ANKYLOGLOSSIA Done by Abdullah Almuttawa Pediatric Surgery Intern

ANKYLOGLOSSIA Done by: Abdullah Almuttawa Pediatric Surgery Intern 2011 Saturday, September 26, 2020 Abdullah Almuttawa 2

objectives Introduction. Epidemiology. Potential effects. Diagnostic clues. Surgery? . Saturday, September 26, 2020 Abdullah Almuttawa 3

The Tongue *The most important articulator for speech production is undoubtedly the tongue. *During speech, the amazing range of movements the tongue can make include tip-elevation, grooving, and protrusion. *Relatively short at birth, the tongue grows longer, and thinner at the tip, as Saturday, September 26, 2020 Abdullah Almuttawa 4

What’s is Ankyloglossia ? ? Commonly known as tongue-tie. It is a congenital anomaly in which a short, lingual frenulum or a highly attached genioglossus muscle restricts tongue movement. It is characterized by partial fusion-or in rare cases, total fusion-of the tongue to floor of the mouth. Saturday, September 26, 2020 Abdullah Almuttawa 5

What’s frenulum ? By definition, a frenulum, which is a small frenum, is a narrow fold of mucous membrane connecting a moveable part to a fixed part. Its purpose is to stabilize and check movement of that part. The lingual frenulum is generally under the midportion of the tongue. As such, it can help to stabilize the base of the tongue but does not interfere with tongue tip movement. With ankyloglossia, however, the lingual frenulum has an anterior attachment near the tip of the tongue and may also be unusually short Saturday, September 26, 2020 Abdullah Almuttawa 6

Frenulum time line !!! �Before we are born, a strong cord of tissue that guides development of mouth structures is positioned in the center of the mouth. It is called a frenulum. After birth, the lingual frenulum continues to guide the position of incoming teeth. As we grow, it recedes and thins. �In some children, the frenulum is especially tight or fails to recede and may cause tongue these mobility problems. Saturday, September 26, 2020 Abdullah Almuttawa 7

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Epidemiology �Research at the University of Cincinnati, USA, published in 2002, found that around 16 percent of babies experiencing difficulty with breastfeeding had a tongue tie. �Another study at Southampton General Hospital, UK, found that 10 percent of babies born in the area had a tongue tie. �Most studies identify an increased frequency in boys with a male-to-female ratio of 1. 5 -2. 6 to 1 Saturday, September 26, 2020 Abdullah Almuttawa 10

Genetic factors and tongue tie �Tongue tie often runs in families. Some relatives may only have mild effects or no apparent symptoms while others show a severe impact on structure and function. �Tongue tie sometimes occurs together with other congenital conditions which affect the structure of the mouth, such as cleft lip or palate. It can also occur together with conditions such as severe hearing loss or cerebral palsy. Saturday, September 26, 2020 Abdullah Almuttawa 11

Classification class severity length Class I Mild 12 to 16 mm ankyloglossi free tongue a Class II Moderate 8 to 11 mm ankyloglossi free tongue a Class III Severe 3 to 7 mm ankyloglossi free tongue a Class IV Complete less than 3 ankyloglossi mm free a tongue The term free- tongue is defined as the length of tongue from the insertion of the lingual frenum into the base of the tongue to the tip of the tongue. Saturday, September 26, 2020 Abdullah Almuttawa 12

Potential effects of tongue tie 1. Speech development It is important to note that tongue tie does not necessarily impair speech, in fact, it rarely appears to do so. Many individuals compensate well and have normal sounding speech, even those with the frenulum attached very close to the tongue tip under the tongue. Some individuals with tongue tie may have imprecise articulation, especially at speed. In a recent survey, Messner and Lalakea (2000) found that 60% of ENTs, 50% of SLPs, and 23% of pediatricians believed that ankyloglossia is likely to cause speech problems. Speech sounds that may be affected include sibilants and lingual sounds (eg, "t, " "d, " "z, " "s, " "th, " "n, " "l") . 2. Mechanical problems *Difficulty with oral hygiene (ie, licking the lips or sweeping food debris from the teeth) that may result in periodontal disease. *Local discomfort. *Diastasis between the lower central incisors. Saturday, September 26, 2020 Abdullah Almuttawa 13

