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Tongue Tie Surgery

Ankyloglossia - Tongue Tie - Hypertrophic Lingual Frenulum Definition, Classification, Examination Methods

Tongue tie release surgery,Hypertrophic Lingual Frenulum, Ankyloglossia


Ankyloglossia (Short Tongue Tie / Hypertrophic Lingual frenulum / Short Frenulum / Tongue Tie) means that the tongue tie, which is a structure normally located under the tongue and in the midline, is shorter or thicker than normal, causing the tongue to remain attached to the floor of the mouth.

Tongue tie can usually be understood during the doctor's examination immediately after birth or when the mother notices symptoms such as difficulty in sucking, sweating and inability to fully grasp the breast in her baby.

25-80 percent of breastfeeding difficulties have been reported in infants with ankyloglossia. Due to the limitation of tongue's mobility, infants are unable to extend their tongue over the gumline to create a proper seal and instead use their jaws to hold the breast in the mouth. This results in ineffective latch, maternal breast pain, poor milk supply, breast rejection, and failure to thrive.

Ankyloglossia also contributes to other feeding difficulties such as bottle feeding, deglutition and licking food. It has also been claimed to be responsible for difficulty playing wind instruments, oral hygiene, kissing and drooling. It can lower self-esteem or contribute to psychological issues for older patients. Although ankyloglossia can contribute to feeding difficulties, children often have other comorbidities, such as hypotonia, oral motor coordination, or laryngomalacia that can cause or contribute to dysphagia.

Babies with tongue-tie cannot fully take the brown area of ​​the breast's outer milk ducts into their mouths and cannot vacuum. In this case, symptoms such as sweating, difficulty in sucking and weight loss due to malnutrition occur due to excessive exertion.

The amount of symptoms may vary according to the short, thick and closeness of the tongue tie to the tongue tip. It is recommended to treat the shortness of the tongue tie (when restriction in tongue movements is noticed) as early as possible.

How Is Tongue Tie Examined?

Tongue Tie Examination in Babies

While examining the tongue tie in babies, the baby is placed on his back on both the mother's or the baby's hands, the doctor passes to the baby's head, and the baby's tongue is lifted from the bottom up with the index fingers of both hands, and the following data about the tongue tie can be checked:

- tension
- location (front tongue tie and back tongue tie)
- changes in language structure
- free tongue area distance - free tongue (distance between tongue tip and tongue tie starting point)

During the tongue tie examination, when the baby is in the lying position, the doctor's lifting the baby's tongue from the bottom up with two fingers, the structure of the tongue tie, the distance of the free tongue area, the structural changes in the tongue, whether the tongue tie is short should be evaluated.

During the examination, the position of the tongue-tie should be evaluated according to the new tongue-tie classification system. Anterior tongue tie (or includes type I, II and III tongue ties) can be easily seen during examination; posterior tongue-tie (or Type IV tongue-tie / submucosal tongue-tie) can only be detected by palpation. For posterior tongue tie examination, both index fingers are placed under the tongue over the patient's head and the middle part of the tongue is lifted upwards. Tongue tie is understood in the midline submucosal. This type of tongue tie causes malnutrition especially in infants. It is a type of tongue tie known as submucosal tongue tie or posterior tongue tie, which is located under the mucosa and can only be seen when the tongue is lifted by hand.

TABBY" Illustrated Tongue Tie Evaluation Tool in the Evaluation of Tongue Ties in Newborn Babies

Yenidoğan Bebekeklerde Dil Bağı Değerlendirilmesinde TABBY" Resimli Dil Bağı Değerlendirme Aracı

In newborn babies, "which baby should have tongue tie surgery?" As an answer to the question, "TABBY" Pictorial Tongue Tie Assessment Tool, which evaluates functional tongue tie limitation by evaluating only the tongue and sublingual with the eye, was published in 2019. In other words, when the baby is born, in order to inform the family about whether to rush the surgery, a simple and practical way of determining the tongue tie in babies. This scale was developed to determine how much it affects language functions (Source: The development and evaluation of a picture tongue assessment tool for tongue-tie in breastfed babies (TABBY).

