Alterations of the lingual frenulum that go undiagnosed and intreated 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 in the setting of oromyofascial dysfunction. Whereas surgical treatment in newborns and infants is supported with post-operative stretches alone, treating tongue tie in children and adults requires pre and post-operative therapy to ensure optimal healing and post-operative functioning. There surgical guidelines were developed based on experience with over 400+ lingual frenuloplasty procedures performed by an ENT surgeon on children and adults in a private practice dedicated specifically to clinical care, research, and education for issues relating to tongue tie, myofunctional, and sleep- breathing disorders.
Guideline 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.
Guideline 2: Whereas functional issues relating to tethered tongue mobility lingers over many years when first identified among adult patients, it is important to observe for compensation patterns for tongue tie in adult patients with restricted tongue mobility. Such compensation patterns may include engagement of the cervical neck, floor of mouth elevation, and lack of lingual- mandibular (tongue- jaw) disassociation with essential movements of the tongue.
Guideline 3: A comprehensive team for tongue tie surgery requires an adequately trained surgeon as well as access to a supportive team including myofunctional therapist, craniosacral therapist, osteopathic specialists, and fascia specialists depending on the clinical circumstance.
Guideline 4: The goal of tongue tie release in children, adolescents, and adults is to restore tongue tone, posture, and mobility; the tongue should rest at 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 myofunctional therapy is essential for optimal preparation and recovery after tongue tie surgery. The goals of pre-operative 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 (i.e. floor of mouth elevation, cervical neck engagement, inability to perform isolated movements with the tongue without moving the jaw.
Guideline 5: Surgical release of the anterior tongue tie is performed while the tongue is protruded up against the maxillary central incisors; release of posterior tongue tie restrictions are performed while the tongue is engaged in lingual-palatal suction. This reinforces the need for pre-operative myofunctional therapy.
Guideline 6: We encourage non-traumatic release of lingual tissues that does not cauterize, burn, or injure surrounding or deeper structures. Whether the provider uses scissors or laser, it is critically important that only restrictive fibers are released, and that excessive or indiscriminate use of cautery be avoided.
Guideline 7: Placement of simple-interrupted sutures using resorbable 3-0 or 4-0 chromic suture promotes healing by primary intention, the body’s fastest and most efficient type of wound healing. If sutures are not used for primary intention closure or if the sutures fall out pre-maturely (sooner than 3-5 days), wound stretches are necessary to optimize healing by secondary intention to avoid wound scarring and contracture.
Guideline 8: Follow up with myofunctional therapy is essential for at least 2 months after a surgical release. The post-operative therapy focuses on optimizing wound healing as well as to re- educate tongue posture and optimal oral functions.
Guideline 9: Pre and post-operative photo documentation with the anterior tongue held up against the maxillary central incisors and with the tongue in lingual-palatal suction are recommended. Pre and post-operative documentation of tongue mobility and maximal opening are also recommended.
Guideline 10: Patients with limited tongue space in the maxilla and/or restricted posterior airway space are recommended to undergo a thorough evaluation of the structural determinants of the upper airway by a trained professional prior to tongue tie release. Methods to assess posterior airway may include cone beam CT and/or flexible laryngoscopy. Lateral cephalogram is deemed insufficient for adequate assessment. Patients with posterior airway space less then 1 cm or maxillary dimensions limited for tongue space are recommended to consider dental orthopedic remodeling prior to tongue tie release.
Providers of surgical interventions for tongue tie release must understand that we as a community depend on each other to maintain a high quality of care for the betterment of our patients as well as for acceptance, standardization, and advancement of this field. We strongly encourage sharing of ideas, clinical collaboration, academic research, and continued education on an annual basis.
