Tongues Tied by Orofacial Myofunctional Therapy about Tongue Tie: A Narrative Review

ABSTRACT

Aim and Background

The respective review articles aim is to provide an overview as well as describes and enlists different orofacial myofunctional therapy exercises as a modality for tongue tie secondary to surgery.

Tongue tie is the basically a connection that joints base of tongue to the floor of mouth. This leads to difficulties various difficulties such as altered speech, oral habits, maligned teeth and many more. During formative years, most children successfully treated of tongue tie by releasing it, but problems start after its correction. That it may can reappear or may lead to same difficulties as prior. Parents and clinicians are only concerned about speech and aesthetics after release of tongue tie. But OMT plays important role ore and post-surgical procedure. OMT help in proper tongue posture along with reducing the probability of tissue reattachment after surgery by exercises. This therapy positively influenced functions by reducing deleterious habits.

Methods

A review of relevant literature is predicated on articles found using free text terms, mesh terms, and some basic tongue tie as well as tongue tie release pamphlets that were published in English up until the year 2023 in the electronic databases PubMed, EBSCO, Scopus, Google Scholar, and Web of Science. With the aid of mesh keywords, the initial search yielded 38–40 articles; 20–35 were chosen depending on the requirements. Also we searched for orofacial myofunctional exercises or exercises recommended after tongue tie release.

Results

Various exercises enlisted in our article that will guide a individual before and after tongue tie release which will give positive outcomes such as proper tongue posture, speech, swallow, regained aesthetics and self-esteem.

Conclusion

Tongue plays an important role in development of perioral structures as well as in the swallow to good speech articulation and dental occlusion. So, as pediatric dentist its important know that after release of tongue tie what to do and how to maintain. This review article is focused on the various orofacial myofunctional therapy techniques employed for tongue tie but not a single one to describe them.

Clinical significance

Our pertaining review act as a guide for clinicians as well as individuals to manage tongue tie after its release.

How to cite this article

Shah SS, Agarwal PV, Rathi N, et al. Tongues Tied by Orofacial Myofunctional Therapy about Tongue Tie: A Narrative Review. Int J Clin Pediatr Dent 2024;17(1):109–113.

Background

What is a Tongue Tie?

Ankyloglossia, or tongue tie, is the alteration of attachment of the tongue from the floor of the mouth to the subsurface area. In simple words, it is a condition in which your child's tongue remains attached to the bottom of their mouth.¹

A few effects of retained tongue tie are listed below, as reported by the authors:

• Promotion of infantile swallow.

• Discomfort during breastfeeding.

• Improper tongue posture.

• Poor oral hygiene.

• Speech defects-mostly sibilants and lingual sounds.

• Dental defects-mandibular prognathism, Anterior open bite, crowding, ”v” shaped palate and oral habits.

• Mechanical and social effects.^2,3

These are different reasons due to which there is restricted tongue mobility can be seen among individuals. This condition can be easily seen in infants and can be treated by surgical approach as early as possible. This altered tongue function due to restricted movements can lead to disruptions. It can negatively impact oral structures and lead to oral habits.⁴

Why and How to Correct Tongue Tie?

Other than that, parents nowadays are concerned about the aesthetics and speech of their children. So, approach toward surgical tongue tie release procedure along with myofunctional therapy.

Part of orofacial myofunctional therapy (OMT) in ankyloglossia release can't be understated. OMT is all about strengthening oral and perioral muscles with the help of exercises. These exercises are adjunct to the therapy to mold and use muscles for improvement functions. As most of the released tissue can reattach even after a surgical procedure, reappearance of ankyloglossia can be expected. To avoid this reattachment and to ensure proper posture of the tongue in relation to other structures, movements by these exercises are essential. All these movements will make sure the reattachment is as less as possible.

There are many authors who observed the development of tongue thrust due to habitatory improper posture of the tongue onto the palate, eventually leading to sleep apnea due to airway obstruction. In recent times, many systematic reviews came forward and stated that myofunctional therapy was shown to retain the tongue properly on the palate with a decrease in sleep apnea.⁵

As said by Pamela Douglas ”Tongues tied about tongue-tie.” There are only a few people who are concerned about this tongue tie release and unaware of its deleterious effects on orofacial structures along with teeth.

Aim

This review acts as a reference guide and enlists the various myofunctional exercises for clinicians and parents as an adjunct to manage ankyloglossia with surgery. Also describes the related instructions and limitations for the same.

Review Results

Management of Tongue Tie?

There are varying types of interventions for the release of tongue tie. A severity scale for ankyloglossia, which grades the appearance and function of the tongue, is recommended before considering any treatment option for tongue tie, because sometimes it can resolve on its own based on severity at in early age.

Management includes:

• Frenectomy surgical procedure.

• Frenuloplasty surgical procedure.

• Supportive therapy: Speech therapy and OMT.

• Self-care.

All managements go hand in hand. But after release, to ensure its relapse, pre- and postmanagement exercises are crucial. Myofunctional treatment prepares the tongue muscles, airway muscles, and posture for what's to come before the release.

