Anatomical classification of lingual frenulum in babies/Classificacao anatomica do frenulo lingual de bebes.
The tongue is an organ that participates in important functions in the oral cavity, such as sucking, swallowing, chewing and speech [1,2]. Its lower side features a fold of mucous membrane that connects the floor of the mouth, called lingual frenulum [3,4].
The frenulum allows free movement of the tongue. During embryonic development, when there is no full apoptosis of the frenulum, the residual tissue may compromise the tongue mobility and, hence, the oral functions, which may lead to ankyloglossia .
The ankyloglossia is a congenital oral anomaly that varies from mild to severe degrees, resulting, in different levels, in reduction of tongue movements .
The evaluation of the lingual frenulum of babies generally comprises visual observation of the aspects of the frenulum, tongue mobility, non-nutritive sucking, nutritive sucking and swallowing [5,7].
The lingual frenulum can be diagnosed as normal or altered, depending on the criteria used by the evaluator . There is considerable controversy among health professionals regarding the classification of the lingual frenulum altered . Different classifications are found in the literature: lisp [1,10,11]; ankyloglossia [1,12-15]; short frenulum, long frenulum, frontal lisp ; short mucosal, long mucosal with mandibular fixing and hypertrophic with fixing the alveolar ridge ; short, anterior fixation and short with anterior fixation [4,16] and altered frenulum [8,17,18].
The diagnosis of alterations in the frenulum requires a thorough knowledge of the evaluator on the anatomy of the tongue and the different aspects of the frenulum and adjacent regions. In addition, the professional must know which functions can be influenced by changes in the lingual frenulum .
The altered lingual frenulum can cause implications in speech [3,6,12,16,17,19,20], malocclusion and oral hygiene ; inadequate latch, trauma and pain in the nipple that contribute to early weaning [3,13,14]; limitation of tongue movements [6,17,18]; suction difficulties [3,6,17,18]; impairment of swallowing [6,17,18], chewing [17,21] and slow weight gain .
In the literature revision on the last 14 years, were found 06 articles on the lingual frenulum changes index (Table 1).
Faced with losses generated by an altered lingual frenulum, it was perceived how important an early diagnosis is in order to promote the development of feeding and child communication. In this sense, the objective of this study was to analyze the anatomy of the lingual frenulum of babies attended the Reference Center for Hearing Health/CRESA of the Speech Therapy Department of the Pontifical Catholic University of Goias/PUC Goias.
This research was approved by the Research Ethics Committee of PUC Goias, with process no. 503708 and followed all the rules established by Resolution 466/12 of the National Health Council.
This is a cross-sectional, observational and analytical study with a quantitative approach.
Were included babies between 1 month and 4 months, of both genders, fed in the womb, referred to the evaluation of the lingual frenulum in CRESA/ PUC Goias, from August 2014 to February 2015, whose mothers were willing to authorize and sign the Instrument Consent. Were excluded babies with anatomophysiological changes in the face, pre or post-maturity or with neurological impairment interfering in the sucking and/or swallowing.
Babies were evaluated in clinics in CRESA/PUC Goias. Data collection occurred in the last 7 months, held twice a week.
In evaluation of the lingual frenulum was used the "Lingual frenulum evaluation protocol for infants" . The Anatomical frenulum classification in normal or abnormal was carried out at from the part of the analysis I (item 4) of the Protocol which includes the thickness of the frenulum, the attachment of the frenulum in sublingual face (ventral) of the tongue and the attachment of the frenulum on the floor from the mouth. The orofacial functions (Part II) were observed non-nutritive sucking (language movement) and nutritive sucking (rhythm of sucking, coordination of sucking/swallowing/breathing, biting the nipple and tongue snaps during suction).
The total duration of the intervention was about 20 minutes, including the interview, the assessment with the baby, photos and footage record, feedback of the results to responsible and the delivery of speech-language pathology report with the diagnosis of lingual frenulum.
Babies, whose frenulum was identified as altered, were referred to the speech therapy with report of lingual frenulum to basic health units corresponding to their respective neighborhoods. In basic health units, they scheduled an appointment with the pediatrician. After this consultation, the patient would be set to the pediatric dentistry clinic for evaluation of the dentist, so these professionals were responsible to define the best procedure for each patient.
The data collection were organized in a spreadsheet of Microsoft[R] Excel 2007 and transferred to Statistical Package for Social Sciences 20/SPSS 20.0. Descriptive analysis was performed, the chi-square test and correlation Kendall's for statistical analysis, and adopted the level of significance of 5% (p [less than or equal to] 0,05).
