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 self-conscious, embarrassed or resentful about
developmental anomaly of the tongue their tongue tie that they may be teased by their
characterized by an abnormally short, thick peers for their anomaly.
lingual frenum resulting in limitation of tongue Nipple pain: An infant with tongue tie
movement. It can be categorized into 2 types. may experience difficulty latching on to the
Total ankyloglossia is rare and occurs when the nipple and may compress the nipple against the
tongue is completely fused to the floor of the gum resulting in pain. Mothers experiencing pain
mouth. Partial ankyloglossia is variable and may often try shifting the baby to a bottle.
encompasses the remainder of the cases.(1) Clinical assessment in infants:
The incidence of tongue tie varies from A through intra oral examination should
0.2% to 5% depending on the population be performed on the infant. Parents should be
examined. The incidents among outpatients of a made aware of potential feeding speech and
children hospital with breast-feeding problems dental problems. The clinician should examine
was almost 3%. Two independent studies have the tongue appearance when the tongue is lifted.
shown a significant predilection for male The attachment should normally be
child.(2) This may also occur with increased approximately 1cm posterior to the tongue’s tip
frequency in various syndromes including and to inferior alveolar ridge it should be
Smith-Lemli-Opitz syndrome,(3) Orofacial proximal to genioglossus muscle on the floor of
digital syndrome, Beckwith Weidman syndrome, the mouth.(7) Mothers should be interviewed
Simpson-Golabi-Behmel syndrome(4) and X regarding the infants ability to breastfeed. Does
linked cleft palate.(5) Consequences of not infant demonstrate frustration at the breast feed?
treating the tongue tie are;(6) Does the mother experience pain or discomfort
Dental caries: Dental caries can occur while the infant nurse? If any of the factors are
due to food debris not being removed by the present, a lactation specialist should be
tongue’s action of sweeping the teeth and consulted.
spreading saliva. Open bite due to thrust created Kotlow’s Classification based on free tongue
by being tongue-tied. Due to long term tongue length.(8)
trust lower incisors show periodontitis and also Normal range of free tongue > 16mm
tooth mobility. Class I: mild ankyloglossia = 12-16mm
Appearance: The tongue can be unduly Class II: moderate ankyloglossia = 8-11mm
Class III: sever ankyloglossia = 3-7mm
obvious or unusual looking in some individuals,
Class IV: complete ankyloglossia < 3mm
improper chewing and swallowing of food can
Clinical assessment in preschool/school age
increase the gastric distress and bloating.
patients:
Snoring and bed wetting at sleep is common
There is lack of scientific evidences
among tongue tied children.
providing a true relationship between tongue tie
Oral play: Children in particular may
and speech disorder. In case of tongue tie the
not be able to participate in play routines
sounds such as ‘t’,‘d’, ‘l’, ’th’ and ‘s’ will not be
involving tongue movements and gestures.
accurate. In certain patients where speech is
Self-esteem: It has been noted clinically
delayed, the parents may demand surgical
that occasionally an older child or adult will be
correction in the hope of normal speech and

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language. In these patients audiological and A free tongue measurement both in

