Tongue-tie, also known as ankyloglossia inferior, is
a relatively common congenital abnormality of lingual frenulum. It has
been defined as a condition in which the tip of tongue cannot be
protruded beyond the lower incisor teeth because of short frenulum
linguae. It is very difficult to assess actual incidence, because of
wide spectrum of presentation ranging from very thin band to fully
developed ankyloglossia. The number of mothers convinced that their
infant is tongue tied far exceeds the number of babies who really have
the condition. Reported incidence of tongue-tie varies from 0.04 to 0.1%
and the male: female ratio is 2.6:1(1). Tongue-tie usually presents as a
sole anomaly, but very rarely may be associated with cleft palate or
Pierre-Robin syndrome(2). The earliest report of tongue-tie division is
by Mark who wrote that "and the string of his tongue was loosened and he
spake plain" (Mark 7:35), since then literature is full of entertaining
anecdotes about the tongue-tie. Midwives used to divide frenulum linguae
of newborn babies with their fingernails. As long ago as 1794, a surgeon
claimed that tongue-tie can be divided in an infant without any pain to
child who will be taken to the breast immediately. A grooved director
was devised more than a century ago for division of tongue-tie. In 1983,
Lao and Ong(3) described a grooved tablespoon for tongue-tie release.
Problems in Tongue-tie
Before deciding whether to treat or not to treat
tongue-tie, its effect on tongue function must be evaluated(4).
1. Sucking and swallowing: Literature is full
of anecdotal evidence that tongue-tie causes significant breast feeding
problems leading to sore nipples, repeated bouts of mastitis, failure to
thrive and can prevent development of adult swallowing mechanism(5,6)
but studies conducted on swallowing mechanism do not support this
argument and unless restriction of tongue movement is quite extreme, it
does not interfere with sucking and swallowing.
2. Speech: Speech problem with tongue-tie is
frequently overrated, as it has no relation with delay or onset of
speech. Sometimes it may cause errors of articulation and affect the
expression of lingua-alveolar and lingua-dental consonants like t, d,
l, n, r and Th; because pronunciation of these requires
opposition of tongue to alveolus or palate. Significantly, more errors
of articulation have been found in people with limited mobility of
tongue as compared to those with normal mobility. On the other hand,
there is enough evidence that good speech is still possible with
significant tongue-tie and speech problems can be overcome without
frenulotomy with speech therapy(78).
3. Mechanical problems: These are the most
underestimated problems of tongue-tie. Lack of mobility of tongue causes
inability to perform internal oral toilet, inability to lick lips and
child cannot play wind instruments. These are the more valid and
scientific indications for frenulotomy(9).
4. Jaw growth: Ankyloglossia minor does not
cause any effect on growth of jaw except minor dental abnormality of
incisors or mucogingival recession. Ankyloglossia major may cause open
bite deformity and prognathism(6,7).
Management
Diagnosis is obvious on inspection, as child is
unable to protrude the tongue beyond incisor teeth and there is a
pseudocleft at the tip of tongue(8). The presence of a non-disturbing
lingual frenulum does not justify its surgical section. The valid
indications for frenulotomy have been highlighted above. There is no
place for clipping or snipping the frenulum without anesthesia
especially in the newborn, as adequate division cannot be achieved by
this method. There is no pre-scribed age for frenulotomy. The
appropriate age is when the surgeon is convinced that it needs to be
done in the best interest of the patient. Many newborn babies appear to
have some degree of tongue-tie for about 12 months and their appearance
and function soon improves by spontaneous improvement in lingual
muscular co-ordination. Release of tongue-tie may sound a minor
procedure but has a distinct possibility of bleeding, infection and
injury to Wharton’s duct. There is agreement that general anesthesia is
needed except in co-operative adult patients in whom local anesthesia
can be used(8). Several surgical methods are available but whichever
method is used, frenulum should be divided up to the genioglossus muscle
and raw area is covered with Z-plasty or V-Y plasty or
transverse-vertical frenuloplasty to avoid recurrence of tongue-tie(10).
In cases of true ankyloglossia, genioglossus muscle is fibro-tic, and
this requires full plastic correction to release the tongue.
Pawan Agarwal,
V.K. Raina,
From the Department of Surgery,
N.S.C.B. Government Medical College,
Jabalpur 482 003,
Madhya Pardesh,
India.
Correspondence to:
Dr. Pawan Agarwal,
292/293, Napier Town,
Jabalpur 482 001,
Madhya Pardesh,
India.
E-mail:
[email protected]
