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ISSN-0303-5212
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Volume 31, Number 2, Jul - Dec 2006 |
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Original Article
ABSTRACT
INTRODUCTION Any physical restriction of the normal movement of the anterior tongue means ankyloglosia (tongue-tie), and is often the consequence of a short lingual frenulum. Incidence of this congenital deformity is reported to be between 0.2 and 6.8 per 1000 birth.1-2 Tongue–tie may contribute to the difficult articulation of specific tongue thrust sounds (T, D, L, N, S, Z, R and TH) in English,3 and (ر- ز- س – ن – ل – د – ت) in Arabic and Persian. Poor sucking, chewing and swallowing may be due to tongue-tie. Ankyloglosia may cause mandibular problems, malocclusion and immobilized tongue results in poor oral hygiene and interferes with wind instrument.4-5 The diagnosis is made by observation of lingual mobility (Fig.1),
and measuring the frenum length. These patients cannot extend the
tip of their tongues beyond the lower incisor teeth. Distance of the
free anterior tongue from the point of frenulum attachment and
maximal inter-incisor distance at which the fully extended tongue
tip can touch the maxillary incisor are measured.6 Techniques for
short frenulum have included laceration of short frenulum technique
by midwifes in newborns in the labor room, cutting with scissors, Z-
Plasty,7 full thickness buccal mucosal graft8 and cutting by bipolar
scissors.9 This article describes a new technique frenuloplasty with
split-thickness skin graft for treatment of ankyloglosia.
METHOD A series of 19 patients underwent frenuloplasty with split
thickness skin grafts during 4 years from September 1998 through
September 2002. In all children, families were offered traditional
treatment methods as well as the newer procedure frenuloplasty with
split thickness skin grafts. The patients were placed in
tonsillectomy position; under general anesthesia the mouth was held
open with special Davis gag. The short frenulum was divided
horizontally immediately below the under face of the tongue and
above the level of the papillae (orifices) of Wharton, s duct. Care
was taken in undermining the mucosal edges to avoid injury to the
underlying genioglossue muscle unless it is ankylosed. A split thickness skin graft was taken from arm. The graft was
fusiform shaped about 10 mm in length and 5 mm in width, but could
be whatever is necessary to fill easily the mucosal defect created
in the floor of the mouth. The skin graft was sutured into the
sublingual wound with at least six deep stitches of absorbable
suture holding it in good position. Patients were sent home with a
prescription for 7 days amoxicillin and acetaminophen for pain. Fig.2. Preoperative view of the short frenulum and tethered tongue
RESULTS There were11 males, 8 females in the study and the age ranged 1-21 years. The diagnosis in all patients was ankyloglossia. The average length of the lingual frenulum was 3.5 mm. 12 patients were over 4 years old and primarily operated with this technique, in 7 patients Z plasty was done before but failed and cicatrisation causes ankyloglossia. There were no complications during surgery; only two minor postoperative complication, one hematoma and one graft dehiscence with cicatrisation were noted. In long term follow up, the mobility of tongue was improved and no complication with the donor site was seen.
DISCUSSION At present, the indication for surgically dividing a short frenulum rests on the clinical judgment of the surgeon .The aim of surgery is improvement in periodontal disease, speech, and problems that are induced by tongue-tie, if it is to be corrected, before speech development.1 Historical study of surgical treatment of the ankyloglossia refers to Fletcher and Godly in which they found that those children with the longest frenulum had a statistically significant lower rate of articulation errors.8 However, in tongue–tie, person may develop compensatory lingual movements. An objective assessment of the frenulum continues to be difficult, but the young age of most patients makes measurement unreliable and frustrating.10 Even measurement under general anesthesia was unreliable, because there is stretch and tension in soft tissue landmarks.8 Clinical assessment of a short frenulum and restricted tongue movement with the opinions of speech therapist and orthodontist is the best way of decision for surgery. Most authors couldn’t say on the postoperative mobility of their patients or about surgical results, because, there is high incidence of scar formation and recurrent ankylosis,1 after closing a horizontal division of the frenulum. The insertion of a buccal mucosal graft in the closure line, the scar wouldn’t form and recipient site is very nice, but in the donor place there is scar formation and sometimes hematoma. The frenuloplasty with split thickness skin graft is a reliable and easy technique with no complication in donor site or recipient place. We found this technique excellent for those who had poor results
from previous surgery and in children older than 4 years. In
conclusion, our experience with 19 patients undergoing frenoloplasty
with split thickness graft showed this new technique to be effective
and technically easy to perform, with good results for, child over 4
years and those who fail primary closure. REFERENCES 1. Catlin FI, De Han V. Tongue-tie. Arch
Otolaryngol1971;94:548-557.
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