How and at what age do children cut the frenulum under the tongue and why do they need plastic surgery? Short frenulum of the tongue in a child: how to correct a developmental anomaly? Short frenulum in a child 3.

Among children, the pathology of the structure of the oral cavity in the form of a short frenulum of the tongue, called ankyloglossia, is common.

Often, a short frenulum of the tongue is determined in newborns immediately after birth, when viewed in a maternity hospital.

Pathology is recognized quite simply: normally, a thin cord connecting the tongue and the lower oral cavity reaches the middle of the tongue, while the abnormal frenulum is attached to its very tip.

It also happens that the frenulum is practically absent and the tongue fuses with the lower part of the mouth.

Prerequisites for the development of a violation

In half of the cases, ankyloglossia is diagnosed in children whose mother and father (or one of the parents) had similar problems. Pathology in the embryo develops in the mother's womb in the first half of pregnancy due to:

• lack or untimely therapy in the expectant mother of a viral disease in the 1st and 2nd trimesters;
• treatment of diseases with antibiotics;
• work with chemical reagents (paints, varnishes, solutions);
• frequent stressful conditions;
• the age of the expectant mother (over 35 years old);
• unfavorable environment.

Varieties of anomalous frenulum

Five types of short hyoid frenulums have been identified:

• transparent thin, restricting the movement of the tongue;
• thin translucent, fixed by the front edge almost at the tip of the tongue;
• thick opaque, fixed near the edge of the tongue;
• a short and tight tie connected to the muscles of the tongue (a common anomaly in children suffering from palatine and labial clefts);
• a fold fused with the tongue muscles.

Symptoms and signs of pathology

It is easy to determine a short frenulum of the tongue from the first days of a child's life. The main and first sign of the disease are difficulties in breastfeeding.

To suck milk from the mother's breast, the newborn needs to make serious efforts, involving other organs in addition to the tongue. The tongue irritates the mother's nipple, resulting in the release of breast milk.

With a shortened frenulum, this process is quite complicated and many babies try to compensate for low mobility of the tongue with their gums and lips, which is quite difficult for both the child and the mother.

On the left is a normal frenulum, on the right is a pathological one.

The baby quickly gets tired, the mother feels discomfort during feeding, the process of breastfeeding is disturbed, meals become frequent, long and restless with breaks for rest.

During attachment to the mother's breast, the child is naughty, arches, throws back his head, and may even refuse to breastfeed. As a result, the baby is nervous, underweight.

In older children and adults, due to a short frenulum, the sound pronunciation of hissing and other letters is difficult, it becomes problematic and develop.

Self-diagnosis of the disease

Frenulum defect is more common in boys. Parents can independently visually diagnose the pathology.

The movements of the child's tongue will be constrained or the tongue will be attached to the lower jaw, the child will not be able to stick it out of the mouth.

At an older age, it is necessary to ask the child to lick his lips - if the frenulum is short, then he will not be able to do this, and he will also not be able to reach the upper teeth with his tongue.

Treatment Methods

To date, two methods of treating a short frenulum in children are in demand: conservative and surgical cutting.

If you deny surgical intervention to cut the frenulum, you can do special gymnastics at home, developed by speech therapists, aimed at stretching.

Exercises:

To stretch the frenulum, a speech therapist may advise you to perform speech therapy massage. The procedure is quite unpleasant, but very effective. It is performed with absolutely clean hands, sometimes the doctor can afford to wrap his fingers with a sterile handkerchief or bandage:

1. Hold the bridle between your thumb and forefinger and move them along the tie from the bottom up.
2. Place the middle and index fingers under the tongue so that the bridle is between them; with your thumb, press on the front of the tongue and gently pull it outward.
3. Pull the tip of the tongue up and down alternately, then gently pull the jumper up with your index finger.
4. Put the edge of the pipette cut off in the form of a ringlet on the tip of the tongue, press the ring against the palate with the tongue and close the mouth; repeat the exercise three times a day, 8-10 times.

Prompt problem solving

Surgery is indicated for:

• displacement of teeth;
• incorrect pronunciation of sounds and letters that cannot be corrected by classical methods;
• with problems with breastfeeding.

It is forbidden to operate in the presence of oncology, blood problems, diseases of the oral cavity and untreated infectious processes in the body.

The decision on the need for surgery should be made jointly by a speech therapist, surgeon and orthopedist. Many doctors believe that the frenulum can stretch on its own with age.

For newborns, the frenulum is incised in the maternity hospital with the help of special scissors. Until the age of 9 months, she does not have time to grow blood vessels and nerve endings, so the operation is completely painless, bloodless and is performed under local anesthesia.

Rehabilitation lasts only a couple of hours, after which the child is applied to the mother's breast. As a result, children's appetite sharply increases.

Older children need to trim the bridle until the complete change of all. The age of 5-8 years is considered a favorable period, but in exceptional cases, the operation can be done earlier.

Before cutting, the attending physician will refer the patient to the laboratory for blood and urine tests. The procedure is performed in the clinic under local anesthesia, its duration is no more than 10 minutes. To avoid possible blood loss, electric scissors or an electrocoagulator are used.

A week later, the child should undergo a rehabilitation speech therapy course, which consists in training and strengthening the muscles involved in raising the tongue, setting disturbed sounds and fixing their correct pronunciation.

Cutting the frenulum of the tongue in children is much easier than in adult patients:

Consequences of ankyloglossia

Children with an abnormal frenulum under the tongue are not able to gain the body weight required for age due to constant malnutrition, they lag behind their peers in growth. They disrupt the sucking process, the newborn baby is not able to clasp the mother's nipple, the feeding process becomes long, intermittent.

