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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 135-140

Successful rehabilitation of a child patient with ankyloglossia using the diode laser of wavelength 808 nm and speech therapy

1 Specialist Pediatric Dental Surgeon, Private Pediatric Dental Practice, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Pediatric and Preventive Dentistry, Faculty of Medicine, Dr. Ziauddin Ahmad Dental College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission24-Nov-2021
Date of Decision18-Jun-2022
Date of Acceptance21-Aug-2022
Date of Web Publication31-Aug-2022

Correspondence Address:
Dr. Mohammad Kamran Khan
Hamdard Nagar-A, Civil Line, Aligarh, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoralsci.sjoralsci_61_21

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Ankyloglossia is an abnormal congenital condition of the tongue characterized by abnormal attachment of lingual frenum or shorter lingual frenulum. Although various conventional surgical modalities and lasers for frenectomy has been described in literature, only few articles have been reported in the existing literature regarding the diode laser of 808 nm wavelength for frenectomy procedure in pediatric patient. Hence, the current article describes the clinical case report of successful and effective treatment of ankyloglossia using soft-tissue diode laser of 808 nm wavelength with minimally invasive dentistry approach in a 10-year-old male pediatric patient. In addition, the tongue-tie was clinically evaluated using the Hazelbaker Assessment Tool for Lingual Frenulum Function. Diode lasers can be used as a safe alternative surgical tool for managing tongue-tie with minimally invasive dentistry approach and also for alleviating the dental anxiety in pediatric patients.

Keywords: Ankyloglossia, diode laser, facial image scale, hazelbaker assessment tool for lingual frenulum function, minimally-invasive-dentistry, pediatric case report, tongue-tie

How to cite this article:
Khan MK, Jindal MK. Successful rehabilitation of a child patient with ankyloglossia using the diode laser of wavelength 808 nm and speech therapy. Saudi J Oral Sci 2022;9:135-40

How to cite this URL:
Khan MK, Jindal MK. Successful rehabilitation of a child patient with ankyloglossia using the diode laser of wavelength 808 nm and speech therapy. Saudi J Oral Sci [serial online] 2022 [cited 2023 Apr 2];9:135-40. Available from: https://www.saudijos.org/text.asp?2022/9/2/135/355225

  Introduction Top

Ankyloglossia is an abnormal congenital condition of the tongue characterized by abnormal attachment of lingual frenum or shorter lingual frenulum.[1],[2],[3],[4],[5] The exact etiology of such anomaly is not known clearly, however, involvement of human G-protein coupled receptor gene (Lgr5) has been suggested as the genetic role in its etiology[6] The prevalence of ankyloglossia has been observed as 4.4% to 4.8%[7],[8] in neonates (newborns) and having male to female ratio 3:1.[3],[7] Due to restricted tongue movements in ankyloglossia; articulation of words and pronunciation of consonants like, d, t, n, and l, and to roll a “r” are found difficult to speak. Tongue-tie causes difficulties during breast feeding and bottle feeding, swallowing, malocclusion problems (open bite/crowding), dental caries, sleep disturbances, gingival recession in mandibular anterior teeth, nasal breathing, and also influence the development of the jaw bones.[9],[10] Hence, early detection of tongue-tie is considered essential in newborns at birth or in childhood in order to prevent the adverse effects of ankyloglossia.[8] The ankyloglossia has been classified by Kotlow[11] into four classes, viz: Class I, mild ankyloglossia 12 mm–16 mm; Class II, moderate ankyloglossia 8 mm–11 mm; Class III, severe ankyloglossia 3 mm–7 mm; and class IV, complete ankyloglossia <3 mm. The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) was developed as the quantitative assessment tool for the tongue-tie condition and accordingly its recommendation for treatment.[3],[12]

