Myofunctional Speech Therapy Intervention After Lingual Frenectomy in Infants - A Case SeriesABSTRACT
Objective: To describe the effect of myofunctional speech therapy performed after lingual frenectomy in infants.
Material and Methods: It is an observational and analytical case series study involving infants aged 0 to 4 months, exclusively breastfed, diagnosed with ankyloglossia, and referred for frenectomy. Seventy-two hours after surgery, the infants received orofacial myofunctional therapy on the tongue, without manipulation of the surgical wound, for four weeks. The caregivers received training to perform the exercises at home three times daily. Thirty days after the last session, the infants underwent a reassessment using the same protocol as the initial assessment. Those with unsatisfactory healing or functional impact were referred for further surgical intervention.
Results: Sixty-five of the 114 evaluated infants were diagnosed with ankyloglossia and referred for frenectomy. Twenty infants were selected, but only 12 met all the inclusion criteria for analysis. The initial assessment using the lingual frenulum evaluation protocol for infants showed a median of 13.5 (q1 = 13, q3 = 14.75), which decreased to 8 (q1 = 7.25, q3 = 9.75) after the intervention (p = 0.002). Fibrosis or re-adhesion cases did not occur, and no infant scored above 10 during reassessment. The findings demonstrated a significant improvement in breastfeeding complaints.
Conclusion: The orofacial myofunctional therapy was effective in oromyofacial rehabilitation after frenectomy, improving tongue mobility and strength while optimizing functions such as sucking and swallowing, thereby benefiting breastfeeding. The findings suggest that orofacial myofunctional therapy supports the recovery of stomatognathic functions and promotes adequate healing.
Keywords:
Ankyloglossia; Breastfeeding; Oral Frenectomy; Speech Therapy; Patient Care Team.
Introduction
Ankyloglossia is a congenital alteration potentially characterized by the short lingual frenulum insertion in the tongue's ventral portion. It may interfere with tongue positioning, mobility, and posture, altering functions such as swallowing, chewing, speech, and breastfeeding [1]. This condition had not represented a barrier to maternal breastfeeding for many years, hence the lack of strategies for ankyloglossia diagnosis and treatment [2].
The lingual frenulum comprises connective and fibrous tissues and superior fibers of the genioglossus muscles. It originates in the lower tongue surface and goes up to the floor of the mouth [3]. Thus, this structure neither extends nor ruptures over time [4]. The tongue is linked to the hyoid bone and connects with the whole body through the connective tissue network - the fasciae. Therefore, a tongue with restricted movement may lead to fascial tension and contribute to neck strain, pain, and postural dysfunctions [5].
Ankyloglossia is a hereditary, autosomal-dominant disorder carried on the X chromosome, meaning that close relatives can manifest it. Its prevalence ranges from 8.2 to 22.5% among newborns [6]. The literature reports frenectomy as the most indicated method for treating ankyloglossia. It comprises a simple surgical procedure that may be performed with sharp or blunt scissors by dividing the frenulum. Physicians and midwives performed frenectomies until the 20th century, then bottle feeding became the solution to breastfeeding problems [7].
Breastfeeding is performed after the procedure to promote hemostasis (bleeding cessation), act as an analgesic, serve as an antiseptic, and aid tongue mobility. Frenectomy is recommended as an outpatient procedure in lactating women of up to three months [8]. Frenectomy alone is insufficient for treating ankyloglossia, and it must always be followed by speech therapy.
Orofacial myofunctional therapy (OMT) is a treatment approach for orofacial myofunctional disorders that aims to develop or restore myofunctional conditions through orofacial motor exercises and sensory stimuli, thereby favoring stomatognathic system functionality [9]. The OMT combined with frenectomy has been potentially effective in adjusting tongue mobility and strength, reducing myofascial tension, and optimizing sucking, swallowing, speaking, and chewing [3,10-12]. However, the optimal time to start therapy remains unclear. Hence, speech therapists have been selecting treatment procedures based on studies demonstrating the benefits of this approach in specific cases through theoretical soundness, when clinical effectiveness has not been documented [9].