The photo shows a short frenulum of the tongue in a child close-up

At an older age, the child has serious problems:

A short frenulum of the tongue in a child should not cause panic among parents. Before you decide on the operation to cut the jumper, you need to get expert advice.

But it cannot be avoided in case of diagnosing acute orthopedic or dental ailments. In other cases, you should rely on the experience of the doctor and his advice.

Classic frenulum therapies, such as special exercises and speech therapy massage, require great strength and patience. Therefore, it is necessary to act, because the health of the child is in the hands of his parents!

Trimming the frenulum under the tongue in children is a fairly common procedure at an early age. Coping with the problem is very simple, so some doctors suggest correcting the defect even in the hospital, so that later there are no problems with nutrition and speech. The procedure is carried out quickly, and the children do not have time to feel discomfort. Cutting the frenulum can be done at a later age, already when speech defects are detected.

The frenulum under the tongue is located on the lower surface of the organ and superficially resembles a continuation of its median line. This formation has received a common name, because it seems to hold the tongue when it rises up. The frenulum starts from the middle of the tongue, where there is a border of the mucosal transition, and then it descends in an arc almost to the base of the gums near the central lower incisors.

This location of the frenulum is normal, so it does not interfere with the movements of the tongue in the oral cavity. On average, in an adult, its length can reach three centimeters.

For the first time, doctors pay attention to the bridle even in the hospital, immediately after the baby is born. Such close attention is due to the fact that very often the bridle has defects and cut it off as soon as possible. The most common pathology is its shortening and displacement: it is located at the very tip of the tongue, and when the tongue is raised, it takes the form of a gutter.

When protruding the tongue out, the frenulum with pathology does not allow the tongue to fully extend, which is why it only slightly covers the edge of the lower lip. Usually such a defect is not accompanied by a true shortening of the size, but an abnormal arrangement leads to the same signs as with, so it has to be cut.

In some children, the frenulum is indeed smaller than necessary, but this feature may not affect the function of the tongue. But not all babies are so lucky - according to the observations of doctors, children with anomalies still experience problems with sucking their mother's breasts, so parents still go to the doctor for cutting, feeling the first problems with latch on the nipple and movements of the baby during feeding.

Signs of a short frenulum can be seen in the following manifestations:

• problems with feeding arise already at the very beginning of the process - the child cannot grab and hold the nipple for a long time, movements during feeding cause him noticeable difficulties;
• children do not eat after feeding;
• on an empty stomach, the baby does not fall asleep, he becomes restless and capricious;
• children with an anomaly may be underweight until a plastic frenulum of the tongue is performed.

In the future, if not trimmed, a too short bridle can interfere with the pronunciation of sounds. Usually children have difficulty with sounds -l, -s, -r. The tongue is located approximately in the middle between the dentition, both when talking and with the mouth closed.

Because of this, extraneous whistling sounds appear during a conversation, and there are problems with chewing and digesting food: a too coarse food lump is swallowed due to insufficient grinding.

Doctors recommend trimming the frenulum of the tongue at an early age, but nothing terrible will happen if the operation is performed a little later, in the preschool period. Usually, significant problems in a child are detected already in the first year of life, if the mucous membrane under the tongue is not cut. Parents complain about the problems to the pediatrician, and the doctor, after examination, gives a referral to a dentist, who performs the cutting.

Children up to a year old have a rather thin mucosa of the frenulum. There are practically no nerve endings in it, and during the neonatal period they are completely absent. Therefore, at such an early age, the plastic of the frenulum of the tongue is performed without anesthesia, and bleeding is minimal.

If the child was not cut in early childhood, then the doctor will recommend this in the future. After all, if problems with the bridle did not manifest themselves in breastfeeding, then the next step is the pronunciation of sounds - with a short bridle, the child has typical problems, and parents turn to a speech therapist.

At an early stage, the doctor will recommend conservative treatment- special exercises for stretching the frenulum, but in the absence of a positive result, the speech therapist still gives a referral to plastic frenulum of the tongue. The dentist also performs cutting, but with the use of local anesthesia, as well as suturing after the operation.

The optimal time to perform the operation to cut the frenulum of the tongue is the age of up to one year. During this period, the intervention is most painless, the kids will not even remember that they have ever undergone a pruning procedure. The mucosa heals quickly, and with early attachment to the breast after surgery, the frenulum is immediately developed in the process of obtaining milk.

Not all doctors support an early frenulum procedure. If a child eats well in the first year of life, then this does not mean at all that problems with the frenulum can appear in terms of speech therapy at the age of four to five years. Therefore, it makes no sense to cut the bridle for the sake of prevention at an early age, so as not to injure the baby once again.

If the speech therapist has determined the indications for cutting, then intervention can be carried out already at this age.

Intervention preparation

Usually, cutting the bridle is carried out without any major preparatory steps. This intervention is low-traumatic and in almost all small patients passes without complications. In rare cases, when there are somatic pathologies or risks during the procedure, doctors may prescribe the following tests and examinations before the operation:

• general blood analysis;
• blood clotting test;
• fluorographic examination.

Before the operation, the child is recommended to feed a little. Firstly, the baby will not experience such severe stress, and secondly, after the procedure, children do not dare to eat for some time, so pre-feeding will be most welcome.

Operation methods

There are several ways in which the plastic of the frenulum of the tongue is performed - using a scalpel and. The frenulum was always cut with a scalpel, this is a classic way to get rid of the anomaly. The laser is a novelty of recent years, which proved to be excellent in carrying out this kind of intervention.

The operation with a scalpel takes about twenty minutes on average. During this time, an incision is made on the mucosa, bleeding stops, and if necessary, sutures are applied. After such an intervention in children, swelling is formed in the tongue area and slight discomfort remains for some time.

Usually the postoperative scar disappears by the end of the first week. All this time it is recommended to rinse the mouth with special solutions.

