Lingual Frenulum Research Articles

A rare presentation of recurrent tongue tie

Ankyloglossia or tongue-tie is the result of a short, tight, lingual frenulum causing difficulty in speech articulation due to limitation in tongue movement. Ankyloglossia is a common finding in infants. Prevalence ranges between 4.2% and 10.7%. Although lingual frenectomy is a common technique it is a sensitive surgical procedure, the anatomic and topographic lingual frenulum makes the site vulnerable to various intraoperative and postoperative complications. In this case study, we have reported a 2-year-old male child with prior history of a frenectomy, presented with difficulty in speech and restricted tongue movements. On examination, a 1x1cm, solitary swelling was noted in the region of the lingual frenulum, firm, cystic, and non-tender. Tongue movements were restricted with an inability to perform protrusion beyond the vermillion border of the lips.Under general anesthesia, the child underwent revision frenectomy, excision of the swelling, and release of fibrous tissue adjacent to the swelling .Intraoperatively protrusion of the tongue was examined and found to have improved .The specimen was sent for histopathology which was reported as organizing mucocele. The Child was reviewed after 6 months, tongue movements were seen to have improved substantially in all ranges of motion.

What is tongue-tie and does it interfere with breast-feeding? - a brief review.

The most common symptom attributed to ankyloglossia is difficulty breast feeding due to poor latch, inefficient milk extraction and/or maternal nipple pain. During the past two decades, despite a declining birth rate, there has been a dramatic increase in the number of infants diagnosed with and treated for ankyloglossia in the United States, Canada and Australia. Despite a dramatic increase in the diagnosis and treatment of ankyloglossia in these countries, there remains no universally agreed upon definition of ankyloglossia and none of the published scoring systems have been rigorously validated. However ankyloglossia is defined, the majority of infants with ankyloglossia are asymptomatic. Perhaps, infants with ankyloglossia have a greater incidence of difficulty breast feeding. Lingual frenulotomy may decrease maternal pain and at least transiently improve the quality of breast feeding in some infants however no published studies take into account the fact that sucking and feeding are soothing to infants and the observed improvements immediately following frenulotomy may be a response to the pain associated with the procedure rather than a result of the procedure itself. While there are almost certainly some infants in whom tongue-tie interferes with breast-feeding, there is currently no good evidence lingual frenulotomy leads to longer duration of breast-feeding. Frenulotomy appears to be a generally safe procedure however there are reports of serious complications. Finally, there are no studies of long-term outcomes following frenulotomy during infancy and given traditional thinking that the lingual frenulum is a cord of connective tissue tethering the tongue to the floor of the mouth may be incorrect and the frenulum contains motor and sensory branches of the lingual nerve, the procedure may be less benign than previously thought.

Woman with a lump under her tongue.

A 44-year-old woman presented to the emergency department with a complaint of a “stone under [her] tongue.” She reported that the “stone” had been present and painless for 2 years. The day prior she began experiencing pain at this site while brushing her teeth. She squeezed the area in an attempt to expel it, but this action only increased her pain. Physical exam revealed erythema and swelling localized to the inferior lingual frenulum at the Wharton's duct. A white calculus was partially visualized and palpable through the mucosal membrane (Figure 1). Otolaryngology was telephonically consulted and recommended infiltrating with local anesthetic and attempting manual expulsion or excising, if needed. Manual expulsion was unsuccessful; a single, 1-cm incision was made over the calculus, and a 0.5 cm × 0.75 cm sialolith was removed with minimal bleeding (Figure 2). The patient was discharged on a course of amoxicillin–clavulanic acid. Dehydration, trauma, anticholinergics, and diuretics predispose to the formation of sialoliths, with 80% to 90% arising from the submandibular glands.1 As with our patient, the most common presentation is a single calculus within Wharton's duct causing pain and swelling during periods of increased salivation (ie, brushing teeth, preparing to eat).2 The majority of sialoliths can be managed conservatively with hydrating, applying moist heat, massaging the gland, milking the duct, and advising the patient to suck on tart candies to promote salivation. Larger, more superficial sialoliths may require excision. Imaging and specialist referral should be considered in cases concerning for tumor, abscess, or treatment failure.3

Management of a case of ankyloglossia using diode laser in a patient of underlying systemic condition/syndrome