Ankyloglossia patients may find it hard to protrude, lateralize, and, most significantly, lift the tongue's tip or body. These functional deficiencies in tongue mobility may complicate the contact between the tongue and palate. This contact is required to create the suction effect that holds the tongue in place and prevents it from falling into the pharynx at rest. Thus, function readjustment therapy is necessary [10]. Therefore, this study aims to confirm the effectiveness of OMT associated with lingual frenectomy in infants.
Material and Methods
Study Design and Ethical Clearance
It is an observational and analytical case series. This research is part of a clinical trial consisting of two speech-language therapy intervention groups and one control group. It was conducted at the speech therapy service associated with the Brazilian public health care system of Mansão do Caminho, at the Caminho da Redenção Spiritist Center in Pau da Lima, Salvador, BA, Brazil. This facility includes volunteer professionals linked to an extension and research project of the School of Speech Therapy at the Federal University of Bahia, idealized and coordinated by the authors.
It was approved by the Research Ethics Committee of the Nursing School at the Federal University of Bahia (Opinion number 6713965), in accordance with Resolution 466/2012 of the Brazilian National Health Council. In this perspective, the minors' parents or guardians had to sign an Informed Consent Form (IFC), as the study included infants.
Participants and Inclusion and Exclusion Criteria
The participants were children under exclusive breastfeeding, aged 0 to 4 months, and referred for lingual frenulum assessment. The following inclusion criteria were established: infants with ankyloglossia, identified after applying the lingual frenulum evaluation protocol for infants [4]. Therefore, the following exclusion criteria were adopted: infants absent in any four weeks of follow-up or who did not attend the reassessment visit; infants receiving complementary feeding who discontinued exclusive breastfeeding; and those with any medical diagnosis. The investigation did not include infants whose mothers had breastfeeding complaints unrelated to the lingual frenulum, infants outside the established age group, carrying some illness that might hinder the procedure, or those no longer under exclusive breastfeeding.
Pre-surgical Procedures
All assessments were recorded on an iPhone® smartphone, model XR (Apple Inc., Cupertino, United States), previously placed on a tripod with white light, fixed to the floor, and framed with tapes fixed to the mat to ensure identical positioning every time. The infants were placed on a cushion to maintain optimal posture for evaluation, with the head elevated above the body to limit excessive head movement. The evaluating speech therapist sat on the mat behind the infant's head, gloved, and lifted the tongue with the index fingers to visualize the lingual frenulum.
After evaluating the lingual frenulum, all infants were placed at their mother's breast to analyze suction during breastfeeding. The families whose infants were referred for frenectomy were invited to participate in the study and received an ICF detailing the objectives and preand postoperative procedures.
Upon arrival for the frenectomy procedure, the team approached the families again for a joint reading of the ICF and its signing. All mothers received instructions and support for more efficient breastfeeding before surgery, including posture and latch correction, management of occasional doubts, and addressing occasional concerns. Support, breastfeeding, and management continued throughout the postoperative follow-up, which consisted of four monthly visits (once weekly) and was conducted by the speech therapist responsible for the intervention. The protocol was reapplied 30 days after release.
Video and photographic records were made with the guardians' authorization, including for public use of images for academic and scientific purposes. They were performed as described in the assessment at all four visits and at reassessment. An independent speech therapist specializing in orofacial motor skills conducted all stages of assessment, intervention, and reassessment. The professional was blind to each stage.
Surgical Procedure
Two volunteer dentists, specialized in pediatric dentistry and stomatology, and experienced in frenectomy, performed the procedure. All procedures used the cold technique, a simple, fast, safe, and adequate surgical approach for treating ankyloglossia. The infants were accompanied by their guardians throughout the procedure. They were swaddled to feel safer and more comfortable and placed knee-to-knee with the surgeons. Topical anesthesia to the lingual frenulum with lidocaine (1:10000) and later infiltrative anesthesia with lidocaine (1:100000) were applied before the procedure, according to each child's weight and age. After the necessary time for the anesthetic effect, an incision was initiated with scissors to remove the lingual frenulum. Fascia divulsion also started. The speech therapy team placed infants in their mother's breasts to finish and contain bleeding. The mother received instructions for the immediate postoperative period and the start of speech therapy follow-up 72 hours after the procedure. The process had a mean duration of 10 minutes.
