the impact of restricted oral frenula on oral structure
TRANSCRIPT
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The Impact of Restricted Oral Frenula on Oral Structure, Function, Feeding & Articulation Linda D’Onofrio, MS, CCC-SLP [email protected] February 22, 2016
Agenda • 6:30-‐6:40 Introduc0on & Disclosures • 6:40-‐7:00 Iden0fying oral restric0ons • 7:00-‐7:20 Evalua0on Considera0ons • 7:20-‐7:40 Referral Criteria • 7:40-‐8:00 Treatment Op0ons • 8:00-‐8:20 Case Studies • 8:20-‐8:30 Ques0ons
My Disclosures • I am a prac0cing clinician and paid lecturer and I receiving an honorarium for this presenta0on.
• I am affiliated and a paid presenter for the Academy of Orofacial Myofunc0onal Therapy.
• I am affiliated and an unpaid member of the American Speech Language Hearing Associa0on and the Academy of Applied Myofunc0onal Sciences.
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My clinical experience & scope of practice • Structural & Sensory-‐Motor Based Speech Disorders • Craniofacial Disorders & CleQ Palate • Dysarthria – childhood & adult • Dyspraxia – childhood & adult • Poor coordina0on & low tone • Poor sensory feedback • StuWering
• Feeding, Swallowing & Oromyofunc0onal Therapy • Social-‐Cogni0ve Therapy for Au0sm & Asperger’s • Developmental Speech & Language • Family Communica0on Support
My Contentions • Most medical and dental providers do not properly check for restricted oral frenula. This results in poor early interven0on and preven0on of a number of disorders.
• Because our caseloads can be highly specialized, we may not appreciate the long term affects of unaddressed tongue 0e and lip 0es.
• Few people know who to refer for evalua0on, proper diagnosis, surgery if required, and post procedure treatment.
Learning Objectives • Iden0fying oral restric0ons • Review the recent research & protocols available • Evalua0on Considera0ons • Referral Criteria • Treatment Op0ons • Case Studies
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Identifying Oral Restrictions • Frenum is a fold of 0ssue inside the oral cavity which connects structures like the lip, tongue and buccal musculature to the alveolar bone. The frenums in the oral cavity include the maxillary midline frenum, mandibular midline frenum, the right and leQ upper and lower buccal frenums and the lingual frenum. The primary func0on of the frenum is to keep a balance between the growing bones, the tongue and the lip musculature during the development of the foetus and limit the movement of the muscular 0ssues like the lip, tongue and cheeks.
• More frequently discussed frenal anomaly in the literature is thick fibrous labial frenum, which causes maxillary midline diastema. Abnormal aWachment of lingual frenum, called as ankyloglossia, is a congenital anomaly characterized by short lingual frenum. (Northcup 2009).
Identifying Oral Restrictions
• Ankyloglossia is a congenital condi0on characterized by an abnormally short, thickened, or 0ght lingual frenulum that restricts mobility of the tongue. While it can be associated with other craniofacial abnormali0es, it is most oQen an isolated anomaly. It variably causes reduced tongue mobility and has been associated with func0onal limita0ons in breasdeeding, swallowing, ar0cula0on, orthodon0c problems including malocclusion, open bite, and separa0on of lower incisors, mechanical problems related to oral clearance, and psychological stress. (Francis et al 2014)
Identifying Oral Restrictions • Anterior ankyloglossia is defined as tongue 0es with a prominent lingual frenulum and/or restricted tongue protrusion with tongue 0p tethering. The diagnosis of posterior ankyloglossia is considered when the lingual frenulum was not very prominent on inspec0on but is thought to be 0ght on manual palpa0on or is found to be abnormally prominent, short, thick, or fibrous cord-‐like with the use of the grooved director. Although treatment is similar in anterior and posterior cases, posterior ankyloglossia is more subtle in presenta0on. Posterior ankyloglossia is more likely to require revision surgery due to the rela0ve difficulty of accurate diagnosis and treatment. In essence, posterior ankyloglossia is under-‐recognized compared to the anterior variant. (Francis et al 2014)
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Marchesan 2012
Lawrence Kotlow, DDS
Identifying Oral Restrictions
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Lawrence Kotlow, DDS
Marchesan 2014
Marchesan 2014
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Marchesan 2012
Evaluation Considerations for Lingual Restriction • Structure
• Func0on
• Behavior
• Other Observa0ons
Structure • Frenum placement • Anterior, Midblade, Posterior
• Quality of tendon • Thickness, Rigidity, Depth
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Function • Tip Eleva0on & Retrac0on • Blade Eleva0on • Lateraliza0on • Protrusion & Retrac0on • Jaw Involvement • Ability to clear molars & buccal cavi0es
• Poor func)on Is not limited to ankyloglossia
Behavior • Low forward rest posture • Tongue thrust swallow • Inefficient or messy ea0ng; Grazing; Nega0ve behaviors around food
• Oversaliva0on; Drooling • Using fingers to clear food • Excessive jaw involvement • Poor ar0cula0on
Other Observations • Malocclusions • Incisor flaring • Open bite
• Molar cavi0es • Lesions on buccal aspects of teeth • Facial and TMJ pain in older pa0ents • Poor self image
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Referral Criteria for Labial Restriction
• Diastema between incisors • Rotated incisors • Recessed gums at incisors • Dental decay at incisors • Pocke0ng liquids at foods in anterior ves0bules
Treatment Options for Lingual Restricion • Stretching program no surgery
• Surgery no stretching program
• Stretching program, surgery, stretching program
Referral Criteria for Lingual Restriction • Anterior placement • Inflexible tendon • Stretching has not improved func0on • Obvious jaw involvement for lateraliza0on, eleva0on, 0p mobility
• Tongue is falling in airway when sleeping • High arched palate secondary to poor lingual-‐palatal suc0oning • Molar cavi0es • Lingual gum recession • Forward head posture • Co-‐occurring face or neck pain • Nega0ve impact on feeding or oral care • Nursing, messy ea0ng, debris, fa0gue
• Ar0cula0on Errors • R & L, Backing, Mumbling, Jaw is liQing tongue
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Frenectomy Referral • Otolaryngologists
• Pediatric Den0sts
• Oromaxillofacial Surgeons
Ferres-‐Amat et al 2016 • A descrip0ve study of healthy pa0ents, without any diagnosis of syndrome, ranging between 4 and 14 years that have been surgically treated and rehabilitated post-‐surgery within a period of 2 years.