Orofacial Myofunctional Therapy: Postfrenectomy Exercises

Prefrenectomy Therapy

It is strongly recommended by dentists to visit myologists before surgery. For all this time, the muscles of the tongue were restricted. All the exercises before surgery allow stretching and help strengthen the tongue muscle and build oral awareness as follows.

Postfrenectomy Therapy

Postprocedure therapy involves home-based exercises along with speech therapy. Muscles of the tongue were attached to the floor of the mouth and may have grown strong while compensating for the inability to use other muscles. A few exercises are advised to improve the movement and posture of the tongue to restore muscle function of those muscles that were not in use.

Tongue around the world:

Without moving the jaw, ask the child to move their tongue in circles clockwise and anticlockwise 10 times each.

Frenal massage exercise:

The child is asked to stretch the tongue as back and wide as possible and, with two fingers, massage both sides of the frenum 10 times each. If possible, rub olive oil with massage onto the frenum.

Teeth-counting exercise:

With the help of the tongue, tell the child to count the tooth by touching each tooth (Fig. 1).⁶

Fig. 1.

Teeth-counting exercise

Tongue push-ups:

Ask the child to get the tongue too forward and use a spoon/blade/scale to push the tongue; hold up to 10 seconds. Around 10–15 holds are advised twice a day.

Lip-licking exercise:

Ask the patient to stretch the tongue up and below to lick the lips (Fig. 2).

Fig. 2.

Lip-licking exercise

Licking exercise:

Practice licking up ice cream cones/candy/any cream placed over a spoon using the tongue tip in an upward motion.

Food scrapes:

Place peanut butter/cream/jam over the palate and ask the child to scrap their tongue all over backwards of the palate.

Tongue popping or clicking exercise:

Ask the child to suck the tongue onto the roof of the mouth and create a clicking or popping sound.

Tongue spot exercise:

Tongue posture is important to avoid further occurrence of tongue thrust habit. After the tongue tie release, it is important to teach the tongue its proper spot.

• Ask the child to look in the mirror and keep the tongue away from the upper front teeth with the help of chewing gum or jelly. Tell the child to practice that position of the tongue while swallowing and even at rest.⁶

Object pull exercise:

Ask the child to draw tongue out and ask to pull objects like pen/pencil, etc. Roll the tongue five times under and over three times a day.

Tongue-to-cheek exercises:

The child is asked to close the mouth tightly and touch the tongue to the right and left cheek simultaneously 10 times on each side (Fig. 3).

Fig. 3.

Tongue-to-cheek exercise

Diving board exercise:

Ask the child to forcefully protrude the tongue out and then retract the back tongue. Perform these at least 10 times a day (Fig. 4).

Fig. 4.

Diving board exercise

Orthodontic rubber band exercise:

Place an orthodontic rubber band on the tip of the tongue; touch the tip of the tongue onto the palatal area with lips apart, and teeth closed in occlusion. Then, ask the child to swallow while keeping the same posture. A total of 30 swallow practices are recommended twice every day.⁶

Tongue palate seal breaker:

Along with water, ask the child to hold the tongue at the spot and create a suction and clicking sound around 10 times each day.

Tongue-to-nose and chin exercise:

Ask the child to open his/her mouth wide, stretch tongue out, and try to touch nose and chin simultaneously 10 times each.

Swallowing exercise:

It is important to practice swallowing with the new posture of the tip of the tongue trained while spot exercise. Ask the child to spot the position and swallow any solid or liquid food. Also, the child can keep any food object on the tip of the tongue and practice swallowing 5–6 times while eating or resting.

Till the tongue tie is released, the child uses few muscles for the movements, which restricts the range of motion. But after surgery, it's important to perform shaping exercises as well as movement exercises. The child was asked to perform the same exercises advised before surgery but thrice as before till 4–6 weeks.

Exercises For Infants

As for infants, it's difficult to follow instructions and do exercises. Parents can participate and carry forward the exercises required in infants to recover their little ones faster. All these exercises will help them in better sucking and breastfeeding. The stretches can be done before, after, or in the middle of a feeding- whichever seems to work best. It may be best to feed before the stretches during the first week. Advise the child to perform suck training exercises along with stretching exercises.

Stretching Exercises

• This exercise helps increase in flexibility and healing of the frenulum.

• Try with clean fingers/gloves.

• Stretch and rub the area 10–15 seconds six times per site.

Suck Training Exercises

These can be opted for before feeding and during playtime. Make sure your fingers don't discomfort the baby in any way.

• Finger-sucking exercise: Place a clean finger/gloved finger inside the baby's mouth by resting it on the chin. The tongue should be toward the lower gums, and the finger should be drawn into the palatal part. At the end, ensure the sucking of the finger.

• Pressure exercise: Now, turn over your finger onto the tongue. Press down the tongue and draw it out using downward and forward (toward lips) pressure. Do these a few times.

• Circular stroke exercise: Help the tongue to move in a circle and touch each part of the mouth with a finger. Avoid insertion too deep and gagging of the baby.

