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Management of Posterior Ankyloglossia using the Er,Cr:YSGG Laser CASE REPORT
Management of Posterior Ankyloglossia using
the Er,Cr:YSGG Laser
Suchetan Pradhan, Effath Yasmin, Amrita Mehta
the potential to psychologically and physically traumatizeboth mother and infant leading to stressful breastfeeding Ankyloglossia or tongue-tie, refers to a minor anomaly in theattachment of the membrane or frenum that attaches the tongue to the floor of the mouth, which may interfere with normal function A number of high-quality studies demonstrate the and mobility of the tongue. Ankyloglossia is a poorly recognized relationship of tongue tie and breastfeeding. Messner et al.
and inadequately defined condition and has been reported to in 2000,1 in a large study from the USA demonstrated that cause breastfeeding difficulties, dental issues and speechproblems. This article discusses assessment criterions to tongue-tie causes breastfeeding difficulties and pain for diagnose posterior ankylogossia and lays down treatment mothers. This study demonstrated that mothers of infants protocol in neonates using the Er,Cr:YSGG (Waterlase MD).
with tongue-tie experienced more breastfeeding difficulties Keywords: Posterior ankyloglossia, Frenum, Tongue-tie,
than mothers whose infants did not have tongue-tie and that Frenectomy, Lasers, Er,Cr:YSGG laser.
tongue-tie can affect breastfeeding duration.
How to cite this article: Pradhan S, Yasmin E, Mehta A.
Management of Posterior Ankyloglossia using the Er,Cr:YSGG 1. To identify several assessment criterions that may help Laser. Int J Laser Dent 2012;2(2):41-46.
better recognize posterior ankyloglossia.
Source of support: Nil
2. To help identify other midline anomalies hampering Conflict of interest: None
3. To lay down patient position protocols and laser INTRODUCTION
The World Health Organization (WHO) recommends ANKYLOGLOSSIA
breastfeeding exclusively for the first 6 months of life with Since, the early 1990s breastfeeding literature is replete with the introduction of complementary foods and continued case studies of infants with ankyloglossia and its treatment.2-6 breastfeeding up to 2 years of age or beyond. Genuine Tongue-tie or ankyloglossia is described as a congenital physiopathological reasons for not being able to breast-feed condition with an unusually thickened, tightened or are very rare and almost all the women should be able to shortened frenum (membrane or string under the tongue— lactate, however, how effectively the mother and infant Hillan 2008; Wallace and Clarke 2006). The term anatomically connect is a crucial factor to the success of ‘ankyloglossia’ comes from the Greek words agkilos for this immensely interactive and co-dependant process. A crooked or loop and glossa for tongue.7 significant number of mothers abandon breastfeeding and The history of ankyloglossia dates back in the writings turn to formula bottle-feeding due to undiagnosed and of 3rd century BC by Aristotle and Roman civilization in untreated anatomical impediments to the feeding dyad. This the 2000-year-old writings of Celsus. It also has a mention most fundamental mammalian processes is sacrificed at the in the Bible and the Quran about Moses being tongue-tied.8 altar of undetected posterior ankyloglossia and an Ankyloglossia is caused by insufficient apoptosis during unfavorable thick maxillary labial frenum attachment.
the early embryonic stage of the midline sublingual tissue.
Tongue and Lip Mobility in Breastfeeding
The severity of the ankyloglossia is determined by Mobility of the infants lip and tongue is critical to the breast- Type 1: Tip of the tongue to, in front of the alveolar ridge.
feeding process. For a neonate to latch on effectively and Type 2: 2 to 4 mm behind the tongue tip, attaches on or draw milk from the mother’s breast, the infant needs to simultaneously gape wide, extend the tongue forward and Type 3: Attaches mid-tongue to the floor of the mouth.
flange the lips to create a seal, and then contour its tongue Type 4: Sits at the base of the tongue, is thick, shiny and in a groove around the nipple and the areola to form a teat very inelastic also called as posterior or submucosal resulting in an effective and deep latch. A thick and inelastic mandibular frenum attachment (tongue-tie, ankyloglossia) Hong classified ankyloglossia as anterior or posterior.