neurodevelopmental factors may be the older patients and infants can be measured using
etiological factors. Such patient’s surgical repairs kotlow’s classification.(8) It is been suggested
should be delayed until appropriate diagnosis is that, given the minor nature of the surgery and
made.(8) A systematic protocol for tongue tie significant potential for speech difficulties and
assessment, lingual functions and need for later social and mechanical problems it may be
surgical correction can be made using Hazel appropriate to consider surgery for children with
baker’s assessment tool(Table 1).(2) significant tongue tie at any age including infants
Function Appearance and toddlers who have yet to demonstrate overt
Lateralization Tongue when lifted symptoms.(2) Treatment options such as
2=complete 2= round or square Observation, speech therapy, frenotomy without
1=body of the 1= slight cleft in the anaesthesia, frenectomy under general
tongue appearance anaesthesia and Z plasty(10) which is more
0=none 0= heart shaped complex and require sutures have all been
Lift of tongue Elasticity of the frenum suggested in the literature.
2= tip to mid mouth 2=very elastic
1= only edges to mid 1= moderately elastic
Snipping (frenotomy(11)): If the only
mouth 0= little or no elastic goal is to improve breastfeeding, snipping the tie
0= tip stays at in infancy would be the obvious solution. No
alveolar ridge anesthetic is needed, it is relatively cheap, the
Extension of tongue Length of the frenum infant's pain is slight, bleeding is negligible, and
2=tip over lower lip when tongue lifted feeding improves immediately. However, when
1= tip over lower 2=>1cm or embedded in ankyloglossia is associated with foreshortening
gum tongue of the genioglossus muscle, as often occurs,
0= neither of the 1=1cm merely snipping the lingual frenum may not
above or mid tongue 0=<1cm
allow free and coordinated movement of the
hump
Spread of anterior Attachment of lingual
tongue sufficient for the demands of a gradually
tongue frenum to tongue growing speech and language structure. As a
2= complete 2= posterior to tip result, further surgery may legitimately be
1= moderate or 1= at tip needed later. Therefore, the possibility that re-
partial 0= <1cm evaluation of the situation might become
0= little or none appropriate later, should be emphasized
Cupping of the Attachment of frenum to Frenotomy Procedure: It is the
tongue inferior alveolar ridge procedure where frenum is cut or divided. It is
2= entire edge, firm 2= attached to floor of the accompanied without anaesthesia and with
cup mouth well below ridge
minimal discomfort in infants. The parent or
1= side edges only, 1= attached just below the
moderate cup ridge assistant holds the head and stabilizes. The infant
0= poor or no cup 0= attached at the ridge is made to sit supine to prevent tongue from
Peristalsis falling back. The tongue is held with gauze and
2= complete anterior lifted gently, and then two gloved fingers of
to posterior clinician’s left hand are held under the tongue to
1=partial originates lift and support tongue. The frenum is then
at posterior to tip divided using small sterile blade at the thinnest
0= none or reverse portion. Occasionally complete release may be
peristalsis
accomplished with a single cut. However when
Snap back
2=none
the frenum is quiet tight 2-3 sequential cuts are
1= periodic required for retraction.(12)Since the frenum is
0= frequent or with poorly vascularized and innervated it is at the
each suck clinician’s advantage to use this simple
Table 1 Hazelbaker assessment tool for lingual procedure without any complications. After the
frenum function(9) procedure, feeding may be resumed immediately
Scoring and is without apparent discomfort. No specific
14= perfect score, follow up care is required. Parents should be
11= acceptable if appearance items score is 10<11= advised that post-operative white fibrin clot
function impaired, might be seen to form at the incision site during
Frenotomy is necessary if function score is <11 and
appearance score is <8.
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 is not extensive. Its proponents describe it as a
weeks should show that the incision is viable office-based procedure in cases of mild
completely healed. Ankyloglossia.(15)
Frenectomy procedure: Frenectomy is Second Revision: Some tongue ties are
the procedure for the patients with thick and much more severe than others and may require
vascular frenum where severe bleeding may be more than one procedure to completely release
expected and in some cases reattachment of the the tongue. This is uncommon, but not unknown
frenum by scar tissue may occur. The procedure and a later operation can deliver completely
in young children is performed under general successful release.
anaesthesia. Older children and adults may The purpose of Post-operative
tolerate the procedure under local anaesthesia exercises: Post-operative exercises following
alone. The frenum is released in the same tongue-tie surgery are not intended to increase
manner as frenotomy although occasionally muscle-strength, but to:
limited division of genioglossus may be required 1. Develop new muscle movements, particularly
for adequate release.(10-12) Z plasty technique those involving tongue-tip elevation and
as described by Kaban is slightly more complex protrusion, inside and outside of the mouth.
procedure but has an advantage of also 2. Increase kinaesthetic awareness of the full
lengthening the scar and providing an increased range of movements the tongue and lips can
potential for the post-operative tongue perform. In this context, kinaesthetic awareness
mobility.(13) Here the releasing incision is refers to knowing where a part of the mouth is,
placed one on the superior boarder of frenum and what it is doing, and what it feels like.
other on the inferior boarder in opposite 3. Encourage tongue movements related to
directions. The two flaps are raised and then cleaning the oral cavity, including sweeping the
interchanged, so that the length of the frenum is insides of the cheeks, fronts and backs of the
increased. For the Z-frenuloplasty, most of teeth, and licking right around both lips.
patients showed at least 2orders of improvement The prevalence of pain in mother’s
in speech, and showed complete resolution of breastfeeding infants with ankyloglossia is much
articulation errors. Z-frenuloplasty was superior higher than that reported in mother’s
to the horizontal to vertical frenuloplasty with breastfeeding normal infants and clearly presents
respect to tongue lengthening, protrusion, and a considerable problem in terms of continuing
articulation improvement for patients with breastfeeding. Intensive breastfeeding support is
symptomatic ankyloglossia. often inadequate for relieving breastfeeding
Laser Surgery: Erbium: YAG lasers and difficulties in babies with ankyloglossia. Despite
diode lasers are becoming extensively utilized. the fact that speech impediment is rare never less
Er: YAG is relatively new option and is suitable for the mere purpose of dental toilette, oral and
for neonates, older children and adults. buccal hygiene, gesture and even future intimacy
Compared to diode laser or CO2 laser the Er; functions every child deserves the privilege to be
YAG does not need general anaesthesia when able to protrude his/her tongue.(12)
used, but an analgesic gel might be applied. The Conclusion
procedure is very quick, taking only 2 to 3 Optimal management of tongue tie
minutes to perform, but some cooperation from including timely and appropriate surgical
the patient in keeping still is required. There is intervention followed by speech therapy when
virtually no bleeding, no pain, no risk of indicated has the capacity to deliver pleasing
infection and the healing period can be as short results, often in a shorter time than expected.
as 2 hours. It is best to have this procedure Development of a concise, practical,
performed by a specialist in the area of laser standardized, validated tool for diagnosing
dentistry who is familiar with tongue tie revision. ankyloglossia and a decision rule for surgical
The patient returns for speech therapy in 2 corrections are important for further research.
days.(14) Authors Affiliations: 1. Dr. H.E.Darshan, M.D.S,
Revision by Electrocautery: This Assistant Professor, Department of Pedodontics , JSS
method does not require a general anaesthetic Dental College and Hospital, S.S.Nagar, Mysore, 2.
and can be performed as an outpatient service Dr. P.M.Pavithra, B.D.S, Savinaya Dental Clinic,
Somwarpet, Coorg District, India.
with a local anaesthetic. Hence, it is an References
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Source of Support: Nil, Conflict of Interest: None Declared

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