• 101 frenectomies and lingual plas0es have been performed and pa0ents have been treated following the protocol of ac0on that we hereby present. AQer the surgical interven0on, the degree of ankyloglossia has been improved, considering correc0on in 29 (28%) of the pa0ents (95% CI: 20%, 38%), reaching, with the post-‐surgical orofacial rehabilita0on, a correc0on of 97 (96%) of the par0cipants (95% CI: 90%, 98%).
Ferres-‐Amat et al 2016 • The treatment of choice for ankyloglossia is the frenectomy and lingual plasty associated to lingual myofunc0onal rehabilita0on. Myofunc0onal rehabilita0on begins one week before the surgical interven0on, and the pa0ent is explained the lingual praxis that will be carried out in the following weeks. The objec0ve of this protocol is that the pa0ent learns the exercises without pain. The results of our study demonstrate that the surgical technique of frenectomy with rhomboid plasty, the pa0ent improves its lingual mobility. If this is reinforced with rehabilita0on exercises and good pa0ent collabora0on, the results are excellent. (Ferrés-‐Amat E, et al. 2016)
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Treatment Goals for Improved Lingual Function • Stability • Elevated to the rugae/alveolar ridge at rest and during swallows
• Mobility • Full range of mo0on; Reaching behind back molars
• Typical Func0oning • Using the tongue like a finger; Differen0ated movement from jaw
Typical Functioning • Tip Eleva0on & Retrac0on • Blade Eleva0on • Lateraliza0on • Protrusion & Retrac0on • Circumlocu0on • Differen0ated movement from jaw
Post Frenectomy Stretching • Typical func0on is not automa0c • Maladap0ve behaviors need be retrained • Tendon & muscle can reaWach • The age of the pa0ent and the type of frenectomy dictates post procedure stretching • Infants – wait un0l wound heals before aggressive stretching • Children & adults – dependent of if sutures are used
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Guilleminault & Akhtar 2014 • All our children with short mandibular frenulum had an associa0on with SDB when seen untreated between 2 and 6 years of age. They all had a narrow and high hard palate. (Guilleminault & Akhtar 2014).
• Example of a short frenulum in a child that presented with speech difficul0es early in life and developed SDB associated with a narrow hard palate. The abnormally short structure limits normal movements of the tongue and keeps it in an abnormally low set posi0on when at rest. While the child had orthodon0c treatment for his abnormal maxillary growth, the presence of his short frenulum was not recognized. It impaired successful results of orthodon0a due to its con0nued restric0on of tongue movements as indicated by persistence of high apnea-‐hypopnea-‐index (AHI) at polysomnogram (PSG).
Case Studies
Additional Current Research
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US Government AHRQ 2015 • Systema0cally reviewed the literature on surgical and nonsurgical treatments for infants and children with ankyloglossia andankyloglossia with concomitant lip-‐0e.
• Included 58 unique studies comprising 6 randomized controlled trials (RCTs) (3 good, 1 fair, 2 poor quality), 3 cohort studies (all poor quality), 33 case series, 15 case reports, and 1 unpublished thesis. Most studies assessed the effects of frenotomy (a procedure in which the lingual frenulum is divided) on breasdeeding-‐related outcomes.
US Government AHRQ 2015 • Four studies reported improvements in breasdeeding efficacy using either maternally reported or observer ra0ngs, while two RCTs using observer ra0ngs found no improvement. Mothers consistently reported improved breasdeeding effec0veness aQer frenotomy, but outcome measures were heterogeneous and short term.
• Pain outcomes improved for mothers of frenotomized infants compared with control in one study of 6-‐day old infants but not in studies of infants a few weeks older.
• Three studies with significant limita0ons reported improvements in other feeding outcomes with frenotomy.
