ANKYLOGLOSSIA Done by Abdullah Almuttawa Pediatric Surgery Intern 2011 Tuesday September 27 2011 2 Abdullah Almuttawa objectives Introduction Epidemiology Potential effects Diagnostic clues ID: 779889
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بسم الله الرحمن الرحيم
Slide2ANKYLOGLOSSIA
Done by:
Abdullah Almuttawa
Pediatric Surgery Intern 2011
Tuesday, September 27, 2011
2
Abdullah Almuttawa
Slide3objectives
Introduction.
Epidemiology.
Potential effects. Diagnostic clues.
Surgery?.Tuesday, September 27, 2011Abdullah Almuttawa3
Slide4The 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 we get older.
Tuesday, September 27, 2011Abdullah Almuttawa
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Slide5What’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.
Tuesday, September 27, 2011Abdullah Almuttawa5
Slide6What’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 mid-portion 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
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Slide7Frenulum 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.Tuesday, September 27, 2011Abdullah Almuttawa
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Slide8Tuesday, September 27, 2011
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Slide9Slide10Epidemiology
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
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Slide11Genetic 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.
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Slide12Classification
class
severity
length
Class IMild ankyloglossia12 to 16 mm free tongue Class IIModerate ankyloglossia
8 to 11 mm free tongue
Class III
Severe
ankyloglossia
3 to 7 mm free tongue
Class IV
Complete
ankyloglossia
less than 3 mm free 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.
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Slide13Potential 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.Tuesday, September 27, 2011
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Slide143. 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
Slide15Clinical featuresTuesday, September 27, 2011
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Slide16Abnormally short frenulum, inserting at or near the tip of the tongue
Slide17Difficulty lifting the tongue to the upper dental alveolus
Slide18Inability to protrude the tongue more than 1 to 2 mm past the lower central incisors
Slide19Notched or heart shape of the tongue when it is protruded
Slide20Surgical 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.
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Slide21Frenotomy 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%
Slide22lingual 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.
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Slide23An 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 absorbable sutures in the sagittal plane.
Slide24Slide25Slide26Revision by Electrocautery
This method does not require a general anesthetic and can be performed as an outpatient service with a local anesthetic.
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Slide27Laser 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.
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Slide28To Clip or Not to Clip? That's the Question.
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Slide29Indications for surgery may include breastfeeding difficultyArticulation problems.
Psychologic problems.
Periodontal disease.
Slide30When
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.Tuesday, September 27, 2011Abdullah Almuttawa30
Slide31Perspectives 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
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Slide32“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
Slide33post-operative exercises
The purpose of post-operative exercises
Post-operative exercises following tongue-tie surgery are not intended to increase muscle-strength, 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.Tuesday, September 27, 2011Abdullah Almuttawa
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Slide34recourses
UpToDate.com
“Tongue Tie – from Confusion to Clarity”by Carmen Fernando.
speech-language-therapy.comThe American Speech-Language-Hearing Association (ASHA).
American Academy of Otolaryngology — Head and Neck Surgery.Tuesday, September 27, 2011Abdullah Almuttawa34