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Ankyloglossia (tongue-tie): A diagnostic and treatment quandary Lawrence A. Kotlow, DDS

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<ul><li>Introduction </li></ul><ul><li>Tongue is an important oral structure that affects speech, position of teeth, periodontal tissue, nutrition, swallowing and nursing. </li></ul><ul><li>Ankyloglossia (tongue-tie) limits the range of motion of the tongue, impairing the ability to fulfill its functions. </li></ul><ul><li>Ankyloglossia is a common congenital anolmaly that is usually detected soon after birth. It is characterised by partial fusion or in rare cases, total fusion of the tongue to the floor of the mouth due to an abnormality of the lingual frenulum (Kummer, A. 2005, Dec 27. Ankyloglossia:To clip or not to clip? That’s the question. The ASHA Leader, 10 (17), 6-7, 30) </li></ul><ul><li>Frenum, connects a moveable part to a fixed part and stabilises the part from undue movement </li></ul><ul><li>Lingual frenum, stabilises the base of the tongue without interfering with the tongue tip movt. </li></ul><ul><li>In ankyloglossia, frenum has an anterior attachment and may be unusually short causing virtual adhesion of the tongue tip to the floor of the mouth </li></ul>

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<ul><li>Incidence </li></ul><ul><li>- Incidence varies widely </li></ul><ul><li>- Ranges between 0.02 to 5% ( Kupietzy, botzer, Pediatric Dentistry, 27:1,2005 ) </li></ul><ul><li>Incidence varies from 1.7-4.8% ( Deshmukh V.Ankyloglossia. Pediatric Oncall [serial online] 2007 [cited 2007 December];4. </li></ul><ul><li>Male/ female ratio is 3:1, with no racial predilection </li></ul><ul><li>Assoc with syndromes like Opitz syndrome, orofacialdigital syndrome, Beckwith-Wiedemann syndrome etc. </li></ul><ul><li>Etiology </li></ul><ul><li>During early development, the tongue is fused to the floor of the mouth. Cell death and resorption free the tongue, with the frenulum left as the only remnant of the initial attachment. Tongue-tie is the result of a short fibrous lingual frenulum or a highly attached genioglossus muscle (Messner AH, Lalakea LM, Aby J, Macmahon J, Bair E. Ankyloglossia: Incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg 2000;126:36-9) </li></ul>

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<ul><li>Complications </li></ul><ul><li>Feeding problems-approx 25% of newborns with ankyloglossia have feeding problems. As the child grows older, he may have difficulty moving a bolus in the oral cavity and clearing food from the sulci and molars. This leads to chronic halitosis and dental decay ( Ankyloglossia:To clip or not to clip? That’s the question. The ASHA Leader, 10 (17), 6-7, 30) </li></ul><ul><li>Dentition- causes a pulling effect on the gingiva away from the teeth and even cause a mandibular diastema. Usually occurs after 8-10 years </li></ul><ul><li>Cosmetics- looks abnormal and tongue has a forked or serpent look </li></ul><ul><li>Speech- usually /l/ sounds and interdental sounds like /th/ are affected because of the restricted movt of the tip </li></ul>

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<ul><li>Classification of ankyloglossia </li></ul><ul><li>Free tongue- length of tongue from the inside of the lingual frenum into the base of the tongue to the tip of the tongue. </li></ul>Source: Ankyloglossia (tongue-tie) : A diagnostic and treatment quandary, Lawrence A. Kotlow, DDS, Quintessence Intl 1999; 30: 259-262

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<ul><li>A groupd of 322 children ranging from 18months to 14years were examined for the length of free tongue and then evaluated for clinical evidence of speech and oral problems. Assesment of these measurements resulted in the development of the above descriptions and categories of ankyloglossia. </li></ul><ul><li>Structural guidelines in determining if the frenum required revision. A normal range of motion of the tongue is indicated by the following criteria: </li></ul><ul><li>The tip of the tongue should be able to protrude outside the mouth without clefting </li></ul><ul><li>The tip of the tongue should be able to sweep the upper and lower lips easily, without straining </li></ul><ul><li>When the tongue is retruded, it should not blanch the tissue lingual to the anterior teeth </li></ul>

