Short frenum of the tongue: signs how to determine what to do

This congenital condition, like a short frenum of the tongue or ankyloglossia, is diagnosed when a small fold of fibrous tissue that connects the surface of the mucous membrane of the lower jaw to the back of the tongue is anatomically incorrectly attached: not in the middle of the lower surface of the tongue, but proximally, that is, closer to its tip. 

Limiting the mobility of the tongue, this defect can sometimes cause health problems for children and adults.

[1], [2]

Epidemiology

According to one statistical data, the prevalence of a truncated lingual frenulum varies in the range 4.2-10.7% of cases. And among the male children this defect is observed one and a half times more often than in girls.

In the Journal of Applied Oral Science, the prevalence of this birth defect in newborns is 4.4-4.8%. And in some studies using other diagnostic criteria, the frequency of detection of a truncated hyoid frenum in children in the range from 25% to 60% is indicated.

Experts of the American Council of Family Practitioners argue that almost 5% of the US population has a genetically determined restrictive ankyloglossia. And the results of the University of Cincinnati (USA), published in 2002, showed that about 16% of children who have difficulty with breastfeeding have a shortened frenum of the tongue, and it is diagnosed three times more often in boys.

Often people do not go to doctors even when there are problems, and in fact a short frenum of the tongue in an adult creates many difficulties arising from the fact that the tongue can not move freely in the oral cavity.

[3], [4], [5], [6], [7], [8], [9]

Causes of the short frenulum

Known to date, the reasons for the short frenulum of the tongue are the violation of ontogenesis (intrauterine formation) of the structures of the oral cavity and the facial skeleton during the first weeks of pregnancy.

The tongue begins to develop from the three pharyngeal arches in the fourth week of pregnancy; A U-shaped groove is formed on the front part and on both sides of the oral part of the tongue. As the tongue develops, the epithelial cells of the bridle undergo apoptosis, are removed from the tip of the tongue and increase the mobility of the tongue - except for the area of the lingual frenum, where it remains attached. Violations at this stage cause ankyloglossia.

This congenital structural anomaly is supposed to be due to the phenotypic effect of gene mutations. The shortening of the lingual frenum (tendon or frenulum of the tongue) is associated with an autosomal change in the karyotype of the X-linked gene encoding the transcription factor TBX22. The aberrations of the gene of LGR5 receptor G proteins or a gene that codes for the interferon-regulating transcription factor IRF6 are also involved in the pathogenesis of this defect. Thus, the short frenum of the tongue in the newborn is present initially.

[10], [11], [12], [13]

Risk factors

And the main risk factors for the birth of a child with ankyloglossia is an autosomal dominant inheritance of an altered karyotype in the male line, isolated or, in more rare cases, as one of the signs of an X-linked cleft palate; the syndrome of Pierre Robin  or Van der Wood; syndromes of Kindler or Simpson-Golaby-Bemmel  syndrome, Beckwith-Wiedemann syndrome  or Smith-Lemli-Opitsa syndrome.

However, it should be borne in mind that up to 10-15% of congenital structural anomalies are the result of adverse effects on prenatal development of the environment and maternal infections. This means that approximately one in three hundred newborns may have a structural abnormality caused by teratogenic factors (including side effects of drugs) that negatively affect the laying and development of a particular embryo or fetal organ system. The most critical period of such exposure is from the 8th to the 15th week after fertilization. A rise in temperature in pregnant women above + 38.5-39 ° C may have a teratogenic effect between the 4 th and 14 th weeks of pregnancy.

[14], [15], [16], [17], [18], [19], [20]

Symptoms of the short frenulum

In many cases - with minimal deviation of the length of the frenum from the anatomical norm - there is no symptomatology. This happens with an easy degree of ankyloglossy: when the distance between the attachment point of the frenum on the ventral surface of the tongue and its tip is at least 12 mm.

By the way, four degrees of ankyloglossia are determined: light (the length of the bridle is 12-16 mm), moderate (8-11 mm), heavy (3-7 mm) and full (less than 3 mm).

Symptoms of a short frenum of the tongue with its moderate and significant shortening in patients of different ages manifest themselves in different ways. In newborns, the most common first signs are expressed in violation or complete absence of the possibility of breastfeeding. Because of the limited mobility of the tongue, the baby can not grab the nipple and normally suck milk, which forces a bottle with a pacifier. Although with intensive allocation of breast milk, breastfeeding is possible and in the presence of this defect.

Mothers who breastfeed should have an idea of how to identify a short bridle of the tongue. The signs of a short frenulum of the tongue in a baby can be its rapid fatigue in the process of sucking: if the baby often falls asleep at the breast, but wakes up hungry and begins to cry. For this reason, the child shows increased anxiety at night and poorly gaining weight.

In addition, eating disorders (seizure of the nipple not by the tongue, but by the gums) leads to the appearance of pain and nipple damage, obstruction of the ducts in the mammary glands and mastitis.

