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INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(1): 48-51

REVIEW ARTICLE

Tongue Tie: From Confusion to Clarity-A Review

H.E. Darshan, P.M. Pavithra

Abstract Ankyloglossia, or tongue-tie, is the result of a short, tight, lingual frenum causing tethering of the tongue tip. The prevalence of ankyloglossia has been reported in several studies, but there is neither an accepted criterion standard nor clinically practical criteria for diagnosing the condition. This review article aims at bringing all the compilation in examination, diagnosis treatment and management of tongue tie together for the better clinical approach. Key words: Tongue Tie, Ankyloglossia, Frenectomy, Frenulum, Z- plasty. Received on: 12/12/2010 Accepted on: 12/01/2011 Introduction Tongue tie or ankyloglossia is a developmental anomaly of the tongue characterized by an abnormally short, thick lingual frenum resulting in limitation of tongue movement. It can be categorized into 2 types. Total ankyloglossia is rare and occurs when the tongue is completely fused to the floor of the mouth. Partial ankyloglossia is variable and encompasses the remainder of the cases.(1) The incidence of tongue tie varies from 0.2% to 5% depending on the population examined. The incidents among outpatients of a children hospital with breast-feeding problems was almost 3%. Two independent studies have shown a significant predilection for male child.(2) This may also occur with increased frequency in various syndromes including Smith-Lemli-Opitz syndrome,(3) Orofacial digital syndrome, Beckwith Weidman syndrome, Simpson-Golabi-Behmel syndrome(4) and X linked cleft palate.(5) Consequences of not treating the tongue tie are;(6) Dental caries: Dental caries can occur due to food debris not being removed by the tongues action of sweeping the teeth and spreading saliva. Open bite due to thrust created by being tongue-tied. Due to long term tongue trust lower incisors show periodontitis and also tooth mobility. Appearance: The tongue can be unduly obvious or unusual looking in some individuals, improper chewing and swallowing of food can increase the gastric distress and bloating. Snoring and bed wetting at sleep is common among tongue tied children. Oral play: Children in particular may not be able to participate in play routines involving tongue movements and gestures. Self-esteem: It has been noted clinically that occasionally an older child or adult will be

self-conscious, embarrassed or resentful about their tongue tie that they may be teased by their peers for their anomaly. Nipple pain: An infant with tongue tie may experience difficulty latching on to the nipple and may compress the nipple against the gum resulting in pain. Mothers experiencing pain may often try shifting the baby to a bottle. Clinical assessment in infants: A through intra oral examination should be performed on the infant. Parents should be made aware of potential feeding speech and dental problems. The clinician should examine the tongue appearance when the tongue is lifted. The attachment should normally be approximately 1cm posterior to the tongues tip and to inferior alveolar ridge it should be proximal to genioglossus muscle on the floor of the mouth.(7) Mothers should be interviewed regarding the infants ability to breastfeed. Does infant demonstrate frustration at the breast feed? Does the mother experience pain or discomfort while the infant nurse? If any of the factors are present, a lactation specialist should be consulted. Kotlows Classification based on free tongue length.(8)
Normal range of free tongue > 16mm Class I: mild ankyloglossia = 12-16mm Class II: moderate ankyloglossia = 8-11mm Class III: sever ankyloglossia = 3-7mm Class IV: complete ankyloglossia < 3mm

Clinical assessment in preschool/school age patients: There is lack of scientific evidences providing a true relationship between tongue tie and speech disorder. In case of tongue tie the sounds such as t,d, l, th and s will not be accurate. In certain patients where speech is delayed, the parents may demand surgical correction in the hope of normal speech and

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language. In these patients audiological and neurodevelopmental factors may be the etiological factors. Such patients surgical repairs should be delayed until appropriate diagnosis is made.(8) A systematic protocol for tongue tie assessment, lingual functions and need for surgical correction can be made using Hazel bakers assessment tool(Table 1).(2)
Function Appearance Lateralization Tongue when lifted 2=complete 2= round or square 1=body of the 1= slight cleft in the tongue appearance 0=none 0= heart shaped Lift of tongue Elasticity of the frenum 2= tip to mid mouth 2=very elastic 1= only edges to mid 1= moderately elastic mouth 0= little or no elastic 0= tip stays at alveolar ridge Extension of tongue Length of the frenum 2=tip over lower lip when tongue lifted 1= tip over lower 2=>1cm or embedded in gum tongue 0= neither of the 1=1cm above or mid tongue 0=<1cm hump Spread of anterior Attachment of lingual tongue frenum to tongue 2= complete 2= posterior to tip 1= moderate or 1= at tip partial 0= <1cm 0= little or none Cupping of the Attachment of frenum to tongue inferior alveolar ridge 2= entire edge, firm 2= attached to floor of the cup mouth well below ridge 1= side edges only, 1= attached just below the moderate cup ridge 0= poor or no cup 0= attached at the ridge Peristalsis 2= complete anterior to posterior 1=partial originates at posterior to tip 0= none or reverse peristalsis Snap back 2=none 1= periodic 0= frequent or with each suck Table 1 Hazelbaker assessment tool for lingual frenum function(9) Scoring 14= perfect score, 11= acceptable if appearance items score is 10<11= function impaired, Frenotomy is necessary if function score is <11 and appearance score is <8.

