Ankyloglossia (Tongue-Tie)

Excerpt

Ankyloglossia, also known as tongue-tie, is a condition that concerns multiple specialties within medicine and dentistry. There is a lack of consensus regarding all aspects of the disease. No definition, classification system, or diagnostic parameters has been generally accepted. Therefore, controversy exists concerning when to treat the condition, when it should be left untreated, and what intervention is best if managed. This activity reviews the available data regarding the etiology, epidemiology, and common clinical findings of ankyloglossia. It also describes the current evaluation and management strategies for patients with ankyloglossia and identifies the differential diagnoses, prognosis, and complications.

Definition

No standard definition of ankyloglossia has been agreed on. The International Affiliation of Tongue-Tie Professionals defines the lingual frenulum as a tissue remnant located in the midline between the tongue's ventral surface and the mouth's floor. When the lingual frenulum limits the function of the tongue, it is called symptomatic tongue-tie or symptomatic ankyloglossia.

In 2020, a group of otolaryngologists with expertise in managing tongue-tie formulated a clinical consensus statement. They agreed on a definition of tongue-tie as a "condition of limited tongue mobility caused by a restrictive lingual frenulum." This panel of experts also acknowledged that professionals have been using the terms anterior and posterior ankyloglossia in recent years.

Anterior ankyloglossia is classic ankyloglossia, where the frenulum attaches at or close to the tongue tip, limiting tongue mobility. Notably, 'anterior ankyloglossia' and 'ankyloglossia' are interchangeable. Diagnosis of posterior ankyloglossia remains a subject of controversy. Posterior ankyloglossia occurs when the frenulum attaches to the posterior aspect of the ventral surface of the tongue and restricts tongue mobility. Some also use the term to refer to the submucosal tethering of the tongue. Others consider posterior ankyloglossia normal frenulum attachment and attribute breastfeeding difficulties to other factors, like nipple anatomy, maternal milk production, and maternal experience. Maxillary lip frenulum tethering has also been reported to affect breastfeeding.

Classification and Assessment Tools

Various grading tools have been proposed. The Coryllos classification is useful to determine the type of frenulum, but it does not include the evaluation of function nor a criterion for ankyloglossia. (See Table 1. Coryllos Lingual Frenulum Classification System).

The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) assesses frenulum anatomy and function and scores ankyloglossia. [See Table 2. The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF)]. This tool uses 10 points for frenulum anatomy and 14 points for the function of the tongue. Surgery is not recommended if the function score is 14, regardless of the anatomy score. A function score of 11 is acceptable if the anatomy score is 10. A function score less than 11 means impaired function; frenotomy is recommended if management fails. Frenotomy is recommended when the anatomy score is less than 8.

Regardless of the evaluation tool used, it is essential to demonstrate restricted tongue movement and ascertain that the lingual frenulum exclusively causes this limitation.