214 babies were analyzed in the period between August, 2014 and February, 2015. Taking into account the inclusion and exclusion criteria, 166 babies were included in this study. As for the 48 excluded infants, 72.9% (n=35) fed by bottle, 25% (n=12) were over the age of 4 months and 2.1% (n = 1) had Down syndrome, 50% of them were preterm and 8.3% post-term.
As for the age at examination, it was observed that 62.1% (n = 103) of the babies were 1 month old, 21% (n=35) two months, 12.7% (n=21) 3 months and 4,2% (n=7) 4 months old. With regard to the gender, 51% (n=84) were females (Table 2).
In the analysis of lingual frenulum were find that most babies (63%) had frenulum with normal aspect (Figure 1).
In only 1 (0.6%) baby was not possible to view the frenulum. From babies with altered frenulum, 54% (n=33) were male and 46% (n=28) female. There was no statistically significant difference between gender and the anatomy of the frenulum (p=0.38).
Regarding to the thickness of the frenulum, 95.1% (n=157) had thin and 4.8% (n=8) thick frenulum. Among the thick frenulum, 50% (n=4) had a fixation on the middle third/sublingual caruncles and 50% (n=4) between the middle third and the apex/inferior alveolar crest.
Regarding the fixing in the sublingual surface (ventral) of the tongue and floor of mouth, in relation to the normal frenulum, predominated in the fixation in the middle third/sublingual caruncles (28%). In the altered frenulum, the highest frequency was with fixing between the middle third and the apex/inferior alveolar crest (32.2%). (Figure 2).
Among the babies with normal frenulum, 10.8% had changed suction and among the babies with altered frenulum, 14.5% had changed suction (Figure 3).
There was a low correlation, with statistical significance, between the frenulum and suction (p <0.01), whose coefficient was 0.252.
The lingual frenulum classifications are used to evaluate and characterize the structure in normal and altered . Diagnosis and early intervention of the lingual frenulum promote breastfeeding and speech development. Deprivation of lingual movement may compromise sucking [3,6,17,18], chewing [17,21], swallowing [6,17,18], speech [3,6,12,17] and lead to early weaning [3,13,20].
In this study, participated babies aged between 1 month and 4 months, different from previous studies that evaluated only newborns. Only two studies evaluated the anatomical characteristics of the lingual frenulum of babies older than 1 month, 1 on the 1st, on the 6th and 12th month of life and another between 0 and 72 months. In this study predominated the age of 1 month, suggesting an awareness of responsible for babies on the importance of evaluation of the lingual frenulum as well as health professionals who carried out the referrals. The predominant age contributed to the diagnosis and early intervention of lingual frenulum favoring the breastfeeding.
The results found in this study showed a similar sample between female and male. Among the others studies, only one  reported gender of the sample, with a prevalence of male. Other reviewed studies only mentioned gender in the prevalence of alteration of the frenulum [10-1518,23].
In clinical evaluation, in only 1 baby was not possible to see the lingual frenulum, in contrast with previous research that evaluated 100 babies and in only 29 was not possible to see the frenulum . In this case, it is recommended to follow the baby until be possible to see the frenulum under the mucosa curtain during the first year of life .
Of the 165 babies in which it was possible to see the frenulum, it was classified as normal or altered [17,18]. Previous studies have classified the altered frenulum babies as ankyloglossia [1,12-15], lisp [1,10,11] or simply change the frenulum . Part of the studies [10,11,14,15] used Hazelbaker protocol to classify the frenulum and the other part did not mention the criteria and instruments used [12,13,16,17,19,20,23]
As the thickness of the frenulum, the highest incidence was thin frenulum which corroborates other studies [13,17]. The thick frenulum favors breastfeeding difficulties , in order to contribute to early weaning.
Most babies had normal frenulum, in accordance with the literature [10,13,14,17,18]. However, it was found 37% of babies with lingual frenulum alterations, this frequency is higher than presented in previous studies [10,13,15,23]. From the raised studies, the highest percentage of lingual frenulum alteration was 22.5% [17,18]. It is believed that this difference is related to the criteria used in the classification of the frenulum in each study and the sample size, which differ in these studies. This research considered the anatomical aspect of the frenulum to classify it as normal or altered. This criterion may have influenced the high index of altered frenulum, since the suction was not considered as a classification parameter and its frequency of alterations was low, which could decrease the altered frenulum index. Regarding the altered frenulum prevailed male babies, in agreement with previous studies [10-15,18,23].