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<ul><li>4. The tongue should not place excessive forces on the mandibular anterior teeth </li></ul><ul><li>5. The lingual frenum should allow a normal swallowing pattern </li></ul><ul><li>6. The lingual frenum should not create a diastema between the mandibular central incisors </li></ul><ul><li>7. In infants, the underside of the tongue should not exhibit abrasion </li></ul><ul><li>8. The frenum should not prevent an infant from latching during nursing </li></ul><ul><li>9. Children should not exhibit speech difficulties associated with limitations of the movement of the tongue </li></ul>

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<ul><li>Clinical assessment </li></ul><ul><li>Infants </li></ul><ul><li>Inspection of the tongue and its functions at the first dental visit </li></ul><ul><li>Parents should be advised regarding the presence and severity of AG and made aware of the potential feeding, speech and dental problems </li></ul><ul><li>The clinician should examine the tongue’s appearance when its lifted as the infant cries or tries to extend the tongue. </li></ul><ul><li>While lifting, the frenum should be palpated and its elasticity determined </li></ul><ul><li>Attachment of the frenum to the tongue should normally be approx. 1cm posterior to the tip </li></ul><ul><li>The frenum’s attachment to the inf. Alv. Ridge should be proximal to or into the genioglossus muscle on the floor of the mouth </li></ul><ul><li>The mother should be interviewed regarding the infants’s ability to breastfeed </li></ul>

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<ul><li>Preschool/school-age patient </li></ul><ul><li>AG does not prevent or delay the onset of speech, but may interfere with articulation </li></ul><ul><li>A simple speech articulation test has been suggested by Williams WN, Waldron CM </li></ul><ul><li>If the elevation of the tongue tip is restricted, the articulation of l or more of the tongue sounds– such as “t”, “d”, “l”, “th”, and “s”– will not be accurate </li></ul><ul><li>Patients who can produce these sounds accurately are probably not candidates for surgical correction and should be referred to a speech pathologist for evaluation </li></ul><ul><li>Several suggestions made in literature regarding a systematic protocol for AG assessment, lingual function and need for surgical correction. </li></ul><ul><li>Hazelbaker developed an assessment tool to quantify the funtion and appearance of tongue in infants with AG </li></ul><ul><li>Kotlow introduced a simple classification, measuring the “free tongue” , can be used in infants and older patients </li></ul>

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<ul><li>Lalakea recommended measuring lingual mobility in children and tongue elevation to document and define the degree of restriction and AG </li></ul><ul><li>Mobility is evaluated by measuring in mm the tip of the tongue extended past the lower dentition </li></ul><ul><li>Elevation is measure by recording interincisal distance with the tongue tip maximally elevated and in contact with the upper teeth. </li></ul><ul><li>Typically, children with AG have protrusion and elevation values of 15mm or less, and 20 to 25 mm or greater in normal children </li></ul>

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<ul><li>Treatment </li></ul><ul><li>Frenotomy technique </li></ul><ul><li>Defined as the cutting or division of the frenum </li></ul><ul><li>May be accomplished without LA and with minimal discomfort to the infant </li></ul><ul><li>The parent or an assistant hold and stabilises the head, infant is placed supine with the elbows held securely close to the body </li></ul><ul><li>The tongue is lifted gently with sterile gauze and stabilised exposing the frenum. This may be achieved by the placement of 2 gloved fingers of the clinician’s left hand placed below the tongue upward and toward the palate and exposing the frenum </li></ul>