Controversy continues about which infants should be treated with frenotomy. The Hazelbaker Assessment for Lingual Frenulum Function (HATLFF), a clear and simple assessment of the severity of tongue-tie, and the Bristol Tongue Tie Assessment Tool (BTAT), developed afterwards, are used worldwide and have been translated into different languages. A simple illustrated version of the BTAT has been created to assist and enhance consistent assessment of tongue-tied infants. The TABBY tool consists of 12 images that show the appearance of the baby's tongue, its attachment to the gum and the limits of tongue mobility. The TABBY tool is scored from 0 to a maximum of 8. a score of 8 indicates normal language function; 6 or 7 can be considered borderline, and 5 or below indicates a deterioration in language functions. Selecting a baby for frenotomy required an additional assessment of breastfeeding, but it was emphasized in the relevant resource that all babies with a score of 4 or less on examinations could undergo a frenotomy following parental consent. In fact, looking at the picture, it can be understood that babies who are affected by the tongue structure and cannot get the tongue out of their mouth are suitable candidates for tongue tie surgery. It is seen that the scores on the TABBY scale are low in these infants. Not only with this scale; it is also appropriate to carry out a detailed breastfeeding assessment of infants. It is appropriate to identify babies with tongue-tie symptoms with a low scale score as surgical candidates. When you look at the photo, if the baby with tongue tie has the following, it can be interpreted that the beard score is quite low and it is suitable for surgery:

- tongue deformity, forked tongue, v-shaped tongue, bowl-shaped, heart-shaped tongue ...
- the less the tongue can be lifted above the floor of the mouth and the less it can be protruded
- the more the tongue sticks to the floor of the mouth and the more it sticks to the gum, the lower the TABBY score

Ferrés-Amat Functional Tongue Tie Classification

Ferrés-Amat Sınıflandırması: Fonksiyonel Dil Bağı Sınıflandırılması
Ferrés-Amat Functional Tongue Tie Classification
Maximum incisive inter-dental mouth opening (maximal interincisal mouthopening / MIO) - Maximum incisive inter-dental mouth opening (maximal interincisal mouthopening / MIO) - Tongue range of motion ratio - Tongue range of motion ratio - TRMR (Source:Figure 6 | Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects | SpringerLink)

evaluation of functional tongue-tie restriction (Ferrés-Amat Classification: Functional Tongue-tie Classification can simply be used for this).

This classification system, which can be used simply in office conditions, consists of evaluating how much of the distance between the teeth can be covered by the tip of the tongue when the mouth is fully open.

In the functional tongue tie classification published by Ferrés-Amat et al., the mouth opening between the tip of the tongue and the maxillary incisive papilla (mouth opening with tongue tip to maxillary incisive papillae at roof of mouth / MOTTIP) and the maximum incisive interdental mouth opening (maximal interincisal mouth opening). / MIO) ratio (MOTTIP / MIO ratio defined as "Tongue range of motion ratio - Tongue range of motion ratio - TRMR") functionally language limitation was measured, and the limitation was classified at increasing rates. In this classification system, Grade 1: tongue gap movement rate is > 80%, Grade 2: 50–80%, Grade 3: < 50%, Grade 4: < 25%. As in the upper left photo, normally, the tip of the tongue should approach the upper teeth by passing at least 80% or more of the maximum incisive interincisal mouth opening (MIO). When performing tongue-tie surgery in adults in the office, it is important to evaluate how much of this distance is covered by the tongue tip immediately after the procedure. As a rough information, if the tip of the tongue can approach the upper teeth when the mouth is open, it will be easier to say hard consonants and touch the tip of the tongue towards the palate while speaking.

How Are Tongue Ties Classified?

Two classification systems used in the classification of tongue-tie are defined as Coryllos Tongue Tie Classification and Kotlow Tongue Tie Classification.

  Coryllos Tongue Tie Classification

Type I Frenulum reaching the tip of the tongue
Type II adhesion 2-4 mm behind the tip of the tongue or 2-4 mm above or behind the alveolar ridge
Type III Adhesion in the middle of the floor of the mouth or tongue
Type IV Thick and inelastic submucosal adherence of the tongue to the floor of the mouth (submucosal tongue tie, posterior tongue tie, posterior tongue tie)

The classification system above is Dr. It was completed by Elisabeth (Betty) Coryllos and similarly popularized by Dr. Kotlow, one of the world's most well-known physicians on this subject.

Kotlow Tongue Tie Classification

Kotlow Dil Bağı Sınıflandırılması
Kotlow Tongue Tie Classification - Image source:Larry-kotlow-spreecast-frenectomy-july-2013

In the classification of tongue tie, Dr. Kotlow suggested measuring the "free tongue part" or "normal tongue gap" that can be used in both adults and babies, and according to this, tongue tie classification should be made as follows:

Clinically acceptable normal tongue gap => 16 mm
Class I: mild ankyloglossia = 12-16 mm
Class II: moderate ankyloglossia = 8-11 mm
Class III: severe ankyloglossia = 3-7 mm
Class IV: complete ankyloglossia = <3 mm

