Ankyloglossia in a Pseudo-Class III Malocclusion: A Case Report

Ankyloglossia in a Pseudo-Class III
Malocclusion: A Case Report
Abstract
This case report describes a 14 year old female patient, with pseudo-Class III incisor
relationship on a mild Class III skeletal base with ankyloglossia. It highlights the
relationship of an unfavorable soft tissue environment exerted by “tongue tie” and
genetic factors proposed by the presence of family history in the development of a
Class III malocclusion. Orthodontic treatment was provided on, a non-extraction basis
to correct the Class III relationship. The patient was then referred for labial and lingual
frenectomy using laser surgery to stabilize the achieved correction and facilitate the
wear of orthodontic retainers by the patient. The first annual review carried out at the
age of 17 years has revealed stable results.
Keywords: Ankyloglossia, Pseudo Class III, Frenectomy.
Salwa Jeragh Alhaddad
BChD, MFDS RCSI, MSc
Orthodontics, M’Orth
RCSEng.
Specialist Orthodontist at Ameri
Hospital and Kuwait University
Kuwait
drjeragh@hotmail.com
Mohammed Alnoori
BDS, MS
Senior Specialist Periodontist at
Ameri Hospital
Kuwait
Manar Alnoori
BDS, MFDS, MGD
Ameri Dental Center
Kuwait
Introduction
The etiology of malocclusions has been the subject of a long standing debate in the
orthodontic literature.1 The role of both genetic and soft tissue factors has been well
established. Monozygotic twin studies suggested a complex interplay between the two
factors.2,3 Successful management of orthodontic patients is dependent on accurate
identification of all etiological factors involved in the development of the malocclusion.
With an estimated incidence of 4.8%4 ankyloglossia is a congenital anomaly in which
the mucous membrane under the tongue is too short, limiting the mobility of the
tongue. The condition varies in the degree of its severity from mild mucous membrane
bands to complete tethering of the tongue to the floor of the mouth. Patients with
ankyloglossia frequently suffer from feeding, cleaning and swallowing difficulties,5
with the later being associated with anterior open bite due to a constant forced tongue
thrust.6
Despite the lack of strong evidence, the constant forward tongue position has also been
implicated, as a factor contributing to the establishment of a Class III malocclusion.7
Diagnosis and Aetiology
A 14 year old female patient, with no relevant medical history, presented to our clinic
with a chief complaint of upper midline diastema and inability to bite. Extraorally, the
patient presented with a mild Class III skeletal pattern, slight maxillary hypoplasia,
flattening of the malar base and increased lower anterior facial height.
The family history revealed a genetic component towards Class III jaw relationship,
with similar presenting features of the malocclusion evident in the patient’s father.
The condition, however, was further complicated by the presence of ankyloglossia.
Intraorally, she had a generally well aligned dentition with a 2mm maxillary midline
diastema associated with a prominent labial frenum.
In occlusion, the patient had a Class III incisal relation, with reverse overjet of 3mm
following a displacement from an initial edge to edge incisal relation (centric relation to
centric occlusion). The overbite was adequate with a 50% vertical overlap of the lower
incisor. Canines and Molars were also in Class III relation. Ankyloglossia was evident,
and the lower centre-line was displaced 2mm to the right of the patient’s mid-facial line
due to mandibular shift on maximum intercuspal position.
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Pre Orthodontic Extraoral Views
Pre Orthodontic intraoral Views
A
B
C
D
E
F
G
H
I
J
(Picture 1) A: Initial facial view, B: Initial facial view with a smile, C: Initial 3-4 view, D: Initial lateral profile view, E: Initial
incisal relation in centric relation, F: Initial incisal relation in centric occlusion, G: Initial right buccal segment in occlusion,
H: Initial left buccal segment in occlusion, I: Initial occlusal view of the lower arch, J: Initial occlusal view of the upper arch.
Cephalometric analysis confirmed a mild skeletal III
pattern (ANB= -3 degrees), mild maxillary hypoplasia
(Angle SNA=76 degrees), normal mandibular length,
and dental compensation through retroclination of the
lower labial segment (Angle LIMP=84 degrees) (Figure 1
& Table 1).
(Table 1)
(Fig. 1) Patient’s lateral cephalogram tracing prior to
orthodontic treatment.
Measurement
Value
Norm
Standard deviation
SNA
77˚
81˚
+/-2˚
SNB
79˚
79˚
+/-2˚
ANB
-2˚
3˚
+/-1˚
UIMP
109˚
113˚
+/-6˚
LIMP
84˚
92˚
+/-6˚
IIA
139˚
135˚
+/-11˚
MMPA
30˚
24˚
+/-2˚
SnMax
10˚
8˚
+/-3˚
LAFH
57%
55%
+/-2%
Rationale for Treatment
Elimination of the forward mandibular posture was
considered; to eliminate the risks of incisal attrition, root
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resorption due to occlusal trauma, and reduce the stress
on the tempomandibular joint as a result of repeated
forward mandibular displacement.
Correction of the lower centerline by eliminating
the lateral mandibular displacement to the right on
maximum intercuspal position, to enhance dental and
facial aesthetics.
Space closure within the maxillary arch was considered
to give favorable aesthetics despite the added difficulty in
Class III correction.
Both patient and parents were informed, that patient’s
co-operation in wearing Class III elastics played a key
role in treatment success. Whilst the adverse effects of
further forward mandibular growth were fully explained.
Post Orthodontic intraoral Views
Post Orthodontic Extraoral Views
Labial and lingual frenectomies using laser surgery were
recommended to eliminate any potential role of these
soft tissues in the etiology of the patient’s malocclusion,
to help stabilize the orthodontic treatment outcome and
to facilitate the wearing of retainers.
