Lingual frenotomy
Lingual frenotomy in neonates
Almost 2000 years ago, Cornelius Celsus, a Roman ency-
clopaedist at the time of Christ, described the condition
known as tongue-tie, and accurately noted the dangers of
frenulotomy to release the tongue.
The treatment and importance of neonatal ankyloglossia
have been controversial. We discuss the current guide-
lines in accordance with the best evidence available, and
the future provision of treatment in the early postpartum
period.
Definition
Ankyloglossia is derived from the Greek words “agkilos”
meaning curved and “glossa” meaning tongue. There is no
universally agreed definition. In the 1960s, Wallace defined
it as “a condition in which the tip of the tongue cannot be
protruded beyond the lower incisor teeth because of short
frenulum linguae, often containing scar tissue.”6 Elsewhere
it has been defined as “the condition in which the tongue
cannot make contact with the hard palate or cannot protrude
more than 1-2 mm past the mandibular incisors”, whilst the
Academy of Breastfeeding Medicine defines it as a “sublin-
gual frenulum which changes the appearance and/or function
of the infant’s tongue because of its decreased length, lack of
elasticity or attachment too distal beneath the tongue or too
close to or onto the gingival ridge”. It is universally accepted
as a condition in which there is a short, tight, lingual frenulum
that may be associated with a
bifid tongue
Pathophysiology
The exact pathophysiology of this congenital abnormality is
the mucosa covering the anterior two thirds of
the mobile tongue is derived from the first pharyngeal arch,
and deviation from its normal development is the most likely
cause of abnormalities in the length and attachment of the
frenulum.
Several syndromes are also associated with the
clinical findings of ankyloglossia, including Ehlers-Danlos
syndrome, Beckwith-Wiedemann syndrome, Simosa cranio-
facial syndrome, orofaciodigital syndrome, van der Woude
syndrome, Kindler syndrome, and Optiz syndrome
Clinical presentation of ankyloglossia
The clinical phenotype varies from an absence of symp-
toms to rare cases of complete ankyloglossia in which the
tongue is fused to the floor of the mouth. A commonly
used criterion was that of the frenulum being abnormally
short and thick, which caused the tongue to become heart-
shaped on protrusion. Other functional impairments include
reduced mobility of the tongue and an inability to protrude the
tongue past the gum line. Most surgeons routinely assess
the extent of tongue-tie by observing the tongue’s mobility
on protrusion.
Symptoms of neonatal ankyloglossia
Many neonates with ankyloglossia will be asymptomatic,
but if left untreated, symptomatic cases can cause func-
tional difficulties with breastfeeding, atypical swallowing,
problems with deglutition, and poor attachment. It can also
result in infants being unsettled, failing to gain weight,and
dehydration.
In 25%–60% of infants it is associated with failure to thrive
and refusal of the breast, and in mothers, painful and damaged
nipples and a poor milk supply. There is a 10% - 26% risk
that breastfeeding will cease during the initial three weeks.
The recommendation by the World Health Organization
that mothers should breastfeed exclusively for the first six
months and, with supplemental feeding, continue to do so
until the age of 2 years, has been adopted in the UK because
of its benefits to health
Management
Ankyloglossia can present as an asymptomatic condition
and may resolve spontaneously, and some babies learn to
compensate adequately with the reduced mobility. Only
symptomatic cases that cause functional problems should be
treated surgically. Treatment remains controversial, however,
and there is no consensus regarding the indications, timing, or
methods of surgical repair. Subjective outcomes show that in
many cases, the division of a tongue-tie improves the mother’s
experience of breastfeeding.
Two systematic reviews have evaluated the effectiveness
of division. They identified five randomised controlled
trials with heterogeneous and short-term outcome measures
. The others were retrospective cohort
studies and case series.
In their UK-based study of 201 babies, Hogan et al con-
cluded that division is safe and improves feeding for both
mother and baby.2 In a US randomised, single-blinded con-
trolled trial by Buryk et al,23 the release of the tongue-tie
reduced pain in the nipples and improved breastfeeding
scores.
The National Institute for Health and Care Excellence
(NICE) guidelines for the division of tongue-tie (2005) rec-
ommends early division (between one day and 12 weeks)
for problems with breastfeeding or restricted mobility of the
tongue. It can be done safely without anaesthesia, a recom-
mendation that is endorsed by NICE. General anaesthesia
should be reserved for older infants or children, as the haz-
ards of operation or reoperation are higher, ranging from 6%
in infants (1-23 months) to 16% in children aged between 6
and 12 years.
The current guidelines by the American Academy of
Pediatric Dentistry recommend frenuloplasty for the man-
agement of problems with breastfeeding. For other functional
problems such as speech, decisions should be made on a
case-by-case basis.
Terms that are used to refer to the division of tongue-tie
are confusing, as they are interchangeable and inconsistent.26
Frenotomy or frenulotomy refers to division of the lingual
frenulum without sutures; frenuloplasty to division with the
placement of sutures; and frenectomy orfrenulectomy to exci-
sion of the lingual frenulum.
Frenotomy (frenulectomy) involves an incision of several
millimetres into the lingual frenulum, which is a brief and
usually bloodless procedure, as the frenulum in infants tends
to be thin and relatively avascular. Haemostasis, if needed, is
achieved by breastfeeding, which also lengthens the tongue
and acts as an analgesic and antiseptic. In infants less than
3 months of age, division is quick and simple, and can be
done without anaesthesia in outpatients .
Complications are rare, but can include bleeding, infec-
tion, injury to the musculature of the tongue, and damage to
the submandibular ducts and orifices. The tie can recur in
young infants after frenotomy, mostly as a result of excessive
scarring
The future
Current evidence suggests that symptomatic ankyloglosssia
will interfere with breastfeeding. Treatment is simple and
effective without complications and there is a minimal cost to
the public healthcare service. Knowledge of the condition by
healthcare professionals and its potential effect on breastfeed-
ing, however, seems to be limited, and seems to coincide with
patchy provision of a service that enables prompt treatment.
In the first 30 days of life, infants are cared for by their
parents, midwives, paediatricians, and healthcare visitors.
We think that the provision of training and education would
enable early identification of treatable symptomatic anky-
loglossia. An agreed, universal, and simple questionnaire,
which could be used to assess functional problems during
the routine examination of neonates by midwives and health
visitors, could easily be implemented and disseminated after
training.
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