What is Frenuloplasty?
Frenuloplasty is surgery to release a tongue tie (ankyloglossia), a band of tissue under the tongue that limits how far the tongue can move.
Tongue tie release has become a popular topic in sleep and breathing care. Its role is best understood within comprehensive care. Dr. Liu has trained and worked with many experts in tongue tie and orofacial myofunctional therapy, and helps patients decide when a release will help and when something else should come first. A simple check: open your mouth as wide as you can, then touch the tip of your tongue to the spot just behind your upper front teeth. If your mouth has to close by more than half to get there, tongue movement is restricted.
Sleep endoscopy before and after frenuloplasty.
Frenuloplasty for patients
The tongue is meant to rest against the roof of the mouth. In a growing child, that gentle pressure helps the upper jaw grow wide. During sleep, it keeps the tongue from falling back toward the throat. A tight tongue tie can hold the tongue low in the mouth instead.
Functional frenuloplasty releases the restriction so the tongue can rise and rest against the palate. This is different from a quick clip of the band. The band is released, deeper fibers that also hold the tongue down are freed when needed, and the area is closed with dissolving stitches.
Myofunctional therapy is the other half of treatment. A therapist works on tongue posture, lip seal and nasal breathing before the release, then helps the tongue use its new range of motion afterward. In the published protocol, therapy starts at least one month before surgery and continues for at least two months after.
A tongue tie is not always the first thing to treat. If the palate is narrow, there may be no room for the tongue to rise into. Creating that space with expansion, such as DOME in adults, may need to come first.
Before the release
- Start myofunctional therapy at least one month before the release.
- Stop aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), fish oil, vitamin E and other supplements that thin the blood 7 days before.
- If a doctor prescribed a blood thinner, do not stop it on your own. We will coordinate with that doctor.
- Most releases are done under local anesthesia. Young children may need general anesthesia, and the anesthesia team will give fasting instructions.
After the release
- Soreness under the tongue is common and usually settles within a few days.
- Rinse with salt water or an alcohol-free mouthwash three times a day for one to two weeks.
- The stitches dissolve on their own, usually within 2 to 10 days.
- Do the stretches and tongue exercises your therapist gives you. They keep the area from tightening as it heals.
- Soft foods are easiest for the first few days.
Call us right away if
- Bleeding does not stop after 15 minutes of firm pressure with gauze under the tongue.
- You have a fever above 101°F (38.3°C).
- Swelling under the tongue or jaw keeps growing, or swallowing becomes hard.
For an emergency, or any trouble breathing, call 911.
In a published series of 348 children and adults treated with frenuloplasty and myofunctional therapy, there were no major complications. The figures below come from that series. We review your own risks with you before the release.
- Pain
- Reported by about 45%, lasting about three days on average.
- Bleeding
- Minor bleeding in about 13%, usually settling within a few hours.
- Numbness of the tongue tip
- About 5%. Most resolves within weeks to months.
- Salivary gland irritation
- About 3%. Swelling of the saliva ducts under the tongue or extra saliva, usually settling within one to two weeks.
- Scar tissue
- About 3% needed a second procedure to release scar that limited movement.
- A second release
- About 3% chose a second release to gain more movement.
- Worse breathing in a small mouth
- Rare. When there is little room for the tongue, freeing it can let it fall back during sleep. This is why tongue space is checked first.
- Anesthesia
- When general anesthesia is used, its risks are reviewed with you by the anesthesia team.
Frenuloplasty for referring physicians
Restricted tongue mobility is graded functionally with the tongue range of motion ratio (TRMR): mouth opening with the tongue tip at the incisive papilla, divided by maximal interincisal opening. Grade 1 is above 80%, grade 2 is 50% to 80%, grade 3 is below 50% and grade 4 is below 25%. In 1052 subjects, TRMR was the only independent measure of tongue mobility directly associated with restricted tongue function. Kotlow free-tongue length was a poor screen for restriction (sensitivity 16.1%).
Tethering tracks transverse deficiency. In 302 orthodontic subjects, lower TRMR predicted a narrower maxillary arch and a longer soft palate, but not Angle class or hyoid position. The palate is also the floor of the nose, so the same patient often presents with nasal obstruction and mouth breathing.
The protocol, which Dr. Liu taught to his former fellow Dr. Soroush Zaghi, pairs functional frenuloplasty with orofacial myofunctional therapy, at least one month before release and two months after. The release uses a scissors and suture technique, without laser or cautery. It extends to the submucosal myofascial fibers of the genioglossus when needed, until the tongue reaches the incisive papilla at maximal opening and holds lingual-palatal suction.
Candidacy depends on tongue space. Frenuloplasty and myofunctional therapy are less effective without adequate oral volume for the tongue, and in a narrow posterior airway a release can worsen sleep-disordered breathing. These patients are better served by expansion first (DOME in the adult), with release in addition or afterward. Within the updated Stanford Sleep Surgery Algorithm, frenuloplasty is a functional adjunct, and it is not a treatment for moderate to severe OSA on its own.
Related Research by Dr. Liu
Frenuloplasty with myofunctional therapy in 348 patients
Children and adults from 29 months to 79 years old were treated with myofunctional therapy and frenuloplasty. 91% were satisfied and 87% reported a better quality of life. Among those who had each problem, nasal breathing improved in 78%, snoring in 73% and teeth clenching in 91%. There were no major complications. The study was led by Dr. Liu's former fellow, Dr. Soroush Zaghi, with Dr. Liu as senior author.
A functional way to grade tongue tie
In 1,052 patients, comparing mouth opening with the tongue tip on the roof of the mouth against full mouth opening was the measure of tongue mobility that best matched how the tongue functions. Measuring the length of the band under the tongue missed most restricted tongues. The resulting four grades are used to plan and follow treatment.
Tongue tie is linked to a narrow upper jaw
In 302 patients from an orthodontic practice, a more restricted tongue went with a narrower upper jaw and a longer soft palate. Both features are common in sleep-disordered breathing. A tongue that cannot rise may leave the palate without the pressure it needs to grow wide.
Choosing the right tongue exercises
With a scope placed through the nose, the team watched the airway while 15 healthy adults performed 13 common myofunctional exercises. Some firmed the soft palate and others moved the tongue base forward. One, pressing the back of the tongue down, narrowed the airway behind the tongue. Exercises are best matched to each patient's own pattern of collapse.