ISSN 0975-8437
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
tongue’s 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 tongue’s 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.
Kotlow’s 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 patient’s 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
baker’s 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.
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A free tongue measurement both in
older patients and infants can be measured using
kotlow’s 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
clinician’s 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
clinician’s 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
INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(1): 48-51
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 mother’s
breastfeeding infants with ankyloglossia is much
higher than that reported in mother’s
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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2.
3.
4.
5.
6.
7.
8.
9.
INTERNATIONAL JOURNAL OF DENTAL CLINICS 2011:3(1): 48-51
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, Marçano 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:[email protected]
Source of Support: Nil, Conflict of Interest: None Declared
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