Tongue Tie Surprise: Releasing the Tongue to Correct Systemic and Occlusal Disfunction

Functional and airway disorders are commonly implicated as causative factors or aggravating factors in dental malocclusion. Although many authors make statements to this effect, treatment recommendations for these problems are widely varied. We, as dentists, focus on the dental occlusion and the face, but airway and functional disorders have vast reaching systemic effects on the body, and dental malocclusion is just one of the many. Both upper airway obstruction and tongue-ties have been implicated as driving factors in forward head posture also known as craniocervical extension. In the following case, both were present for the patient named Alex.

Learning to recognize the manifestations of these disorders will help us to more successfully treat orthodontic patients who suffer from them rather than fighting a malocclusion that is functionally driven and then watching it relapse after treatment. Informing patients and parents of patients about these disorders can allow radical changes in a person’s wellness and quality of life.

What is remarkable in young patients is the immediate postural effect of a mandibular lingual frenectomy after surgery. The challenge is to maintain the benefits during the healing phase.

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CLINICAL ANALYSIS

Alex received his orthodontic evaluation at my office after being referred from another practice. At that time, he was 11.7 years old. His medical history revealed that he was born prematurely, with a birth weight of 2 pounds and 13 ounces. He was placed on supplemental oxygen until he was six months old, and currently suffers from ADHD. At his orthodontic evaluation, it was noted that he is a mouth breather with a severely collapsed posture. (Figs. 1–3)

The photographs (Figs. 1–3) also show other effects such as a right head cant, forward shoulder rotation, hands that follow the shoulders rather than rest comfortably at one’s side, a collapsed chest area, ears postured low and flared, open mouth posture, very low facial tone, cervical dysfunction, and tenderness of the muscles of mastication. Alex’s upper airway obstruction was so severe that plugging his nose during his examination caused him no distress at all!

A few questions about his sleep experience revealed restless sleeping with lots of flopping around during sleep, occasional enuresis and consistently waking up tired in the mornings.

His dental examination revealed “V” shaped dental arches, which were narrow anteriorly and nearly normal in width in the molar regions, causing a lack of room for his permanent canines to erupt into his arches. (Fig. 4) His right molars were Class I and his left molars were Class II; the anterior bite was moderately deep. His tongue posture was low with a Mallampati grade 3 soft palate architecture.

The left TMJ appeared distalized concentric to the glenoid fossa on radiographic images. (Fig. 5) During the examination, Alex reported occasional popping noises while chewing firm foods such as meats.

CEPHLAMETRIC ANALYSIS

Cephalometric analysis with the Sassouni+B analysis revealed:

  1. Skeletal Class I platform.
  2. Clockwise tendency in the growth pattern.
  3. Retruded upper and lower incisors with low interincisal angulation, and
  4. Normal A-P position of the maxilla and the mandible.

TREATMENT OBJECTIVES

Phase 1 treatment goals for Alex included the following:

  • Improve his nasal breathing.
  • Restore his posture.
  • Stabilize the left TMJ.
  • Expand the upper and lower dental arches.
  • Reevaluate his mouth breathing, posture, sleep and ADHD symptoms

Phase 2 treatment goals for Alex included:

  • Straight wire series.
  • Guidance of the canines into the dental arches.
  • Opening the deep bite.
  • Correction of the dental malocclusion to a Class I.

TREATMENT PLAN

Before beginning Phase I, it was recommended that Alex begin utilizing saline nasal drops to improve his nasal airway and be seen for allergy evaluation to determine if any allergies were contributing to and aggravating his nasal obstruction. He was also referred to physical therapy to work on his posture restoration, cervical and shoulder dysfunction and improper breathing. Once this was resolved, he would then be fitted with an upper RPE Hyrax appliance with reverse pull face gear arms to advance the maxilla this should help to alleviate the distalizing postural effect on the mandible and especially the left TMJ. The lower arch will be fitted with a Williams expander, which would be activated with a key in similar fashion to the Hyrax appliance. The upper Hyrax appliance was to be activated once a day, and the lower Williams appliance will be activated twice a week. My preference is to activate the upper appliance 12 turns for 3 mm in sequential days, then pausing to allow the lower arch to catch up on its schedule of twice a week turns. This keeps the arches coordinated and avoids crossbites and scissors bites being introduced during the expansion phase. Once the lower arch has caught up to the upper arch, another similar expansion phase is repeated until the desired expansion is achieved in each arch based on pre-operative arch width analysis and visual evaluation on orthodontic recall.

