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TREATMENT OF AN ADOLESCENT WITH

TOTAL ANKYLOGLOSSIA

This is a report about the orthodontic treatment of a 13-year, 10-month-

old boy with total ankyloglossia combined with a Class III occlusion.

The patients tongue was fixed to the floor of his mouth and could not

be elevated at all. He had a maxillary deficiency and a mandibular pro-

trusion with a negative overjet. However, he was able to retrude his

mandible to an edge-to-edge position. Before orthodontic treatment,

the ankyloglossia was surgically rectified. Orthodontic treatment was

initiated to improve the patients occlusion and facial appearance by

correcting his retruded maxilla by means of a face mask, fixed appli-

ances, and Class III elastics. This led to a functional occlusion and an

acceptable facial appearance. World J Orthod 2010;11:278283.

Key words:ankyloglossia, Class III occlusion, face mask, maxillary

deficiency, tongue dysfunction

Ankyloglossia is a congenital anomaly

that inf luences the mobil ity of the

tongue (eating and speaking), as well as

a patients oral hygiene is also

affected.1,2 Because ankyloglossia pre-

vents contact between the anterior

palate and tongue, affected patientshave an infantile swallow pattern that

results in jaw deformities such as

mandibular prognathism.3

The incidence of ankyloglossia ranges

from 0.002% to 4.8%. The wide range

may be due to the lack of an objective

grading system.4 In addition, there is dis-

agreement among professionals about

the importance of this problem, as docu-

mented by Messner and Lalakea.5

According to the literature, ankyloglossia

is generally characterized by a short,

thick labial frenulum that is connected

to the very tip of the tongue.16 The man-

ifestation varies from mild to severe.3

Total ankyloglossia in adolescents is

very rare because it is generally treated

early in childhood to correct feeding and

speech limitations.

This report also presents the craniofa-

cial measurements of an adolescent

with untreated total ankyloglossia and

demonstrates the results of combined

surgical and orthodontic treatment.

DIAGNOSIS AND ETIOLOGY

The patient was a still-growing 13-year,

10-month-old boy who complained abouthis appearance and difficulties with eat-

ing and speaking (Fig 1). He said he felt

socially embarrassed and therefore did

not talk much.

Intraoral examination revealed total

ankyloglossia (Fig 2). His tongue was

attached to the floor of his mouth, and

as such, the patient could not elevate it

at all. He had a negative overjet but was

able to retrude his mandible into an

edge-to-edge position. As a result, the

patient was diagnosed with a pseudo

Class III occlusion resulting from a tether-

ing of his tongue to the floor of his

mouth. For financial reasons, he had not

undergone any previous surgical tongue

intervention. He further presented with

mandibular crowding, an increased curve

of Spee, and a maxillary diastema (Fig 3).

The lateral cephalometric analysis

revealed a Class III relationship with an

ANB of 12 degrees. The distance from

Steiners S-line to the upper lip was

Nihal Hamamc, DDS, PhD1

Trn zer, DDS, PhD2

Orhan Hamamc, DDS,

PhD3

Emin Caner Tmen, DDS,PhD4

Engin Agakran, DDS5

278

1Assistant Professor, Department of

Orthodontics, Dicle University,

Diyarbakir, Turkey.2Associate Professor, Department of

Orthodontics, Dicle University,

Diyarbakir, Turkey.3Professor, Department of Orthodon-

tics, Dicle University, Diyarbakir,

Turkey.4Assistant Professor, Department of

Pedodontics, Dicle University,Diyarbakir, Turkey.

5Research Assistant, Department of

Pedodontics, Dicle University,

Diyarbakir, Turkey.

CORRESPONDENCE

Dr Nihal Hamamci

Dicle University

Faculty of Dentistry

Department of Orthodontics

21280 Diyarbakr

Turkey

Email: [email protected]

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VOLUME 11, NUMBER 3, 2010 Hamamc et al

4 mm; to the lower lip, it was 8 mm.

BaPtmGn was 102 degrees, indicating an

anterior position of the mandible. The

anterior face height was 116 mm, and

the posterior face height, 80 mm, which

reflected a skeletal deep bite with an

S-Go/N-Me ratio of 69% (Figs 4 and 5,

Table 1).

Treatment objectives

The patient underwent surgical removal

of his ankyloglossia, correction of the

anterior crossbite and the sagittal maxil-

lary deficiency to provide a normal overjet

and overbite. Also, the deep curve of

Spee was levelled. The ultimate goal was

to achieve an acceptable facial appear-

ance and a stable occlusion.

Figs 1a to 1c Pretreatmentfacial photographs revealing a de-creased lower facial height, anunderdeveloped maxilla with avery low lip line, and a prognathicmandible.

Fig 2 (left) Position of the tongue prior to surgical intervention.

