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Case Report

Phonetic Rehabilitation by Speech Therapy Following Lingual

Frenectomy
Priya Gopal Shetty, Ramya R. Iyer
Department of Public Health Dentistry, KM Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Abstract
A patient named Miss. Ayesha Saiyad, 18‑year‑old female, reported to the Department of Public Health Dentistry after undergoing lingual
frenectomy for ankyloglossia, in the Department of Periodontics. As she was tutoring school students, she wanted improved clarity of her
speech. Through postfrenectomy speech therapy sessions, we aimed to rehabilitate the patient’s phonetics and improve her confidence in
performing her work. Speech therapy sessions included counseling, motivation for improved speech outcomes and exercises to improve the
range of the tongue movements. In the first visit, after recording the chief complaint and speech assessment it was noted that the patient’s
speech was comprehensible. However, problems were observed during production of speech sounds such as/l/,/ll/,/th/,/tha/and/r/. The patient
was diagnosed with a phonetic articulation disorder. Subsequently, the patient was advised to undergo speech therapy sessions. The counseling
session was carried out and tongue protrusion and elevation exercises were demonstrated with the aid of the mirror. The patient was advised
to practice the same at home. The patient was recalled after 1 week. Counseling was given and tongue elevation exercise holding water in the
tongue was taught to the patient. While exercise and rolling of tongue were taught to improve tongue mobility. There was an improvement in
tongue protrusion by 2 mm postspeech therapy. The patient was able to touch the palate with her tongue with mouth open, postspeech therapy.
There was improvement in production of speech sounds/l/,/ll/,/th/,/tha/and/r/. The patient’s speech significantly improved after speech therapy.

Keywords: Lingual frenectomy, phonetic rehabilitation, social stigma, speech therapy, tongue exercise

Introduction therapy patients, with special emphasis on speech improvement

The tongue plays a major role in pronouncing the consonants
by making contact with specific parts of the oral cavity which
are teeth, alveolar ridge, and hard palate.[1] Movement of the
tongue , such as, protrusion, elevation and grooving, with a
good range of mobility, is pivotal to sound production and
flawless phonetics.[2]
Case Report
The patient named Ayesha Saiyad, (case number: 1807090029)
18‑year‑old female, was diagnosed with ankyloglossia
Class  III  (according to Kotlow’s Classification)[3] in the
Department of Periodontics and after undergoing lingual
frenectomy reported to the Department of Public Health
Dentistry for counseling related to speech improvement. She
felt that her speech clarity needed to be improved, to pursue her
home tuitions more confidently. The principal investigator and
her guide had undergone training and observation of the speech
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DOI:
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in postfrenectomy done on ankyloglossia patients under the
guidance of speech pathologist Mr. Vikas Kumar, Assistant
Professor Audiology and Speech‑Language Pathology, Dhiraj
Hospital, Sumandeep Vidyapeeth for 15 days.
The patient expressed that after frenectomy, her speech
significantly improved, however, she needed professional help
to bring clarity in speech. The chief complaint of the patient
was recorded, preliminary speech assessment and tongue
movements were examined [Figure 1]. She was motivated to
undergo speech therapy including tongue movements which
were of significance in phonetics as well as intimacy functions.
On preliminary examination, it was noted that the patient’s
Address for correspondence: Dr. Ramya R. Iyer,
Department of Public Health Dentistry, KM Shah Dental College
and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India.
E‑mail: ramya83_r@rediffmail.com
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remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Shetty PG, Iyer RR. Phonetic rehabilitation
by speech therapy following lingual frenectomy. J Integr Health Sci
2020;8:25-8.
Received: 09-Oct-2019 Revised: 10-Jan-2020 Accepted: 28-Mar-2020 Available Online: 30-Jun-2020

© 2020 Journal of Integrated Health Sciences | Published by Wolters Kluwer - Medknow 25

