• Pathophysiology of Ankyloglossia
• Causes of Ankyloglossia
• Symptoms of Ankyloglossia
• Diagnosis of Ankyloglossia
• Treatment of Ankyloglossia
• Next steps

Ankyloglossia is a congenital condition characterized by an abnormally short, thickened, or tight lingual frenulum, or an anterior attachment of the lingual frenulum, that restricts the mobility of the tongue.^[rx] It variably causes reduced anterior tongue mobility and has been associated with functional limitations in breastfeeding; swallowing; articulation; orthodontic problems, including malocclusion, open bite, and separation of lower incisors; mechanical problems related to oral clearance; and psychological stress.

Ankyloglossia, also known as tongue-tie, is a short lingual frenum that interferes with normal tongue movement. Prevalence has been estimated to be from less than 1% to 10%. This significant wide range can be attributable to the lack of diagnostic criteria for tongue-tie.[rx][rx][rx][rx]

Pathophysiology of Ankyloglossia

There is no standard definition of ankyloglossia, and multiple classifications exist. When examined, the ‘free tongue’ length in newborns should be greater than 16 mm. Measurements of less than 11 mm indicate moderate ankyloglossia and less than 7 mm indicates severe ankyloglossia. However, this measurement may not be useful in infants. The term posterior ankyloglossia is used when the frenulum is attached at the middle to the posterior aspect of the undersurface of the tongue. Taking into consideration the anatomy and function, there are many assessment tools for classification.

One of them is the Hazelbaker Assessment for Lingual Frenulum Function. This tool uses a scoring system using anatomy and function.

• Anatomy: Appearance of the tongue when lifted, the elasticity of frenulum, length of lingual frenulum when tongue lifted, attachment of lingual frenulum to tongue and attachment of lingual frenulum to the inferior alveolar ridge
• Function: Lateralization, a lift of tongue, an extension of the tongue, spread, cupping of the tongue, peristalsis, snap-back

It consists of 10 points for frenulum appearance and 14 points for tongue function.

Causes of Ankyloglossia

A genetic cause of ankyloglossia has been reported as X linked cleft palate syndrome. A gene mutation on TBX22 causes this.

Symptoms of Ankyloglossia

Signs and symptoms of tongue-tie include:

• Difficulty lifting the tongue to the upper teeth or moving the tongue from side to side
• Trouble sticking out the tongue past the lower front teeth
• A tongue that appears notched or heart shaped when stuck out

Diagnosis of Ankyloglossia

History and Physical

The clinical presentation of symptomatic ankyloglossia varies; however, the biggest concern, as well as research and data collection, focus on breastfeeding difficulties that include prolonged feeding, difficulty latching, and irritability while feeding. These all lead to poor weight gain. During breastfeeding periods, it has also been reported that mothers with infants with these conditions have a higher risk of significant nipple pain, which could lead to frustration and the start of formula feeding in newborns. With the American Academy of Pediatrics campaign to exclusively breastfeed babies up to 6 months of age, ankyloglossia and its management have gained more attention due to the difficulties that babies encounter when breastfeeding is attempted.

There are concerns that ankyloglossia can persist beyond the neonatal period. While some authors describe the possibility of speech-related issues due to decreased tongue mobility, others disagree. However, concerned parents frequently ask their pediatricians about future problems with articulation. As the speech develops, some children may exhibit difficulties with the sounds of several letters or a combination of letters: l, r, t, d, n, z, th, and sh. It is quite difficult to predict which patients will have articulation problems, or if in fact, this association exists.

Other reported problems in patients with ankyloglossia include difficulty eating certain foods that include licking (ice cream), playing certain wind instruments (examples include flutes, clarinets, tubas, trumpets), and orthodontic problems (open bite and malocclusion).

Among complications, self-esteem and psychological issues can also be a concern in patients with tongue-tie.[rx][rx]

The Coryllos ankyloglossia grading scale is a system for noting the type of tongue-tie.

• Type I: The frenulum is thin and elastic, and anchors the tip of the tongue to the ridge behind the lower teeth.
• Type II: The frenulum is fine and elastic, and the tongue is anchored 2 – 4 millimeters from the tip to the floor of the mouth close to the ridge behind the lower teeth.
• Type III: The frenulum is thick and stiffened, and anchors the tongue from the middle of the underside to the floor of the mouth.
• Type IV: The frenulum is posterior or not visible, but when touching the area with the fingertips, the examiner can feel tight fibers anchoring the tongue, with or without a thickened, shiny surface on the floor of the mouth.

Evaluation

Making the diagnosis for ankyloglossia is not difficult. However, management has many controversies, and it can be very confusing for parents, and they seek different opinions. The best approach for any physician who encounters this issue is to weigh the benefits for the patient. If the condition is not causing any problems during the neonatal period, observation is the best treatment option. If other causes of difficulty feeding have been ruled out, then a frenotomy can be offered as a treatment option. Only a trained and qualified healthcare provider should do this procedure. Regarding those patients who present with articulation problems, the decision is more difficult, and evaluation and therapy with a speech pathologist can be recommended.

Treatment of Ankyloglossia

The biggest question for physicians dealing with patients with ankyloglossia remains whether to treat or not to treat. There is evidence that supports treatment in symptomatic patients.[rx][rx][rx][rx][rx]

When physicians choose treatment over observation, frenotomy is the most commonly used procedure. This procedure is quick and can be done in an outpatient setting.