With the help of a laser, you can deal with a bridle much faster– The intervention takes approximately ten minutes. The cutting process is painless, there is practically no blood, since it is immediately "baked" by the laser. The wound closes immediately, so there is no need for stitches.

A spray or gel can be used as anesthesia, and this is done more for the purpose of calming, since even after the operation the discomfort is insignificant. The scar heals within one to two days.

The differences between the methods are significant, although the result is the same- one way or another, the wound surface heals and the child solves the problem with the length of the frenulum. Laser treatment is more expensive, but the procedure is more gentle, so doctors recommend choosing it.

Possible Complications

After the procedure, children may experience some complications. Particularly responsive to the procedure of the baby - they may refuse to eat, become whiny and restless, sleep poorly - this is a normal reaction of the body to intervention.

Children receive such stress infrequently, so parental support is important at this time. Most of the complications are completely manageable. Among them, doctors note:

• minor soreness after the procedure, which usually disappears after a couple of days;
• increase in body temperature, which may be an individual reaction of the body to the intervention. If the temperature does not drop, then it is necessary to re-visit the doctor - perhaps an infection was introduced and the inflammatory process began;
• the appearance of a postoperative scar, which sometimes forces you to do plastic surgery again.

Full rehabilitation after surgery takes from seven to ten days.. During this time, all the negative consequences after the operation disappear, the children begin to eat normally, pronounce all the sounds, return to the usual rhythm of life.

After the frenuloplasty in children is performed, doctors give recommendations for a speedy recovery:

• parents need to take care of their own hygiene oral cavity of the child, since the baby can spare the affected area, does not clean his teeth well.

If white plaque appears at the site of the intervention, you should not panic - this is not pus, but the initial stage of scar formation, at this time it is necessary to continue rinsing the mouth;

• children are not recommended to give solid food, which requires prolonged chewing so as not to provoke soreness under the tongue;

• babies can be spoon fed, in small doses, and immediately after the procedure, the baby can be breast-fed - milk will have the best effect on the scar;
• kids need to talk less so that the seams do not come apart.

As soon as the postoperative scar heals, you can begin exercises to stretch the mucosa.

Trimming the frenum of the tongue in newborns and older children is a necessary intervention if there is an indication for it. Do not think that the problem will be solved on its own or the bridle will increase in the process of growth. It is better to carry out the operation at an early age so as not to provoke stress to the child. Bridle cutting is not a complicated procedure and in almost all babies it happens quickly and without complications.

Unfortunately, even parents who are not initiated into medical subtleties are familiar with the opinion that a short frenulum of the tongue in a child is the cause of speech therapy problems. Why "Unfortunately"? Because it is ignorance of the material that leads to an unequivocal decision - the bridle must be cut!

Remember, in the film "Pokrovsky Gates" a characteristic female surgeon with her famous phrase "Cut! .. without waiting for peritonitis"? So the same thing often happens with a poor bridle. However, as experience shows, there is not always only one way out. Not every case of the so-called "short frenulum" requires drastic measures.

What is a short frenulum of the tongue

A frenulum is a thin partition that connects the tongue and the lower oral cavity. Normally, the frenulum is quite elastic, stretches well and is attached to the tongue in its middle part.

An abnormal structure may be the location of the frenulum closer to the edge of the tongue or completely at its tip. In addition, a significant decrease in its elasticity, that is, the ability to stretch, is possible.

So in fact, the concept of "short bridle" is not entirely correct. Therefore, there is no single solution to this issue.

What prevents the incorrect structure of the frenulum of the tongue

In infants, the abnormal structure of the frenulum can cause difficulty suckling. In this case, the problem is solved even in the hospital by cutting. If the baby is still able to eat normally, doctors try to leave the situation alone, giving, as they say, time to grow. Indeed, in many cases, along with the growth of the jaw, the frenulum gradually stretches and takes on a normal shape.

In older children, a short hyoid frenulum creates some speech therapy difficulties:

• There are difficulties with the pronunciation of hissing sounds.
• Correct reproduction of sonorants is not given.

To pronounce the so-called upper lingual sounds, it is necessary to raise the tip of the tongue up. Insufficiently elastic bridle interferes with this.

However, it is very important to understand that it is not "responsible" for all speech problems. So if a child has a delay in speech development, syllables and sounds are “confused” in speech, vocabulary is limited or other problems, a short bridle has nothing to do with it. Speech therapist to suggest effective ways of correction.

How to check if a child has a short frenulum

The presence of difficulties with the bridle can be easily determined independently:

1. Open your mouth slightly and place the tip of your tongue behind your upper teeth. In this position, the place of attachment of the frenulum is clearly visible. If it is not where it is needed, it is difficult to lift the tongue up.
2. Pull your tongue forward. A short frenulum does not allow this, in addition, the tip of the tongue visually looks forked
3. Open your mouth and try to touch your upper lip with your tongue, lick it. Difficulties with the bridle make this movement difficult to perform.

Please note: sometimes a child cannot cope with these exercises, not because something is wrong with the bridle. The cause may be weak muscles of the articulatory apparatus. Take a clean handkerchief and try to help the tongue. If resistance is felt during movement, then the matter is still in the hyoid frenulum.

Who to contact for help

Depending on the complexity of the situation, an orthodontist or speech therapist will help to cope with the problem. In any case, it makes sense to first get a consultation in order to decide which method of correction the child needs.

The dentist will carefully cut the frenulum, relieving the child of inconvenience with one movement of the hand. Recently, however, doctors still recommend leaving surgery as a last resort. An experienced speech therapist will offer a set of exercises and massage to stretch the frenulum.

Experts say that there are not many situations when the hyoid frenulum is absolutely incapable of stretching. In almost all cases, a conservative approach achieves results.

