Ankyloglossia (Tongue-Tie): from a dentist’s standpoint
Definition of Ankyloglossia
Ankyloglossia, or tongue-tie, is a congenital condition and happens when the tissue connecting the tongue to the bottom of the mouth is too short, thick, or tight. This can make it harder for the tongue to move freely, which may affect things like breastfeeding, talking, or swallowing.
Prevalence of Ankyloglossia
Tongue-tie is found in around 3% to 11% of infants, although some reports suggest it could be as common as 10.7%. It tends to be more common in boys than girls, but we’re not entirely sure why. The wide range in these numbers comes from differences in how tongue-tie is diagnosed in various studies.
Presentation
In cases of ankyloglossia, the lingual frenulum can vary significantly in its attachment and structure. It may connect to the tip of the tongue or further back towards the base, and it can present as short, thick, muscular, or fibrotic. These variations in the frenulum can restrict the tongue’s ability to move forward (anteriorly) and upward (superiorly), which can impact essential functions such as breastfeeding, speech, and swallowing.
Impact of Ankyloglossia
Ankyloglossia, or tongue-tie, can have a range of effects on feeding, speech, swallowing, dental health, and overall development. While not all individuals experience significant problems, when issues do arise, they may impact quality of life. Here’s a closer look:
Feeding
Infants with tongue-tie often struggle to latch effectively during breastfeeding. This can lead to prolonged feeding times, leaving both the baby and the mother frustrated. Mothers may also experience nipple pain due to improper latching, which can discourage continued breastfeeding. Frequent feeding and poor weight gain in the infant may follow because they are not able to extract milk efficiently. Bottle-fed babies may also show signs of difficulty, such as clicking sounds, swallowing air, or excessive drooling.
Speech Articulation
Restricted tongue movement can interfere with producing specific sounds that require the tongue-tip to lift or move forward, such as /t/, /d/, /n/, and /l/. Children with tongue-tie may speak at a slower rate or have reduced speech intelligibility, making it difficult for others to understand them. These articulation challenges can sometimes lead to frustration or impact confidence in social or learning environments.
Swallowing
Ankyloglossia may make it hard for some children to control saliva properly, leading to issues like drooling. For some, it may also complicate the act of swallowing food, especially foods that require intricate tongue movements. This can create challenges during mealtimes and even increase the risk of choking in some cases.
Dental Issues
In the long term, tongue-tie may contribute to spacing issues between the lower front teeth (incisors) due to the abnormal attachment of the frenulum pulling on the gums. It may also lead to gingival recession, where the gum tissue pulls away from the teeth, increasing the risk of gum disease and tooth sensitivity.
Jaw and Psychological Effects
During childhood, tongue-tie may potentially influence jaw skeletal development, especially as the tongue’s restricted movement limits its natural role in shaping the oral cavity. This could result in structural imbalances or misalignment of the teeth and jaw. Psychologically, living with the functional challenges of tongue-tie may lead to stress, particularly if feeding, speech, or appearance issues persist into adolescence or adulthood. For children, it may also impact social development if they struggle to communicate effectively or feel self-conscious.
Note: Some individuals with tongue-tie do not experience any noticeable functional problems.
Classification Systems
Coryllos Classification
This system divides tongue-tie into four types based on the location of the frenulum’s attachment:
Type 1: The frenulum is attached at the very tip of the tongue, severely limiting tongue mobility.
Type 2: The frenulum is attached slightly behind the tip, approximately 2–4 mm back, still affecting tongue movement but less restrictive than Type 1.
Type 3: The frenulum connects at the mid-tongue and to the middle of the floor of the mouth. This can moderately restrict movement.
Type 4: The frenulum is located at the base of the tongue. While less visible, this type can still significantly impair tongue movement and function.
Kotlow Classification
The Kotlow Classification focuses on measuring the “free tongue” length. This is the distance from where the frenulum attaches at the base to the tip of the tongue. It categorises tongue-tie as follows:
- A free tongue length greater than 16 mm is considered normal.
- Lengths below 16 mm are classified as restrictive, with shorter lengths indicating more severe restrictions.
This classification is particularly useful for evaluating how much the tongue is able to move and helping the kids dentist determine if treatment could improve feeding, speech, or other functions. Together, these classification systems provide a comprehensive approach to diagnosing and managing tongue-tie, ensuring that assessments are both thorough and practical.
Anterior vs. Posterior Ankyloglossia
Ankyloglossia, or tongue-tie, can be described as either anterior or posterior, depending on the location of the lingual frenulum and how it restricts the tongue’s movement.
Anterior Ankyloglossia
In anterior ankyloglossia, the lingual frenulum is attached closer to the tip of the tongue. This type is visibly noticeable, as it significantly restricts the tongue’s ability to move forward or upward. It is easier to diagnose due to its obvious presentation, and it can often cause difficulties with breastfeeding, speech articulation, and other tongue-related functions.
Posterior Ankyloglossia
Posterior ankyloglossia involves the frenulum being located further back, closer to the base of the tongue. This type is less visible and may not be immediately obvious during a standard examination. Diagnosis often requires palpation (feeling the tissue with fingers) to assess the restriction. Despite being less apparent, posterior tongue-tie can still cause functional problems, including challenges with feeding and speech, and should not be overlooked.
