tie (ankyloglossia) associated with breastfeeding problems. J Hum Lact 1991;7:82-4.  Back to cited text no. 13  [PUBMED]    
14.Catlin FI. Tongue-tie. Arch Otolaryngol 1971;94:548-57.  Back to cited text no. 14  [PUBMED]    
15.Peters KM, Kass EJ. Electro surgery for routine pediatric penile procedures. J Urol 1997;157:1453-5.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Smith TL, Smith JM. Electro surgery in otolaryngology-head and neck surgery: Principles, advances, and complications. Laryngoscope 2001;111:769-80.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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