• Four poor-‐quality studies reported some improvements in speech ar0cula0on but mixed results related to overall speech sound produc0on.
• Minor and short-‐term bleeding following surgery (Francis, et al 2015)
Huang et al 2015 • A retrospec0ve study of prepubertal children referred for suspicion of obstruc0ve sleep apnea, found 27 subjects with non-‐syndromic short lingual frenulum. The children had findings associated with enlarged adenotonsils and/or orofacial growth changes.
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Huang et al 2015 • Children with untreated short frenulum developed abnormal tongue func0on early in life with secondary impact on orofacial growth and sleep disordered breathing (SDB). AQer presence of SDB, analysis of treatment results revealed the following: • The apnea-‐hypopnea index (AHI) of children with adenotonsillectomy (T&A) performed without frenectomy improved, but surgery did not resolve fully the abnormal breathing. Similar results were noted when frenectomy was performed simultaneously with T&A. Finally, frenectomy on children two years or older without enlarged adeno tonsils also did not lead to normaliza0on of AHI. The changes in orofacial growth related to factors including short lingual frenulum lead to SDB and mouth-‐breathing very early in life.
• Recogni0on and treatment of short frenulum early in life—at birth, if possible—would improve normal orofacial growth. Otherwise, myofunc0onal therapy combined with educa0on of nasal breathing is necessary to obtain normal breathing during sleep in many children.
Meenakshi S & Jagannathan N (2014) • This study was performed to analyze the lingual frenal lengths in skeletal class I, class II and Class III malocclusion and to correlate rela0onship between both.
• The lingual frenum was found to be longest in class III malocclusion, with a sta0s0cal significant value of p<0.01. The class II and class I malocclusion did not show much difference. The maximum mouth opening posi0on was also increased in class III malocclusion, followed by class II and class I malocclusion, in a descending order.
• The lingual frenum exerts erra0c forces and a long lingual frenum pushes the mandibular anteriors forwards, resul0ng in malocclusion. Hence, a rela0onship between the lingual frenum and malocclusion is essen0al, so that the erra0c forces can be eliminated and excellent results can be achieved, following the correc0on of malocclusion.
Additional Resources
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Bibliograhy • Acevedo AC, da Fonseca JA, Grinham J, Doudney K, Gomes RR, de Paula LM, Stanier P.
2010. Autosomal-‐dominant ankyloglossia and tooth number anomalies. J Dent Res. 2010; 89(2):128–32.
• Ferrés-‐Amat E, Pastor-‐Vera T, Ferrés-‐Amat E, Mareque-‐Bueno J, Prats-‐Armengol J, Ferrés-‐Padró E. (2016) Mul0disciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Medicina Oral, Patología Oral y Cirugía Bucal Jan 1;21(1):e39-‐47.
• Francis DO, Chinnadurai S, Morad A, Epstein RA, Kohanim S, Krishnaswami S, Sathe NA, McPheeters, ML. 2015.Treatments for Ankyloglossia and Ankyloglossia with Concomitant Lip-‐Tie [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 May. Report No.: 15-‐EHC011-‐EF. AHRQ Compara0ve Effec0veness Reviews.
• Guilleminault C, Akhtar F (2015). Pediatric sleep-‐disordered breathing: New evidence on its development. Sleep Medicine Reviews. 2015 Dec;24:46-‐56. doi: 10.1016/j.smrv.2014.11.008. Epub 2014 Dec 4.
• Huang YS, Quo S, Berkowski JA, Guilleminault C (2015) Short Lingual Frenulum and Obstruc0ve Sleep Apnea in Interna0onal Journal of Pediatric Research1:003
• Marchesan, I.Q. 2012 Lingual Frenulum Protocol. The Interna0onal Journal of OrofacialMyology , v. 38, p. 89-‐103.
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Bibliography • Meenakshi S, Jagannathan N (2014). Assessment of lingual frenulum lengths in
skeletal malocclusion. Journal of Clinical and Diagnos0c Research Mar;8(3):202-‐4. doi: 10.7860/JCDR/2014/7079.4162. Epub 2014 Mar 15.
• NorthcuW ME. 2009. The lingual frenum. J Clin Orthod. 2009; 43(9):557–65. • Olivi G, Signore A, Olivi M, Genovese MD (2012). Lingual frenectomy: func0onal
evalua0on and new therapeu0cal approach. European Journal of Paediatric Den0stry. 2012, Jun;13(2):101-‐6.
• Segan LM, Stephenson S, Dawes M. Feldman. 2007. Prevalence, diagnosis, and treatment of ankyloglossia. Methodologic review. Can Fam Physician. 2007; 53:1027–33.
• Srinivasan B, Chitharanjan AB(2013). Skeletal and dental characteris0cs in subjects with ankyloglossia. Progress in Orthodon0cs. 2013 Nov 7;14:44. doi: 10.1186/2196-‐1042-‐14-‐44.
Websites
• hWp://www.kiddsteeth.com/ar0cles/websiteWlnbew.pdf
• hWp://www.rdhmag.com/ar0cles/print/volume-‐35
• hWp://tongue0e.net/the-‐book/
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