Functional Improvements of Speech, Feeding, and Sleep After Lingual Frenectomy Tongue-Tie Release: A Prospective Cohort Study

Figure 1.
Example of partial versus full release. An 11-year-old child with a tongue restriction (not part of the study) was
incompletely released under general anesthesia at age 8 and had persistent speech and sleep difficulty. Notice the impaired function and lift of the tongue (left) and restricted tissue with digital elevation preoperatively (middle left). After a full CO laser release with no bleeding, he can elevate his tongue to the palate (middle right) and final sutured closed result (right).

Ankyloglossia has been linked to sleep difficulties and sleep apnea in children and adults. A tongue-tie
prevents the tongue from resting on the palate. This lack of tongue to palate suction, especially during sleep,
allows the tongue to fall into the pharynx at night and restrict or obstruct the airway and leads to sleep-disordered breathing or sleep apnea. In a recent systematic review, myofunctional therapy was shown to retrain
the tongue to properly rest on the palate and prevent it from occluding the airway. Children achieved a 62%
decrease in apnea-hypopnea index and adults attained a 50% decrease in apnea-hypopnea index. Myofunctional therapy often can help but is sometimes limited by inadequate tongue mobility.Speech, feeding, and sleep significantly affect a child’s and family’s quality of life in the early years. We sought to investigate the effects of complete frenectomies combined with myofunctional therapy on the lives of children and families. Many studies of tongue-ties in infants and children utilize partial frenotomies, or snipping connective tissue with scissors. This method of treatment often leaves thick fascia untouched and does not allow the tongue to achieve a full range of motion and function (Figure 1) We utilized a 10 600 nm CO laser (LightScalpel LLC, Bothell, WA) to perform all releases, ensuring a full and functional release of fascia, as well as recommending postoperative myo-
functional exercises and active wound management to minimize reattachment. This study was carried out prospectively in a continuous fashion with institutional review board (IRB) approval from Solutions IRB #2018/12/8.

Treatment Protocol
The consultation visit included an in-depth history utilizing the assessment sheet, as well as a careful examination of the oral cavity. The Kotlow rating scale was used to assess the degree of restriction. A diagnosis of  symptomatic tongue restriction was required for participation. Some patients also had restricted maxillary frena causing difficulty with oral hygiene. A compounded topical anesthetic was applied to the surgical sites, and 2% lidocaine with 1:100 00 epinephrine was injected if cooperative. Nitrous oxide, oral sedation, and general anesthesia were not required.
The treatment consisted of removing the frenum at 2 W, 29 Hz, 72.5% duty Non-SuperPulse with the 10 600
nm LightScalpel CO laser in a horizontal fashion beginning in the middle of the frenum. The release continued
until all fascia and tension of the mucosa were removed, and a diamond shape was evident. The genioglossus
muscle was visualized but left undisturbed and minimal to no bleeding occurred in all cases. The average lasing
time was 15 seconds. Postoperatively, pain was managed with acetaminophen or ibuprofen. Manual stretching of
the wound 2 to 3 times daily as tolerated by the child was recommended. Myofunctional exercises were recom-
mended if the child was able to follow commands. The patients returned for a 1-week follow-up to assess
wound healing, manually stretch the wound to ensure no reattachment, and assess symptom improvement. The
patients also returned or completed a phone survey at 1 month.

Parents of all 37 children enrolled completed the 1-week follow-up questionnaire. Thirty parents of study children completed the 1-month questionnaire; 7 were lost to follow-up. The mean age was 4.2 years (range 13 months to 12 years), and 62% of participants (23/37) were male. For each item in the questionnaire, parents marked whether symptoms improved, worsened, or did not change. Many participants noticed an improvement in symptoms not previously recognized or reported. The results are summarized in Tables 1 to 5. At 1 week, 76% of parents reported improved speech, 69% noticed improved feeding, and 85% observed improved sleep in their children (Table 1). At 1 month, 89% of parents reported improved speech, 83% noted improved feeding, and 83% witnessed improved sleep.
One child’s parents reported somewhat worse feeding and sleep at 1 week. At 1 month, significantly worse
speech and sleep were stated concerning 1 child, another parent reported somewhat worse feeding in her child, and 2 parents observed somewhat worse sleep quality in their children. Significant improvements in children’s speech were
reported (Table 2). There was less frustration with communication (P < .001). It was easier for parents (P = .001)
and others (P < .001) to understand the children. It was easier for the children to speak quickly (P = .004), get words out (P < .002), and make previously difficult sounds (P < .001). Speech-delayed children produced new
words (P = .008), children mumbled less (P = .008) and used less baby talk (P = .031). Parents also reported
positive feeding changes (Table 3) as children ate more rapidly (P < .001), exhibited less grazing behavior. (P< .001), were less picky (P= .002), choked and gagged on food less (P = .002), and spit food out less often (P= .001). Sleep improved significantly as reported by parents (Table 4). Children were less likely to sleep in strange positions (P < .001), or kick and move at night (P < .001). They slept more deeply (P < .001), woke up less fatigued (P = .002), had less tooth grinding (P= .002), less mouth breathing (P< .001), and less snoring (P < .001). Interestingly, additional changeswere noted by parents (Table 5) as children reported less neck pain (P < .031), fewer headaches (P = .008), less gag reflex (P = .002), less mouth breathing (P < .001), less reflux (P = .002), less hyperactivity and inattention

The results suggest that speech, solid feeding, and sleep can be affected by a restricted tongue, and releasing a tongue-tie properly combined with oral motor or myofunctional exercises can provide functional and quality
of life improvement. Twenty-five patients had 2 or more symptoms of tongue-tie in infancy, and 8 had 4 or more infant feeding symptoms that were not recognized as being due to a restriction of the tongue, and the patients were

left untreated. Difficulties with speech, solid feeding, or sleep ensued within a few years. Early treatment in
infancy is best.