The surgical modality for lingual frenectomy using scalpels or scissors has been the conventional treatment approach for ankyloglossia patients. However, this modality has several disadvantages such as intraoperative bleeding, use of local anesthesia, need of suture, possibility of damage to adjacent important neurovascular structures and salivary ducts, prolonged and complex operative procedure, fear and apprehension associated with conventional surgery with scalpel and anesthetic injection needle, longer postoperative healing period and the need of post-operative antibiotics.[1],[4],[5],[8] Laser-assisted frenectomy has shown several benefits and advantages over traditional scalpel surgery.[1],[4],[5],[7],[8],[9],[10] It has been reported in a study that the patient's satisfaction with quality of oral and dental health care is essential aspect in dentistry.[13] Dental anxiety and fear in patients especially in pediatric patients have been a challenge for dental clinicians in providing the optimum oral health care in friendly and stress-free clinical environment.[14],[15] Treatments with conservative and minimally invasive modalities should be opted for reducing fear and anxiety and in which lasers can play a pivotal role.[9],[16] Furthermore lasers are considered as an essential component for minimal invasive dentistry approach.[9],[16]

Although literature demonstrates many articles regarding the use of diode lasers of various wavelengths for various oral soft-tissues procedures such as lingual frenectomy,[1],[4],[5],[7],[8],[17],[18] there are only few published articles in the existing literature regarding the diode laser of 808 nm wavelength for frenectomy procedure.[19],[20],[21],[22] The present article describes the clinical case report of successful and effective treatment of ankyloglossia using the soft-tissue diode laser in 10-year-old male patient. In addition, the anxiety/fear was assessed using the Facial image scale (FIS).[23] The evaluation of appearance and function of tongue-tie in the present case was done with the help of HATLFF.[3],[12] The manuscript of this case report has been prepared as per the CARE check-list of case reporting guidelines.

[TAG:2]Case Report[/TAG:2]

A 10-year-old male patient presented with a chief complaint of difficulty in speaking and pronouncing the words properly due to restricted tongue movements since early childhood. His medical and drug history was found nonsignificant. His dental history was not remarkable. His family and personal history was also found not significant. Psychosocial history revealed that patient used to remain lowered in confidence and also used to remain hesitant in making conversation with his peer groups in school because of speech problems.

On general examination, the patient was found healthy systemically. Extraoral examination revealed no any abnormal findings. Intraoral examination showed a short lingual frenulum at the ventral aspect of the tongue [Figure 1]a. The attachment of lingual frenum was up to the tip of the tongue on its ventral surface [Figure 1]a. Restricted tongue movements were seen. V-shaped notch was visible at the tip of the tongue on protrusion which confirmed the ankyloglossia or tongue tie condition [Figure 1]b. The length of the frenulum was measured using the periodontal probe and found to be 11 mm (Kotlow's Class-II: moderate ankyloglossia) [Figure 1]c.
Figure 1: Preoperative photographic images of ankyloglossia in a patient showing. (a) Shorter lingual frenulum and abnormal attachment extending up to tip of tongue on vetral surface. (b) V-shaped notched at the tip of tongue (heart-shaped appearance) on protrusive movement. (c) Height of lingual frenulum measured using the periodontal probe

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HATLFF was used to assess the appearance and functions of lingual frenulum. In the patient, the appearance item score was found to be 4, while function item score was found to be 7. HATLFF scoring confirmed the abnormal appearance with impaired functions of lingual frenulum in the patient and hence, suggested the treatment for tongue-tie. Mixed dentition stage was present. Oral mucosa was apparently normal. Oral hygiene status was fair. The patient showed cooperative and positive (+) behavior according to Frankl's behavior rating scale (1962).[24]

Based on the detailed history and oral examination findings, the diagnosis of nonsyndromic ankyloglossia was established. The patient's parents were informed about the diagnosis, prognosis and treatment options for the ankylogossia. Considering the patient's age and also the behavior management, the treatment plan included the excising the abnormal lingual frenulum using the diode laser under topical anesthesia. Written informed consent was taken from patient's parents. Hematological investigations (complete blood count, bleeding time, and clotting time) were advised and found normal. Tell-show-do method was employed as behavior management technique during the entire procedure for the pediatric patient.