After 72 hours of the surgery, a speech therapy specialist performed direct intraoral myofunctional intervention on the infants' tongues, using procedure gloves, without the manipulation of the surgical wound, for four weeks. The mother or primary caregiver was adequately trained during each visit and instructed to perform the same exercises at home daily, three times a day. They also received instructions on biosafety, execution, and the relevance of performing the exercises regularly for a better prognosis.
The authors developed the protocol described below, entitled "Speech Therapy Exercise Protocol after Lingual Frenectomy in Infants". The protocol was tested and involved approximately 1 year of training to conduct the research.
Week 1 - Oral cavity inspection, photographic and video recording of the surgical wound:
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Tongue lifting by the edges for four seconds to visualize the diamond-shaped surgical wound, repeating four times.
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Lateral gum ridge friction aiming at tongue mobility, with five repetitions on each side.
Week 2 - Oral cavity inspection, photographic and video recording of the surgical wound, and healing process:
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Tongue lifting by the edges for 10 seconds to visualize the diamond-shaped surgical wound, repeating twice.
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Lateral gum ridge friction aiming at tongue mobility, with five repetitions on each side.
Week 3 - Oral cavity inspection, photographic and video recording of the surgical wound, and healing process:
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Index finger rolling, starting with the digital facing down and finishing with the digital facing up, from the gum ridge center to the tongue tip, repeating the movement four times, with four repetitions each time.
Week 4 - Oral cavity inspection, photographic and video recording of the surgical wound, and healing process:
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Index finger rolling, starting with the digital facing down and finishing with the digital facing up, from the gum ridge center to the tongue tip, repeating the movement two times, with 10 repetitions each time. After each assistance, the infants were placed on their mother's breasts for breastfeeding management. Also, any possible doubts regarding the procedure so far were resolved.
Reassessment
All patients were called to the medical center 30 days after the fourth session to apply the Martinelli et al. protocol again [4]. If anatomical and functional outcomes were satisfactory, the infants were released from speech therapy. Those with poor healing and functional impact were referred for further surgical treatment.
Statistical Analysis
The data processing and analysis were conducted using R (version 4.4.1; R Core Team, 2024, Vienna, Austria). Initially, a descriptive analysis was performed. Categorical variables were presented as absolute and relative frequencies, while the median and interquartile range were used to describe the quantitative variables, given potentially nonparametric data. The Shapiro-Wilk test verified the normality of distributions.
The Wilcoxon and McNemar tests assessed differences between measurements before and after the intervention for paired quantitative data and dichotomous categorical variables, respectively. The McNemar-Bowker test evaluated the symmetry between categorical variables with more than two categories. The binomial test was applied in cases of specific changes to verify the significance of the identified alterations. All analyses used a 5% significance level (α = 0.05).
Results
The study evaluated 128 infants, of which 65 were diagnosed with ankyloglossia and referred for frenectomy. Twelve of the 20 infants allocated to this group met all inclusion criteria and were included in the analysis. Table 1 presents data on identification, family history of ankyloglossia, absolute scores from the protocol, and ponderal weight before and after the speech therapy intervention.
The median of the evaluation protocol was 13.5 (q1 = 13 and q3 = 14.75) and 8 (q1 = 7.25 and q3 = 9.75) at reassessment, with p = 0.002.
Table 2 presents the percentage scores from the protocol application regarding clinical history, which evaluates breastfeeding complaints before and after the intervention.
Table 3 presents the findings of the anatomo-functional component of the protocol, in which orofacial structures, including lip posture, lingual frenulum anatomy, and its fixation and insertion, were analyzed.
Table 4 presents non-nutritive sucking with a gloved finger, nutritive sucking at the maternal breast, suck-swallow-breath (S/S/B) coordination, and symptoms that may indicate dysfunction.