In fact, Class IV tongue-tie in the classification of tongue-tie made by Dr.Kotlow is like Type I tongue-tie in the Coryllos tongue-tie classification and is defined from front to back. In this classification system, there is no posterior tongue tie, namely Type IV tongue tie. This classification system, which was first defined in 1999, is combined with the Coryllos tongue-tie classification and is accepted as follows:

Dil Bağı Sınıflandırılması
Kotlow Tongue Tie Classification - Image

According to the placement of the tongue ties under the tongue, roughly anterior (anterior) and posterior (posterior or submucosal) tongue ties and again as a lower classification, anterior tongue ties are classified as Type 1-3 and posterior tongue tie is classified as Type 4 tongue tie. In other words, type 4 tongue tie is also called posterior tongue tie, posterior tongue tie or submucosal tongue tie.

Negative Health Effects of Tongue Tie

In children with tongue-tie and restricted tongue movements for a long time, bifurcation at the tip of the tongue and a split in the middle may occur over time. Performing tongue-tie surgery in the early period prevents these structural changes. Application of tongue-tie release procedures in the early period will prevent possible language functions being affected in the baby.

Tongue-Tie Symptoms

How a Tongue Tie Can Affect Babies

A tongue tie can have a variety of effects on babies. A few of these are:

Irritability and crying: If your child is always hungry and frustrated, he may become irritable and cry a lot. He may also have trouble sleeping.

Breast rejection: Some babies refuse the breast if it annoys the nurse and they are not getting enough breast milk.

Poor weight gain: If your child can't latch on and suck well, he won't be getting enough breast milk to grow and gain weight at a consistent rate.

Other issues: As the baby grows, eating a short frenulum can cause problems with swallowing and speaking.

Most babies open their mouths while crying and a sublingual tie is seen!
Tongue tie should be suspected in children in the following cases:

- Having a speech disorder
- Talking sloppy when talking fast
- Inability to get the tongue out of the mouth
- Bifurcation at the tip of the tongue
- Difficulty sucking, sweating or inability to grasp the breast
- Jaw pain (lower jaw)
- Neck pain (due to using the auxiliary neck and jaw muscles while protruding the tip of the tongue)

Tongue Tie Symptoms in Adults

In adults, there are difficulties with speech, problems with social situations, self-esteem, work environment and dental health due to restricted tongue mobility due to tongue-tie.

Adults with short and tight tongue-tie may experience the following symptoms:
  • Restricted mouth opening and tongue lifting (may affect speech and eating habits)
  • Impaired clarity or difficulty speaking quickly and saying words containing hard consonants
  • Sharpness distortion when talking fast / loud / soft
  • Difficulty speaking after drinking moderate amounts of alcohol
  • Clicking sound when opening and closing the jaw (clicky jaws)
  • jaw pain
  • Migraine
  • Protrusion of the lower jaws (prognathism)
  • Concentration problems in the work environment
  • Social situations, eating out, kissing, effects on relationships
  • Dental health, propensity for inflammation of the gums and increased need for fillings and tooth extractions
  • Sensitivity about personal appearance
  • Emotional factors leading to increased stress
  • Tongue tie in the elderly often makes it difficult to keep the denture in place.

The Effects of Tongue Tie on Mothers

A tongue tie can also have some negative effects on mothers.

Nipple sores If your newborn is simply pinning on your nipple or chewing while trying to suckle, it can lead to sore, cracked, damaged nipples.

Painful breast problems: When the baby is not able to breastfeed well, the breast milk cannot be discharged from the breasts. Accumulation of breast milk in the breasts can lead to breast enlargement, clogged milk ducts and mastitis.

A low breast milk supply: A poor latch and ineffective removal of breast milk can quickly reduce breast milk supply.

Emotional stress: Breastfeeding difficulties can lead to frustration and a lack of breastfeeding confidence.6 If the baby does not get enough milk, it can be frightening or cause feelings of sadness and guilt.

Early weaning: Painful breastfeeding, low breast milk supply, and dealing with an irritable, hungry baby who gains weight very slowly can all lead to early weaning.

Tongue Tie and Lip Tie Can Cause Air Swallowing and Reflux in Babies!

In the article titled "Aerophagia Induced Reflux Associated with Lip and Tongue Tie in Breastfeeding Infants" published in "Pediatrics", a respected medical journal, babies with lip and tongue tie, excessive swallowing of air (gas swallowing - aerophagia), crying afterwards, colic pain and It was emphasized that the risk of gastroesophageal reflux (GERDH - GERD) may increase with the nose.