All the necessary safety precautionary measures were followed during the laser-surgery procedure. First, the lingual frenum region was anesthetized using the topical anesthesia.

A diode laser of class-4 GaAlAs diode of wavelength 808 nm ± 10 nm (emitted wavelength = 808 nm) (Elexxion claros pico® Singen Germany) was used to perform laser-assisted lingual frenectomy procedure. The laser parameters settings were used such that pulse power: 5 W; pulse length: 26 μs; average output: 5 W; frequency: 20 Hz.

A fiber tip of 600 μm was used for conducting the laser beam in lingual frenectomy. The laser was applied in pulsed mode for excising the frenulum optimally in brushing strokes with the optical fiber tip was moved from the apex of frenulum to the base of the frenulum [Figure 2]. High-volume suction and evacuator system were used for laser-plume. Sufficient time intervals were given in between the laser-application to prevent the underlying tissue from thermal effects. Sterile wet gauze and cotton-pellet were applied intermittently to the operated region of the frenulum for cooling effect. Optimal care of orifices of ducts of submandibular and sublingual salivary glands was done. After completing the lingual frenectomy procedure, no suture was needed to place as no active bleeding was present. The whole laser surgery was accomplished within 8 min and caused no discomfort or pain to the patient.
Figure 2: Intraoperative images showing the application of diode laser for lingual frenectomy procedure

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The patient was comfortable throughout the laser-surgery procedure. The patient was sent to home with all the necessary postoperative instructions. The patient was advised to avoid hot, spicy, acidic, and sharp foods for initial 3–4 days postoperatively. No antibiotic was prescribed, only analgesic was suggested to take as and when required. Oral rinse with betadine was advised postoperatively. Meticulous oral hygiene was advised to maintain. The patient was instructed for periodic follow-ups for clinical evaluation of the healing process.

On follow-up visits, the patient was found asymptomatic and was satisfied with the treatment outcomes. On each clinical follow-up examination, healing was found progressive and excellent without any complications [Figure 3]a and [Figure 4]a. Tongue mobility was significantly improved after the laser-surgery of tongue [Figure 3]b and [Figure 4]b. The patient also had been advised for speech therapy which resulted in significant improvement in pronunciation and articulation of consonants, linguoalveolar, and linguopalatal sounds. The FIS demonstrated the patient's favorable dental behavior without any anxiety or fear for the laser-assisted frenectomy. The patient chose face 3, 2, and 1 out of five faces of the FIS during, after, and subsequent follow-up visits.
Figure 3: Postoperative clinical images after 24 h of laser-assisted frenectomy procedure showing the (a) optimum healing process of the operated site. (b) disappearance of V-shaped notch at the tip of tongue on protrusion

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Figure 4: Follow-up clinical images after 1 week of laser-assisted frenectomy showing the: (a) Excellent healing outcomes. (b) Significant improvement in the appearance and movements of the tongue

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  Discussion Top

The advent of lasers for the minimally invasive intervention therapeutic modalities is considered as the boon to the dentistry owing to its several benefits and advantages.[1],[25],[26] The AAPD recognizes the prudent use of laser as an advantageous instrument in oral and dental procedures for pediatric age group patients and also for patients with special health care needs.[27] Previous studies have shown that pediatric patients are more cooperative during restorative, endodontic, and surgical treatments using laser and thereby optimum dental care can be delivered to them.[28] The lasers such as CO2 laser, Er: YAG laser, Er, Cr: YSGG, Nd: YAG, and diode laser for frenectomy have been reported in literature.[10] Diode lasers are the most commonly used laser system in dentistry because of its versatility, reliability, and convenience, along with its handiness/portable and simple setting-up.[17],[18],[29] Diode lasers are available in various wavelengths near infra-red spectral zone for oral soft-tissue surgeries such as 635, 670, 808, 810, 830, 940, and 980 nm.[18],[19],[20],[21],[22],[29] The clinical use of diode laser of wavelength 808 nm in various oral soft-tissue surgeries has been reported in literature.[20],[21],[30],[31],[32]