causes the tongue to retract during the wide gape. This has Anterior ankyloglossia was defined by Hong as tongue-ties International Journal of Laser Dentistry, May-August 2012;2(2):41-46 with a prominent lingual frenum and/or restricted tongue RELATIONSHIP BETWEEN ANKYLOGLOSSIA
INCIDENCE OF ANKYLOGLOSSIA
The effect of ankyloglossia on breastfeeding has been a matter of controversy in the medical literature for 50 years.19 Ankyloglossia or tongue-tie, represents a significant Ankyloglossia in infants is associated with 25 to 60% proportion of the identified impediments to successful incidence of difficulties with breastfeeding,20 such as failure breastfeeding. It is more common in boys than in girls and to thrive, maternal nipple damage, maternal breast pain, poor seems to be genetic in origin.11 The prevalence of milk supply, breast engorgement and refusal of the breast.
ankyloglossia ranges between 4.2 and 10.7% in the Studies have shown that, for every day of maternal pain during the initial 3 weeks of breastfeeding, there is a 10 to The incidence is 2.8 to 10.7% in infants.13 The varying 26% risk of cessation of breastfeeding. The ineffective latch figures of incidence of ankyloglossia could be attributed tofact that there is no standard method of diagnosing caused by ankyloglossia could be one of the primary ankyloglossia. Tongue-tie usually presents as a sole underlying causes of all of these problems.1 anomaly, but very rarely may be associated with cleft palateor Pierre Robin sequence14 (formerly known as Pierre Robin DIAGNOSIS OF ANKYLOGLOSSIA
Assessment of the infant tongue is challenging as both Tongue-tie has also been associated with Opitz maternal nipple-areola tissue and the tongue and other oral syndrome, orodigitofacial syndrome, Van der Woude structures of the baby are not visible during breastfeeding.
syndrome and X-linked cleft palate. A tight lingual frenum Posterior ankyloglossia is difficult in its diagnosis. Careful is considered a minor malformation by some investigators.15 examination of the attachment of the frenum to the base of It is also found to be a part of certain malformation the tongue is imperative to reveal this subtle anatomical syndromes.16,17 Although a high-arched palate and recessedchin may be seen as part of the craniofacial constellation, limitation to tongue mobility. Practitioners who may be most commonly a tight lingual frenum is seen as an isolated looking for a heart-shaped tongue tip are most likely to miss the posterior tongue-tie which is a short frenula along the In a prospective study, Messner et al. reported the posterior half of the tongue and is normally found to be incidence of ankyloglossia in a well-baby population and studied whether affected patients with this condition Murphy maneuver is a test to diagnose posterior experienced breastfeeding difficulties. Only 50 babies of ankyloglossia which involves running a finger along the the 1,041 newborns that were screened in the well-baby underside of the baby’s tongue to assess possible frenulum nursery had tongue-tie as defined by their liberal definition.
This incidence of 4.8% corresponds with what is reported The Hazelbaker assessment tool for lingual frenulum function (HATLFF) was developed to provide a quantitative In a study done by Jeanne L Ballard, Christine E Auer, assessment of ankyloglossia and has been proven to be Jane C Khoury, examined 2,763 breastfeeding inpatient highly reliable. However, it was not widely used since the infants and 273 outpatient infants with breastfeeding process of scoring is lengthy and complex.19 problems for possible ankyloglossia and assessed each infant The parameters analyzed in the Hazelbaker assessment with ankyloglossia, using the Hazelbaker assessment tool are length, attachment site and elasticity and the functional for lingual frenulum function. Ankyloglossia was diagnosed parameters include extension cupping and peristalsis of the in 88 (3.2%) of the inpatients and in 35 (12.8%) of the Morphofunctional analysis, such as length of the frenum The reported prevalence of ankyloglossia varies from and interincisal distance are important aids in assessment 0.02 to 4.8%, but only causes feeding difficulties in 44% ofbreastfeeding mothers.1 of ankyloglossia but the mother’s history, which should In the authors’ opinion, the varying percentages of the include quality of infants latch and degree of nipple pain incidence of ankyloglossia in the newborn population as during breastfeeding is a crucial input and needs to be shown in the different studies does not appear to be to correlated with the lingual function and appearance representative of true incidence of ankyloglossia in the newborn population particularly owing to the factor of non- The breastfeeding history would comprise maternal standard diagnosis of ankyloglossia.
Management of Posterior Ankyloglossia using the Er,Cr:YSGG Laser Maternal Factors
deciding whether to treat or not to treat ankyloglossia, itseffect on tongue function, a morphofunctional analysis, Creased or blanched nipples after feeding: Flattened nipple pain and soreness must be evaluated. Not all cases require intervention. The presence of a non-disturbing lingual frenum does not justify its treatment. In the light of current research on breastfeeding and its importance to neonatal growth early intervention in case of demonstrable functional disturbance is imperative.
