The wait is over... It's finally here!
The wait for the new book, Functional Assessment and Remediation of TOTs (Tethered Oral Tissues) has been long (and we mean loooong)... but well worth it. Authors Robyn Merkel-Walsh, MA, CCC-SLP and Lori Overland, MS, CCC-SLP, C/NDT, CLC have been working hard to deliver you the quality content you deserve.
The book is a comprehensive, evidence-based program that assists in the identification and functional implications of TOTs (also known as tethered oral tissue, tongue tie and ankyloglossia).
This practical speech and feeding program includes a pre- and post-surgical treatment plan to avoid long-term issues, such as scarring and reattachment.
Without further ado, here is a sneak peek into this new, innovative guide to tongue tie!
Can't see the image? Read it here:
POSTOPERATIVE CONSIDERATIONS AND CARE
Postoperative therapy is important for three main purposes: 1) decreasing the risk of scarring; 2) decreasing the risk of reattachment; and 3) improving functional skills for feeding and speech. Generally there are two phases of postoperative therapy. The first stage is stretching exercises that are scripted from the surgeon/physician’s office. This is more common in laser revisions with a dentist or oral surgeon. Patients are instructed to “keep the diamond open.” There must be a diamond-shaped wound in order to have a full release of a tongue-tie (Ghaheri, 2017). Scissor or scalpel procedures may or may not discuss a diamond depending on the type of procedure completed. (See chapter 5 by Anthony F. Jahn, MD, and chapter 6 by Scott Siegel, MD/DDS).
Since dentists and oral surgeons often work with registered dental hygienists, they often collaborate from a myofunctional perspective. Stretches are scripted three to five times a day until the wound is thoroughly healed. The stretches may also involve applications of emollients such as coconut oil, so the wound does not get too dry (see appendix G, a journal diary). Many times these exercises are done by the patient independently, which could leave room for error and confusion.
The second stage of exercises targets the functional range of motion for the oral motor skills needed for feeding and the oral placement skills needed for speech. Both stages of treatment are equally as important. This is why patients should be encouraged to have postsurgical sessions scheduled with the appropriate therapist(s) after the revision. Therapy can start several days after the procedure with medical clearance.
For the purpose of this text, we will describe three distinct parts of postfrenectomy therapy that can be performed concurrently:
- Chapter 8, “Pre-Feeding”: This chapter targets the oral sensory-motor skills required for safe and effective nutritive feeding to include breast, bottle, cup, spoon, straw, and solids.
- Chapter 9, “Feeding”: This chapter focuses on facilitating safe, nutritive feeding and reducing compensatory (myofunctional) movement patterns.
- Chapter 10, “Speech”: This chapter focuses on oral placement therapy to support the positions of the articulators to improve speech clarity.
Before we discuss therapeutic procedures, we need to consider general postsurgical complications to monitor during therapy sessions.
COMPLICATIONS/RED FLAGS As with any surgical procedure, there are risks that in part depend on the skill of the surgeon, the procedure employed, the type of anesthesia, and the follow-up care (Taylor, 2011). For example, Yang, Woo, Won, Kim, Hu, and Kim (2009) reported possible tongue-tip numbness with frenectomy, and Schuster (2014) chronicled her neuropathy pain from an errant stitch postfrenectomy that caused complex medical complications with pain management through pharmaceuticals.
One incident of a life-threatening complication after lingual frenotomy has been reported in the literature. A seven-year-old boy with a tight lingual frenum was placed under general anesthesia. Right after the frenectomy was performed, the child immediately suffered upper-airway obstruction due to an upper-airway collapse. This resolved spontaneously within an hour. Normally, contraction of the genioglossus muscle pulls the tongue and hyoid bone anteriorly, but a tight lingual frenum also holds the tongue anteriorly; therefore, after a surgical release, the genioglossus muscle may not be able to generate sufficient force to prevent airway collapse (Walsh & Kelly, 1995). Another study by Genther, Skinner, Bailey, Capone, and Byrne (2015) looked at airway obstruction after lingual frenulectomy in two infants with Pierre- Robin sequence. These are unique cases, as most patients have an uneventful procedure, but it is important to note that no surgery goes without risks.
Seemingly different surgical procedures come with different risks. Frenectomy can be accomplished either by the routine scalpel technique, by electrosurgery, or by using lasers. A scalpel technique carries typical risks of surgery such as bleeding and patient compliance. Electrocautery is associated with certain complications, which include burns, the risk of an explosion if combustible gases are used, interference with pacemakers, and the production of surgical smoke. The use of a CO2 laser in lingual frenectomies has been associated with delayed healing as compared to that of conventional scalpel techniques, a reduced surgical precision that results in an inadvertent laser-induced thermal necrosis, and/or a photo acoustic injury. Since the conventional procedure of frenectomy was first proposed, a number of modifications of the various surgical techniques like the Miller’s technique, ... READ MORE