The chromophore of diode lasers is colored (pigmented) tissues, mainly melanin, hemoglobin, and oxy-hemoglobin. Diode laser is safer, suitable, and well indicated for oral soft-tissue surgeries without harming the adjacent dental hard tissues because the specific wavelength of diode laser is poorly absorbed by dental hard tissues.[29] In the current case also, diode laser of wavelength 808 nm ± 10 nm (emitted wavelength = 808 nm) was used successfully and effectively for lingual frenectomy procedure. Similarly, previous studies have reported the successful use of the diode laser of particular wavelength 808 nm for frenectomy procedure.[19],[20],[21],[22] In the current clinical case, the diode laser application was found successful and satisfactory in various favorable intraoperative and postoperative clinical aspects of frenectomy. Similar clinical advantages of using diode laser for frenectomy have been reported in other studies.[8],[18],[19],[20],[21],[22],[33]

The multi-disciplinary approach has been suggested in literature which consists of lingual frenectomy, physiotherapy, logopedics, and phoniatrics.[5],[10] In the existing literature, there are no conclusive or definitive criteria regarding the timing (age of patient) for frenectomy.[7] However, treatment for tongue-tie should be done before the child develops aberrant swallowing and speech patterns.[7] However, when the frenectomy is carried out in older children, such children need adjunct speech therapy by speech-therapist in order to restore the tongue's normal movements or functions.[7] In the present case, as the patient was 10-year-old, speech therapy was suggested and that resulted in excellent favorable outcomes in improving significantly the patient's phonetics of linguo-alveolar sounds and linguo-palatal sounds and articulation of consonants like t, n, d and l, and r.

In the present clinical case report, HAATLF was found very helpful and valuable in evaluating the tongue-tie condition comprehensively. HATLFF helps in evaluating both the appearance and function of the lingual frenulum of the patient by observing the five appearance items and seven function items.[3],[12],[34],[35] Score 8 is maximum score for appearance items while 14 is the highest score for function items of lingual-frenulum.[12],[35] If function score is found to be 14 regardless of appearance score, no treatment is suggested. The function score of 11 is acceptable only when the appearance score is 10. However, the function item score of <11 indicates the impaired lingual frenulum. Furthermore, treatment for ankyloglossia is necessary if appearance item score is <8.[12],[35] In the present case, using the HATLFF the appearance item score was found to be 4, while function item score was found to be 7 which indicated the abnormal appearance and impaired functions of lingual frenulum and hence the treatment for tongue-tie was done. HATLFF has been described previously only in few published articles.[3],[30],[31],[35]

The various risks/hazards of using the lasers such as ocular hazards, tissue damage, respiratory hazards/environmental hazards, combustion hazards, and electrical hazards have been reported in literature.[36],[37],[38] The laser should be used safely in dentistry as per laser device's manufacturer's instructions and precautionary safety measures suggested by OSHA and ANSI guidelines.[18],[35],[37] The appropriate safety measures are essential for the application of dental lasers; such as wavelength-specific safety goggles should be worn by dental surgeon, assistant and patient during laser-surgery.[26],[29],[35],[37] High-volume suction, high-volume evacuation system, and high-efficiency filtration masks should be used in dental operatory to prevent cross-infection from laser plume.

  Conclusion Top

This case report showed the success and effectiveness of diode laser of wavelength 808 nm in performing the lingual frenectomy in a pediatric patient along with optimum healing outcomes and significant improvement in articulation of consonants with speech-therapy. HATLFF was found very helpful in clinically evaluating the tongue-tie comprehensively. Hence, Diode lasers of 808 nm wavelength can be used prudently as a safe and alternative surgical tool for managing tongue-tie in growing patients with minimally invasive dentistry approach.

Statement of informed consent

Written informed consent was obtained from the patient's parents for the anonymized information to be published in this article.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for the patient's images and other clinical information to be reported in the journal. The patient's parents understand that the patient's name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

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