Surgery in the Hospital
Surgery in the hospital is a cumbersome procedure for the Infant Factors to Consider
parents as well as the infant as it involves a half-day stay,fasting prior to the operation, administration of general anesthetic and sutures at the operated site. There is usually discomfort until healing is complete and this may take Laser Surgery
The use of lasers in treating posterior ankyloglossia makes it a minimally invasive procedure. Lasers have many advantages over conventional treatment options. They arebactericidal, provide a bloodless operating field, and do not MAXILLARY LABIAL FRENUM AND ITS
require placement of sutures or local anesthetic.
RELATED IMPEDIMENT TO BREASTFEEDING
Additionally, they are fast and safe without significant post-surgical complications.
A maxillary frenum is defined as a vertical band of lip tissueextending from the inside portion of the upper lip attaching LASER-ASSISTED SURGERY OF
to the alveolar mucosa to the maxillary arch.20 POSTERIOR ANKYLOGLOSSIA
A classification of maxillary frenum attachment has been developed by Dr Kotlow on the basis of the position of the Case Presentation
lip attachment to maxillary arch’s soft tissue.
A 30-year-old primigravida presented to the lactationspecialist with a 10-day-old baby reporting low milk Kotlow’s Classification of Maxillary Frenum
supply. The infant had not gained weight (13% less than Class I: Attached to the marginal gingiva birth weight on day 10) and the mother experienced Class II: At the junction of free attached gingiva excruciating pain while breastfeeding. The mother reported Class III: Attachment in front of the anterior papilla the baby being painfully attached to the breast constantly Class IV: Attachment to anterior incisive papilla and throughout the day and night with no signs of satisfaction.
The mother stated the first attempt at breastfeeding was In instances when the frenal attachment is papillary or papilla penetrating it (class III and class IV), hinders themobility and function of the upper lip and subsequently Clinical Infant’s Oral Evaluation
with Digit Test
The infant tongue was unable to cup the finger of the Treatment
lactation specialist as normally predicted prefeeding In the 1970s the midwives used to divide frenum linguae of behavior. Tongue retraction and excessive gum biting was newborn babies with their fingernails. In 1983, Lao and observed and it was almost impossible to get a finger under Ong22 described a grooved tablespoon for tongue-tie release.
the tongue. An overactive gag reflex was elicited on the Disturbances caused due to morphofunctional variation digit test. Assessment indicated significant tongue restriction of the tongue and lip frenum warrant interventional indicative of posterior ankyloglossia based on guidelines treatment-based solely on functional factors. Before of Hazelbakers assessment (Fig. 1). The maxilla also International Journal of Laser Dentistry, May-August 2012;2(2):41-46 Fig. 1: V-shaped tongue
Fig. 3: Patient positioning
Fig. 2: Thick labial frenum
Fig. 4: Indian baby bath position
revealed a high thick labial frenum which was diagnosed to A new position for placement of the infant was devised be grade II according to Dr Lawrence Kotlow’s to help stabilize the head and jaws. In ‘The Indian baby bath’ position the head of the baby was placed between the Breastfeeding management methods were instituted to legs of the mother (Figs 3 and 4). Lateral support from the maintain mother’s milk supply and counter birth-related legs provided some stabilization from lateral movement of trauma on the cranium of the baby. The second oral the head. The baby’s legs were positioned near the mother’s assessment of the baby confirmed: No change in oral seal thighs. The head low placement of the head allowed the during breastfeeding, continued tongue retraction and gum tongue to roll back making the surgical site easily accessible.
Additionally, the baby’s movement in a vertical direction After a comprehensive examination of both the infant was controlled by a stabilizing hand. Two fingers were and mother, it was concluded that a procedure to relieve placed on either side of the frenum. As the baby’s jaws the lingual frenum and maxillary frenum would be beneficial clamped on the fingers some amount of jaw stabilization was achieved. The great advantage was that at every stagethe baby could view the mother’s face and be reassured by Preparation of the Infant for Laser Surgery
the same. All standard laser safety norms were followed.
Psychological preparation of the mother is the first step in Treatment
preparing the infant. Counseling and emotional support fromboth the dentist and lactation consultant are the cornerstone Local anesthetic gel was applied to both the surgical sites.
of successful treatment outcomes for neonates.
