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Surgical treatment of ankyloglossia

  • Aaron R. Baker
    Affiliations
    Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University—Milton S. Hershey Medical Center, Hershey, Pennsylvania
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  • Michele M. Carr
    Correspondence
    Address reprint requests and correspondence: Michele M. Carr, DDS, MD, PhD, Division of Otolaryngology, H091, Penn State Hershey Medical Center, 500 University Dr., Hershey, PA 17033.
    Affiliations
    Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University—Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Published:January 02, 2015DOI:https://doi.org/10.1016/j.otot.2015.01.006
      Ankyloglossia, although difficult to define and quantify, is present in approximately 4%-5% of the pediatric population. Tongue-tie typically presents with difficulty in breast-feeding because of reduced mobility of the tongue and is implicated in difficulty with speech later in life. The lingual frenulum is typically a structure with low vascularity innervation and amenable to surgical treatment in an outpatient clinic as well as the operating room. Multiple techniques from simple division to multiple-flap frenuloplasties have been developed to treat the disorder and are tolerated well, with near-immediate improvement in breast-feeding quality.

      Keywords

      Introduction

      Ankyloglossia, or tongue-tie, is a common congenital abnormality where the lingual frenulum is abnormally short and tight (posterior ankyloglossia) or abnormally attached anteriorly to the ventral surface of the tongue (anterior ankyloglossia),
      • O’Callahan C.
      • Macary S.
      • Clemente S.
      The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding.
      “tying” the tongue to the floor of the mouth. Owing to the variable nature of the amount of restriction, defining ankyloglossia has proven to be difficult, but recent reports suggest an incidence of approximately 4%-5% of the population.
      • Ballard J.L.
      • Auer C.E.
      • Khoury J.C.
      Ankyloglossia: Assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.
      • Klockars T.
      • Pitkäranta A.
      Pediatric tongue-tie division: Indications, techniques and patient satisfaction.
      • Messner A.H.
      • Lalakea M.L.
      • Aby J.
      • et al.
      Ankyloglossia: Incidence and associated feeding difficulties.
      Typically an isolated finding in otherwise normal infants, there are known associations with congenital syndromes such as Beckwith-Wiedemann
      • Patterson G.T.
      • Ramasastry S.S.
      • Davis J.U.
      Macroglossia and ankyloglossia in Beckwith-Wiedemann syndrome.
      and X-linked cleft palate.
      • Gorski S.M.
      • Adams K.J.
      • Birch P.H.
      • et al.
      The gene responsible for X-linked cleft palate (CPX) in a British Columbia native kindred is localized between PGK1 and DXYS1.
      Although attempts have been made to quantify the effect of the tongue-tie on function and mobility,
      • Ballard J.L.
      • Auer C.E.
      • Khoury J.C.
      Ankyloglossia: Assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.
      the true effects of ankyloglossia can be difficult to define. The conventional worries are that limited tongue movement, particularly protrusion, affect the ability to breast-feed early in life and affect speech or dental eruption later in life. Given these concerns, and the typically well-tolerated procedures, division of the lingual frenulum when tongue-tie is present is frequently undertaken. Although the most commonly performed procedure is a simple division of the frenulum with scissors in an office setting, we describe here the current operative techniques for frenotomy, frenectomy and frenuloplasty.

      Anatomy

      The lingual frenulum is a short mucosal membrane with underlying connective tissue connecting the ventral surface of the tongue to the floor of the mouth. The frenulum is typically not a very vascular or sensitive structure, making for a simple procedure when dividing. However, nearby structures in the tongue and the floor of the mouth must be taken into consideration when performing frenulum division. The bilateral lingual arteries and nerves typically course on the ventral surface of the tongue, although lateral from the midline location of the frenulum and deep to the intrinsic musculature. Care must be taken to avoid these structures to preserve sensation to the tongue and avoid serious bleeding, especially in an office setting where gaining control of such bleeding may be difficult. Inferiorly and into the floor of the mouth, the genioglossus muscle runs from the symphysis of the mandible to the tongue. Superficial to the genioglossus on the floor of the mouth, bilateral Wharton ducts may be visible, draining saliva from the submandibular glands into the oral cavity. Care must similarly be taken to avoid damage to these to avoid difficulty with salivation or stricture of the duct, which could lead to sialocele formation.