Background Tongue-tie or ankyloglossia is a rare congenital anomaly. It is a short, thick, and fibrosed lingual frenulum which causes restriction in function of the tongue and also in speech. For its management laser has some advantages over other techniques like less operative time, haemostasis, less postoperative complications. Result Uneventful healing was observed in 7 days as laser is less invasive, resulting in better healing. Conclusion Tongue being highly vascular and mobile structure, laser-assisted lingual frenectomy is the simplest, safest and less traumatic of all the treatment modalities available. Keywords: Ankyloglossia, Diode laser, Tongue-tie

Atmospheric Plasma Lingual Frenectomy Followed by Post Operative Tongue Exercises: A Case Series.

The lingual frenulum is a submucosal component significantly involved in the mobility of the tongue. In the case of short lingual frenulum, different surgical approaches have been proposed. Atmospheric plasma is a thermal technique of vaporization or sublimation of the superficial tissues, without going deep, and the resulting fine carbonized layer avoids bleeding. The aim of the present investigation was to evaluate the effectiveness of atmospheric plasma (voltaic arc dermabrasion) for the frenectomy of a short lingual frenulum. A total of 30 patients with an age range between 6-11 years old and a class III/IV Kotlow's ankyloglossia classification were included in the study. The Kotlow's free-tongue, maximal interincisal mouth opening (MIO, mm) and interincisal mouth opening with tongue tip to maxillary incisive papillae at roof of mouth (MOTTIP, mm) were calculated at the baseline, immediately postoperatively (T0), at one week (T1), one month (T2) and two months (T3). A significant increase of Kotlow's measurements, MOTTIP and MIO were detected when comparing the baseline and the T0 (p < 0.05). No significant difference was detected between the T0, T1 and T2 (p > 0.05). The atmospheric plasma demonstrated a very minimal invasive approach for frenectomy, without important or fibrotic complications and with very low recurrence rates.

Lingual frenulum length: A prospecting link to craniofacial morphology in adults.

The aim of this study was to evaluate the correlation of the length of the lingual frenulum with the craniofacial morphology in adults. The study comprised a total of 144 subjects, aged 18 to 28 years, divided into 3 groups (48 in each group), based on ANB angle i.e., Skeletal Class I, Skeletal Class II & Skeletal Class III. To measure the length of the lingual frenulum direct and indirect methods were used. A Lingual frenulum ruler was used for direct measurement and the differences between the maximum mouth opening reduction (MMOR) with and without the tip of the tongue touching the incisive papilla measurement were taken for the indirect method. A lateral cephalogram was collected from each subject and a cephalometric analysis was done to assess craniofacial morphology. Statistical analysis was done by ANOVA and the significance of the mean difference between (inter) the groups was done by Tukey's HSD (honestly significant difference) post hoc test after ascertaining normality by Shapiro-Wilk's test and homogeneity of variance between groups by Levene's test. The lingual frenulum length and maximum mouth opening reduction were significantly increased in the Skeletal Class III subjects with a statistically significant value of P < 0.001 when compared with the Skeletal Class I and Skeletal Class II subjects. A balance in the teeth positioning is maintained by orofacial musculature and any disturbance which occurs in this, results in malocclusion. Malocclusion can result in a long lingual frenulum that pushes the mandibular anterior forwards. Hence, the malocclusion and lingual frenulum length relationship are essential to eliminate the erratic forces and to attain excellent results, following the elimination of malocclusion.

Untying a tongue tie using diode laser: A case report

Tongue tie or ankyloglossia, causes the tongue to become fused to the floor of the mouth. The tongue's mobility is slightly hampered by the short, thick lingual frenulum. This developmental aberration has an impact on speech, oral hygiene maintenance, and other areas. The salivary gland duct at the mouth's floor and other crucial tissues must be protected from damage during surgery in this situation. As a result, LASERs have been employed frequently in a variety of soft tissue surgeries, simplifying them and improving their results. Our case focuses on the most effective management of ankyloglossia using a 980 nm diode laser.