Parents can evaluate the pros and cons of different approaches on their own.

Surgical method:

• Quick, radical solution to the problem.
• The operation is performed using anesthesia.
• The healing process takes some time and is inconvenient.
• Dietary restrictions due to surgery.
• It is advisable to observe voice rest for several days.
• Possible psychological trauma in the child.
• After the operation, sessions with a speech therapist are necessary to correct sound pronunciation.

Bridle Stretch Method:

• Conservative, does not cause psychological difficulties in the child.
• Effective in most cases.
• Does not require changes in the usual mode of life.
• It takes some time (several months).
• Requires discipline and regular practice.

In any case, to resolve the issue, you need to consult a speech therapist.

How to stretch the hyoid frenulum of the tongue

Here, parents will need perseverance, patience and even resourcefulness. In addition to a special set of exercises, you need to use every opportunity to give the tongue a workout. For example, invite your child to ... lick a plate. Yes, perhaps this goes against the rules of good manners, but it will help to cope with speech problems. Make it a game!

It's also good to tease a little. Let the child stick out the tongue as far as possible.

Bridle Stretching Exercises:

• Open your mouth, the tongue is relaxed, put it on the lower lip and hold it in this position for several seconds.
• Try to touch the tip of the tongue to the nose, then the chin. Repeat several times.
• Lick the upper lip (exercise "Jam"), the mouth is slightly ajar.
• Hold the tongue in a forward position.
• Click your tongue (exercise "Horse").
• With your mouth slightly open, move your tongue across the sky from front to back (in the direction from the teeth to the throat).
• Rest with the tip of the tongue in a place just behind the upper teeth. Try to open your mouth as wide as possible.

To stretch the bridle, you can do a special massage. It would be better if a speech therapist does this, but some techniques can be performed at home:

• Carefully take the tip of the tongue with your fingers and gradually move it in different directions (up, down, right, left).
• With your fingers, gently stroke the stretched bridle from the base to the end.

Of course, when performing a massage, you need to take a sterile bandage or a clean handkerchief.

You need to exercise regularly, preferably several times a day. Increase the load and the applied efforts should be very careful so that the exercises do not cause pain and do not provoke injuries. Working under the supervision of a speech therapist will help you achieve success safely and with maximum effect.

Ankyloglossia is a pathology characterized by a shortened membrane that attaches the tongue to the lower jaw. Such an anomaly limits the movement of the tongue, which causes problems with speech. The formation of a short frenulum of the tongue in infants occurs even before birth.

The formation of an abnormal membrane can be caused by the following reasons:

What does a short bridle look like: signs

A short frenulum of the tongue in a child is easily detected by a doctor during an external examination of the baby. With such a pathology, the tongue resembles a heart with a slightly elongated tip.

Signs of an anomaly of the frenulum in infants:

• smacking during feeding;
• chest bites;
• the frequency of feeding increases;
• the baby rests for a long time when feeding;
• underweight;
• breast rejection;
• whims during feeding.

A short frenulum of the tongue in a child, a symptom is whims during feeding.

Signs of frenulum pathology in children after a year:

• speech disorder;
• incorrectly formed bite;
• periodontitis;
• the central teeth are bent inward from below.

External signs of an anomaly:

1. The tongue does not protrude beyond the mouth.
2. The child is unable to lick his lips.
3. The tongue does not reach the sky.
4. When protruding, the tip of the tongue bifurcates.
5. A notch forms in the middle of the tongue when it is pulled forward.
6. The lower incisors are curved.

How to independently identify the problem in newborns

The length of a normal child's ligament is 8 mm or more. You can identify the pathology yourself. To do this, you need to pull the bottom sponge so that the baby opens its mouth. If the tongue joins at the tip and does not reach the lip, then the frenulum is short.

You can also identify this pathology in newborns according to the following criteria:

Classification of pathology

A short frenulum of the tongue in a child has 5 main types:

Diagnosis of a short frenulum of the tongue in newborns

A frenulum defect can be identified by specialists such as a pediatrician, surgeon, pediatric dentist, orthodontic specialist, speech therapist. Diagnosis of this anomaly occurs by external examination of the baby. It also helps to identify a frenulum defect by conducting the E. Hazelbaker test, which determines the size of the membrane and the degree of tongue mobility.

Any discrepancies in the test are abnormal and are indicative of ancoglossia.

With a normal length of the ligament, the baby can easily reach the tongue to the lips and palate.

Treatment Methods

There are several methods for correcting the pathology of the frenulum:

• correction exercises;
• laser operation;
• surgery.

Types of surgical operations:

Method	Description	Contraindications
Frenulotomy	The operation is performed with mild and moderate anomalies. This is a cut of the membrane with suturing of the edges of the mucous membrane.	Small amount of tissue for dissection.
Frenuloectomy	The same operation as a frenulotomy. The difference in the implementation of the incision from the side of the incisors.	Hemophilia (blood clotting disorder)
Frenuloplasty	This technique is performed for severe anomalies. The tissue is cut out of the triangular mucosa with further sewing.	Presence of oral infections.

Correction exercises

In children with a mild degree of pathology, with the help of special exercises, it is possible to correct the defect at home. Speech therapists have developed a whole range of highly effective exercises that help stretch the shortened frenulum of the tongue. With their systematic implementation and compliance with all recommendations, it will be possible to avoid surgery.

A set of exercises:

When performing such gymnastics, you can use additional items (a teaspoon, tubes, pencils) to help the baby achieve results faster.

Operation

A short frenulum of the tongue in a child is easily corrected surgically. Before the operation, the specialist pays attention to the age of the child, the degree of complexity of the pathology and its location.

The defect is removed under local anesthesia. The surgeon makes an incision with a special instrument and then sutures it. There may be slight bleeding. In time, this procedure takes about 30 minutes.

