Ankyloglossia

# Overview
Ankyloglossia, commonly known as tongue tie, is a congenital oral anomaly which may decrease mobility of the tongue tip. Ankyloglossia is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth. Ankyloglossia varies in degree of severity from mild cases characterized by mucous membrane bands to complete ankyloglossia whereby the tongue is tethered to the floor of the mouth. Ankyloglossia can have feeding, speech and mechanical/social effects as well as result in other problems such as an open bite and mandibular prognathism. There is professional disagreement regarding how often ankyloglossia is symptomatic. In addition, intervention is also controversial as researchers such as Horton et al. believe that people with ankyloglossia can compensate in their speech for limited tongue range of motion and do not require surgery.

# Classification

## Hazelbaker Assessment Tool For Lingual Frenulum Function
Hazelbaker assessment tool for lingual frenulum function is used to diagnose ankyloglossia by using 5 appearance items and 7 function items. Significant ankyloglossia is diagnosed when appearance score total was 8 or less and/or function score total was 11 or less.
Shown below is a table illustrating Hazelbaker assessment tool.

# Epidemiology and Demographics
- The incidence of ankyloglossia has been reported as ranging from 0.02 percent to 4.8 percent.
- According to Lalakea and Messner, the different reports of incidence may be due to the lack of objective grading systems and uniform definitions of ankyloglossia. It has been found to occur more frequently in males than in females, with a 2.6:1 ratio.
- The prevalence of ankyloglossia has been to shown to increase with maternal use of cocaine.
- Harris et al. examined 500 infants at a well-baby nursery and found that ankyloglossia occurred in 3.5 percent of non-drug users offspring and 10.4 percent of cocaine-users offspring. The study also found that ankyloglossia was not dependent on race. Limitations of this study include that examiners were not blinded to the purpose of the study and the effects of ankyloglossia in the infants were not assessed.

# Natural History, Complications and Prognosis
- Ankyloglossia can affect feeding, speech and oral hygiene as well as have mechanical and social effects. Ankyloglossia can also prevent the tongue from contacting the anterior palate. This can then promote an infantile swallow and hamper the progression to an adult-like swallow which can result in an open bite deformity. It can also result in mandibular prognathism; this happens when the tongue contacts the anterior portion of the mandible with exaggerated anterior thrusts.
- Opinion varies, however, regarding how frequently ankyloglossia truly causes problems. Some professionals believe it is rarely symptomatic, whereas others believe it is associated with a variety of problems. The disagreement among professionals was documented in a study by Messner and Lalakea (2000). The authors sent a survey to a total of 1598 otolaryngologists, pediatricians, speech-language pathologists and lactation consultants with questions to ascertain their beliefs on ankyloglossia; 797 of the surveys were fully completed and used in the study. It was found that 69 percent of lactation consultants but only a minority of pediatricians answered that ankyloglossia is frequently associated with feeding difficulties; 60 percent of otolaryngologists and 50 percent of speech pathologists answered that ankyloglossia is sometimes associated with speech difficulties compared to only 23 percent of pediatricians; 67 percent of otolaryngologists compared to 21 percent of pediatricians answered that ankyloglossia is sometimes associated with social and mechanical difficulties. Limitations of this study include a reduced sample size due to unreturned or incomplete surveys. It was not clear why otolaryngologists and pediatricians differed in their opinions.

## Feeding
- Messner et al. studied ankyloglossia and infant feeding. Thirty-six infants with ankyloglossia were compared to a control group without ankyloglossia. The two groups were followed for six months to assess possible breastfeeding difficulties, defined as nipple pain lasting more than six weeks, or infant difficulty latching onto or staying onto the mothers breast. Twenty-five percent of mothers of infants with ankyloglossia reported breast feeding difficulty compared with only 3 percent of the mothers in the control group. The study concluded that ankyloglossia can adversely affect breastfeeding in certain infants. Infants with ankyologlossia do not, however, have difficulties when feeding from a bottle. Limitations of this study include the small sample size and the fact that the quality of the mothers breast feeding was not assessed.
- Wallace and Clark also studied breastfeeding difficulties in infants with ankyloglossia. They followed 10 infants with ankyloglossia who underwent surgical tongue tie division. Eight of the ten mothers experienced poor infant latching onto the breast, 6/10 experienced sore nipples and 5/10 experienced continual feeding cycles; 3/10 mothers were exclusively breastfeeding. Following a tongue tie division, 4/10 mothers noted immediate improvements in breastfeedings, 3/10 mothers did not notice any improvements and 6/10 mothers continued breastfeeding for at least four months after the surgery. The study concluded that tongue tie division may be a possible benefit for infants experiencing breastfeeding difficulties due to ankyloglossia and further investigation is warranted. The limitations of this study include that the sample size was small and that there was not a control group. In addition, the conclusions were based on subjective parent report as opposed to objective measures.