Management of ankyloglossia by functional frenuloplasty using diode laser

Ankyloglossia or tongue-tie is a condition present since birth that results in restricted movement of the tongue due to the attachment of the lingual frenulum. The condition affects breastfeeding, speaking, swallowing, occlusion, and proper tongue posture. Tongue ties vary in degree of severity from mild cases of mucus membrane bands to complete tongue ties where the tongue adheres to the floor of the mouth. Treatment options such as speech therapy, frenotomy,frenectomyhave all been suggested in the literature. Surgical correction often causes, bleeding,chances of infection, swelling, and relapse. A systemically healthy 23-year-old male patient who experienced difficulty in speech since childhood was referred for treatment to the dental clinic in September 2020. He was diagnosed with Kotlows class III tongue tie and angles class 3 malocclusion. Orthodontic correction and Functional frenuloplasty using a diode laser was carried out. In conjunction with it,orofacial myofunctional therapy was advised. Follow-up: The surgical procedure was uneventful. The patient was reviewed post-operatively at regular intervals every 3 months to check for relapse. This paper elaborates on the newer modes of diagnosis, orofacial myofunctional therapy, and lingual frenuloplasty with diode laser. This technique will help to overcome all the challenges of conventional tongue-tie treatments providing long-term excellent results.

Does Frenotomy Modify Upper Airway Collapse in OSA Adult Patients? Case Report and Systematic Review.

Ankyloglossia (tongue-tie) is a condition of the oral cavity in which an abnormally short lingual frenulum affects the tongue's mobility. Literature on the correlation between ankyloglossia and obstructive sleep apnea (OSA) is scarce. The main objective of this study was to report our preliminary experience in adult OSA patients before and after ankyloglossia treatment, using drug-induced sleep endoscopy (DISE) to evaluate the upper airway modifications resulting after treatment, and to present a systematic review of the impact of ankyloglossia and its treatment on OSA adults. We found that, after frenotomy, regarding the DISE findings, and according to the VOTE classification, two of the three patients showed an improvement in tongue level, from 2A-P (complete anteroposterior collapse) to 1ap (partial anteroposterior collapse). The third patient showed no changes in his UA after frenotomy, neither worsening nor showing improvement. Thus, the results of this study suggest that frenotomy in OSA patients with ankyloglossia could reduce tongue collapse, probably by allowing the tongue to take into the physiological position in the oral cavity. These patients should undergo speech therapy and oropharyngeal exercises prior to any surgical procedure, in order to avoid glossoptosis and to improve the quality of life and sleep apnea results.

Grouping of Ankyloglossia According to Coryllos Anatomical Classification and Follow-Up Results for Breastfeeding: Single-Center, Cross-Sectional Study.

Ankyloglossia is a condition of limited tongue mobility caused by a short lingual frenulum. The diagnosis and treatment of ankyloglossia are still controversial. The main clinical problems encountered during breastfeeding are difficulty in sucking and its clinical reflections. This study aims to evaluate the infant population born with ankyloglossia and to determine the results of frenotomy. We conducted an observational, cross-sectional study among infants born in a tertiary hospital. We included all infants born between 1 January and 30 June 2022. The neonatal follow-up protocol for ankyloglossia was determined before the defined dates, and data were recorded during the screening period. The recorded data were retrospectively collected from the files. Within six months, 705 infants were born. Due to additional problems and other conditions that prevent breastfeeding, evaluable data of 207 (29.3%) infants could not be provided. Of the remaining 498 infants, 234 (33.2%) had ankyloglossia. While none of the infants without ankyloglossia had a breastfeeding problem after appropriate training, 28.6% of the ankyloglossia group had a breastfeeding problem (p &lt; 0.001). The need for frenotomy differed significantly between Coryllos groups (p &lt; 0.001). Breastfeeding was unsuccessful before frenotomy in 12 Coryllos type-1 patients, and all had difficulty in sucking. Frenotomy was performed within the three-month follow-up period in all patients with complaints of inability to firmly grasp the breast, nipple slipping from the mouth, and nipple biting during the first 24 h. In terms of breastfeeding problems, regardless of the anatomical typology, frenotomy can be performed safely in early life with successful results. If deficiencies or difficulties in breastfeeding are noticed in ankyloglossia patients even at the first control, frenotomy should be recommended in clinical conditions.