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<ul><li>The incision begins at the frenum’s free border and proceeds posteriorly, adjacent to the tongue. This is necessary to avoid injusry to the more inferiorly placed submandibular ducts in the floor of the mouth </li></ul><ul><li>each cut provides some release, allowing improved retraction and visualization for subsequent cuts. </li></ul><ul><li>Care is taken not to incise any vascular tissue </li></ul><ul><li>Crying usually limited to the time of restraining </li></ul><ul><li>Feeding may be resumed immediately and acetaminophen mey be used for pain control </li></ul><ul><li>Antibiotics not necessary </li></ul><ul><li>Follow up in 1 to 2 weeks should show complete healing of the incision </li></ul>

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<ul><li>Frenectomy </li></ul><ul><li>Defined as the excision or removal of the frenum </li></ul><ul><li>Preferred procedure for patients with a thick and vascular frenum where severe bleeding may be expected, and in some cases, reattachment of the frenum by scar tissue may occur. </li></ul><ul><li>Procedure in young children performed under GA, in older children and adults under LA </li></ul><ul><li>Frenum is released ina similar manner as in frenotomy </li></ul><ul><li>Wound is sutured </li></ul>

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<ul><li>Discussion </li></ul><ul><li>22% of a around of 425 North American Pediatricians who responded to a survey indicated that they had performed frenotomies, although only 10% reported that they have been taught the technique in residency (Lalakea ML, Messner AH. Ankyloglossia: Does it matter? Pediatr Clin North Am 2003;50:381-397) </li></ul><ul><li>This should encourage dentists not familiar with the procedure to study the technique and incorporate into their practice </li></ul><ul><li>Complications of frenotomy include infection, excessive bleeding, recurrent AG due to excessive scarring, new speech disorders developing postoperatively, and glossoptosis (tongue “swallowing”) due to excessive tongue mobility </li></ul><ul><li>One incident of a life threatening complication has been reported by Walsh F, Kelly D in 1995 (Partial airway obstruction after lingual frenotomy, Anesth Analg 1995;80:1066-1067) </li></ul>

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<ul><li>References </li></ul><ul><li>Ankyloglossia (tongue-tie): A diagnostic and treatment quandary. Lawrence A. Kotlow, DDS, Quintessence Intl 1999;30:259-262 </li></ul><ul><li>Ankyloglossia in the Infant and Young Child: Clinical Suggestions for Diagnosis and Management. Ari Kupietzky, DMD, MSc, Eyal Botzer, DMD, Pediatric Dentistry 2005;27:40-46 </li></ul><ul><li>Kummer, A. (2005, Dec. 27). Ankyloglossia: To clip or not to clip? That's the question. The ASHA Leader, 10 (17), 6-7, 30 </li></ul><ul><li>Deshmukh V.Ankyloglossia. Pediatric Oncall [serial online] 2007 [cited 2007 December];4. Available from: http://www.pediatriconcall.com/fordoctor/diseasesandcondition/ PEDIATRIC_SURGERY/ankyloglossia.asp </li></ul><ul><li>Ankyloglossia Incidence and Associated Feeding Difficulties Anna H. Messner , MD; M. Lauren Lalakea , MD; Janelle Aby , MD; James Macm ah on , MD; Ellen Bair, MS, PNP Arch Otolaryngol Head Neck Surg. 2000;126:36-39. </li></ul><ul><li>Ankyloglossia: a morphofunctional investigation in children.Oral Diseases. 11(3):170-174, May 2005. Ruffoli, R 1; Giambelluca, M A 1; Scavuzzo, M C 1; Bonfigli, D 2; Cristofani, R 3; Gabriele, M 2; Giuca, M R 2; Giannessi, F 1 </li></ul><ul><li>Ankyloglossia and breastfeeding Canadian Paediatric Society (CPS) Paediatrics & Child Health 2002; 7(4), 269-70Reference No. CP02-02 Reaffirmed February 2007 </li></ul><ul><li>Lauren M. Segal MD Randolph Stephenson PHD Martin Dawes MB BS MD FRCGP Perle Feldman MD FCFP Prevalence, diagnosis, and treatment of ankyloglossia Methodologic review </li></ul><ul><li>June 2007, Canadian Family Physicians </li></ul>