Ankyglossia (Tongue-tied)
Our daughter has a hearing loss, as well as a speech delay. We are concerned as her speech does not seem to be as clear as her speech therapist thinks it should be at this time. Her tongue’s range of motion appears to be limited. Is it common for a child with CdLS to need their tongue clipped? Because she is already 6, we are nervous about this option.
Ankyglossia &appears to be common in children with CdLS. Midline discrepancies, structures found in the middle of the mouth and face are not a rarity. Cleft palate is seen and malpositioned frenulae are also common. The frenulum is a muscle that helps hold down facial tissues, such as the lips, cheeks and tongue. If these muscles, most found in the midline of the mouth, are either too low or too high or too short, problems can arise. Sometimes the problems can express themselves in altering the teeth positioning and thus causing malocclusions that will need to be treated orthodontically,etc.
Other times the malposed frenulum can cause a limitation of the range of motion of those tissues they hold down. The frenulum holds the tongue in place and if it is too short or malpositioned, it can cause a limitation of the range of motion of the tongue and thus cause articulation problems during speech production. If the little muscle underneath the tongue is short or positioned too far forward towards the tip of the tongue, then the tongue cannot reach to the upper teeth or palate or other structures used in articulation for proper speech. The speech pathologist is the best person to determine if the tongue is being restricted in its movement to such a degree that speech is being affected. Once that is determined, and once efforts to help compensate for the malposed frenulum via speech therapy and exercises have been exhausted to no avail, a referral can be made to a surgeon for assistance. There are many specialists who possess the expertise to perform a frenulectomy, or repositioning of the offending frenum. The family dentist, pediatric dentist, oral surgeon, otolaryngologist and plastic surgeon all have the training to perform this procedure.
As a pediatric dentist, I perform a great number of these procedures throughout the year upon request of the speech pathologist. Even when I diagnose a case of ankyglossia, I refer the child to a speech pathologist for their input and counsel. If they feel the frenulum is not causing any problem, or if the feel they can work with the child to compensate for the limited tongue movement, then we defer any surgery until they have exhausted their efforts and feel that surgery is the only answer. It is important to remember that freeing up the tongue for a better range of motion, by way of a frenulectomy, is not the sole answer. The patient still needs speech therapy to train the tongue to move properly for good quality articulation. The physical freeing of the tongue is just part of the equation leading to great speech. The procedure is a relatively easy one. The age of the child, or even adult, dictates whether sedation or general anesthesia will be needed. The ability of the patient to offer adequate cooperation with a long attention span dictates how the surgery will best be accomplished. The procedure takes much less than a half an hour to perform. I recommend that if it is to take place under general anesthesia, which would be expected in our CdLS patient population, that all treating physicians and dentists be alerted to the scheduling of a procedure to take place under general anesthesia so that other health care providers may take advantage of the anesthetic experience, should they need to examine the child or place tubes in the ears, etc. This makes the most out of a trip to the operating room. I, personally, use a CO2 (carbon dioxide) laser to do my frenulectomies. This surgical approach gives me a bloodless surgical site and offers a very comfortable post operative period for the patient. The laser ablates the muscle fibers ( evaporates them) with knife like precision, the laser seals off blood vessels so minimal bleeding takes place and the nerve endings also are sealed so that post operative pain or discomfort is minimal. Some Motrin or Tylenol (if not allergic) afterwards is all that is needed during recovery. Feeding is no different than if a tooth is extracted, in that a soft, bland diet is recommended for a day. I use resorbable sutures (stitches that dissolve) when needed. Therefore, one does not have to go back days later to cut out stitches. Everything is geared towards a comfortable recovery period. Usually the next day the children are back to their normal routines.<. Electrosurgical devices (Bovey or dental electro surgery units) can also be used to the procedures. There can be a slight more bleeding and a higher degree of post operative discomfort with this approach, but the ablation or elimination of the muscle fibers is accomplished with very good results. Conventional scalpels are probably the most commonly used instruments for performing a frenulectomy. The expertise of the surgeon is certainly enhanced with the use of a scalpel, for it is the main instrument of choice in all forms of surgery. Bleeding and post operative discomfort are average. There should be no real anxiety regarding the necessity for a lingual (tongue) frenulectomy. It is a well established procedure–not a “clipping” of the tongue, but rather a well defined surgical procedure for eliminating the problems associated with a tied down tongue. The risks are minimal and the gains are huge when properly diagnosed with the established need for treatment. Again, I rely upon the speech pathologist to make the call on the necessity for treatment. The mentioning of “clipping the tongue” comes from the old days (and maybe not so old days) when newborn nursery personnel would see a tongue tie and “clip” it with their fingernails. I do not recommend this approach.