The recovery process after the operation lasts up to 10 days. At this time, the child will have swelling, pain, discomfort.

In this case, it is necessary:

• exclude hot and spicy foods from the diet;
• carry out oral hygiene;
• perform special exercises for the rapid resorption of scars;
• observe speech peace;
• consult with a speech therapist to eliminate speech defects.

laser treatment

To correct the pathology of the frenulum, laser cutting is also used. This treatment method is more gentle and therefore more suitable for younger children.

Advantages of laser surgery:

• fast healing;
• sealing of the wound;
• lack of seams;
• no bleeding;
• sterilization of incisions;
• duration of the operation (10 min.).

Laser treatment goes without complications. After the procedure, you must follow all the doctor's instructions (the same as after surgery with a scalpel).

Is an operation necessary?

The decision on the need for a surgical operation to eliminate the defect should be made by doctors such as an orthopedist, speech therapist and surgeon. It depends on when ankyloglossia was detected (the age of the child), as well as on the individual characteristics of the anomaly.

Often, doctors prescribe an operation 1-2 years after the discovery of a defect, since during this time the frenulum can stretch to the desired size as the baby grows.

Optimal age for surgery

Doctors recommend performing an operation to eliminate the pathology of the frenulum for children under 1 year old. The younger the baby, the easier the procedure will be for him. At this age, the membrane is weak, has no capillaries and nerve endings. The operation is performed without anesthesia.

If a child older than 4 years has speech impairments, and exercises to stretch the frenulum do not help, it is necessary to solve the problem surgically. At this age, the procedure causes discomfort as well as pain. The operation is performed using local anesthesia and suturing.

Consequences of ankyloglossia

A short frenulum of the tongue in a child leads to the following consequences:

The prognosis for a short frenulum of the tongue in children

With the timely detection of ankyloglossia and the operation, the prognosis for children is positive. After the procedure, breathing, nutrition, weight gain are normalized. Early treatment of frenulum pathology prevents malocclusion and speech defects.

If surgery is performed on older children, then to eliminate speech problems, it is necessary to attend speech therapy classes.

Correcting the pathology of the frenulum with exercises to stretch the membrane requires regular performance and patience. This technique is effective at the age of 5 years. What method of treatment to choose for a shortened frenulum of the tongue in children is decided by parents. The main thing is to eliminate the anomaly in a timely manner so that the baby develops normally.

Article formatting: Lozinsky Oleg

Video about a short frenulum in a child

Presentation on the topic of a short frenulum of the tongue in a child:

The frenulum of the tongue (frenulum linguae) is a fold of the oral mucosa that runs along the midline and connects the floor of the oral cavity with the lower surface of the tongue (encyclopedic dictionary of medical terms, 1984). Sometimes the terms lingual ligament, hyoid ligament are used. The function of the frenulum of the tongue is to fix the tongue to the soft tissues of the oral cavity, to prevent retraction of the tongue, glossoptosis, especially during the neonatal period. Normally, the frenulum of the tongue extends from the middle of the lower surface of the tongue and attaches to the mucous membrane of the floor of the mouth in the region of the excretory ducts of the sublingual salivary glands (Fig. 1). The free tip of the child's tongue by the age of 18 months should reach at least 16 millimeters. The measurement of the absolute dimensions of the frenulum of the tongue has not found wide application in clinical practice. It is believed that the length of the frenulum of the tongue during the mixed bite should be at least 21 mm, and the width should not exceed 4 mm.

Fig.1. Options for attaching the frenulum of the tongue are normal. The permissible place of attachment to the lower surface of the tongue is highlighted in black. Green - to the mucous membrane of the bottom of the mouth.

Tongue frenulum- one of the most common SMALL ANOMALIES OF DEVELOPMENT of the organs of the oral cavity. This pathology is sometimes called ankyloglossia. Ankyloglossia (ankyloglossia) - an anomaly of development: shortening of the frenulum of the tongue from Ankilos - (Greek, curved, curved) an integral part of compound words, meaning 1) “curvature”, hook-shaped form 2) “stiffness or fusion of parts” and Glossa - (Greek. ) - language (encyclopedic dictionary of medical terms 1982). This term has not found wide distribution in the domestic medical literature and clinical practice, although it reflects some clinical manifestations (curvature of the tongue and its stiffness).

According to various authors, a short frenulum of the tongue is diagnosed in 2.3-19% of the examined, and in boys, significantly more often than in girls, a short frenulum of the tongue occurs with a frequency of 1: 300 in newborns. Such a significant scatter of statistical data indicates the fuzziness of the applied diagnostic criteria, different principles of classification. The length of the short frenum of the tongue is no more than 1.7 cm, but this does not always cause violations of the function of the tongue, especially if the frenulum is anatomically located correctly.

Etiologically, a short frenulum of the tongue is more often due to hereditary predisposition. There is also information about the significance of intrauterine trauma to the frenulum of the tongue (when sucking a finger).

Clinical manifestations of a short frenulum of the tongue.

In the period of a toothless oral cavity (up to 6 months), with closed jaws, the tongue occupies the entire oral cavity, its edges extend beyond the gums. Normally, in the anterior part of the oral cavity there is a gap between the gingival ridges of approximately 3 mm. the tip of the tongue is located between them. The mobility of the root of the tongue is small and increases to normal by 3-6 months. During this period, sucking and swallowing in a child infantile, i.e. when swallowing, the tongue is repelled from closed lips, there is a visible tension of the mimic muscles of the perioral region. In the future, the infantile type of sucking and swallowing is replaced by somatic when the tongue is repelled from the palatal surface of the teeth and the anterior surface of the hard palate. During the formation of a temporary bite, the tongue is normally located behind the teeth.