      Frenotomy or frenectomy

      The simplest procedure for division of a short lingual frenulum is division without any suture or revision of the remaining tissues.
      • O’Callahan C.
      • Macary S.
      • Clemente S.
      The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding.
      • Ballard J.L.
      • Auer C.E.
      • Khoury J.C.
      Ankyloglossia: Assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.
      This procedure is often done in the office or the newborn nursery without anesthesia or with local anesthesia in infants, because they can be restrained for the procedure. However, the authors recommend performing the procedure in an operating room or procedure room under general anesthesia to control movement, especially in older children, and to be better prepared in the circumstance of bleeding.
      The child is then placed supine, typically with a laryngeal mask in place. A midline 2-0 silk suture is placed to retract the tongue (Figure 1A). The edge of the frenulum is snipped at approximately its midportion. Division of the frenulum may be undertaken with a variety of instruments, although sterile Iris scissors or cautery is typically used. The remainder of the dissection is done bluntly, using a sponge to push against the ventral tongue and open the rest of the frenulum. The muscle of the tongue base can usually be seen, but by using blunt dissection, the veins on either side of the frenulum are not disturbed, and the muscle is not breached (Figure 1B). This minimizes the risk of bleeding. This method also minimizes the risk of damaging the Wharton duct. The cut frenulum does not require suturing, but if the muscle is exposed, we close the mucosa over this area (Figure 1C), taking care to stay away from the salivary ducts. Pain is controlled with oral administration of acetaminophen. Patients are discharged home the same day. Oral intake starts immediately in the recovery room, and postoperative feeding problems are uncommon.
      Figure thumbnail gr1
      Figure 1Simple release in a 12-year-old patient. Tight frenulum prerelease (A), after release (B), and with the tongue mucosa closed with resorbable suture (C). (Color version of figure is available online.)
      Follow-up is organized to monitor resolution of symptoms and to look for scar contracture, which causes recurrence of ankyloglossia.

      Frenuloplasty

      Given the possibility of posttreatment scarring and recurrence of the ankyloglossia after a simple frenotomy, multiple techniques have been developed to minimize these complications. All involve closing the mucosa in some fashion with sutures and are based on plastic surgery techniques for releasing contractures or scarred tissue.
      The simplest frenuloplasty technique is a horizontal-to-vertical frenuloplasty.
      • Velanovich V.
      The transverse-vertical frenuloplasty for ankyloglossia.
      • Heller J.
      • Gabbay J.
      • O’Hara C.
      • et al.
      Improved ankyloglossia correction with four-flap Z-frenuloplasty.
      As described, this converts the mucosal defect from a horizontal wound to a vertical one. Performed under general anesthesia, the frenulum and ventral surface of the tongue are anesthetized with 0.25% Marcaine with epinephrine. The tongue tip is elevated with a hook or suture placed through the midline of the tongue, to stretch the frenulum. A horizontal incision is made in the midportion of the frenulum along its entire length, and the submucosal connective tissues are divided. Submucosal soft tissues are released with blunt dissection as necessary, to bring the edges of the mucosa together in a vertical configuration, and are closed with interrupted 4-0 chromic sutures.
      In an effort to further minimize contracture from scar tissue, Z-plasty techniques have also been used in frenuloplasty, commonly 2-flap configurations,
      • Strader R.J.
      • House R.E.
      Treatment of tongue ankylosis with Z-plasty.
      and more recently 4-flap
      • Heller J.
      • Gabbay J.
      • O’Hara C.
      • et al.
      Improved ankyloglossia correction with four-flap Z-frenuloplasty.
      configurations. The patient is positioned similarly as in the horizontal-to-vertical technique, with the tongue tip elevated for maximum exposure and tension on the frenulum. For the 2-flap technique, the vertical midline is marked with a marker from the connections of the frenulum to the tongue, to the alveolus. Lines are then made at approximately 45°-60° from the vertical line, equaling the length of the frenulum (Figure 2A). After anesthetizing with 0.25% Marcaine with epinephrine, the vertical incision is made and the submucosal tissue is bluntly dissected down to the tongue musculature. The angulated incisions are then made and the flaps are developed. These flaps are then rotated and the mucosal tissue is sutured into place with interrupted 4-0 chromic sutures (Figure 2B). The 4-flap technique again uses a similar setup, and the vertical line is marked similarly. The lateral lines are marked as 90° at the superior and the inferior margins of the vertical line on alternate sides, with 45° divisions of each of these angles (Figure 3A). These flaps are 1-1.2 times the length of the frenulum. After anesthetizing the frenulum and the ventral surface of the tongue, the incisions are made along the lines through the mucosa and the flaps are developed bluntly (Figure 3B). Any submucosal connective tissue within the frenulum is divided, and the flaps are rotated from an “ABCD” configuration to a “CADB” configuration and sutured into place with interrupted 4-0 chromic sutures (Figure 3C).
      Figure thumbnail gr2
      Figure 2Orientation of flaps in the Z-plasty technique before (A) and after (B) flap rearrangement. (Redrawn from Strader and House.
      • Strader R.J.
      • House R.E.
      Treatment of tongue ankylosis with Z-plasty.
      )
      Figure thumbnail gr3
      Figure 3Orientation of flaps in the W-plasty technique. Planning the flaps around the short frenulum (A), flaps raised in their natural orientation (B), and flaps rearranged and inset (C). (Redrawn from Heller et al.
      • Heller J.
      • Gabbay J.
      • O’Hara C.
      • et al.
      Improved ankyloglossia correction with four-flap Z-frenuloplasty.
      )