CASE SUMMARY AND ANALYSIS

Phase I orthodontic treatment began with expansion of the upper arch and the lower arch. An RPE Hyrax with reverse pull (RP) arms was used on the upper arch (Fig. 6) and on the lower arch a Williams expander was used. (Fig. 7) The goal for upper expansion was the 8 mm dimension of the expansion screw with the lower to follow.

Reverse pull face gear was dispensed with instructions. At Alex’s first re-evaluation during his expansion phase, he complained that his tongue was very sore. At that time, a severe mandibular lingual frenum was noted which had been abraded by the lower Williams appliance causing the discomfort. A lower lingual frenectomy was recommended and performed with a diode laser and follow-up tongue exercises were dispensed.

In my practice today, I would not perform a lingual frenectomy without preoperative myofunctional therapy and myofunctional therapy during the healing and restorative phase for the tongue, as reattachment and scarring are a significant problem without appropriate therapy. Nevertheless, at the time, without having a myofunctional therapist as a resource, the treatment was given to the best of our ability as the tongue needed an immediate release to allow his dental expansion to continue.

Alex was to be monitored once a month for progress, but with cancellations, he did not return for 10 weeks at which time he had maxed out the upper appliance and was in a complete scissors bite. Although this can be a scary moment at the return exam, he was instructed to reverse the upper appliance for 14 days and continue with the normal activation of the lower appliance. Within six weeks, the problem was corrected. Next, the U2-2 was bonded to allow an upper .016TN wire to be placed with OCS to prepare room for the U3’s. (Figs. 8-9) Alex had begun his physical therapy for shoulder and posture restoration at this point in treatment. There was a significant uprighting of the cervical and head posture after the initial frenectomy in combination with his physical therapy. With time, however and lack of proper myofunctional therapy, Alex’s lingual frenum redeveloped as scar tissue formed and his forward head posture began to relapse. At his next visit, the frenectomy was revised and the procedure was performed again. From this point following the second frenectomy, Alex did his exercises faithfully. (Figure 10a-10b)

What was remarkable were the changes that occurred to his posture immediately after the second release and in the weeks following the second release. His head posture uprighted dramatically and his mouth breathing transitioned to nasal breathing in combination with his maxillary and mandibular expansion. (Figs. 11a–11e)

The first photograph is the preoperative profile (Fig. 11a), the second photo is after the first lingual frenectomy and physical therapy (Fig. 11b), the third photo is after relapse of the lingual frenum (Fig. 11c), the fourth photo is immediately after the second release procedure (Figure 11d), and the fifth photo is two weeks after the second frenectomy procedure with Alex performing his tongue stretching exercises, (Fig. 11e).

After the lower arch was expanded, a lower Wilson lingual arch was placed. (Figs. 10–11). I prefer the lower Wilson appliance due to its simple removal with a dental scaler without removing the cemented bands. It is also very helpful for increasing or decreasing the arch width based on treatment progress and needs for the patient. His Hyrax was removed and the upper and lower arches were banded and bonded and .018N archwires were placed. (Figs. 12-13) Next, the deep bite began to be addressed with a lower .018S omega loop archwire with tie back and reverse curve, which was successively increased at later visits with the addition of Incisal blocks on the lingual of the U1’s to further open the vertical dimension and the dental deep- bite. Alex progressed up the archwire sequence up to 19x25TN (Figure 14) and finally an upper 19x25S keyhole wire and an upper 19x25S archwire on the lower arch. That was to correct 1mm of Class II molar relationship on each side and with the use of Class II elastics to the lower 5 and 6, to open the deep bite further, (Figure 15). His appliances were removed at the next visit, (Fig. 16). Final panoramic and cephalometric x-rays were then taken, (Figs. 17 & 18).

Alex’s treatment lasted 26 months with expansion and straight wire series. His dental arches developed very well, and Alex was one of the first patients that really brought the issue of tongue-tie to my attention. His case sparked an interest to learn more to be able to help patients who suffer from ankyloglossia, which affects far more than the tongue. His postural restrictions were released and his deformed posture largely corrected itself as his deep bite was opened, (Figs. 20 – 23). Both the expansion appliances and tongue tie release enhanced his airway and resolved his mouth breathing (Fig. 19), further improving his posture and should pay dividends on his sleep, well-being and quality of life!

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