A free tongue measurement both in older patients and infants can be measured using kotlows classification.(8) It is been suggested that, given the minor nature of the surgery and significant potential for speech difficulties and later social and mechanical problems it may be appropriate to consider surgery for children with significant tongue tie at any age including infants and toddlers who have yet to demonstrate overt symptoms.(2) Treatment options such as Observation, speech therapy, frenotomy without anaesthesia, frenectomy under general anaesthesia and Z plasty(10) which is more complex and require sutures have all been suggested in the literature. Snipping (frenotomy(11)): If the only goal is to improve breastfeeding, snipping the tie in infancy would be the obvious solution. No anesthetic is needed, it is relatively cheap, the infant's pain is slight, bleeding is negligible, and feeding improves immediately. However, when ankyloglossia is associated with foreshortening of the genioglossus muscle, as often occurs, merely snipping the lingual frenum may not allow free and coordinated movement of the tongue sufficient for the demands of a gradually growing speech and language structure. As a result, further surgery may legitimately be needed later. Therefore, the possibility that reevaluation of the situation might become appropriate later, should be emphasized Frenotomy Procedure: It is the procedure where frenum is cut or divided. It is accompanied without anaesthesia and with minimal discomfort in infants. The parent or assistant holds the head and stabilizes. The infant is made to sit supine to prevent tongue from falling back. The tongue is held with gauze and lifted gently, and then two gloved fingers of clinicians left hand are held under the tongue to lift and support tongue. The frenum is then divided using small sterile blade at the thinnest portion. Occasionally complete release may be accomplished with a single cut. However when the frenum is quiet tight 2-3 sequential cuts are required for retraction.(12)Since the frenum is poorly vascularized and innervated it is at the clinicians advantage to use this simple procedure without any complications. After the procedure, feeding may be resumed immediately and is without apparent discomfort. No specific follow up care is required. Parents should be advised that post-operative white fibrin clot might be seen to form at the incision site during the first couple of days, and they should be reassured that it is part of healing process and not

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to mistake for an infection. Follow up in 1-2 weeks should show that the incision is completely healed. Frenectomy procedure: Frenectomy is the procedure for the patients with thick and vascular frenum where severe bleeding may be expected and in some cases reattachment of the frenum by scar tissue may occur. The procedure in young children is performed under general anaesthesia. Older children and adults may tolerate the procedure under local anaesthesia alone. The frenum is released in the same manner as frenotomy although occasionally limited division of genioglossus may be required for adequate release.(10-12) Z plasty technique as described by Kaban is slightly more complex procedure but has an advantage of also lengthening the scar and providing an increased potential for the post-operative tongue mobility.(13) Here the releasing incision is placed one on the superior boarder of frenum and other on the inferior boarder in opposite directions. The two flaps are raised and then interchanged, so that the length of the frenum is increased. For the Z-frenuloplasty, most of patients showed at least 2orders of improvement in speech, and showed complete resolution of articulation errors. Z-frenuloplasty was superior to the horizontal to vertical frenuloplasty with respect to tongue lengthening, protrusion, and articulation improvement for patients with symptomatic ankyloglossia. Laser Surgery: Erbium: YAG lasers and diode lasers are becoming extensively utilized. Er: YAG is relatively new option and is suitable for neonates, older children and adults. Compared to diode laser or CO2 laser the Er; YAG does not need general anaesthesia when used, but an analgesic gel might be applied. The procedure is very quick, taking only 2 to 3 minutes to perform, but some cooperation from the patient in keeping still is required. There is virtually no bleeding, no pain, no risk of infection and the healing period can be as short as 2 hours. It is best to have this procedure performed by a specialist in the area of laser dentistry who is familiar with tongue tie revision. The patient returns for speech therapy in 2 days.(14) Revision by Electrocautery: This method does not require a general anaesthetic and can be performed as an outpatient service with a local anaesthetic. Hence, it is an economical and safe option which can be used to revise mild tongue ties, i.e. when blood vessels are not heavily involved, and tethering of the tie