Another new source book on this subject, "The Book: Tongue Tie – From Confusion to Clarity", was published by Tandem Publications and you can find very interesting information. For example, the weakening of the bond between the mother and the baby in infants with tongue-tie, difficulty in transitioning to solid food, changes in the jaw structure, changes in the tongue structure according to tongue-tie types in advancing ages (for example, tongue-tie until the tip of the tongue - Type I anterior tongue-tie in infants, tongue-tie lateral growth - bulky tongue, having a heart-shaped tongue tip ... ) such as an increase in salivation or splashing of saliva during the speaking period ...

As tongue-tie symptoms are clarified with scientific studies, the symptoms that may occur in infancy and adulthood are gradually published in guide sources. Other interesting information I've seen in the above book and other websites:

- Adult and tongue-tied patients tend to talk more into their own speech than usual, since their own speech may seem strange to them.

- Difficulty in adult patients with tongue-tie when speaking quickly, loudly or softly
- Forward protrusion of the lower jaw (jaw pain and neck pain!)
- Adult patients with tongue-tie are more affected in speaking when they drink alcohol
- Switching to bottle earlier than expected (due to lack of vacuuming), decrease in milk intake with wrong sucking movements, decrease in growth rate.
- Early transition to formula instead of breast milk, decreased immunity and increased frequency of infection in the baby.
- Difficulty vacuuming the bottle in tongue-tie and bottle-fed babies
- Adult patients with tongue-tie have feelings of inadequacy, withdrawal, and sensitivity about their external appearance. In this case, there are scientific studies showing that a feeling of inadequacy and depression can also be seen in the mother (source: Tongue-tie). If you want to read the article published by UNICEF on this subject >> Breastfeeding and Postpartum Depression
- For example, elderly patients with tongue-tie have difficulty holding their dental prostheses.

Jaw Pain and Neck Pain Added to the Symptoms of Tongue Tie!

The movement of the tongue in childhood has a great influence on the placement and development of teeth and the structure of the jaw. When there is a tongue tie, the tongue cannot move properly and this often leads to a smaller mouth, jaw and palate. Moving the lower jaw forward more than normal during tongue movement may cause pain in the temporomandibular joint that connects the mandible to the skull. In the same way, the use of auxiliary neck muscles in jaw movement can cause neck pain. Temporomandibular joint pain and neck pain are more common in tight and short tongue ties.

It Works Like An Organ Involved In Shaping The Tongue, Jaw And Facial Bones!
Do you know that the tongue is vegetated towards the upper palate in babies and thus acts as an expander that expands the jaw bones to the sides?

In infants with tongue tie, tongue contact with the upper palate and chin decreases in infants due to the fixation of the tongue to the floor of the mouth and may cause the appearance of "dome palate", "a deep and narrow palate structure" in the upper palate (long-term nasal congestion and mouth breathing, genetic factors may also cause this palate structure). Again, due to the tongue being adhered to the floor of the mouth and attached to the gingiva on the inner surface of the lower jaw, negative structure may occur in both the jaw and the tongue itself. While some patients experience recession in the gingiva on the inner surface of the lower incisors and backward growth in the lower jaw in others, these effects may change depending on the placement of the tongue tie and the tension pressure. Lateral growth of the tongue, rounding at the tip of the tongue, bifurcation can be seen. In the video above, you can see almost all of the following features in a patient with an untreated tongue tie:

- dome palate, narrow and deep palate structure
- back of the lower jaw
- Too much distance between the upper and lower teeth and tooth closure disorders
- blunt tongue tip
- calculus formation

Tongue Tie Causes Sleep Apnea!

Due to the tongue and/or lip disorder caused by ankyloglossia, the oral structures and airway tend to be smaller than normal. If the oral tissue begins to sag, Obstructive Sleep Apnea (OSA) can occur. This may cause the oral tissue airway to close overnight, usually for 10 seconds or more. OSA interferes with restful sleep and may even contribute to the risk of heart attack or stroke.

A short lingual frenulum has been associated with difficulty in sucking, swallowing, and speaking. Oral dysfunction caused by a short lingual frenulum can lead to oral-facial dysmorphosis, which reduces the size of the upper airway support. Such gradual changes increase the risk of upper airway collapse during sleep. Obstructive sleep apnea syndrome (OSAS) is associated with abnormal collapse of the upper airway during sleep. This abnormal collapsibility in both children and adults is related to sleep causing fundamental changes in pharyngeal muscle tone and reflex responses; Considering that sleep usually takes place in a lying position; and intrinsic and extrinsic factors: the upper airway has collapsibility, which is examined by the "critical pressure" assessment, and extrinsic factors can lead to increased collapsibility.

