Ankyloglossia

Ankyloglossia, commonly known as tongue tied, is a congenital oral anomaly which may decrease mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth. Ankyloglossia varies in degree of severity from mild cases characterized by mucous membrane bands to complete ankyloglossia whereby the tongue is tethered to the floor of the mouth.

Effects
Ankyloglossia can affect feeding, speech, and oral hygiene as well as have mechanical/social effects. Ankyloglossia can also prevent the tongue from contacting the anterior palate. This can then promote an infantile swallow and hamper the progression to an adult-like swallow which can result in an open bite deformity. It can also result in mandibular prognathism; this happens when the tongue contacts the anterior portion of the mandible with exaggerated anterior thrusts.<ref name="Horton" }. this also limits someone who is suffering from this condition's ability to eat an ice cream cone or perform acts of oral sex on woman '

Professional opinion
Opinion varies, however, regarding how frequently ankyloglossia truly causes problems. Some professionals believe it is rarely symptomatic, whereas others believe it is associated with a variety of problems. The disagreement among professionals was documented in a study by Messner and Lalakea (2000). The authors sent a survey to a total of 1598 otolaryngologists, pediatricians, speech-language pathologists and lactation consultants with questions to ascertain their beliefs on ankyloglossia; 797 of the surveys were fully completed and used in the study. It was found that 69 percent of lactation consultants but only a minority of pediatricians answered that ankyloglossia is frequently associated with feeding difficulties; 60 percent of otolaryngologists and 50 percent of speech pathologists answered that ankyloglossia is sometimes associated with speech difficulties compared to only 23 percent of pediatricians; 67 percent of otolaryngologists compared to 21 percent of pediatricians answered that ankyloglossia is sometimes associated with social and mechanical difficulties. Limitations of this study include a reduced sample size due to unreturned or incomplete surveys.

Speech
Messner and Lalakea studied speech in children with ankyloglossia. They noted that the phonemes likely to be affected due to ankyloglossia include sibilants and lingual sounds such as 'r'. In addition, the authors also state that it is uncertain as to which patients will have a speech disorder that can be linked to ankyloglossia and that there is no way to predict at a young age which patients will need treatment. The authors studied 30 children from one to 12 years of age with ankyloglossia, all of whom underwent frenuloplasty. Fifteen children underwent speech evaluation before and after surgery. Eleven patients were found to have abnormal articulation before surgery and nine of these patients were found to have improved articulation after surgery. Based on the findings, the authors concluded that it is possible for children with ankyloglossia to have normal speech in spite of decreased tongue mobility. However, according to their study, a large percent of children with ankyloglossia will have articulation deficits that can be linked to tongue tie and these deficits may be improved with surgery. The authors also note that ankyloglossia does not cause a delay in speech or language but, at the most, problems with enunciation. Limitations of the study include a small sample size as well as a lack of blinding of the speech-language pathologists who evaluated the subjects’ speech.

Messner and Lalakea also examined speech and ankyloglossia in another study. They studied 15 patients and speech was grossly normal in all of the subjects. However, half of the subjects reported that they thought that their speech was more effortful than other peoples’ speech.

Horton et al. discussed the relationship between ankyloglossia and speech. The authors believe that tongue tie contributes to difficulty in range and rate of articulation and that compensation is needed. Compensation at its worst, the article states, may involve a Cupid's bow of the tongue.

While the tongue tie exists, and even years after removal, common speech abnormalities include mispronunciation of words. The most common is pronouncing Ls as Ws; for example the word "lemonade" would come out as "wemonade."

Mechanical/Social
Ankyloglossia can result in mechanical and social effects. Lalakea and Messner studied 15 people, aged 14 to 68 years. The subjects were given questionnaires in order to assess functional complaints associated with ankyloglossia. Eight subjects noted one or more mechanical limitations which included cuts or discomfort underneath the tongue and difficulties with kissing, licking one’s lips, eating an ice cream cone, keeping one’s tongue clean and performing tongue tricks. In addition, seven subjects noted social effects such as embarrassment and teasing. The authors concluded that this study confirmed anecdotal evidence of mechanical problems associated with ankyloglossia and that it suggests that the kinds of mechanical and social problems noted may be more prevalent than previously thought. Furthermore, the authors note that some patients may be unaware of the extent of the limitations they have due to ankyloglossia since they have never experienced normal tongue range. A limitation of this study is the small sample size that also represented a large age range.

Lalakea and Messner note that mechanical and social effects may occur even without other problems related to ankyloglossia such as speech and feeding difficulties. Also, mechanical and social effects may not arise until later in childhood as younger children may be unable to recognize or report the effects. In addition, some problems may not come about until later in life, such as kissing.

Intervention
There are varying types of intervention for ankyloglossia. Horton et al. have a classical belief that people with ankyloglossia can compensate in their speech for limited tongue range of motion. For example, if the tip of the tongue is restricted for making sounds such as /n, t, d, l/, the tongue can compensate through dentalization; this is when the tongue tip moves forward and up. When producing /r/, elevation of the mandible can compensate for restriction of tongue movement. Also, compensations can be made for /s/ and /z/ by using the dorsum of the tongue for contact against the palatal rugae. Thus, Horton et al. proposed compensatory strategies as a way to counteract the adverse effects of ankyloglossia and did not promote surgery.

However, intervention for ankyloglossia sometimes includes surgery in the form of frenotomy (also called a frenectomy or frenulectomy) or frenuloplasty. This may be done by laser. However, authors such as Horton et al. are in opposition to it. According to Lalakea and Messner, surgery can be considered for patients of any age with a tight frenulum as well as a history of speech, feeding, or mechanical/social difficulties. Adults with ankyloglossia may elect the procedure. Some of those who have done so report post-operative pain.

A viable alternative to surgery is to take a wait-and-see approach. Ruffoli et al. report that the frenulum naturally recedes during the process of a child's growth between six months and six years of age;