A short frenum of the tongue in a child of the first three years of life creates problems with eating food that requires chewing. Clear symptoms of ankyloglossia are:

• inability to stick out his tongue over the upper gum;
• bending the tongue down when it protrudes from the mouth;
• impossibility to touch the palate with the tongue;
• the difficulty of moving the language from side to side;
• V-shaped form of the tip of the tongue (resembling the pictogram of the heart) when it is raised.

After three years, speech problems become noticeable, especially distortions in the articulation of the sounds of DT, ZS, L, R, H, C, W. A visit to a specialist is required if more than half of the speech of a three-year-old child is not understood outside the family circle.

With age, the short frenulum of the tongue in an adult can stretch out and become longer: it all depends on its thickness and initial size.

Complications and consequences

The shortening of the hyoid frenum restricts the range of movement of the tongue, which can cause certain consequences and complications.

As already noted, in infants, natural feeding is difficult, and feeding from the bottle requires a completely different movement of the tongue, which often leads to the formation of a high, narrow arched palate (which directly affects the nasal cavity).

A short frenum of the tongue in a child can influence the position of the lower jaw and lead to its prognathism (forward movement) with the formation of an  open bite. And the constant mechanical pressure of the tongue on the alveolar part of the gums and the incising teeth of the teeth determines the crowding of teeth and an  incorrect bite in the child. Children have difficulties with chewing food and retaining saliva in the mouth, speech development slows down. Pediatricians note the presence of habitual vomiting and frequent ingestion of food in the trachea (with severe coughing and suffocation) due to lack of mobility of the tongue during meals, and ingestion of air during eating (aerophagia).

In adults, ankyloglossia with varying degrees of immobility of the tongue can cause:

• impossibility to open your mouth wide;
• difficulty in drinking and swallowing tablets;
• spattering of saliva during a conversation (due to inadequate coordination of swallowing);
• inability to clean teeth after tongue;
• orthodontic problems (anomalies of occlusion and malocclusion, curvature of the dentition, a gap between the lower incisors, prognathism of the lower jaw);
• specific disorders of speech articulation  (violation of diction)
• sleep disturbances and sleep apnea;
• dysfunction of the temporomandibular joint (pain and restriction of the jaw movement).

[21], [22], [23], [24], [25], [26]

Diagnostics of the short frenulum

The main method by which the short bridle is diagnosed is the examination of the oral cavity with the definition of the length of the lingual jumper when the tongue is lifted and the length of the free tongue, by measuring the distance between the tip of the tongue and the ligual frenum's anchorage point to the tongue and attachment to the lower alveolar process.

We remind you that the length of the sublingual cuff more than 16 mm is considered clinically acceptable.

In addition, the mobility of the language (the maximum range of displacement) and its tip is estimated.

To confirm the diagnosis, children from two to three years old and adults are undergoing palpation of the muscle on the underside of the tongue - the genioglossus (Musculus genioglossus).

Also, the patient's speech is evaluated: her speed and articulation disorders.

[27], [28], [29], [30], [31], [32]

Treatment of the short frenulum

In the expectant approach to this structural defect and in the absence of its clearly negative influence on the child's dentoalveolar system, in the course of growth, the tension of a not very thick, shortened frenulum of the tongue (mild and moderate) may decrease with time, and the mobility of the tongue increases. This is facilitated by classes with a speech therapist and special exercises with a short frenulum of the tongue. But you can wait until six years, that is, before the beginning of the change of milk teeth permanent.

In other cases, it may be necessary to treat a short frenum of the tongue operatively, which is performed on an outpatient basis by an otolaryngologist / surgeon or dental surgeon.

Surgical treatment for ankyloglossia includes two types of procedures: frenectomy (frenectomy) and frenuloplasty.

With frenectomy, which is considered a relatively common procedure, the dissection of the frenum can be performed with surgical scissors or with a carbon dioxide laser. The procedure is carried out quickly, and the discomfort from it is minimal, since there are few nerve endings and blood vessels in the lingual frenum (one or two drops of blood may come out). After the procedure of an infant you can immediately breastfeed.

However, rare complications of frenectomy of the bridle are possible - in the form of bleeding, infection or damage to the tongue or salivary glands. Also, the fusion of the dissected bridle is not excluded.

Frenuloplasty (excision of the frenulum part) is resorted to with a severe and full degree of ankyloglossia (the length of the frenum is less than 3-7 mm), or the bridle is too thick for simple dissection. After surgical excision, the wound is usually covered with absorbable sutures. Possible complications of frenuloplasty are similar to frenetomy; may be the formation of scar tissue (scar) due to the more extensive nature of the procedure, as well as the response to anesthesia.

After frenuloplastiki also recommended exercises to develop the mobility of the tongue and reduce the possibility of scarring.

Prevention

To prevent violations that cause ankyloglossy, it is not possible. 

[33], [34]

Forecast

The prognosis of treatment of a short frenum of the tongue in children is favorable in most cases. The dissection of a frenum in a newborn leads to an improvement in its natural feeding and ensures normal physiological development.

[35], [36], [37]