Discussion
The findings of this study demonstrate a significant change in the protocol scores between the initial and reassessment assessments. The initial median of 13.5 (q1 = 13 and q3 = 14.75) decreased to 8 (q1 = 7.25 and q3 = 9.75) at reassessment, with a statistically significant difference. These findings suggest the efficacy of the applied interventions and corroborate the protocol's sensitivity in monitoring postoperative evolution and speech therapy interventions.
The prevalence of ankyloglossia in Brazil remains controversial in the literature due to the lack of standardization of assessment protocols. A study conducted in Salvador, Brazil, reported an 11.3% prevalence of ankyloglossia, with 69% of individuals being male [11].
Considering the significance of breastfeeding, the Tongue Test (Teste da Linguinha, in Portuguese) became mandatory for all newborns in Brazilian hospitals and maternity centers, according to Law #13,002 of June 20, 2014 [4,12]. However, enforcing this law remains unfeasible nationwide, and several infants need to seek outpatient care for assessment. Evaluations performed in hospital units have no follow-up of ankyloglossia cases, leaving mothers and infants reliant on the public or private health system. That is the reality of most infants assisted in Mansão do Caminho.
All infants were assessed with the Martinelli et al. [4] protocol for frenectomy indication and reassessed with the same protocol 60 days after surgery and speech therapy intervention. The findings in Table 1 show a significant improvement in crude scores after speech therapy intervention. Also, no infants scored above 10 at reassessment, which is outside the normal range. That means that infants who underwent orofacial myofunctional therapy (OMT) showed satisfactory healing with adequate anatomical and functional outcomes, and there were no cases of fibrosis or re-adhesion that required referral for further surgical intervention.
Perfect tissue regeneration in humans occurs only during the fetal period. Outside this context, wounds close by replacing the original tissue with a scar. The collagen matrix forms during healing, and densely compacted fibers fill the wound bed. Endogenous factors, such as deprivation, and exogenous factors, such as oxygen supply, nutritional status, age, and infection vulnerability, may directly affect healing quality.
Hence, orofacial myofunctional therapy (OMT) is a therapeutic approach for treating orofacial myofunctional disorders by developing or restoring function through orofacial motor exercises and sensory stimuli, promoting stomatognathic system functionality [13]. The OMT combined with frenectomy has effectively improved tongue mobility and strength, reducing myofascial tension while optimizing functions such as sucking, swallowing, speaking, and chewing [13-16]. The hypothesis to justify orofacial myofunctional therapy after frenectomy is that speech therapy intervention with sensory stimuli helps organize collagen fibers, promoting oral function rehabilitation and more satisfactory healing.
Among the objectives of orofacial myofunctional therapy after frenectomy in infants is the guarantee of efficient breastfeeding. Anatomical alterations in the lingual frenulum may limit breastfeeding, such as ponderal weight loss, milk leaking from the sides of the mouth, and choking episodes [17]. An adequate latch is essential to ensure the infant extracts sufficient milk for a full feeding. It also prevents lesions, pain, and cracks in the mother's nipples. Effective suction occurs when the infant's mouth involves the nipple and a portion of the lower areola [18]. In cases of ankyloglossia, an inadequate latch often promotes discomfort for mothers and infants, potentially causing critical lesions in the mother's breast that hinder the exclusive breastfeeding recommended by the World Health Organization [19].
The protocol reapplication after 60 days confirmed that this instrument detects improvements in initial complaints when reapplied after the proposed intervention. Four of the five evaluated items showed improvements. The only item that did not progress was "Bites the nipple." However, most infants were around six months old during reassessment, and the referred biting was associated with the emergence of the first teeth.
Lingual frenulum alterations may significantly impact an individual's life due to the various potential compensations and limitations in the tongue musculature throughout all life stages [20]. An early diagnosis of ankyloglossia is essential because its effects may compromise relevant stomatognathic system functions during development, such as breathing, sucking, swallowing, and later chewing and articulating speech [21]. Although this study did not focus on improving breastfeeding quality to promote exclusive breastfeeding, it acknowledges the importance of an unaltered stomatognathic system and the crucial role of its adequate development in the efficient performance of orofacial functions.