Identifying a sublingual triangle as the ideal site for assessment of sublingual microcirculation

The sublingual mucosa is a commonly used intraoral location for identifying microcirculatory alterations using handheld vital microscopes (HVMs). The anatomic description of the sublingual cave and its related training have not been adequately introduced. The aim of this study was to introduce anatomy guided sublingual microcirculatory assessment. Measurements were acquired from the floor of the mouth using incident dark-field (IDF) imaging before (T0) and after (T1) sublingual cave anatomy instructed training. Instructions consists of examining a specific region of interested identified through observable anatomical structures adjacent and bilaterally to the lingual frenulum which is next to the sublingual papilla. The anatomical location called the sublingual triangle, was identified as stationed between the lingual frenulum, the sublingual fold and ventrally to the tongue. Small, large, and total vessel density datasets (SVD, LVD and TVD respectively) obtained by non-instructed and instructed measurements (NIN (T0) and IM (T1) respectively) were compared. Microvascular structures were analyzed, and the presence of salivary duct-related microcirculation was identified. A total of 72 video clips were used for analysis in which TVD, but not LVD and SVD, was higher in IM compared to NIM (NIM vs. IM, 25 ± 2 vs. 27 ± 3 mm/mm2 (p = 0.044), LVD NIM vs. IM: 7 ± 1 vs. 8 ± 1mm/mm2 (p = 0.092), SVD NIM vs. IM: 18 ± 2 vs. 20 ± 3 mm/mm2 (p = 0.103)). IM resulted in microcirculatory assessments which included morphological properties such as capillaries, venules and arterioles, without salivary duct-associated microcirculation. The sublingual triangle identified in this study showed consistent network-based microcirculation, without interference from microcirculation associated with specialized anatomic structures. These findings suggest that the sublingual triangle, an anatomy guided location, yielded sublingual based measurements that conforms with international guidelines. IM showed higher TVD values, and future studies are needed with larger sample sizes to prove differences in microcirculatory parameters.

A Single Institution Cadaveric Study on Anatomical Variation of the Sublingual Gland Duct.

The purpose of this study was to conduct a cadaveric dissection study on the anatomical variation of the sublingual (SLG) excretory ducts and dictate an improved understanding of the anatomical communication between the SLG duct and submandibular (SMG) ducts. This study is carried out by standardized dissection of anterior floor of mouth in 6 formalin-fixed adult cadavers in Silent Mentor Workshop University Malaya in August 2020. The cadavers had no trace of scars, adhesions, signs of trauma or operation. SMG duct opening was identified lateral to the lingual frenulum through a papilla in the floor of mouth behind the lower incisor tooth. A horizontal incision line was done over floor of mouth just lateral to the opening. SMG duct and SLG was traced and skeletonized. Any presence of major duct arising from the SLG and its communication with SMG duct were investigated. We found there are 3 patterns of SLG excretory duct variants; (1) One major (Bartholin's) duct which open independently at its own orifice adjacent to the orifice of the Wharton's duct of SMG. (2) One major (Bartholin's) duct which joined into the Wharton's duct of SMG. (3) Absent of a major duct arising from SLG. The overall mean diameter of SLG ducts were 1.3 ± 0.41and the mean length of SLG ducts were 18.5 ± 6.55. The overall mean diameter of SMG ducts was 2.6 ± 0.74 and the mean length of SMG ducts were 46.5 ± 6.57. Excretory ductal system of SLG showed great variations, not only between the different cadavers but also within the different sides of the same cadaver. Awareness of potential anatomical variations can aid in the accurate diagnosis and treatment of patients with salivary gland pathology as well as help surgeons reveal potential risk factor and avoid complications during surgical procedures in the floor of mouth.

Frenula of tongue and lips: are there or not?

BACKGROUND: The absence, hypoplasia, or hyperplasia of the frenula of the lips and tongue is suggested as a sign of some diseases. This study assessed the presence of frenula among patients with orthodontic concerns.&#x0D; AIM: This study aimed to analyze the prevalence of the absence of the frenulum of the tongue and lips to determine the possibility of using the absence of frenula as a diagnostic criterion for other pathologies.&#x0D; MATERIALS AND METHODS: A retrospective analysis photographs of 391 patients was performed.&#x0D; RESULTS: In total, 100% of the patients have a maxillary frenulum. The inferior labial frenulum was absent in 67.02% of the patients, and 252 patients (95% CI 62.2771.77%) had multiple strands of the mucosal membrane. Hypoplastic mandibular frenulum was found in 109 (28.99%) patients (95% CI 24.433.58%). Absence of lingual frenulum was noted in 6 (1.68%) patients (95% CI 0.353.01%) and hypoplasia in 33 (9.24%) (95% CI 6.2412.24%).&#x0D; CONCLUSIONS: The absence of inferior labial and lingual frenulum cannot be a diagnostic criterion for other pathologies without specifying the method of displacement of the lower lip.

