What I learned from Soroush Zaghi MD ENT and Sanda Valcu-Pinkerton RDHAP, COM
Alterations of the lingual frenulum (a tongue-tie) that go undiagnosed and untreated during infancy may later contribute to speech and swallowing impediments, mouth breathing, underdevelopment of the maxillofacial skeleton and even predispose to sleep and breathing disorders is the setting of oromyofascial disfunction.
A comprehensive team for tongue-tie surgery requires an adequately trained surgeon as well as access to a supportive team including myofunctional therapy, speech therapy, physical therapy, crainiosacral therapy , myofascial therapy, occupational therapy, dentistry, and orthodontics / orthopedics / facial orthotropics depending on the clinical circumstance.
Where as surgical treatment in new borns and infants is supported with post operative stretches alone, treatment of tongue-tie in children and adults requirers pre- and post- operative therapy to ensure optimal healing and post-operative functioning.
The following are guidelines for collaboration between surgeons and therapists in the treatment of tongue-tie among children and adults.
1. Assessment of tongue-tie in children and adults requires evaluation of anterior tongue mobility based on tongue range of motion ratio, as well as an assessment of submucosal restrictions that may impair mobility of the posterior two-thirds body of the tongue.
2. It is important to identify habituated compensatory patterns accommodating the limitations of impaired tongue mobility. Such compensation patterns may include engagement of the muscular neck, floor of the mouth elevation, and lack of lingual-mandibular (tongue-jaw) disassociation with essential movements of the tongue.
3. The goal of tongue-tie release in children, adolescents and adults is to establish tongue tone, habituate correct posture, and enhance mobility; the tongue should maintain continuous contact with the roof of the mouth at rest and normalization of a mature lingual-palatal swallow must be achieved at the completion of treatment. As such, pre- and post-operative oral myofunctional therapy is essential for optimal preparation and recovery after tongue tie surgery.
4. The goals of pre-operative myofunctional therapy are to create awareness of oral posture and tongue functions, improve tongue tone, and rehabilitate compensation patterns that may affect the post operative recovery (e.g. floor of mouth elevation, muscular neck engagement, inability to preform isolated movements with the tongue without moving the jaw). For children, active parent involvement is critical in optimizing the success of the therapeutic program.
5. Recommencing myofunctional therapy is essential for at lease 2 months after surgical release. Post operative myofunctional therapy for lingual frenuloplasty provides individualized care for the patient to optimize recovery and healing after surgery by providing guidance with passive and active wound stretching, as well as strength training and pattern retraining exercises for the tongue and orofacial muscles. Myofunctional therapy often continues for one year or longer (as needed) to prevent relapse of dysfunctional oral motor habits, promote exclusive nasal breathing, and ensure long-term habituation of ideal resting oral posture.
6. Addressing compensatory muscular and joint tension through hands-on manual therapy (e.g. myofacial therapy, craniosacral therapy, osteopathy, orthopedic physical therapy, massage, and/or chiropractic therapy) before and after surgery can help to optimize rehabilitation and improve dysfunctional postural patterns and habits that have developed as functionally compromised compensatory behaviors accommodating myofascial lingual frenulum restrictions.
7. Surgical release of the anterior tongue-tie is preformed while the tongue is protruded up against the maxillary central central incisors; release of posterior tongue-tie restrictions is preformed while the tongue is engaged in lingual-palatal suction. This reinforces the need for pre-operative myofunctional therapy. Pre and Post-operative documentation of tongue mobility (anterior tongue held up against the maxillary central incisors and with the tongue in lingual-palatal suction) can be helpful for case reviews.
8. We encourage non-tramatic release of lingual tissues that does not cauterize, burn, or injure surrounding or deeper structures. Whether the provider uses scissors or laser or scalpel, it is critically important that only restrictive fibers are released, and that excessive or indiscrimative use of cautery be avoided. The provider must be able to identify and avoid the trajectory of the lingual nerve, as well as the deep lingual artery and vein. In addition, the provider should recognize that whereas deep dissection of submucosal genioglossus myofascial fibers may result in a more thorough release, there is increased risk of bleeding and potential scarring, and patients often experience a greater severity of acute pain in the first 3-5 days immediately following the procedure.
9. Placement of simple-interrupted sutures using resorbable 4-0 or 3-0 chromic gut suture promotes healing by primary intention to reduce the propensity for restrictive for restrictive scar tissue and reattachment. If sutures are not used for primary closure or if the sutures fall out prematurely (sooner than 3-5 days), wound stretches are necessary to optimize healing by secondary intention to avoid wound scarring and contracture. Other suture material such as Nylon and Vicryl, can also be used with satisfactory results. Plain-gut suture material, however, appears inadequate to support the wound tension required to sustain primary closure during the acute healing period.
10. Patients with limited tongue space within the oral cavity and/or restricted posterior airway space are recommended to undergo a thorough evaluation of the upper airway prior to tongue tie release. Methods to acess posterior airway may include cone beam CT and/or flexible laryngoscopy. Patients with posterior airway space less than 1cm or maxillary dimensions limited for adequate tongue space are recommended to consider dental orthopedic remodeling prior to tongue tie release.
CONCLUDING THOUGHTS:
There is much more involved in treating Tongue Tie or tethered oral tissue (TOTS) than just cutting the thin tissue or sail of tissue under the tongue. but this tiny string or sail of tissue under the tongue IMPACTS:
Nursing,
Speech,
Feeding,
Proper Swallowing,
Good tongue Posture,
Good Oral Posture (closed Mouth posture – lips together – teeth lightly touching),
Proper Mouth Size Development (Narrow Palates are not normal or optimal,
Mouth development determines Nasal and Nasal Passage Development),
Nasal Development,
Nasal Breathing (Which needs to be full time nasal breathing),
Anterior Facial Development (Many dentists today only focus on width development of the mouth, but equally important is forward development or growth of the Maxilla or Upper Jaw and Mandible or lower jaw),
Tonsils / Adnoids (T and As),
neck tension and pain, other spinal issues
headaches, TMJ, TMD,
Forward Head Posture,
Heightened state of stress and fight-or-flight response of the sympathetic nervous system,
Poor Sleep (which effects healing, brain health and development, energy, Inflaimation which is negative for all body processes)