A
B
Treatment
The patient was treated on a non-extraction basis,
keeping orthognathic surgery as a valid treatment option
should future growth dictate it. Treatment objectives
were, to close the spaces within the maxillary arch, and
eliminate forward mandibular displacement.
Upper and lower fixed appliances of MBT prescription,
with a 0.022 inch bracket slot were bonded with the four
first molars banded using Andrew’s prescription due to
their characteristic lingual torque to maintain the molar
relation.
Treatment Results
The patient completed the orthodontic treatment in 23
months at the age of 16 years. Complete space closure
with correction of the incisal relation were achieved
enhancing the existing dentoalveolar compensation.
The mandibular shift was eliminated successfully and
the patient and parents were happy with the treatment
outcome.
Following debond, the patient was referred to undertake
C
D
E
F
G
H
I
(Picture 2) A: Facial view, B: Facial
smile, C: 3-4 view, D: Lateral profile
view, E: Anterior view of the dentition in
occlusion, F: Right view of the dentition
in occlusion, G: Left view of the dentition
in occlusion, H: Lower occlusal view, I:
Upper occlusal view.
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laser frenectomy for the labial and lingual frenal
attachments. Signs of healing were evident on the next
day review and salt water mouth rinses in conjunction
with routine tooth cleaning were advised.
Upper and lower Begg style, wrap around retainers were
A
B
augmented with local anaesthesia for more severe
cases as required. Laser surgery eliminates the need for
general anaesthesia but it is essential that the patient
is cooperative and remains motionless throughout the
procedure. The procedure offers virtually no bleeding,
with reduced reported pain and risk of infection.
The “pseudo” nature of the Class III relationship in this
case, may suggest a stronger influence of the soft tissue
over the inherited genetics.
However, it is very difficult to draw conclusions based
on the presenting findings in isolation, regular reviews
of future growth, as well as the stability of the achieved
correction, are the only ways to determine the roles
played by soft tissues and growth in the etiology of the
malocclusion seen in this case.
Cephalometric analysis at the first annual review at the
age of 17 years, revealed a stable enhancement of the
dental compensation presented initially at 14 years of
age, with a 3 degrees increase in the upper incisor to
maxillary plane angle (109 to 112 degrees, 8 degrees
of retroclination of the lower labial segment with regard
to the mandibular plane (84 to 76 degrees) and stable
skeletal features and vertical proportions. (Figure 2 &
Table 2).
(Picture 3) A: Anterior view one day post laser labial
frenectomy, B: Lower occlusal view one day post laser
lingual frenectomy.
The stability observed in this case may suggest a
potential relation between the unfavorable soft tissue
“tongue tie” and the Class III malocclusion seen in this
case.
given to the patient emphasizing the importance of full
time wear and the need for regular reviews until growth
ceases. At the age of 17, the patient attended her first
annual post-orthodontic treatment review with a stable
treatment outcome.
Discussion
This case report highlights the role of both genetic
influence proposed by the patient’s family history, as well
as the role of unfavorable soft tissue environment exerted
by ankyloglossia, in the development of a pseudo-Class
III skeletal pattern in a 14 year old female patient.
While accepting milder cases of ankyloglossia
remains a common option, particularly if there was
a lack of patient’s concern, surgical intervention
may be considered in more severe cases. Different
types of surgical procedures have been described
in the literature. However, case selection remains
the key to successful management. Surgical partial
frenectomy, complete frenectomy, revision frenoplasty
or electrocautery procedures have all been described.8
More recently, however, laser surgery has been used
to relieve ankyloglossia.9,10 Topical gel analgesia has
been recommended for this procedure which may be
(Fig. 2) Patient’s lateral cephalogram tracing after
orthodontic treatment.
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(Table 2)
Measurement
Value
Norm
Standard deviation
SNA
76˚
81˚
-1˚
SNB
79˚
79˚
0˚
ANB
-3˚
2-4˚
-1˚
UIMP
112˚
113˚
+3˚
LIMP
76˚
92˚
-8˚
IIA
142˚
135˚
+3˚
MMPA
30˚
24˚
0˚
SnMax
10˚
5-11˚
0˚
LAFH
57%
55%
0%
Conclusion
The coexistence of both genetic “family history”
and soft tissue “tongue tie’’ factors and their
association with the development of Pseudo Class
III malocclusion has been highlighted in this case
report. Special emphasis is placed on the need
for accurate diagnosis, elimination of unfavorable
features and regular reviews of future growth,
as these are regarded as keys to successful
management.
References
1. Subtelny JD. Malocclusions, orthodontic corrections
and orofacial muscle adaptation. Angle Orthod.
1970;40(3):170-201.
2. Kawala B, Antoszewka J, Necka A. Genetic or environment?
A twin-method study of malocclusions. World J Orthod.
2007;8(4):405-10.
3. Jena AK, Duggal R, Mathur VP, Parkash H. Class III
malocclusion: Genetic or environment? A twin study. J Indian
Soc Pedod Prev Dent. 2005;23(1):27-30.
4. Messner AH, Anna H, Lalakea M, et al., Ankyloglossia:
Incidence and associated feeding difficulties.
Otolaryngology–Head and Neck Surgery. 2000;126:36-9.
5. Messner AH and Lalakea ML, The effects of ankyloglossia on
speech in children. Otolaryngology-Head and Neck Surgery.
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9. Kotlow LA. Using the Erbium: Yag Laser to correct an
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journal of the Academy of Laser Dentistry. 2004;12(3):22-3.
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