In practice, many parents of patients undergoing a tongue-tie release report symptom improvement in seemingly unrelated issues. These are reported in Table 5, as parents reported that children had less neck pain, headaches, gagging, mouth breathing, reflux, hyperactivity and inattention, and constipation. Explaining all of these connections is beyond the scope of this article, but many of these results could be explained by less restricted head and neck fascia, improved oral rest postures, improved sleep quality, and better ability to chew food.

There was no difference between children who had anterior to-the-tip or close-to the-tip ties versus those who had less visible posterior tongue-ties. The symptoms children present with are more important than appearance when determining the need for a release. With minimal appearance of a tie but many tongue-tie symptoms, the posterior tongue-tie patients saw the same improvements as those who had anterior, obvious ties. The concept of tongue-ties as a spectrum of restriction allows the provider to understand that some children with visible ties may be able to function well as they adapt or compensate without a procedure. Others with minimal appearance have many symptoms and are unable to compensate, indicating that the fascia underlying the frenum is too restrictive and warrants a release.

Tongue elevation, not protrusion, is the critical movement for speech, feeding, and sleep, and releasing the restriction so elevation normalizes is the reason children see improvement. The typical health care practitioner
when checking a child’s oral cavity says, “Stick out your tongue and say ‘Ah.’” One easy change to practice that
would allow better identification of a restricted tongue is asking the child (or adult) to lift the tongue. If this task is
not possible due to poor volitional control, the examiner can manually check elevation digitally with both index
fingers coming from behind the patient. The tongue should elevate most of the way to the palate to the spot
behind the incisors with the mouth open normally. If the tongue lifts 50% or less, it is significantly restricted
and the patient should be assessed for symptoms. Refer for treatment if symptomatic. Some children and adults
can lift greater than 50% but still have symptoms. Symptoms are more important than appearance. Some
children had lip-tie releases at the same time due to difficulties with oral hygiene, or large diastemas between
the teeth. There was no difference in improvement noted between the children who had lip- and tongue-ties
released versus those who had only tongue releases, indicating that the tongue is the major factor for symptom
improvement in speech, feeding, and sleep.

These results are dependent on proper release techniques and on maintaining the wounds with proper stretching and oral motor and myofunctional exercises to achieve the greatest range of motion and normal function. A proper release can certainly be performed with scissors, but a CO laser provides a clear surgical field to easily remove all restricted fascia. Not all lasers are the same, as a diode laser utilizes a heated quartz tip to remove tissue thermally (at around 1000 °C, similar to cautery), whereas the CO laser removes tissue without contacting the tissue and optically vaporizes (100 °C) the tissue. A CO laser release is not a deep release as some warn against, but rather allows the surgeon to precisely remove the mucosa and thick webbing of fascia underneath the frenum layer by layer. This method allows a complete dissection and avoids any structures that should be left undisturbed such as the lingual nerve, submandibular ducts, deep lingual vein, and the genioglossus muscle. The result is a bloodless diamond shape, often only a millimeter or two deep, without tension, that allows full elevation of the tongue.

A minimum of 1 follow-up visit is critical to check healing and guide the family on proper stretching techniques. A team approach working closely with a speech language pathologist or dental hygienist who utilizes oral motor and/or myofunctional therapy will enhance the likelihood of long-term benefits because neuromuscular reeducation, swallowing, and resting posture benefit from their professional guidance. Most patients in this study had speech therapy but did not have a therapist trained in myofunctional therapy, so oral motor and myofunctional exercises were given to each patient. The patients in this study saw results in many cases the same or next day, indicating the release was the precipitating factor for the observed improvement, but the stretching was critical to ensure that the patient retained the new found freedom, and exercises were important to reeducate the muscles of the tongue and oral cavity to achieve long-term symptom improvement. At 1 week, most patients had some regrowth of the frenum, and a stretch was performed to reopen the restricted area to help prevent reattachment.

One patient reported significantly worse feeding and sleep at 1 month, and a few were unsure if they would do
the procedure again. The procedure is not 100% effective, and that patient did not follow-up after 1 week and,
to our knowledge, did not work with a therapist after the procedure. With proper case selection, a team approach
to care, proper follow-up, and exercise protocol, negative outcomes can be minimized.

These results should encourage health care professionals treating children suffering from speech, feeding,
and sleep trouble to evaluate for tongue restrictions, and consider releases if these commonly associated symptoms are present, regardless of the degree of visible restriction. If children have symptoms in multiple domains and especially with a history of feeding issues in infancy, a low-risk, in-office procedure along with proper therapy should be considered.

Limitations
Speech and feeding assessments before and after treatment relied on parental reports, which although prone to
bias, have been shown to be reliable in other studies. Validated instruments for these assessments would help
research in this area. There was no control group to compare the results achieved afterward, but most of the improvements in sleep, feeding, or speech were reported by the parents the same day or within a few days of
release. Generalizability of results could be affected if the procedure does not fully release the mucosa and
fascia, exercises and stretches are not performed, and follow-up is not monitored.

Conclusion
1. This study demonstrates that CO2 laser tongue-tie releases can yield significant functional improvements in speech, solid feeding, and sleep of children, as reported by parents.
2. The best outcomes were achieved in patients with full releases of restricted fascia as well as a team approach incorporating therapy.
3. Health care providers should check for restrictions to determine if speech, feeding, or sleep difficulties might be related to limitations in tongue movement.
4. Individualized care plans with therapists trained in oral motor and myofunctional therapy are
helpful.