With a short frenulum, during tension of the tongue, its tip is bifurcated in the form of a stylized heart, the edges of the tongue rise (Fig. 2).

Fig.2. Short frenulum of the tongue. The length of the bridle is 1.3 cm - less than the norm by 8 mm. The tip of the tongue is forked.

The child cannot lick the upper and lower lips. The back of the tongue, when you try to stick it out, rises, the tongue becomes curved, "humped". A short frenulum starts from the tip of the tongue or in its anterior third and is attached to the mucous membrane of the alveolar process of the lower jaw (Fig. 3). There are variants of ankyloglossy, when the frenulum is attached in the region of the excretory ducts of the sublingual salivary glands, and then, changing direction, is woven into the mucous membrane of the alveolar process in the form of a "crow's foot" (Fig. 4).

Even with a short frenulum (less than 1.5 cm), if it is attached to the soft tissues of the bottom of the mouth, functional disorders do not always occur - difficulty in sucking during breastfeeding and impaired sound pronunciation during the formation of phrasal speech.

Fig.3. Options for attaching the frenulum of the tongue in ankyloglossia. The place of attachment of the frenulum to the tip of the tongue and its anterior third is highlighted in black. Green - to the mucous membrane of the alveolar process and the transitional fold of the mucous membrane of the floor of the mouth.

Rice. 4. A short frenulum of the tongue is attached to the mucous membrane of the alveolar process in a fan-like manner - in the form of a "crow's foot". The back of the tongue bends when you try to lift it.

As a result of tongue stiffness caused by a short frenulum, occlusion anomalies may form, the first signs of which during the period of temporary occlusion is the turn of the central lower incisors to the lingual side.

Language functions.

Language functions can be divided into two large groups: sensory and motor (mechanical). In some animal species, the tongue plays a significant role in thermoregulation.

Sensitive functions include taste, temperature, tactile, pain. The pathology of the frenulum of the tongue does not affect the sensitive functions.

The motor functions of the language, in turn, can be divided into alimentary, speech and aesthetic.

The tongue, as an organ of the digestive system, is involved in providing alimentary functions - chewing, swallowing, sucking, licking, licking, cleaning the mouth (spitting). A short frenulum of the tongue may interfere with the implementation of these mechanical functions, mainly sucking. Licking and lapping are rudimentary alimentary functions for humans.

The tongue is one of the main articulators that provide the function of speech. Speech is inherent only to man, its physiological basis is second signal system. The pathology of the frenulum of the tongue does not affect the formation of speech in general, but only the formation of some sounds.

The aesthetic value of language plays a significant role in the socialization of the individual. Various "teasers", showing the tongue, are typical for people of different ages, social status, races and nationalities.

Sucking.

At present, the importance of the implementation of the sucking instinct during the neonatal period and breast (natural) feeding is beyond doubt - “... it is in natural feeding that the real ways and opportunities for achieving biological perfection within the framework of one’s own species, the implementation and adjustment of the genetic fund, species-specific forms of initial socialization ... The work of the muscular apparatus of sucking when feeding a child determines the occurrence of efforts and stresses that most adequately regulate the anatomical formation of the dentoalveolar system, the brain skull, as well as the sound reproduction apparatus ”(Vorontsov I.M., Fateeva E.M. Khazenson L.B., 1993 ).

Sucking is an innate unconditioned reflex (instinct), which is formed during fetal development. In an 18-week-old fetus, sucking movements of the lips are observed at 21-22 weeks - spontaneous sucking, at 24 weeks - searching and sucking reactions. The sucking reflex is one of the most stable, the absence or significant suppression of which is extremely rare. Thus, the sucking reflex is observed even in mammals with aencephaly. Excitation from the receptors of the lips and tongue is transmitted through the centripetal nerves (trigeminal) to the sucking center located in the bulbar region, the centrifugal nerves (trigeminal, facial, hypoglossal) transmit excitation to the tongue, chewing and facial muscles that provide the act of sucking. In the first weeks of a child's life, sucking is an unconditioned reflex, gradually changing to a mixed, and then to a conditioned reflex.

Unrealized sucking instinct often leads to various types of obsessive-compulsive disorder, sometimes manifesting throughout life.

When breastfeeding, the act of sucking is divided into two stages - suction and compression. The child clasps the areola of the chest with lips and gums, moreover, from below it is more than from above, the nipple is at the level of the soft palate and does not participate in sucking. At the same time, the palatine curtain descends. Tongue taking the form of a gutter descends along with the lower jaw downward and backward, a muscle wave is formed, passing from the front to the middle part of the tongue, thus creating a negative pressure in the oral cavity - 2-4 mm. mercury column. Tightness is also provided by transverse folds on the mucous membrane of the lips and palate, Bish's fat lumps in the cheeks. Then the lower jaw rises and the alveolar arches squeeze the chest, providing relaxation of the sphincters of the milk ducts. Thus, the alternation of negative pressure during suction and positive pressure during compression ensures a dosed and rhythmic flow of milk. The tongue does not have an exclusively independent role in sucking., his movements are strictly coordinated with the movements of the lower jaw, chewing and facial muscles.

Bottle sucking is different from breastfeeding. When sucking a bottle, the child makes mainly retracting movements, which provide the muscles of the cheeks and the translational movements of the tongue. In this case, the flow of milk is continuous.

Feeding difficulties in the neonatal period.

Contraindications to breastfeeding.

In the mother: especially dangerous infections (variola, hemorrhagic fevers, etc.), open form of tuberculosis, syphilis, decompensation of chronic diseases of internal organs, malignant neoplasms, acute mental illness, treatment with certain drugs. Contraindications to early breastfeeding are operative delivery, large blood loss.

Child: Phenylketonuria, galactosemia, "maple syrup odor disease". Contraindications to early breastfeeding - Apgar score below 7.