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Shetty and Iyer: Speech therapy postlingual frenectomy
speech was comprehensible. A list of words was prepared in
the Hindi language as the patient was comfortable in Hindi.
During speech assessment, it was observed that patient
replaced the sound/l/and/ll/with the sound/da/, especially
when the sound/l/was at the end of words such as “ladla.”
The patient had difficulty in pronunciation of sound/th/and/
tha/when asked to speak the sentence “Thandi thaili leke aao”
and was unable to roll tongue to pronounce the sound/r/as in
American accent “river.”
The patient was diagnosed with speech sounds disorder
precisely phonetic  (articulation) disorder with distortion in
production of sounds/th/and/tha/and substitution of sound/l/
and/la/according to Bernthal et al.[4] classification of speech
disorders. When the patient’s maximum tongue protrusion and
maximum elevation were assessed, the patient was not able to
touch her palate with the tip of the tongue.
In the first speech therapy session, the patient was taught
the movements of tongue retraction, tongue protrusion and
tongue elevation with the aid of mirror [Figure 2] and lateral
movements of the tongue to the right and left corner of the
mouth  [Figure  3]. The patient was advised to practice the
exercise for five times a day.
After 1 week, the second session was planned for a domiciliary
visit; but due to privacy concerns, the patient denied for a
Figure 1: Counselling
Figure 3: Lateral tongue movement
26 Journal of Integrated Health Sciences  ¦  Volume 8  ¦  Issue 1  ¦  January-June 2020
domiciliary visit. Hence, the second session was arranged
in the Department of Public Health Dentistry, wherein
counseling session and assessment of improvement in a
speech in pronunciation of sound/th/,/tha/,/l/,/ll/and/r/were
carried out [Figure 4]. The exercise of holding water with the
tongue [Figure 5], whistling exercise and rolling of tongue was
taught, the patient was advised to practice the exercises every
day, and reinforcement was done through telephone once in a
week over a period of 1 month. Photographs and videos were
taken from the patient after obtaining written consent.
At the 1  month recall visit, the speech of the patient had
improved and was able to pronounce sound/th/,/tha/,/l/,/
ll/and/r/with clarity. Unlike the previous visit, the patient
was able to touch the palate with her tongue with mouth
open [Figures 6 and 7] and there was an improvement (2 mm)
in tongue protrusion from 4.2 mm to 4.4 mm as measured from
corner of the mouth to tip of the tongue.
Discussion
Major deviations in the articulate structure of sounds change
phoneme structure of the sound and are noticed but slight
deviations may go unnoticed as speech is still comprehensible.[5]
In the present case, the patient did not have any difficulty
in pronunciation of lingua‑alveolar  (/t/,/d/,/n/) and fricative
(/s/and/z/) sounds as they can be produced with very slight
Figure 2: Demonstration of sound production with the aid of a mirror
Figure 4: Tongue elevation assessment
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Shetty and Iyer: Speech therapy postlingual frenectomy

It has been recommended by Segal et al.[6] and Steehler et al.[7]

that, to improve the mobility of the tongue, the patients have
to practice nonspeech oral‑motor exercises.[6,7] Accordingly,
favorable outcomes could be appreciated in our patient’s
phonetics and extent of tongue protrusion and elevation after
the patient continuously practiced tongue exercises.
Chinnadurai et al.[8] reported that speech concerns were the
second most prevalent outcome described in the ankyloglossia
literature. A  longitudinal study reported that there is an
improvement in articulation after frenectomy treatment, but
the benefits of fluent speech warranted phonetic rehabilitation
in postfrenectomy patients.[8]
In our study, the patient was unwilling for domiciliary
counseling sessions. This reflects on the fact that there could
Figure 5: Holding water in the mouth be a stigma attached to undergoing speech therapy. Hence,
care should be taken regarding the respect of privacy in speech
therapy.[9]
The prognosis of speech therapy for individuals after
frenectomy is solely based on the self‑interest of an
individual.[2] Speech therapy should be an integral part of the
treatment plan in patients indicated for lingual frenectomy due
to ankyloglossia. Phonetic rehabilitation in this case not only
restored speech function but also limited social embarrassment
and vocationally rehabilitated the individual.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient has given her
consent for her images and other clinical information to be
reported in the journal. The patient understands that name
and initials will not be published and due efforts will be made
Figure 6: Preoperative tongue elevation to conceal the identity, but anonymity cannot be guaranteed.
Acknowledgement
1. Authors acknowledge the guidance of Dr. Vikas Kumar,
Speech Pathologist, Assistant Professor (ENT Department
of Audiology and Speech Language Pathology, Dheeraj
Hospital, Vadodara) for his guidance
2. We also thank the Dr.  Dhwani Vyas  (Periodontist)
for timely referral of case for phonetic rehabilitative
management
3. We also thank Faculty of Department of Public Health
Dentistry and Department of Periodontics, KM Shah
Dental College and Hospital, Sumandeep Vidyapeeth, for
their support.
Financial support and sponsorship
Figure 7: Postoperative tongue elevation Nil.

tongue elevation and can be generated with little distortion

Conflicts of interest
There are no conflicts of interest.
even if the tongue tip is held down. However, the alveolar ridge
requires to be elevated in the production of linguo‑alveolar
sound/l/l/, lingua‑palatal sound/r/and lingua‑dental sound/th/
References
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in the production of those sounds. 2. Sudarsan S, Iyer VH. A comprehensive treatment protocol for lingual

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Shetty and Iyer: Speech therapy postlingual frenectomy

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