Benefits and Drawbacks of a Frenectomy

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Answer

Benefits of a frenectomy at age 6:  Children who are 6 years of age are in a stage of rapid orofacial growth and development. Increasing the range of motion (ROM) of the tongue may allow the child to position the tongue normally in the palate when it is not being used for functional activities. This gentle positioning of the tongue against the palate can help to shape the palate within normal parameters and prevent or reduce in severity the orthodontic difficulties that may result from a narrow maxillary dental arch that often results from a low tongue posture.

In addition, many changes occur in the orofacial environment during this stage in which the tongue must learn to function. A child whose tongue is capable of a normal ROM may be better able to make the necessary adjustments in tongue function for chewing, swallowing, and speech within this changing environment than one whose tongue movement is reduced by a restricted lingual frenum. 

Drawbacks of a frenectomy at age 6: When considering a 6 year old it is important to note that this age group usually presents with mixed dentition.  During this stage of transition from deciduous (baby) teeth to permanent teeth, the child experiences times when teeth are missing. If there is a sudden increase in the ROM of the tongue as may occur after a lingual frenectomy, there may be an increased propensity for the tongue to position itself in the space created by the missing teeth. This static resting position of the tongue may contribute to an anterior open bite as the permanent teeth erupt, and/or the development of a tongue thrust swallow. It may also contribute to development of a frontal lisp. It is important to children in this age group to be closely monitored by a Speech Therapist/Orofacial Myologist after a lingual frenectomy procedure.

General considerations: When surgical correction is considered for a restricted lingual frenum (tongue tie) there are additional benefits and drawbacks which are applicable to the population in general across age groups.  ‘Tongue tie’, or ‘ankyloglossia’ are the terms most commonly used to describe a condition in which the band of tissue, the frenum, (or frenulum), that connects the under-side of the tongue to the floor of the mouth is attached in such a manner that it restricts the Range of Motion (ROM) of the tongue.  While there are no universally agreed upon criteria for the types and severity of ankyloglossia, Marchesan (2004) proposed a classification system for this disorder, and described the frenum as: normal, short, anterior insertion, or short with anterior insertion. She also provided excellent photographs which demonstrate the variety of attachments that may occur with this condition.

A lingual frenectomy is a surgical procedure used to remove this band of lingual tissue and release the tongue so that it may move more freely.  Important considerations are based not so much on age as on the location, degree of restriction of ROM, and related functional limitations. There are various surgical procedures employed for resolving a restricted lingual frenum.  Procedures most commonly employed include a simple clipping of the frenulum (not recommended except for a newborn), a frenectomy,  a Z-plasty lengthening procedure.  Tools used include a cold scapel, a CO2 Laser,  and a specialized laser, the erbium:yttrium-aluminium-garnet lazer (ER:YAG lazer) - which may be used without local anesthesia (Aras, Göregen, GüngörmüÅ , & Akgül, 2010.) The pediatric ENT, oral surgeon, or plastic surgeon who performs lingual frenectomies can discuss the benefits and drawbacks of each of these procedures with the patient and family to determine which is the appropriate procedure.

General benefits of a frenectomy:  For individuals whose restricted lingual frenum is very mild, there may not be any benefit.  In addition, individuals may be able to make adaptations which are adequate for functional activities and not need surgery.  In general, the benefits of a lingual frenectomy focus on creating an increased ROM for the tongue.  Benefits may be viewed from the perspective of reducing the difficulties that may be experienced by individuals who have a restricted lingual frenum/ankyloglossia.  

• Ankyloglossia may contribute to feeding difficulties, especially in infants, although adaptations for chewing and swallowing may be necessary in older individuals as well.
• A restricted frenum may contribute to speech difficulties, especially for sounds that require tongue elevation such as: “s, z, t, d, l, r.”  Although, some individuals are able to use a tongue down production for these sounds which is acoustically acceptable, many are not able to make the necessary accommodations.
• Saliva management may also be a problem during speech and or eating.
• Some individuals have difficulty when the tongue attempts to move forward in the mouth with the frenum scraping against the lower central incisors, and at times becoming pinched between these teeth.
• In an attempt to compensate for the lack of tongue movement, some children demonstrate an increase in lateral or forward mandibular movement.
• Some authors feel that orofacial development may be effected due to the low position of the tongue in the mouth.  For example, in a seven year follow up case study, Defabianis (2000) indicated that after a lingual frenectomy there was a spontaneous expansion of the child’s palate which negated the need for orthodontic treatment.
• Individuals with ankyloglossia may also experience an increase in dental caries due to the lack of ability to sweep the maxillary and mandibular dentition to remove food particles.  Most people will recall how it feels when something becomes stuck between the teeth. The first reaction may be to attempt to dislodge this using the tongue tip.  With a restricted frenum this may be impossible.
• An inability to sweep the lips may also create difficulties. It is common while eating an ice cream cone for a person to lick their lips.  Individuals with a restricted lingual frenum may not be able to do this.
• There may also be social implications. When a child with a restricted lingual frenum so severe that the tongue is heart-shaped, do other children laugh or otherwise make fun of that child if he/she tries to stick the tongue out?

General drawbacks of a frenectomy: As with any surgical procedure there are risks which in part depend on the skill of the surgeon, the procedure employed, the type of anesthesia, and follow-up care. Drawbacks related to the procedure are dependent on the type of surgery performed and the follow-up care.  Drawbacks related to the surgery are usually not serious and include but are not limited to:

• numbness of the tongue tip  (Yang, Woo, Won, Kim, Hu, & Kim, 2009);
• post-surgical infections;
• pain and/or soreness;
• bleeding;
• hematoma;
• Difficulty eating for a few days.
• An additional drawback is that without proper post-surgery exercises the frenum may reattach, and become even more restricted than pre-surgery.  
• At times there is a need for treatment that addresses properly adjusting tongue function to the increased range of motion for lingual function. For additional information on therapeutic techniques contact a Speech Therapist who is also a Certified Orofacial Myologist. This individual should be able to provide information on the type, and severity of the lingual frenum attachment, and any follow-up therapy that may be necessary. The International Association of Orofacial Myology provides a member directory on their website: www.iaom.com. 

References

Aras MH, Göregen M, GüngörmüÅ M, Akgül HM. (2010) Comparison of diode laser and Er:YAG lasers in the treatment of ankyloglossia. Photomed Laser Surg. 28(2):173-177.

Defabianis P. (2000) Ankyloglossia and its influence on maxillary and mandibular development. (A seven year follow-up case report). Funct Orthod. 17(4):25-33.

Marchesan, I. (2004) Lingual Frenulum: Classification and Speech Interference. IJOM. 30, 31-38.

Yang HM, Woo YJ, Won SY, Kim DH, Hu KS, Kim HJ.  (2009) Course and distribution of the lingual nerve in the ventral tongue region: anatomical considerations for frenectomy. J Craniofac Surg.  Sep;20(5):1359-63.

Patricia M. Taylor, Med, CCC-SLP, COM is a speech-language pathologist in private practice and a certified orofacial myologist (COM).  She has served as Speech Therapist, Hearing Therapist, Special Education Program Supervisor, Act 89 Non-Public Schools Program Supervisor* Supervisor of EHA-B Program Support Services*, Special Education Grants Writer*, Special Education Computer Liaison*, Preschool Program Supervisor/Case Manager*, Teacher of Demonstration Class for Hearing Impaired (*Positions held concurrently).  She is currently IAOM Research Director, and EDITOR-IN-CHIEF of the International Journal of Orofacial Myology, receiving a Special Award of Dedicated Service from the IAOM in 2004.