Difficulties in breastfeeding.

On the mother's side: primary hypolactia, significant hyperlactia, abrasions, cracks, changes in the shape of the nipples (Fig. 5), improper feeding technique, alternation of breastfeeding and bottle feeding. Changes in the taste and smell of milk when eating certain foods and medicines.

Fig.5. Types of nipples. Difficulties or even impossibility during feeding causes a depressed, poorly extensible nipple. In such cases, a nipple corrector (usually a vacuum one) is used in the prenatal period. A long nipple can also affect the quality of feeding during the formation of the so-called. "Nipple sucking" is when the baby does not latch onto the breast, but sucks mainly on the nipple.

On the part of the child: the child’s diseases, both acute (ARVI, rhinitis, etc.), and congenital, birth trauma, etc. The child’s rapid fatigue during sucking is more often associated with neurological problems. The presence of microgenia, cleft palate create significant problems in feeding. There is a category of children who suckle poorly and do not show anxiety from hunger from the very beginning of feeding. An in-depth examination of both mother and child does not reveal any pathology. The terms "lazy suckers" and "hungry lucky" describe this problem quite accurately. According to I.M. Vorontsova (1993) in such children, the maturation of the hypothalamic centers of hunger may be slowed down.

In itself, the presence of a short frenulum of the tongue during the neonatal period and breastfeeding does not affect or slightly affects the quality of feeding. Especially if the short frenulum of the tongue is attached in the area of ​​the soft tissues of the floor of the mouth, without causing stiffness of the tongue. In this case, the functionality of the tongue necessary for sucking is not violated. Healthy children, with the right feeding technique and the absence of other reasons, adapt quite quickly.

The only exceptions are the extreme variants of ankyloglossia, when the frenulum of the tongue starts from the very tip and is attached to the top of the alveolar process. In any case, the decision on surgical treatment is made only after examination by a neonatologist, pediatrician and other specialists.

Speech

At birth, a child has only the potential ability to form speech. The articulators are not sufficiently developed, the larynx is located much higher than in an adult, the speech-motor analyzer is not able to provide accurate articulatory movements of the lips, tongue, etc. In the second month of life, the first articulatory movements appear in the form of babbling, not connected by a conditioned reflex with primary irritants. By the end of the first year of life, the first words used by the child for the purpose of verbal communication with other people are formed. A second signal system is being formed. The child learns to form an image abstracted from the circumstances. Abstraction and systematization of complex concepts make it possible to create first a passive and then an active vocabulary. At the age of 2-3 years, the development of phrasal speech begins. Coordination of the functioning of the speech apparatus is provided by the cortical part of the speech-motor analyzer, located in the left hemisphere of the brain in the posterior part of the third frontal gyrus. The motor center of speech (Brock's center) in its work is connected with the centers of auditory (Wernicke's center) and written speech, as well as with extensive mnestic fields in the frontal and posterior parts of the cerebral hemispheres, which provide the semantic and meaningful aspects of speech.

There are three critical periods in the development of speech. The first (up to 2 years) - the formation of the prerequisites for speech, the foundations of communicative behavior. The second (2.5 -3 years) - the transition from situational speech to contextual. The third - (6-7 years) the beginning of the development of written speech. The influence of unfavorable environmental and hereditary factors (acute and chronic diseases of the child, CNS lesions, anomalies of articulators, insufficient socialization, etc.) can lead to speech development disorders.

Here are some definitions of speech disorders.

Agrammatism- violation of understanding (impressive side of speech) and use (expressive side of speech) of the grammatical means of the language.

Agraphia and dysgraphia- impossibility (agraphia) or partial specific violation of the writing process (dysgraphia).

Alalia- the absence or underdevelopment of speech due to an organic lesion of the speech zones of the cerebral cortex in the prenatal or early period of a child's development.

Alexia and dyslexia- impossibility (alexia) or partial specific violation of the reading process (dyslexia).

Dyslalia- violation of sound pronunciation with normal hearing and intact innervation of the speech apparatus. Synonyms: tongue-tied tongue, defects in sound pronunciation, phonetic defects, shortcomings in the pronunciation of phonemes. Dyslalia may be mechanical(wrong structure of articulators) and functional(no apparent anatomical cause).

dysarthria- violation of the pronunciation side of speech, due to insufficient innervation of the speech apparatus. In mild cases of dysarthria, when the defect manifests itself mainly in articulatory and phonetic disorders, they speak of its erased form.

Stuttering- violation of the tempo-rhythmic organization of speech, due to the convulsive state of the muscles of the speech apparatus.

Mutism- cessation of verbal communication with others due to mental trauma.

Underdevelopment of speech- a qualitatively low level of formation of a particular speech function or speech system as a whole.

ONR(general underdevelopment of speech) - various complex speech disorders in which children have impaired formation of all components of the speech system related to the sound and semantic side. OHP can be I, II, and III levels. ONR can be complicated by dysarthria, rhinolalia, alalia, etc.

Rhinolalia (twang)- violation of the timbre of the voice and sound pronunciation, due to anatomical and physiological defects of the speech apparatus.

FFN(phonetic-phonemic underdevelopment) - a violation of the formation of the pronunciation system of the native language in children with various speech disorders due to defects in the perception and pronunciation of phonemes.

The stiffness of the tongue, caused by a short frenulum, does not affect the overall development of speech. A short frenum of the tongue can only contribute to the formation of some variants of dyslalia.

Treatment of patients with a short frenulum of the tongue.

Indications to surgical treatment.

1. During the neonatal period and breastfeeding.

Pronounced violations of sucking. The child is not gaining weight. Significant stiffness of the tongue with an extreme version of the shortening of the frenulum (goes from the tip of the tongue to the top of the alveolar process). At the same time, the child is somatically and neurologically healthy. Absence of reasons that make breastfeeding difficult on the part of the mother.