No other analyzed study sub-classified the frenulum from the evaluation of the frenulum fixing tongue and mouth floor, as done in this study. It was found the predominance of frenulum with fixing in the middle third and sublingual caruncles and between the middle third and the apex and the inferior alveolar crest, normal and altered, respectively. Were found a single study  that observed, isolated, the fixing of the frenulum in the tongue and in the floor, in which prevailed the frenulum with fixing the tongue in the middle third, and on the floor, in the alveolar crest. As for the other studies, it was found that the sub-classification occurred in the degree of change in severity of the frenulum , severity and thickness of the frenulum , as total and partial ankyloglossia  and the others no sub-classified the frenulum [10,14,15,23].
From babies with normal frenulum, 10.8% had altered suction. Problems like irritability, lips reversed in the suction, inadequates latch and posture were observed during breastfeeding, although not see covered in the protocol. It is believed that several factors interfere with the baby's suckling, beyond the frenulum, as the mother's lack of experience with the practice of breastfeeding, the anatomy of the breast, the latch and the inadequate baby posture, fatigue, among others [24,25].
From the babies with altered frenulum, 14.5% had altered suction. The alteration of the lingual frenulum brings harm to breastfeeding and the baby sucking [3,6,10,13,14,17,18,23], since the participation of tongue movements is essential for this function. In this sense, any limitation on the movement of the tongue can compromise it .
The correlation between the lingual frenulum and suction, despite being significant, was low, in accordance with previous studies that mentioned a minority of problems in the breastfeeding of babies with altered lingual frenulum [10,13,23]. However, the change rate was higher than in infants with normal frenulum, justifying the early diagnosis of frenulum. Whatever the etiology of early weaning, it is worth investing in prevention, to take into account the importance of breastfeeding and sucking on the baby's development.
The lingual frenulum were classified as normal and altered, with predominance of the normal lingual frenulum. Alterations in the lingual frenulum corresponded to 37% of babies, with higher incidence in males. Among the normal frenulum, the prevalence was of babies with fixing of the frenulum in the middle third, visible from sublingual caruncles. Regarding the altered frenulum, they were more frequent with fixation between the middle third and the apex and visible from the inferior alveolar crest, the thin thickness was the most observed in both cases.
Despite the low correlation between the frenulum and suction, babies with altered lingual frenulum had more chances in the change of suction, which justified the realization of frenulum evaluation aiming an early intervention and promotion of breastfeeding and speech development.
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Enajes Silva Soares Marcione (1)
Fernanda Gomes Coelho (1)
Cejana Baiocchi Souza (1)
Ellia Christinne Lima Franca (1)
(1) Pontificia Universidade Catolica de Goias / PUC Goias, Goiania- Goias, Brasil.
Source of help: Catholic University of Goias Conflict of interest: non-existent
Received on: December 30, 2015
Accepted on: June 17, 2016
Fernanda Gomes Coelho
Rua JC 67 Qd. 147 Lt. 15
Jardim Curitiba III
Table 1. Distribution of publications of indices of alterations of lingual frenulum of babies, according the author, year, objectives, sample, age and results Authors/Year Objective Sample/Age MESSNER; LALAKEA; To analyze Were examined 1.041 ABY; MACMAHON, 2000 the incidence of babies, from 0 to 30  ankyloglossia and days. difficulties of breastfeeding in babies with ankyloglossia. BALLARD; AUER; KHOURY To identify the 3.032 babies, from 0 2002  incidence, gender, to 30 days, were age and the impact of examined the ankyloglossia in breastfeeding babies and the efficacy of the frenuloplasty with respect to solving specific breastfeeding problems. RICKE; BAKER; MADLON- To determine whether 3.490 babies were KAY; DEFOR; 2005  breast-fed infants examined, the age was with altered lingual not mentioned. frenulum have decreased rates of breastfeeding at 1 week and 1 month of age, to determine the prevalence of lingual frenulum altered in babies; to test the usefulness of the Hazelbaker protocol in assessing the severity of altered frenulum in breastfeeding newborns. HOGAN; WESTCOTT; To determine whether, Were examined 1.866 GRIFFITHS, 2005  in babies with