The current knowledge about ankyloglossia

Introduction: The topic of tongue tie causes a lot of discussion among specialists in areas of interest. The term ankyloglossia has been defined as a state of the lingual frenulum hindering its motor function. Aim: The aim of the study is to present the current views on the short lingual frenulum. Material and methods: The literature from 20192021 on this topic was searched for in PubMed and Google Scholar using keywords. Results: Ankyloglossia is a congenital abnormality that can cause difficulties in breastfeeding newborns and infants and that is the most important problem of this structure. Discussion: The affected sucking reflex generates further dysfunctions in the area of the oropharyngeal space, which may lead to malocclusion and speech impediments. The procedure of frenotomy is primarily aimed at achieving the correct tongue motility. High individual variability in the structure of the frenulum and the occurrence of compensation mechanisms among newborns who suck the breast incorrectly, make it difficult to develop a universal classification for assessing the indications for surgery. The current state of knowledge justifies the need for further, extensive interdisciplinary research and reaching a consensus regarding the procedure.

Topographic Positions of the Wharton's Duct Orifice in Children

Sialoendoscopic, orthodontic, and surgical interventions within the floor of the mouth require precise knowledge of the topography of the Wharton's duct orifices which is still lacking for the pediatric population. We aimed to establish a normative database for the topography of these orifices in children. The prospective cross-sectional analytic study was performed during January to December 2021. The distances between the mandible gonions and each orifice and the lingual frenulum were defined as primary outcome variables. The secondary outcome variables were the inter-position of the orifices and their location against the base of the tongue and the mandibular alveolar ridge. The segments of the cohort were classified by sex and age groups (4 to 7, 8 to 14, 15 to 17years old) as the primary predictor variables. The data were evaluated by a 3-way ANOVA for analysis of selected distances with the level of significance at P≤.05. The correlation analysis between sex and locations of the orifices was performed using χ2 criterion (95% confidence interval) and r≥0.60 was counted as a strong correlation. The study involved 3,000 healthy children from 4 to 17years of age. The orifices were symmetrical (89.3%), frenulum-independent (78.0%) openings that were usually located in the middle part of the floor of the mouth. The distance between the orifices varied from 0mm in the frenulum-attached cases to 4.6±1.8mm for 4 to 7years old, 7.6±1.9mm for 8 to 14years old, and 9.1±2.6mm for 15 to 17years old individuals. The orifices were attached to the frenulum (5.7%), were frenulum-related (16.3%), and frenulum-independent (78.0%). The sagittal asymmetry of the orifices was noted in 10.7%, and in 1.6% the lateral asymmetry was detected. No statistically significant sex-related differences were noted. In the pediatric population, the Wharton's duct orifices are usually symmetrical frenulum-independent openings that are located in the middle part of the floor of the mouth. The distance between the orifices normatively varies according to sex and age. The size of the mandible does not influence the positions of the orifices. The position of the duct orifices must be established prior to submandibular sialoendoscopy, orthodontic interventions, frenotomy, and other oral surgeries.

Evaluation of tongue mobility following release operation of ankyloglossia with genioglossus myotomy.