      Discussion

      Regardless of the method used, most patients see improvements in tongue mobility immediately. The procedures described earlier are all well tolerated by the patient and are typically done as outpatient procedures. Complication rates are low, although there has been research presented by Klockars and Pitkäranta
      • Klockars T.
      • Pitkäranta A.
      Pediatric tongue-tie division: Indications, techniques and patient satisfaction.
      that suggests that the reoperation rates for ankyloglossia are higher for those procedures done in an office setting. They found no difference in reoperation rates between frenotomy and frenuloplasty and suggest that the attention to division of the frenulum is easier to achieve under general anesthesia, resulting in more complete treatment.
      The primary reason for presentation of infants with ankyloglossia is difficulty with breast-feeding and is detected by many in the health care field, including pediatricians and lactation consultants. Although most breast-feeding difficulties can be remedied with proper lactation consultation, those cases where tongue-tie may be playing a role have been shown to have improvement when frenotomy or frenuloplasty is performed.
      • O’Callahan C.
      • Macary S.
      • Clemente S.
      The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding.
      • Ballard J.L.
      • Auer C.E.
      • Khoury J.C.
      Ankyloglossia: Assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.
      • Buryk M.
      • Bloom D.
      • Shope T.
      Efficacy of neonatal release of ankyloglossia: A randomized trial.
      • Sethi N.
      • Smith D.
      • Kortequee S.
      • et al.
      Benefits of frenulotomy in infants with ankyloglossia.
      The study by Ballard et al
      • Ballard J.L.
      • Auer C.E.
      • Khoury J.C.
      Ankyloglossia: Assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.
      showed decreased maternal pain scores and subjective improvement in breast-feeding by mothers’ reports. Buryk et al
      • Buryk M.
      • Bloom D.
      • Shope T.
      Efficacy of neonatal release of ankyloglossia: A randomized trial.
      took this a step further and showed improved pain scores and a nearly 25% improvement in an objective measurement of breast-feeding, the Infant Breastfeeding Assessment Tool.

      Conclusion

      Although ankyloglossia is a difficult entity to define, and its sequelae may be hard to distinguish from normal problems with breast-feeding or speech, its treatment is well tolerated. Multiple techniques are available to surgeons for treatment, from simple frenotomy to multiple-flap Z-plasty. Division of the lingual frenulum is typically a simple procedure that can be performed either in the office or in the operating room, depending on patient (or parent) comfort and surgeon preference, and research has found subjective as well as objective improvement in breast-feeding.

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