Tongue Tie – To snip or not to snip
Tongue tie or ankyloglossia is defined as an embryological congenital oral condition characterised by an abnormally short or thickened lingual frenulum that may interfere with the mobility and function of the tongue.
The frenulum may vary in length, elasticity and placement along the base of the tongue to the floor of the mouth. The prevalence of tongue tie ranges from as low as 2.8% in some studies up to 10.7% in a 2011 literature review(1). It affects males more than females in a ratio of 2.6-3:1(2). Usually it is an isolated midline malformation or it may be associated with a tight maxillary lingual frenulum (lip tie) (3) or infrequently with syndromes such as cleft palate, orofacial-digital syndrome etc.
Diagnostic criteria for tongue tie are a controversial issue with no standardised approach. Kotlow uses a set of criteria based on the clinical appearance of the tongue and the position of the frenulum attachment. If the frenulum attaches to the anterior portion of the tongue or the tip, it is identified as an anterior tongue tie. Often this causes a heart shaped tip and is easier to detect. If the frenulum attaches to the posterior half of the tongue or submucosally then this is classed as a posterior tongue tie. This is much harder to detect and is often missed unless the examiner is skilled as it may be necessary to push down on either side of the frenulum location to show this malformation or palpate deeply under the tongue(3).
Functional issues associated with tongue tie:
1) Breastfeeding difficulties:
poor stimulation of milk ejection reflex/ decreased milk supply
poor weight gain or failure to thrive
painful damaged nipples
mastitis and thrush
difficulty with attachment and poor seal
continuous feeding cycle due to inefficient feeding
2) Speech problems
3) Dental caries on the anterior maxillary teeth due to inability to remove excess milk (4)
4) Orthodontic issues due to narrow palate/reduced maxillary spread and excessive mandible growth due to low lingual posture (2)
5) Inadequate labial (lip) seal and tendency to mouth breathe (2)
6) Some authors have associated altered posture (or morphological dentoskeletal alterations) with ankyloglossia (2)
TREATMENT FOR TONGUE TIE
Frenulectomy or Frenulotomy/ Frenotomy is a surgical procedure indicated for cases of ankyloglossia with functional impediment. Most studies in the literature used blunt-ended scissors to divide the frenulum without the need for anaesthetic when the tongue tie was diagnosed in a neonate or breastfeeding infant.
In older children and adults, the procedure is usually performed using local or general anaesthetic and may involve frenuloplasty or sutures. More recently laser has been successfully used to divide the tongue tie with topical or injected anaesthesia. Benefits include no need for sutures in older subjects and reduced chance of scar tissue or reattachment (3-5).
Complications historically attributed to frenulectomy include haemorrhage from lingual artery damage, infection, reattachment and damage to sublingual glands. In the studies noted below there were very few if any complications and functional improvement immediately followed the procedure (6-8).
In neonates and infants undergoing frenulectomy for breastfeeding difficulties, the improvement in feeding was around 45-50% immediately following the procedure and up to 80-95% within a few days (6). In one randomised controlled trial, 28/29 mothers from the control group requested the procedure following the study (6).
A short frenulum is not adequate indication for surgical division as sometimes the tissue is elastic enough to allow normal breastfeeding and tongue function. Awareness of the relationship of tongue tie with feeding problems will allow early referral and division to be performed without delay as prolongation of breastfeeding issues is an unnecessary misery for the mother-infant dyad.At Health Matters we refer a suspected tongue tie to a known lactation consultant or GP/Paediatrician or Dentist that performs frenulectomy. Many midwives and paediatricians who are unfamiliar with posterior tongue tie will give conflicting advice to mothers and advise them against tongue tie division.
After a frenulectomy stretching exercises to prevent reattachment and scar tissue and promote functional improvement in the tongue mobility are essential. The earlier the tongue tie is divided the better the outcome for breastfeeding and the less likely the mother will be to stop feeding due to nipple trauma, poor infant weight gain and inadequate milk supply.
Adapted from article in CCNP Newsletter Vol 24 May 2015 by Kimberlie Furness B.App.Sci (Chiropractic)
1.Janet Edmunds RN RM BHSc(Nrg) IBCL et al Breastfeeding a Review of the Literature
Breastfeeding Review 2011; 19(1): 19–26
2. G. Olivi et al; Lingual Frenectomy: functional evaluation and new therapeutical approach;Eur Journal of Paed D entistry vol. 13/2-2012
3. L. Kotlow et al; Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants using Er:YAG and 1 064 diode lasers; European Archives of Paediatric Dentistry 12 (Issue 2). 2011
4.L. Kotlow, DDS The Influence of the Maxillary Frenum on the Development and Pattern of Dental Caries on Anterior Teeth in BreastfeedingInfants: Prevention, Diagnosis, and Treatment J Hum Lact 2010 26: 304
5.Mutan Hamdi Aras et al; Comparison of Diode Laser and Er:YAG Lasers in the Treatment of Ankyloglossia; P hotomedicine and Laser Surgery Vol 28, No.2, 2010
6.D. Mervyn Griffiths, MCh, FRCS Do Tongue Ties Affect Breastfeeding? J Hum Lact 2004 20: 409
7.M Hogan et al; Randomized, Controlled Trial of Division of Tongue-Tie in Infants with Feeding Problems J. Paediatr. Child Health (2005) 41, 246–250
8.Lori A. Ricke, MD et al Newborn Tongue-tie: Prevalence and Effect on Breast-Feeding; J Am Board Fam Pract 2005;18:1–7.