Ankyloglossia is a congenital anomaly characterized by a short lingual frenulum and severe form needs release surgery. Our goal in this study was to confirm the long-term safety and efficacy of Z-plasty with genioglossus myotomy compared with traditional Z-plasty alone and to develop a proper measurement tool to validate the postoperative results of release operations for ankyloglossia. Patients were divided in 2 groups, release with Z-plasty only group (group 1) and Z-plasty combined with genioglossus myotomy group (group 2) In group 2, the release of central longitudinal fiber of genioglossus muscle was added in the conventional Z-plasty operative procedure. To analyze the results of the surgery, we developed an objective assessment tool which is the direct length from the innermost point of the floor of mouth to the tip of the tongue, preoperatively and postoperatively, which is called “functional tongue length.” A total of 101 patients with ankyloglossia ranging in age from 36 months to 8 years underwent release operation. Although there was no significant difference in terms of postoperative measurements between groups in Kotlow class II, group 2 patients in Class III and IV showed greater postoperative functional tongue length. Also, there was no significant complication requiring secondary surgery. Our study demonstrated that adding genioglossus myotomy to a simple Z-plasty is a safe and effective method for improving the tongue mobility required to make lingual sounds, especially in moderate to severe form of ankyloglossia, along with suggestion of a new measurement tool, which can objectively assess tongue mobility with possibility for universal utilization in ankyloglossia release operation.

Oral cavity, lingual frenulum and head forward posture in children at risk of OSAS

Oral cavity, lingual frenulum and head forward posture in children at risk of OSAS

A minimally invasive surgical approach for treatment of ankyloglossia (Tounge Tie) with diode laser: A case report (A developmental anomaly)

Tongue tie otherwise called as Ankyloglossia is a developmental anomaly commonly characterized by a very short lingual frenulum that literally restricts the movements of tongue from the floor of mouth. An uncommon thick band extending beneath the ventral surface of tongue to floor of the mouth. This represents a uncommon length of the lingual frenulum. This causes problems in daily life of the person who was affected with the following difficulties of speech, deglutition, poor oral hygiene etc. This article reports a 19 year college going guy came to the department with the complaint of difficulty in speech and poor oral hygiene. The case was successfully treated with a soft tissue diode laser and followed up.

Effectiveness of tongue-tie assessment tools in diagnosing and fulfilling lingual frenectomy criteria: a systematic review.

It is unclear how effective tongue-tie classification assessment tools are in diagnosing symptomatic tongue-tie and fulfilling lingual frenectomy criteria. The purpose of this systematic review is to determine and evaluate any association between tongue-tie severity, as measured by pre-treatment assessment tools, and post-operative outcome following tongue-tie division. PubMed, EMBASE, and the Cochrane search engines were used to retrieve articles published between 1947 and 2021. Included studies consisted of patients with symptomatic tongue-tie, assessment by either the Coryllos, Kotlow, or Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) classification tool, and tongue-tie division. A total of 205 abstracts were identified; 31 studies met the criteria for a full-text review, of which, only 14 studies met the criteria for data extraction and analysis. Six studies used the HATLFF, 2 studies used the Kotlow, 5 studies used the Coryllos, and 1 study used a combination of both Kotlow and Coryllos methods. Significant heterogeneity was evident across all studies. No statistical correlation between the two variables could be determined. Although tongue-tie division procedures appear to provide benefits in breastfeeding and speech, there are no data to suggest a statistically significant association between the severity of tongue-tie, and the correct identification of patients who would benefit from tongue-tie division. © 2022 Australian Dental Association.

Comparison of the Effects of High-Power Diode Laser and Electrocautery for Lingual Frenectomy in Infants: A Blinded Randomized Controlled Clinical Trial.

The aim of the study was to evaluate the release of the lingual frenulum through frenectomy in newborns zero to 90 days of age who breastfed and had diagnosis of ankyloglossia with an indication for surgery, comparing two methods: electrocautery and a high-power diode laser. Fifty-seven patients were randomly allocated to two groups (23 submitted to electrocautery and 34 submitted to a high power diode laser). Tongue movements were evaluated based on a clinical assessment and using the Bristol Tongue Assessment Tool (BTAT) before and 15 days after the surgical procedures. The visual analog scale was administered to the mothers on the same occasions for the measurement of pain during breastfeeding. Both groups had an increased BTAT score (favorable outcome) at the post-surgical evaluation, but the anterior third of the tongue was not always free to enable the movements necessary for lingual functions. It is fundamental for surgeons to have skill and in-depth knowledge of the equipment used to avoid accidents and complications in the region of important structures. Both techniques employed in this study were safe and effective, causing little bleeding and few postoperative complications. The group submitted to a high-power diode laser exhibited less post-surgical bleeding compared to the group submitted to electrocautery and no inflammation at the edges of the surgical cut.