Ankyloglossia may also impact respiratory function because adequate breathing through the upper airways requires the tongue to remain lifted and in contact with the palate. However, in ankyloglossia, the tongue tends to lower in the oral cavity, impairing nasal breathing and potentially compromising children's craniofacial development [22]. The tongue resting on the palate is physiologically adequate and essential for efficient breathing. That requires the mouth to remain closed, which may be impossible with a short frenulum. Regarding speech articulation, alterations are perceived in the distortions of Portuguese phonemes that depend on tongue movement, such as /t/, /d/, /l/, /n/, /r/, /s/, and /z/ [23].
Tongue position while crying shows the extent of frenulum restriction on tongue mobility, as infants are expected to cry with a lifted tongue. Also noteworthy is the detection of frenulum fixation on the sublingual surface and the floor of the mouth, characterizing it as short, anteriorized, or short with an anteriorized insertion. A short frenulum attaches to the lower alveolar ridge, while an anteriorized frenulum stands in the tongue's ventral surface more anteriorly [24,25].
The anatomo-functional characteristics evaluated during the protocol's clinical examination did not show a predominance of improvement across different frenulum insertions. The verified enhancement was more systemic, i.e., all evaluated items improved in blocks.
The evaluated infants presented with incoordination of nutritive sucking at the mother's breast. The protocol items to confirm incoordination include cough, choking, dyspnea, regurgitation, hiccup, and swallowing noise; infants may present with one or more of these alterations. Infant incoordination improved by 66.7% after orofacial myofunctional therapy.
There is no consensus in the literature regarding orofacial myofunctional therapy after frenectomy, limiting and complicating the speech therapist's work in these cases. The consulted databases did not show Brazilian articles using this approach. Some international studies [5,8] show that therapeutic interventions focused on tongue mobility are effective for infants with ankyloglossia, children in the developmental phase, and young adults. These therapies may be highly effective when combined with structured protocols, adequate frequency, and strategies tailored to the needs of each age group. However, there is no consensus regarding the protocol. Moreover, the methodologies of several studies omit or inadequately describe methodological details, hindering study reproducibility and reducing the quality of scientific evidence.
The association between orofacial myofunctional therapy and breastfeeding management in this study was promising for preventing adhesion and improving oral function. However, adhering to such an approach may be critical, particularly because caregivers depend on performing the exercises correctly.
It is worth noting that the orofacial myofunctional therapy proposed in this study differs from that of Bhandarkar et al. [26], who performed the exercises on the surgical wound. Scientific events and fellow clinicians have criticized such a method. Thus, given knowledge of tissue repair, approaches that interfere with the natural progression of wound formation when a scar is formed by connective tissue deposition would alter the healing phases and might contribute to tissue re-adhesion.
The presented findings suggest the efficacy of orofacial myofunctional therapy as a therapeutic approach for treating orofacial myofunctional disorders after frenectomy. They also demonstrate the relevance of orofacial myofunctional therapy in post-frenectomy oromyofacial rehabilitation, suggesting that its implementation in clinical practice supports the rehabilitation of stomatognathic functions and promotes a more satisfactory healing process.
One of the main limitations of this study is the sample, which consisted of infants from low-income families. This may have directly impacted adherence to the proposed follow-up. Although the legal guardians signed the informed consent form, in which they acknowledged the importance of continuous participation for one month without absences, the reliance on voluntary attendance and the socioeconomic reality of these families - often marked by transportation difficulties, routine instability, and multiple demands - compromised regular attendance at the sessions. These factors may have affected both the final sample size and the consistency of the collected data, thereby limiting the generalizability of the results.
Conclusion
The findings suggest the efficacy of the applied interventions and corroborate the protocol's sensitivity in monitoring postoperative evolution and speech therapy interventions.
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Financial Support
None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Alessandro Leite Cavalcanti