Tongue Range-of-Motion Ratio (TRMR)
The Tongue Range-of-Motion Ratio (TRMR) is a clinical measurement used to assess the functional mobility of the tongue. This method compares how far the tongue can extend to touch the upper gums (specifically the maxillary incisive papilla) relative to the person’s maximal mouth opening. By calculating this ratio, healthcare providers can determine the severity of tongue restriction and classify it into grades.
How It’s Measured
The distance from the tongue tip to the maxillary incisive papilla (the small bump behind the upper front teeth) is measured when the tongue is extended upward as far as possible. This is divided by the maximum mouth opening (measured as the distance between the upper and lower teeth when the mouth is open fully) and expressed as a percentage.
Grading
TRMR is classified into four grades based on the ratio:
- Grade 1 (TRMR >80%): This indicates excellent tongue mobility with minimal or no restriction.
- Grade 2 (TRMR 50–80%): Tongue mobility is somewhat restricted but may not cause significant functional problems.
- Grade 3 (TRMR 25–50%): Tongue restriction is moderate and likely impacts functions like feeding, speech, or oral hygiene.
- Grade 4 (TRMR <25%): This is the most severe restriction, where tongue movement is significantly limited and intervention is often necessary.
Why TRMR is Useful
The TRMR provides an objective way to measure tongue mobility, moving beyond just visual observations. It helps the Brisbane paediatric dentist decide whether intervention, such as a frenotomy or speech therapy, is needed based on the functional impact of the restriction. By grading severity, parents can better understand how the condition might affect their child’s feeding, speech, or dental development.
Treatment Options for Ankyloglossia
Treatment for ankyloglossia (tongue-tie) depends on the severity of the condition and its impact on the individual’s feeding, speech, or other functions. Here are the main options:
Observation
In mild cases of tongue-tie, no immediate treatment may be necessary. These cases often resolve naturally as the child grows, with the frenulum stretching or loosening over time. If there are no functional problems, healthcare providers may recommend a “wait-and-see” approach, monitoring the child’s development to ensure no difficulties arise.
Speech Therapy
For cases where tongue mobility affects speech articulation, speech therapy can be highly beneficial. A speech therapist works with the child to improve tongue movement and develop strategies for clearer pronunciation of sounds like /t/, /d/, /n/, and /l/. This non-invasive approach is particularly helpful for children with mild to moderate restrictions or as a complementary therapy following a surgical procedure.
Frenotomy or Frenectomy
When intervention is necessary, two common surgical procedures are available:
Frenotomy: This is a simple procedure that involves cutting the frenulum to release the tongue. It is often performed on infants and young children with minimal anaesthesia. The procedure is quick, usually taking just a few seconds, and has minimal risks.
Frenectomy: A more comprehensive surgical option, frenectomy, involves the removal of the frenulum. It is typically performed on older children or adults and may require sutures to close the incision. This procedure can be done using scissors, a laser, or a scalpel, depending on the preference of the Brisbane dentist and the specific case.
Both procedures aim to improve tongue mobility, and recovery is typically quick. Parents are often advised on post-operative care, including exercises to maintain the tongue’s range of motion and prevent reattachment of the tissue.
Choosing the Right Treatment Option
The decision to treat ankyloglossia should be based on the severity of the condition and the presence of functional issues. For some children, a conservative approach like observation or speech therapy may be sufficient. In cases where tongue-tie significantly impacts feeding, speech, or oral hygiene, surgical intervention may be recommended to improve quality of life.
Controversy and Debate
Ankyloglossia, or tongue-tie, is a topic of ongoing debate due to variability in diagnosis and treatment approaches. Different healthcare professionals—such as dentists, paediatricians, speech therapists, and lactation consultants—often have differing opinions on the condition’s severity and the need for intervention, influenced by their areas of expertise. There is also controversy over the benefits of surgical procedures like frenotomy or frenectomy, particularly regarding speech improvement, as not all individuals with tongue-tie experience functional issues. This variability underscores the need for a personalised, multidisciplinary approach when considering treatment.
Conclusion
In summary, ankyloglossia, or tongue-tie, is a condition that can restrict tongue mobility and lead to challenges with feeding, speech, and dental health in some individuals. However, not all cases require intervention, as many people experience no significant problems. When treatment is necessary, options should be carefully tailored to the individual’s needs and the severity of the condition, ensuring the best possible outcome.
Confident Tongues, Happy Smiles
If your child is experiencing challenges related to tongue-tie, Pure Dentistry offers tailored solutions to improve feeding, speech, and overall oral health. Our experienced team provides professional assessments and treatments, including frenotomy and frenectomy, designed to restore tongue mobility and comfort.
We prioritise making procedures comfortable for children by offering options like sleep dentistry and laughing gas to eliminate anxiety. According to Brisbane Dental Sleep Clinic, sleep dentistry Brisbane can make dental visits relaxing and less stressful for patients who fear dental treatments.
With payment options like Humm and Supercare available, expert care is accessible and stress-free. Call us today at 07 3343 4869 to take the first step toward better oral health.