babies, from 0 to 30 altered lingual days. frenulum and a feeding problem, the medical treatment (referral to a lactation consultant) or immediate division works best and enables the babies to feed normally. MARTINELLI; MARCHESAN; To verify the Were examined 100 BERRETIN-FELIX, 2013 anatomical features babies, with 30 days.  of the lingual frenulum influence in sucking and swallowing functions in term infants, in order to propose adjustments in the protocol proposed by Martinelli et al, 2012. MARTINELLI; MARCHESAN; To evaluate 71 babies were BERRETIN-FELIX, 2014 anatomical features examined at 1, on the  of the lingual 6th and 12th month of frenulum of babies on life. the 1st, on the 6th and 12th month of life, comparing with the literature. Authors/Year Results of alterations of lingual frenulum MESSNER; LALAKEA; Fifty newborns (4.8%) were identified ABY; MACMAHON, 2000 with ankyloglossia, 36 males and 14  females. Breastfeeding difficulties were experienced by 9 (25%) of the mothers of babies with ankyloglossia BALLARD; AUER; KHOURY 123 babies with ankyloglossia were 2002  identidied, 70 presented symptoms of poor latch and 53 nipple pain. After frenuloplasties, it was observed an improvement in the latch in all cases and maternal pain levels fell significantly. The proportional of males for females was 15:1. RICKE; BAKER; MADLON- 80% of babies with altered frenulum have KAY; DEFOR; 2005  successful in the breastfeeding in 1 week, with 3 times more chance to use bottle. By 1 month, altered frenulum babies were as likely as controls to be bottle fed only. There was 148 (4.24%) of babies with altered lingual frenulum, 103 males and 45 females. The Hazelbaker is not useful to identify if babies with lingual frenulum alteration has difficulties to breastfeeding. HOGAN; WESTCOTT; Were identified 10,7% (n=201) babies GRIFFITHS, 2005  with ankyloglossia, 124 males and 77 females, of whom 88 had breastfeeding or bottlefeeding problems. Chirurgical intervention resulted in improved feeding in 54 (95%) of babies. This procedure was significantly better for feeding improvement than the intensive support of the feeding consultant. MARTINELLI; MARCHESAN; Among 100 evaluated babies, 29 was not BERRETIN-FELIX, 2013 possible to see the frenulum. Of the 71  (71%) whom was possible to see it, 16 (22.5%) had anatomical features that restricted the tongue movement in nutritive and not nutritious sucking, and 55 (77.5%) remaining considered normal. MARTINELLI; MARCHESAN; 16 (22.5%) babies were diagnosed with BERRETIN-FELIX, 2014 altered frenulum. It was found that the  lingual frenulum did not modify in the first year of life. Table 2. Frequency of chronological age and gender of babies attended In Reference Center In Hearing Health/CRESA between August, 2014 and February, 2015. Sociodemographic n % factors Age (months) 1 month 103 (62,1%) 2 months 35 (21%) 3 months 21 (12,7) 4 months 7 (4,2%) Gender Female 84 (51%) Male 82 (49%) Figure 1. Classification lingual frenulum of babies attended in the Reference Center in Hearing Health/CRESA between August, 2014 and February, 2015 Altered 37% Normal 63% Note: Table made from pie chart. Figure 2. Distribution of the anatomic aspects of lingual frenulum in babies attended in the Reference Center in Hearing Health/CRESA Puc Goias between August, 2014 and February, 2015 Altered (apex / sublingul caruncles) 0,6% Altered (apex / inferior alveolar 4,2% crest) Altered (middle third and the apex 32,2% / inferior alveolar crest) Normal (middle third / inferior 13% alveoar crest) Normal (middle third and the apex 22% / sublingual caruncles) Normal (middle third / sublingual 28% caruncles) Note: Table made from bar graph. Figure 3. Distribution of changes in suction in normal and altered frenulum in babies attended in Reference Center in Hearing Health/ CRESA--Puc Goias between August, 2014 and February, 2015 Suction normal Suction altered Normal (middle third/sublingual 24,8% 3,0% caruncles) Normal (middle third and the 9,7% 3,6% apex/sublingual caruncles) Normal (middle third/inferior 18,2% 4,2% alveolar crest) Altered (middle third and the 18,8% 12,7% apex/inferior alveolar crest) Altered (apex/inferior alveolar 0,6% crest) Altered (apex/sublingual 3,4% 1,8% caruncles) Note: Table made from bar graph.
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|Title Annotation:||Original articles. Texto en ingles|
|Author:||Marcione, Silva Soares; Coelho, Fernanda Gomes; Souza, Cejana Baiocchi; Franca, Ellia Christinne Lim|
|Publication:||Revista CEFAC: Atualizacao Cientifica em Fonoaudiologia e Educacao|
|Date:||Sep 1, 2016|
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