Figs 3a to 3f (below) Pretreatment intraoral photographs showing a severe Class IIIocclusion with a deep reversed overjet, a bilateral crossbite, congenitally missingmaxillary lateral incisors, and severly retruded mandibular anterior teeth. Thepatient is still able to achieve an edge-to-edge bite (Fig 6), indicating a long slidefrom centric relation into centric occlusion.

a

a cb

d fe

a cb

d fe

cb

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Treatment progress

The patient underwent tongue surgery at

the Plastic and Reconstructive Surgery

Department of Dicle University. The

patients parents then decided that their

son should not have a second operation

to correct his jaw relationship because

the possible esthetic improvement would

not be worth the increased cost and risk.

Because of this decision, the sagittal

maxillary deficiency had to be corrected

with a face mask during orthodontic

treatment.

280

Hamamc et al WORLD JOURNAL OF ORTHODONTICS

Fig 4 Pretreatment cephalometric radiographindicating a severe Class III occlusion with a deepreversed overjet, a retruded maxilla, a protrudedmandible, and decreased lower facial height.

Table 1 Pre- and posttreatment cephalometric

measurements

Parameter Pretreatment Posttreatment

SNA (degrees) 73 74

SNB (degrees) 85 80

ANB (degrees) 12 6

SND (degrees) 83 79

Co-A (mm) 88 92

Co-Gn (mm) 131 132

Na-Me (mm) 116 126

ANS-Me (mm) 55 65

SNGoMe (degrees) 29 33

SN-OcP (degrees) 3 10

ArGoGn (degrees) 128 130

ANS-PNS-SN (degrees) 7 4

NSBa (degrees) 120 130

S-Go/Na-Me (%) 69 67

S-Go (mm) 80 83

BaPtmGn (degrees) 102 98

U1-upper lip (mm) 16 13

L1-lower lip (mm) 15 13

Pog-Pogs (mm) 10 14

Soft tissue/S-line (maxillary/mandibular) 4/+8 5/0

Maxillary depth (degrees) 78 80

Nasolabial angle (degrees) 50 74

U1-NA (mm) 25/4 30/6

L1-NB (mm) 8/6 10/3U1-L1 (degrees) 176 154

Fig 5 Pretreatment panoramic radiograph showing that allteeth except for the maxillary lateral incisors are present.

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This treatment began in the maxilla

with 0.018-inch 0.025-inch Roth

straight-wire appliances. As there was a

crossbite (tendency), an occlusal splint

was used to unlock the occlusion. After

leveling the maxillary arch, a 0.016-inch

0.022-inch stainless steel archwire was

inserted and a face mask applied to move

the maxilla ventrally while simultaneously

moving the maxillary posterior teeth ante-

riorly to close all existing spaces resultingfrom the congenitally missing lateral

incisors. The force of the face mask

amounted to 350 cN per side, and the

force vector was parallel and slightly

above the occlusal plane so that the max-

illary plane rotated anteriorly. The patient

complied with face mask wear very well,

so the anterior crossbite was eliminated

after 5 months. To compensate the

Bolton discrepancy that resulted from the

missing lateral incisors, one mandibular

incisor was extracted.

After a positive overjet was established,

the mandibular teeth were bonded. The

remaining maxillary diastema was closed

with the assistance of Class III elastics.

RESULTS

By the end of treatment, the anterior

crossbite, deep overbite, maxillary retru-

sion, and the mandibular crowding were

corrected (Fig 6). The ANB had increased

to 6 degrees by a posterior mandibular

and anterior maxillary rotation (Figs 7 to 9,

Table 1). In addition, an acceptable

esthetic facial appearance was achieved

(Fig 10); the patient wore Hawley retain-

ers for retention.

DISCUSSION

Ankyloglossia is an oral anomaly result-

ing from failing cellular degradation of

the tongue frenum between the 8th to

11th prenatal week.7,8 It is more common

in males.9,10 Ballard et al11 found a posi-

tive family history, although this was not

the case here.

There is no standard definition or

grading system for ankyloglossia. Simi-

larly, the possible consequences and

management of ankyloglossia are contro-

versial. Lalakea and Messner4 noted that

besides problems while speaking and

eating, pain and cuts of the frenum may

occur while wetting ones lips and kiss-

ing. In addition, the aforementioned prob-

lems may be noticed only later in

childhood, as small children may be

unable to recognize or report any nega-

tive ef fect. In addition, problems with

kissing, for instance, may not be noted

until later in adolescence.

Figs 6a to 6e Posttreatment intraoralphotographs after space closure in themaxilla and extraction of one mandibu-lar incisor with Class II occlusion butnormal overjet and overbite. The cross-bite was eliminated, and the maxillarylateral incisors were reshaped toresemble lateral incisors.

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Hamamc et al WORLD JOURNAL OF ORTHODONTICS

Fig 7 Posttreatment cephalometric radiographindicating remarkably improved sagittal and verti-cal jaw and profile relationship.