Indications for surgical treatment are jointly determined by the dentist, neonatologist or pediatrician, neurologist, and other specialists, if necessary.

We believe that there are no absolute indications for surgical treatment of a child with ankyloglossia at this age. Especially when the short frenulum of the tongue is attached to the soft tissues of the floor of the mouth.

2. During the formation of phrasal speech (from 2.5 years onwards).

Mechanical dyslalia - a violation of the pronunciation of certain sounds (mainly R, L).

Indications for surgical treatment are jointly determined by the dentist, speech pathologist-defectologist if it is impossible to “stretch” the frenulum of the tongue with the help of speech therapy massage and speech therapy is ineffective. At the same time, it is necessary to clearly differentiate the types of speech disorders, tk. surgical treatment of ankyloglossia with ONR, dysarthria, psychomotor retardation can significantly aggravate the existing pathology.

To perform an operation with a short frenulum of the tongue in order to prevent possible speech disorders, especially at an early age, we consider it not only inappropriate, but also harmful.

3. Indications for surgical treatment of patients with dento-maxillary anomalies and a short frenulum of the tongue are determined by the orthodontist. Malocclusion, caused, among other things, by the unfavorable influence of a short frenulum of the tongue, is characterized by the absence of a tendency to self-regulation. In such cases, surgical treatment is also indicated from a prophylactic point of view, starting from the period of formation of a temporary occlusion.

Anesthesia. We consider it unacceptable to perform surgical treatment of patients with a short frenulum of the tongue without anesthesia.

With local anesthesia, both application and infiltration, it is necessary to remember the phenomenon sublingual suction. The toxic or allergic effect of the anesthetic when it is injected into the sublingual region increases significantly. In addition, the bottom of the oral cavity is a powerful reflexogenic zone. Secretory and motor activity of the gastrointestinal tract can be inhibited or activated when exposed to the mucous membrane of the middle part of the tongue. Stimulation of the tip and lateral sections of the tongue reflexively affect the cardiovascular and respiratory systems.

The use of local anesthesia in operations for short frenums of the tongue is considered inappropriate at the age of 7-8 years and in children with various behavioral disorders, hyperactivity, etc.

The decision on the choice of the method of general anesthesia is made by the anesthetist, while it is necessary to remember the possibility of aspiration of blood and saliva during the operation.

Types of surgical treatment of patients with a short frenulum of the tongue.

With any option of surgical treatment of patients with a short frenulum of the tongue, a preliminary laboratory examination is necessary (clinical laboratory minimum - clinical blood, urine, ALT)!

Frenulotomy- dissection of the frenulum of the tongue (what is often called "cutting the frenulum"). The tongue is lifted with tweezers or the reverse side of the grooved probe at the site of attachment of the frenulum to the lower surface of the tongue. The bridle is cut with scissors. Seams are not applied. This type of operation is used in the neonatal period. Some authors, substantiating this technique, write about the so-called. "avascular zone" of a thin and transparent frenulum of the tongue in the neonatal period. We believe that with this type of frenulum of the tongue, surgical treatment during breastfeeding is not indicated, because. at the same time, there is no pronounced violation of the sucking function. We do not recommend using this method due to possible complications. Bleeding, despite the common belief about the “avascular zone”, is possible and can lead to serious consequences. Long-term complications of frenulotomy performed without suturing include the formation of cicatricial shortening of the frenulum, cicatricial stiffness of the tongue (Fig. 6).

Rice. 6. Cicatricial shortening of the frenulum of the tongue. Child 5 years old. At the age of three months, a frenulotomy (without sutures) was performed to prevent speech disorders. Severe mechanical dyslalia. Forming progeny. Chronic desquamatous glossitis.

Frenuloplasty - local plastic lengthening of the short frenulum of the tongue.

There are two types of frenuloplasty.

First way. The frenulum in the place of its attachment to the tongue is fixed with tweezers and cut with scissors by about 2-3 mm. the resulting wound is stitched with catgut or other rapidly absorbable suture material. The remaining ends of the ligature are used as a holder. The tongue is pulled up and anteriorly by the ligature, while dissecting the frenulum at the place of attachment to the lower surface of the tongue to the mouth of the excretory ducts of the sublingual salivary glands. The underlying fibrous bands are dissected and the tongue is mobilized. The resulting diamond-shaped defect is sutured "on itself" with catgut. This variant of the operation is a type of V-Y plasty (Fig. 7).

Rice. 7. The diamond-shaped defect is sutured "on itself" while constantly pulling the tongue up and forward by the handle. If the frenulum is fan-shaped woven into the mucous membrane of the alveolar process, you can additionally dissect it with an electrocoagulator at the point of attachment to the alveolar process.

The second method differs from the first one in that additionally, after partial suturing of the surgical wound, plasty is performed with figures of counter triangular flaps 60 0 x60 0 .

When applying coarse sutures in the area of ​​the excretory ducts of the sublingual salivary glands, acute saliva retention may occur - the so-called. "salivary colic". This rare complication associated with a violation of surgical technique develops during the first hours after surgery. In such cases, 1-2 sutures are removed and antibiotic therapy is prescribed to prevent sialodochitis.

Frenuloectomy - excision of the frenulum of the tongue. The frenulum of the tongue is wedge-shaped excised and sutured. A variant of frenuloectomy is laser ablation. The disadvantages of this method include the lack of language mobilization.

Postoperative period usually runs smoothly . In rare cases, anesthesia is required. Assign a sparing diet for one to two days, rinsing the mouth with antiseptic solutions. 3-4 days after the operation, you can start classes with a speech therapist, conduct special classes.