## Speech
- Messner and Lalakea studied speech in children with ankyloglossia. They noted that the phones likely to be affected due to ankyloglossia include sibilants and lingual sounds such as . In addition, the authors also state that it is uncertain as to which patients will have a speech disorder that can be linked to ankyloglossia and that there is no way to predict at a young age which patients will need treatment. The authors studied 30 children from one to 12 years of age with ankyloglossia, all of whom underwent frenuloplasty. Fifteen children underwent speech evaluation before and after surgery. Eleven patients were found to have abnormal articulation before surgery and nine of these patients were found to have improved articulation after surgery. Based on the findings, the authors concluded that it is possible for children with ankyloglossia to have normal speech in spite of decreased tongue mobility. However, according to their study, a large percent of children with ankyloglossia will have articulation deficits that can be linked to tongue tie and these deficits may be improved with surgery. The authors also note that ankyloglossia does not cause a delay in speech or language but, at the most, problems with articulation. Limitations of the study include a small sample size as well as a lack of blinding of the speech-language pathologists who evaluated the subjects speech.
- Messner and Lalakea also examined speech and ankyloglossia in another study. They studied 15 patients and speech was grossly normal in all of the subjects. However, half of the subjects reported that they thought that their speech was more effortful than other peoples speech.
- Horton et al. discussed the relationship between ankyloglossia and speech. The authors believe that tongue tie contributes to difficulty in range and rate of articulation and that compensation is needed. Compensation at its worst, the article states, may involve a Cupids bow of the tongue.

## Mechanical and Social Effects
- Ankyloglossia can result in mechanical and social effects. Lalakea and Messner studied 15 people, aged 14 to 68 years. The subjects were given questionnaires in order to assess functional complaints associated with ankyloglossia. Eight subjects noted one or more mechanical limitations which included cuts or discomfort underneath the tongue and difficulties with kissing, licking ones lips, eating an ice cream cone, keeping ones tongue clean and performing tongue tricks. In addition, seven subjects noted social effects such as embarrassment and teasing. The authors concluded that this study confirmed anecdotal evidence of mechanical problems associated with ankyloglossia and that it suggests that the kinds of mechanical and social problems noted may be more prevalent than previously thought. Furthermore, the authors note that some patients may be unaware of the extent of the limitations they have due to ankyloglossia since they have never experienced normal tongue range. A limitation of this study is the small sample size that also represented a large age range.
- Lalakea and Messner note that mechanical and social effects may occur even without other problems related to ankyloglossia such as speech and feeding difficulties.  Also, mechanical and social effects may not arise until later in childhood as younger children may be unable to recognize or report the effects. In addition, some problems may not come about until later in life, such as kissing.

# Symptoms
- Dysphagia
- feeding difficulty
- Hygiene difficulty
- Mandibular prognathism
- Speech difficulty

# Diagnosis
- According to Horton et al., diagnosis of ankyloglossia may be difficult; it is not always apparent by looking at the underside of the tongue but is often dependent on the range of movement permitted by the genioglossus muscles.
- For infants, passively elevating the tongue tip with a tongue depressor may reveal the problem.
- For older children, making the tongue move to its maximum range will demonstrate the tongue tip restriction. In addition, palpation of genioglossus on the underside of the tongue will aid in confirming the diagnosis.

# Treatment

## Compensatory Speech Strategies
- Horton et al. have a classical belief that people with ankyloglossia can compensate in their speech for limited tongue range of motion. They proposed compensatory strategies as a way to counteract the adverse effects of ankyloglossia and did not promote surgery.
- For example, if the tip of the tongue is restricted for making sounds such as /n, t, d, l/, the tongue can compensate through dentalization; this is when the tongue tip moves forward and up. When producing /r/, elevation of the mandible can compensate for restriction of tongue movement. Also, compensations can be made for /s/ and /z/ by using the dorsum of the tongue for contact against the palatal rugae.

## Surgery
- Intervention for ankyloglossia sometimes includes surgery in the form of frenotomy (also called a frenectomy or frenulectomy) or  frenuloplasty. This may be done by laser.
- According to Lalakea and Messner, surgery can be considered for patients of any age with a tight frenulum as well as a history of speech, feeding or mechanical/social difficulties.  Adults with ankyloglossia may elect the procedure. Some of those who have done so report post-operative pain.
- Horton et al. are currently in opposition to it.

## Wait-And-See Approach
- P A viable alternative to surgery is to take a wait-and-see approach.
- Ruffoli et al. report that the frenulum naturally recedes during the process of a childs growth between six months and six years of age.