Dental Asia May/June 2018

Clinical Feature
In severe instances, the frenum may be attached high on the
alveolar ridge, even into the region of the incisive papillae. When a
lip-tie restricts the movement of the upper lip, it may be dicult for
an infant to evert its upper lip and latch properly onto the breast.
If the infant can only take the mother’s nipple into its mouth,
rather than the surrounding areola, traumatic breakdown of the
nipple may occur, causing pain and discomfort for the mother and
an inadequate transfer of milk for the infant. 24 In 2004, Kotlow
proposed a classication for lip-ties, this is displayed in Table 1. 25
Tongue-tie, also known as ankyloglossia, is an abnormal lingual
frenum which limits the normal range of movement and function
of the tongue (Fig. 2). There is currently no consensus on a precise
denition of ankyloglossia; however, several attempts have been
made to categorise various types of tongue-tie based on both
anatomy and functional limitations. Kotlow developed one of
the most commonly used classications of tongue-tie (Table 2),
based on the measurements of 322 children ranging from ages 18
months to 14 years. 26 Class I and II tongue-tie is considered to be an
anterior tongue-tie, while Class III and IV are referred to as posterior
tongue-tie. 27 This dierentiation between anterior and posterior
t o n g u e - t i e i s a r e l a t i v e l y a n e w d i s t i n c t i o n . U n l i k e a n t e r i o r
tongue-tie, posterior tongue-tie is not obvious at rst glance as
the frenum is hidden beneath the mucosal layer. There may not
be a frenal membrane present, instead the diagnosis may be made
based on the mid-tongue’s inability to elevate.
Type Characteristics Range of tongue
movement
Clinically
acceptable
Table 2. Kotlow’s classication of the
dierent types of ankyloglossia. 26
Normal range of free
tongue movements
Greater than 16mm
Class I Mild tongue-tie 12-16mm
Class II Moderate tongue-tie 8-11mm
Class III Severe tongue-tie 3-7mm
Class IV Complete tongue-tie Less than 3mm
Fig. 2 (a)
Fig. 2 (b)
Fig. 2: (a) shows a tongue tie that has not been released and is attached
close to the tip and (b) is preventing the tongue from being raised and is
distorting the tip into a “W” shape.
Tongue-tie has been linked to difficulties in breastfeeding
due to the infant’s inability to move the tip of the tongue during
suckling. While many studies have suggested that the presence of
ankyloglossia adversely aects an infant’s ability to breastfeed,
the same studies indicate that not every child with ankyloglossia
is adversely aected. 28-30 The quality of research-based evidence
in the literature is limited, with retrospective audits or case series
making up the bulk of the published literature.
Consequences of poor feeding ecacy
Poor feeding can have physical and psychological implications on
both the infant and mother (Table 3). In particular, the psychological
impact of poor breastfeeding practices is often overlooked. The
worry of an infant failing to thrive, combined with a lack of sleep,
complicated by frequent night feeds and persistent crying, can
lead to maternal stress and post-natal depression. This stress can
result to decreased milk production which perpetuates the poor
feeding cycle.
Table 3. The maternal and infant consequences of
poor breastfeeding ecacy21,31-34
Maternal Consequences
Mastitis
Breast abscess
Fissured and cracked nipples
Stress
Post-natal depression
Rejection of breastfeeding
Reduced milk production
Infant Consequences
Poor weight gain or weight loss
Failure to thrive
Death
Frequent or prolonged feeding
due to hunger
Frustrated crying
Management of Lip-tie
Removal of an offending frenum can be achieved either by a
frenotomy which is the incision and subsequent relocation of the
frenal attachment, or by a frenectomy which involves the complete
excision of the frenum along with the attachment to the underlying
bone.
Traditionally, a high buccal frenal attachment in the maxilla that
prevents eversion of the upper lip has been managed either by a
medical, dental or nursing practitioner by snipping the oending
attachment with scissors or a scalpel. 35 However, this frenotomy
procedure does not remove the dense collagenous tissue and elastic
bres that insert into the bone between the central incisors. 36 This
may result in the maintenance of bres that may prevent the upper
lip from everting, as well as maintaining the diastema between the
central incisors.
Management of Ankyloglossia
Similarly, if a tongue-tie is simply snipped, posterior lingual frenal
bres may not be severed, consequently the movement of the
tongue may still be limited. A complete frenectomy ensures that
adequate tongue and lip movement is achieved without the need
for further frenum revision.
48 DENTAL ASIA
MAY / JUNE 2018