Fig 8 Posttreatment panoramic radiograph after space clo-sure with good root parallelism.

Fig 9 (right) Superimpo-

sition of cephalometrictracings from the begin-ning and end of treatment.

Figs 10a to 10c (below)Posttreatment facial photo-graphs underlining the re-markably improved sagittaland vertical jaw and profilerelationship.

Pretreatment

Posttreatment

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There are various interventions for

ankyloglossia. Horton et al3 believe that

individuals with ankyloglossia can com-

pensate for the limited tongue motion

when it comes to speech. For example, if

sounds such as en, tee, dee, and

ell are impeded, they will be compen-sated by dentalization. To produce the

sound arr, an elevation of the mandible

can compensate for the restricted tongue

movement. Overall, Horton et al3 propose

compensatory strategies, not surgery.

Intervention for ankyloglossia includes

laser surgery in the form of a frenotomy

(also called frenectomy or frenulectomy)

or frenuloplasty.12 These procedures are

indicated for patients of any age with a

tight frenulum, as well as objective and

subjective impairments.A viable alternative to surgery is to

wait and see.4 Ruffoli et al13 reported

that the to ngue frenulum natural ly

recedes between 6 months and 6 years

of age. As this patient was already older

than 13 years, more waiting likely would

not have improved his condition.

The craniofacial configuration of this

patient was clearly abnormal. According

to the equilibrium theory of Weinstein et

al,14 the pressure from the tongue and

lips near the maxillary second premolars

and first molars and maxillary anterior

teeth is balanced. In patients with anky-

loglossia, there is no tongue pressure

against the maxilla, so transverse and

sagittal growth is inhibited. As the maxil-

lary anterior teeth had no antagonists,

they continued to erupt and the maxillary

occlusal plane rotated posteriorly. Con-

versely, the overerupting mandibular

anterior teeth rotated the mandibular

occlusal plane anteriorly. Because the

force vector of the face mask acted

below the center of resistance of the

maxillary dentition, the maxillary anterior

dentition rotated anteriorly while estab-

lishing a positive overjet. The decrease in

the SN-OcP (7 degrees), the increase in

SNA (1 degree), and the increase in Co-A

(4 mm) indicated an anterior rotation of

the maxilla, whereas the 5 degree SNB

decrease and the increase in facial

height can be attributed to a posterior

rotation of the mandible.

CONCLUSION

Because his parents could not afford the

costs for orthognathic surgery, this

patient was treated with orthodontics

alone. However, the patient ultimately

attained a functional occlusion andacceptable facial appearance.

REFERENCES

1. Messner AH, Lalakea ML. The effect of anky-

loglossia on speech in children. Otolaryngol

Head Neck Surg 2002;127:539545.

2. Travis LE. Handbook of Speech Language

Pathology and Audiology. New York: Meredith,

1971.

3. Horton CE, Crawford HH, Adamson JE, Ashbell

TS. Tongue-tie. Cleft Palate J 1969;6:823.

4. Lalakea ML, Messner AH. Ankyloglossia: Does

it matter? Pediatr Clin North Am 2003;50:

381397.

5. Messner AH, Lalakea ML. Ankyloglossia: Contro-

versies in management. Int J Pediatr Otorhino-

laryngol 2000;54:123131.

6. Lalakea ML, Messner AH. Ankyloglossia: The

adolescent and adult perspective. Otolaryngol

Head Neck Surg 2003;128:746752.

7. Kalu PU, Moss ALH. An unusual case of anky-

loglossia superior. Br J Plast Surg 2004;57:

579581.

8. Gartlan MG, Davies J, Smith RJH. Congenital

oral synechiae. Ann Otol Rhinol Laryngol 1993;

102:186197.9. Harris EF, Friend GW, Tolley EA. Enhanced

prevalence of ankyloglossia with maternal

cocaine use. Cleft Palate Craniofac J 1992;29:

7276.

10. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA.

Newborn tongue-tie: Prevalence and effect on

breast-feeding. J Am Board Fam Pract 2005;

18:17.

11. Ballard JL, Auer CE, Khoury JC. Ankyloglossia:

Assessment, incidence, and effect of frenulo-

plasty on the breast-feeding dyad. Pediatrics

2002;110:e63.

12. Lalakea ML, Messner AH. Frenotomy and frenu-

loplasty: If, when, and how. Oper Tech Otolaryn-

gol Head Neck Surg 2002;13:9397.13. Ruffoli R, Giambelluca MA, Scavuzzo MC. Anky-

loglossia: A morphofunctional investigation in

children. Oral Dis 2005;11:170174.

14. Weinstein S, Donald CH, Morris LY, Snyder BB,

Attaway HE. On an equilibrium theory of tooth

position. Angle Orthod 1963;33:126.

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