Normally at birth, the tongue is located high on the palate, and its continuous activity related to sucking, swallowing and chewing causes stimulation of the intermillary synchondrosis (the fusion of the cartilage surfaces of the two bones forming the joint with each other), which is active until the age of 13-15 and normal oral-facial growth. Normal nasal breathing is associated with this tongue position.

It has been shown to cause mouth breathing with secondary orthodontic effects resulting in a change in tongue position due to tongue tie, anterior and posterior cross bite, a disproportionate growth of the mandible, and an abnormal growth of the maxilla. All these anatomical changes affect the size of the upper airway and increase the risk of collapse during sleep. Scientific study emphasizing that tongue tie causes susceptibility to sleep apnea and its link >> A frequent phenotype for paediatric sleep apnoea: short lingual frenulum -

When Should Tongue Ties Be Cut in Babies?

 In fact, the reason why the American Academy of Pediatrics recommends that the tongue tie should be cut as soon as it is noticed, for those who have breastfeeding problems and do not improve with breastfeeding counseling, so that the baby can reach the breast milk that he can get in the earliest period, and to avoid the problems related to tongue tie and the necessary treatment processes associated with them. (sources: Tongue-tie - Better Health Channel / Frenotomy for breastfed tongue-tied infants: a fresh look at an old procedure). Indeed, there is a lot of controversial information on the subject at the moment, but no old source says that tongue-tie can cause so many symptoms. There are serious expression changes and new information about treatment methods, tongue-tie classification and tongue-tie symptoms in the last 5 years.

Should Your Baby Have Tongue Tie Cut?

If the newborn has a tongue-tie but is okay with breastfeeding, then a frenotomy is not necessary. If the tongue tie is elastic and loose and has a minimal effect on the restriction of tongue movement, it is appropriate to wait and get breastfeeding counseling. However, if your child is having trouble latching on and you find it too uncomfortable to breastfeed, you may want to consider getting this procedure.

Cutting a tight tongue tie allows your baby's tongue to move more freely and protrude enough out of his mouth so he can latch on to the breast well and latch on well. When your newborn catches better, she can get more breast milk and breastfeeding should become easier and more comfortable for both of you.

While a frenotomy is the answer for some children, it doesn't solve all breastfeeding problems. Therefore, there is a possibility that your baby may still have difficulty breastfeeding even after the procedure. However, for many newborns and mothers, it can make breastfeeding more successful and help keep it going longer. Especially in babies with a thick posterior tongue tie, the pain felt after the procedure and the possibility of breast rejection in the first week may be higher.

Diagnosis and treatment guide link named Ankyloglossia in the Infant and Young Child: Clinical Suggestions for Diagnosis and Management of the American Academy of Pediatric Dentistry > > In this guide, otolaryngologists, oral surgeons, pediatricians, speech therapists, and lactation consultants discuss various aspects of tongue-tie. The importance of surgical treatment in infants, especially when there is malnutrition, was emphasized. It is recommended in this guideline that surgery should be considered as a treatment option in infants with feeding problems that do not improve with breastfeeding counseling and nursing services, and in children and adults with speech problems. In other words, it is not necessary to have surgery for every tongue tie.

Tongue Tie Surgery

Application of tongue-tie release procedures in the early period will prevent possible language functions being affected in the baby. Tongue tie surgery (lingual frenectomy: tissue removal, frenotomy: simple incision) or hypertrophic lingual frenulum plastic is an operation to re-release the tongue by cutting the tongue tie. In small babies, it can usually be done under local anesthesia. General anesthesia and operating room conditions may be required in older children and those with vascular and thick tongue ties. Tongue tie can be cut with scalpel, scissors, electrocautery, laser or thermal welding method, preserving the vessels and nerves passing under the tongue. After tongue tie surgery, various tongue exercises and tongue tie massage are recommended for babies in order to prevent the tongue tie from sticking again and to return the tongue movements to normal as soon as possible. After tongue tie surgery, simple exercises for the tongue tip can be performed in adult patients.

A frenotomy (also known as frenulotomy) is a minor surgery or procedure for babies with tongue-tie. A simple piece of the frenulum on your child's tongue is cut. The doctor may use a local anesthetic, but most newborns can manage without anesthesia. It does not bleed much and stitches are usually not needed.

Much of the literature surrounding the surgical treatment of ankyloglossia has focused on breastfeeding difficulties and outcomes. Strong scientific evidence and data on frenotomy outcomes for problems other than breastfeeding difficulties are limited (source >> Kids ENT Health Month: Ankyloglossia).

Dr. Murat Enöz - MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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Fax: +90 212 542 74 47