• Tongue pointing exercise: Place your finger on the baby's lower lip and wait until the baby responds. Then tap and stroke onto the lower jaw with a finger 3–4 times with a pause in between.

• Side-to-side exercise: Let the baby follow your finger on the left, followed by the right back side, which will help in lateralization. Do this three times slowly.

• Groove-making exercise: Place your finger onto the roof of the mouth while sucking baby by making a groove by raising the sides of the tongue. You can also put a little pressure on it and play ”tug of war.”

Do these exercises when the baby isn't so hungry that they get frustrated and go into panic mode, and may be delayed until after a meal. Do not let >6 hours lapse between stretches, as reattachment is possible. Follow instructions and perform exercises five times per day for 6 weeks a day after surgery.

Speech Therapy

• We often notice that improper tongue placement causes speech difficulties.

• Commonly, this is a lisp on ”s” and ”z,” ”sh,” ”zh,” ”ch” and ”j,” ”t,” ”d,” ”l,” and ”n” sounds. Tongue-tied children also can experience speech errors while pronouncing these sounds.

• Read aloud exercise: Ask the child to say loudly words involving these sounds in front of the mirror three to four times each for 4–6 weeks.

• Sing along to the song exercise: Ask the child to sing along to his/her favorite song loudly, which helps in improving muscle actions.

• Vowel practice exercise: Ask the child to say out a, e, i, o, and u vowels out loud for 3 minutes at a time, a few times a day.

Bioexercise Therapy

• This is the OMT protocol recently given by Lim et al., which is patient-centered and can be followed easily at home. Basically, this therapeutic approach combines OMT and BioEx Xenium appliances.

• In the case of the tongue, this protocol assesses the position of the tongue and movement of the tongue limited by lingual frenum or its attachment.

• Before and after the bioexercise, the tongue tip and base are traced onto the lateral cephalogram.

• Bioexercises in tongue training consist of empty swallowing, water swallowing, tongue palate seal breaker, and reading aloud, as explained above.

• Tongue elevator: It's an appliance along with exercises because of which the tongue rests onto its resin body and stays lifted. It also helps in proper swallowing and positioning of the tip of the tongue after the release of the tongue tie or in case of tongue thrust.

Remember, even if these exercises are there in training, self-assisting charts, tables, videos, and images can act as a better guide for the child to ingrain correct movements and postures without a therapist.

Discussion

The tongue plays a crucial role in so many activities in the oral cavity. It's reduced mobility that can induce dysfunctional compensations. A restricted tongue can cause neck strain, pain, and postural instability by putting tension on the deep front line of the fascia.^7,8 Myofunctional therapy was first described in 1918, but only a few people are aware of its importance and how miraculously it helps in correction. Basically, OMT is a treatment to improve mandibular growth, nasal breathing, and facial appearance. Myofunctional treatment prepares the tongue muscles, airway muscles, and posture for what's to come before the release. Even after release, it will change the child's current tongue pattern, posture, and airway. This will eventually help in functions such as breathing, swallowing, eating, chewing, speech, and a few social aspects. So, the multidisciplinary treatment protocol combining the surgical procedure with myofunctional therapy, as described above, will result in a life-changing experience for both the child and parents. So, in this pertaining review we tried to incorporate those exercises with instructions along with it to create awareness amongst clinicians as well as parents. Also, this review can be a guide for the parents and children to avoid relapse of tongue tie with the help of OMT.

Number, Duration, and Frequency of Sessions

Prerelease

• The child was advised to perform exercises twice daily for 1–2 weeks prior to surgery.

• Exercises will be difficult initially due to limited motion, but it's important to have familiarity to perform after release.

Postrelease

• The same exercises were told to be performed before four to six times daily for 4–6 weeks.

• After release, pain will be there, but exercises will help to adapt to proper resting and functional postures.

• Assessment after each week is advised.

• As weeks go by, three to six exercises should be reduced to two to four times a day.

Limitations of Orofacial Myofunctional Therapy

It is important to understand that OMT cannot replace the main modality for correction. It is a concept of active exercise, the success of which depends critically on the motivation levels and compliance of children and their parents equally.⁶ The incorrect speech patterns, incorrect tongue placement at rest, and swallowing functions will likely not correct themselves but it will require proper guidance to carry out all these OMT exercises.

Conclusion

Parents and clinicians should be aware of the deleterious effects of tongue tie and the importance of its early management. Along with the surgical approach, OMT also plays a crucial role. OMT can help in avoiding such effects and helps in increasing muscle activity but cannot help completely in avoidance of reattachment. It can be considered as a comprehensive treatment plan for the patient.

Clinical Significance

Orofacial myofunctional therapy (OMT), pre- and postmanagement of tongue tie aids in:

• Controlled movements of the tongue.

• Tongue resting and functional posture.

• Swallowing pattern.

• Speech improvement.

• Prevent relapse of tissue attachment.

Orcid

Sejal S Shah https://orcid.org/0000-0002-1119-5857