is not extensive. Its proponents describe it as a viable office-based procedure in cases of mild Ankyloglossia.(15) Second Revision: Some tongue ties are much more severe than others and may require more than one procedure to completely release the tongue. This is uncommon, but not unknown and a later operation can deliver completely successful release. The purpose of Post-operative exercises: Post-operative exercises following tongue-tie surgery are not intended to increase muscle-strength, but to: 1. Develop new muscle movements, particularly those involving tongue-tip elevation and protrusion, inside and outside of the mouth. 2. Increase kinaesthetic awareness of the full range of movements the tongue and lips can perform. In this context, kinaesthetic awareness refers to knowing where a part of the mouth is, what it is doing, and what it feels like. 3. Encourage tongue movements related to cleaning the oral cavity, including sweeping the insides of the cheeks, fronts and backs of the teeth, and licking right around both lips. The prevalence of pain in mothers breastfeeding infants with ankyloglossia is much higher than that reported in mothers breastfeeding normal infants and clearly presents a considerable problem in terms of continuing breastfeeding. Intensive breastfeeding support is often inadequate for relieving breastfeeding difficulties in babies with ankyloglossia. Despite the fact that speech impediment is rare never less for the mere purpose of dental toilette, oral and buccal hygiene, gesture and even future intimacy functions every child deserves the privilege to be able to protrude his/her tongue.(12) Conclusion Optimal management of tongue tie including timely and appropriate surgical intervention followed by speech therapy when indicated has the capacity to deliver pleasing results, often in a shorter time than expected. Development of a concise, practical, standardized, validated tool for diagnosing ankyloglossia and a decision rule for surgical corrections are important for further research.
Authors Affiliations: 1. Dr. H.E.Darshan, M.D.S, Assistant Professor, Department of Pedodontics , JSS Dental College and Hospital, S.S.Nagar, Mysore, 2. Dr. P.M.Pavithra, B.D.S, Savinaya Dental Clinic, Somwarpet, Coorg District, India. References 1. Neville B, Damm D, Allen CM, Bouquot J. Developmental defects of the oral and maxillofacial region. Oral and Maxillofacial

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Pathology Philadelphia: WB Saunders2008:6957. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002; 110 (5):e63. Meinecke P, Blunck W, Rodewald A, Opitz JM, Reynolds JF. Smith Lemli Opitz syndrome. American Journal of Medical Genetics 1987; 28 (3): 735-9. Neri G, Gurrieri F, Zanni G, Lin A. Clinical and molecular aspects of the Simpson Golabi Behmel syndrome. American Journal of Medical Genetics 1998;79(4):279-83. Braybrook C, Doudney K, Marano ACB, Arnason A, Bjornsson A, Patton MA, Goodfellow PJ, Moore GE, Stanier P. The T-box transcription factor gene TBX22 is mutated in Xlinked cleft palate and ankyloglossia. Nature Genetics2001;29(2):179-83. Messner AH, Lalakea ML. Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology 2000; 54(2-3):123-31. Warden P. Ankyloglossia: a review of the literature. General dentistry1991;39(4):252-3. Kotlow L. Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence International 1999;30(4):259-62. Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF): Use in a lactation

consultant private practice: Pacific Oaks College; 1993. 10. Heller J, Gabbay J, O'Hara C, Heller M, Bradley JP. Improved ankyloglossia correction with fourflap Z-frenuloplasty. Annals of Plastic Surgery 2005; 54(6):623. 11. Newkirk G. Tongue-tie snipping (frenotomy) for ankyloglossia. Procedures for Primary Care Physicians 1st ed St Louis, MO: Mosby-Year Book Inc1994:287-90. 12. Knox I. Tongue Tie and Frenotomy in the Breastfeeding Newborn. Neo Reviews 2010; 11 (9):e513. 13. Kaban LB. Intraoral Soft Tissue Abnormalities. Pediatric oral and maxillofacial surgery1990:123. 14. Gontijo I, Navarro RS, Haypek P, Ciamponi AL, Haddad AE. The applications of diode and Er: YAG lasers in labial frenectomy in infant patients. Journal of Dentistry for Children 2005; 72(1):10-5. 15. Tuli A, Singh A. Monopolar diathermy used for correction of ankyloglossia. Journal of Indian Society of Pedodontics and Preventive Dentistry 2010; 28(2):130. Address for correspondence Dr. H.E.Darshan, M.D.S, ADC (PERTH), Assistant Professor, Department of Pedodontics , JSS Dental College and Hospital, S. S. Nagar, Mysore 570015, India. Email:dashi_us@yahoo.com

Source of Support: Nil, Conflict of Interest: None Declared

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