3. Eating and digestion due to a restricted ability to tidy up inside and outside of their mouths while they are having a meal. Although approximately 25% of newborns with ankyloglossia will have some trouble latching on to a nipple for sucking the majority have no early feeding problems 4. Cosmetics and personal interactions

Clinical features Saturday, September 26, 2020 Abdullah Almuttawa 15

Abnormally short frenulum, inserting at or near the tip of the tongue

Difficulty lifting the tongue to the upper dental alveolus

Inability to protrude the tongue more than 1 to 2 mm past the lower central incisors

Notched or heart shape of the tongue when it is protruded

Surgical Options The goal of surgery is to increase the mobility of the tongue, not to improve its contour. Even after surgery, the tip of the tongue may retain a heart shape. Saturday, September 26, 2020 Abdullah Almuttawa 20

Frenotomy of neonates(tongue clipping) Snipping the frenum, This procedure, carried out as an out-patient procedure at the Southampton General Hospital, UK, is described as follows by Mr Mervyn Griffiths, a neonatal and paediatric surgeon, and requires no anaesthetic or analgesic. Results were described as: improving breastfeeding immediately - 57%, and feeding better by 24 hours - 80%

lingual frenectomy involves more than just a simple clipping or a quick snip, but more involved tissue resection under general anaesthetic. It is therefore not recommended unless there is a good (speech, dental or other) justification for doing it. Saturday, September 26, 2020 Abdullah Almuttawa 22

An assistant elevates the tip of the tongue to expose the lingual frenulum. The frenulum is divided in the coronal plane with bipolar electrosurgical scissors. Dissection is sometimes carried into the genioglossus muscle fibers to complete the ankyloglossia release. A diamond-shaped mucosal defect results. The mucosa is closed with multiple

Revision by Electrocautery This method does not require a general anesthetic and can be performed as an outpatient service with a local anesthetic. Saturday, September 26, 2020 Abdullah Almuttawa 26

Laser Surgery This relatively new option is suitable for neonates, older children and adults. No general anaesthetic is used, but an analgesic gel might be applied. no bleeding, no pain, no risk of infection and the healing period can be as short as 2 hours. Saturday, September 26, 2020 Abdullah Almuttawa 27

To Clip or Not to Clip? That's the Question. Saturday, September 26, 2020 Abdullah Almuttawa 28

Indications for surgery may include breastfeeding difficulty Articulation problems. Psychologic problems. Periodontal disease.

�When ankyloglossia is noted at birth, one option is to leave it alone and let nature take its course, unless there are early feeding problems. �If the child demonstrates any of the problems noted above, a frenulectomy (surgical release of the tongue) can be done. �In past times, midwives used a sharpened fingernail to slit the frenulum immediately after birth. Saturday, September 26, 2020 Abdullah Almuttawa 30

Perspectives on Tongue-Tie and Speech "Most experienced speech-language pathologists would conclude that frenulectomy is rarely indicated for speech reasons unless it is very severe or there are oral-motor problems. " Ann W. Kummer Saturday, September 26, 2020 Abdullah Almuttawa 31

“Delayed speech is not an indication for surgical release of tongue tie; children with ankyloglossia are expected to acquire speech and language at the normal rate”, Glenn C Isaacson, MD, FAAP, FACS

post-operative exercises The purpose of post-operative exercises �Post-operative exercises following tongue-tie surgery are not intended to increase musclestrength, but to Develop new muscle movements, particularly those involving tongue-tip elevation and protrusion, inside and outside of the mouth. �Increase awareness of the full range of movements the tongue and lips can perform. . �Encourage tongue movements related to cleaning the oral cavity, including sweeping the insides of the cheeks, fronts and backs of the teeth, and licking right around both lips. Saturday, September 26, 2020 Abdullah Almuttawa 33

recourses Up. To. Date. com “Tongue Tie – from Confusion to Clarity”by Carmen Fernando. speech-language-therapy. com The American Speech-Language. Hearing Association (ASHA). American Academy of Otolaryngology — Head and Neck Surgery. Saturday, September 26, 2020 Abdullah Almuttawa 34