The procedure involves holding the tongue up to make the frenulum tight, then cutting through the fascia-like tissue along a line parallel with, and close to the tongue. The cut is made in a single motion as is done very quickly, less than a second. The infant is restrained by swaddling or in a Papoose board, with an assistant holding the child’s head for better support. The timing of frenotomy varies from 6 days to 18 days of age. In a study of 200 infants undergoing frenotomy without analgesia, researchers found that 18% cried during the procedure and 60% after the procedure. According to an article titled Do tongue ties affect breastfeeding? by Griffiths, the mean crying time for frenotomy was 15 seconds. Some physicians choose to give sucrose before the procedure, to minimize and help with pain. Rarely the frenulum grows back.

Before deciding to treat patients with tongue tie, physicians should keep in mind other differential diagnoses that could present with feeding difficulties and failure to gain weight. A lactation nurse should always be involved in the care and assessment of these patients and to help mothers with feeding techniques.

Risk and complications of frenotomy are uncommon but have been described. Bleeding is the most common and usually resolved with local pressure. A family history of bleeding disorders should be assessed before the procedure, and in older patients, a history of bleeding should be elicited.

Another procedure used to treat ankyloglossia is frenuloplasty. However, it is rarely performed, and it does require general anesthesia.

A systematic review published in Pediatrics Journal 2015 titled Treatment of Ankyloglossia for Reasons Other Than Breastfeeding: A Systematic Review by Sivakumar Chinnadurai, MD mentioned some data points to the fact that there is no need for treatment. However, since the short frenulum will likely elongate spontaneously with use and stretching, there is no sufficient data to support this statement. In this particular review, authors concluded that among children with ankyloglossia, there is limited evidence to suggest intervention for this condition, and there is not enough data to support that frenotomy is associated with positive outcomes in other issues besides breastfeeding.

Surgery

on-surgical treatments for ankyloglossia are typically performed by Orofacial Myology specialists, and involve using exercises to strengthen and improve the function of the facial muscles and thus promote the proper function of the face, mouth, and tongue ^[rx]

Intervention for ankyloglossia does sometimes include surgery in the form of frenotomy (also called a frenectomy or frenulectomy) or frenuloplasty. This relatively common dental procedure may be done with soft-tissue lasers, such as the CO₂ laser.^[rx] However, authors such as Horton et al. ^[rx] are in opposition to it. According to Lalakea and Messner, surgery can be considered for patients of any age with a tight frenulum, as well as a history of speech, feeding, or mechanical/social difficulties. Adults with ankyloglossia may elect the procedure. Some of those who have done so report post-operative pain.

A viable alternative to surgery for children with ankyloglossia is to take a wait-and-see approach.^[rx] Ruffolo et al. report that the frenulum naturally recedes during the process of a child’s growth between six months and six years of age.^[rx][rx]

Key Questions

We synthesized evidence in the published literature to address the following Key Questions (KQs):

KQ 1. What are the benefits of various treatments in breastfeeding newborns and infants with ankyloglossia intended to improve breastfeeding outcomes? Surgical treatments include frenotomy (anterior and/or posterior), frenuloplasty (transverse to vertical frenuloplasty), laser frenulectomy/frenulotomy, and Z-plasty repair. Nonsurgical treatments include complementary and alternative medicine therapies (e.g., craniosacral therapy), lactation intervention, physical/occupational therapy, oral motor therapy, and stretching exercises/therapy.

KQ 2a. What are the benefits of various treatments in newborns, infants, and children with ankyloglossia intended to prevent, mitigate, or remedy attributable medium- and long-term feeding sequelae, including trouble bottle-feeding, spilling and dribbling, difficulty moving food boluses in the mouth, and deglutition?

KQ 2b. What are the benefits of various treatments in infants and children with ankyloglossia intended to prevent, mitigate, or remedy attributable other medium- and long-term sequelae, including articulation disorders, poor oral hygiene, oral and oropharyngeal dysphagia, sleep disordered breathing, orthodontic issues including malocclusion, open bite due to reverse swallowing, lingual tipping of the lower central incisors, separation of upper central incisors, crowding, narrow palatal arch, and dental caries?

KQ 3. What are the benefits of various treatments for ankyloglossia in children through 18 years of age intended to prevent or address social concerns related to tongue mobility (i.e., speech, oral hygiene, excessive salivation, kissing, spitting while talking, and self-esteem)?

KQ 4. What are the benefits of simultaneously treating ankyloglossia and concomitant tight labial frenulum (lip-tie) in infants and children through age 18 intended to improve or remedy breastfeeding, articulation, orthodontic and dental, and other feeding outcomes? What are the relative benefits of treating only ankyloglossia when tight labial frenulum (lip-tie) is also diagnosed?

KQ 5. What are the harms of treatments for ankyloglossia or ankyloglossia with concomitant lip-tie in neonates, infants, and children through age 18?

Next steps

Tips to help you get the most from a visit to your child’s healthcare provider:

• Know the reason for the visit and what you want to happen.
• Before your visit, write down questions you want answered.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.
• Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.
• Ask if your child’s condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if your child does not take the medicine or have the test or procedure.
• If your child has a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.

References