Both the procedures were done using the Er,Cr:YSGG which Management of Posterior Ankyloglossia using the Er,Cr:YSGG Laser is a 2,780 nm free running pulsed soft and hard tissue lasercommercially known as Waterlase MD. A flexible fibre-optic device delivers the laser energy. For soft tissueprocedures the laser itself does the cutting with thewater stream acting as a coolant. A visible light emittedfrom distal end of the handpiece pinpointed the area oftreatment. Since the Er,Cr:YSGG laser irradiation causedsplashing of water and blood as a result of explosiveablation, adequate high-speed evacuation was required toprevent contamination.
The laser settings were checked and test fired: Figs 5A and B: Treatment using Waterlase MD
Maxillary frenectomy: The maxillary frenectomy was done with the same laser using the same settings at the lingual frenectomy. The patient’s head was stabilized, all the necessary precautions were taken and the laser was applied The settings used on the infant were lower than those to the maxillary frenum in a non-contact mode and the tissue normally used in adult patients owing to the differences in the thickness of the tissue. The oral tissues in infants areless fibrotic and thinner compared with the oral tissues of Postoperative Care
Postoperative prevention of frenum reattachments is oneof the most critical elements of a successful treatment Preliminary to Patient Treatment
outcome. Educating the parent, and instilling a regimen Prior to the treatment, the infants head was secured in the of daily surgical site massage during and after Indian baby bath position. The operatory was secured and breastfeeding for at the minimum of 6 days after the laser following safety precautions followed.
surgery was implemented. Breast milk acts as an analgesic 1. The operatory was secured and proper laser warning sign and the act of breastfeeding brings comfort to the infant.20 was placed at the door of the operatory. The laser was Dr Kotlow also recommends that prior to each feeding the set and test fired for proper operation and tip function.
mother sweep her finger across the floor of the mouth 2. The infant, mother, staff and dentist were given 3. The patient’s record and treatment plan was reviewed.
Postoperative Management of Pain
To prevent or reduce post-surgical soreness and discomfort, THE TREATMENT USING
it is recommended to give the infant an appropriate dose of THE Er,Cr:YSGG LASER
acetaminophen/paracetamol at the time of surgery and again Both the procedures were done a week apart.
Lingual frenectomy: The infant’s head was steadied using Patient Recall
the ‘Indian baby bath’ procedure as described above. Thelaser tip was used in non-contact mode with continuous and The infant was recalled for a checkup the following day controlled movement to avoid any injury to the surrounding and then after 7 days to check the healing.
oral tissues. Care has to be taken to avoid any injury to the CONCLUSION
floor of the mouth where salivary glands, blood vessels, aswell as the Wharton’s duct are located. Once the tissue was Anatomical variation in lingual and maxillary buccal frenum ablated, it was checked with the movement of a finger to attachment in neonates can lead to significant breastfeeding check for any remnants of tissue or any interference. After difficulties. The breastfeeding dyad could be hampered in the completion of the surgery the infant was allowed to suck case of failure to diagnose and detect the extent of the problem. Conformational diagnosis can only be presented International Journal of Laser Dentistry, May-August 2012;2(2):41-46 based on morphofunctional factors. Inability to feed, failure 12. Segal LM. Stephenson R, Dawes M, Feldman P. Prevalence, to thrive, maternal nipple pain and early weaning to the diagnosis, and treatment of ankyloglossia methodologic review.
Can Fam Physician 2007;53:1027-33.
bottle are factors that would help decide, if surgical 13. Edmunds J, Miles SC, Fulbrook P. Tongue-tie and breastfeeding: intervention is warranted. Once surgery is advised the laser A review of the literature. Breastfeed Rev 2011 March 19(1); surgery with the Er,Cr:YSGG is a far easier and superior option as compared to conventional surgery under general 14. Jones SE, Derric GM. Difficult intubation in an infant with Pierre Robin syndrome and concomitant tongue-tie. Pediatr Anaesth anesthesia with sutures, associated pain and postoperative complications. Post-surgery success in breastfeeding is 15. Rosegger H, Rollett HR, Arrunategui M. Routine examination exhilarating for the mother and extremely beneficial to the of the mature newborn infant. Incidence of frequent ‘minor findings’. Wien Klin Wochenschr 1990;102:294-99.
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Consultant, Department of Periodontics, Pradhan Dental Centre
B.O.C. y L. - N.º 221 Martes, 16 de noviembre 2004 I V. OTRAS DISPOSICIONES Y AC U E R D O S 2.– Sus órganos de go b i e rno y administración tendrán su sede en la loca-Y A D M I N I S T R ACIÓN T E R R I TO R I A L3.– En lo que respecta al personal al servicio de la Mancomunidad seregirá en todos sus extremos, por lo determinado en la Legislación deRégimen Local. ORDEN