Effectiveness of Frenuloplasty and Postoperative Speech Rehabilitation in Patients with Ankyloglossia and Dysarthria

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Methods Articulation testing was done before and after surgery in 74 patients with ankyloglossia and dysarthria who underwent frenuloplasties. Overall evaluations included disease classification, Tongue-tie Assessment Score status, correctly pronounced word counts (word accuracy test), abnormal articulation profiling (omission, substitution, and distortion), speech intelligibility rating, and range of tongue mobility. Articulation testing took place at preoperative baseline and postoperatively at 1, 3, and 6 months, as well as at 1 year and on final days of any training required beyond 1 year. Test results were appraised in phases, examining patient groups at 6 months (n = 39), 1 year (n = 19), and > 1 year (n = 8) of rehabilitation. Results Rehabilitation ≥ 6 months was necessary in 89.2% (66/74) of patients. Counts of correctly pronounced words gradually rose as a result. Both speech intelligibility and range of tongue mobility also steadily improved. In terms of abnormal articulation, omission and substitution increasingly declined after surgery, whereas distortion showed a slowing or heightened tendency at ~ 3–6 months. Conclusions Long-term rehabilitation is required to correct dysarthria, once acquired. Ankyloglossia should be corrected before patients learn to speak. ankyloglossia tongue-tie dysarthria speech disorder frenuloplasty speech therapy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 1. Introduction Recommendations of the Japanese Children's Health Association (2013) have stated that “ankyloglossia or tongue-tie is not related to feeding disorders and does not require surgery in infancy", while also stipulating "if dysarthria is present at the age of 5, when the development of articulation skills is achieved, the need for surgery should be considered "[1]. Many medical institutions throughout Japan have since adopted this guidance for treatment of ankyloglossia. Because the tongue is a muscularized motor organ that cannot fully exert its function if a short frenulum limits the range of motion [2], our clinic has instead advocated frenotomy in early infancy under local anesthesia [3,4] (Fig. 1). However, the reality is that many of our clinic patients are already impaired and arrive with speech problems. From our perspective, lingual frenuloplasty itself (under general anesthesia) is insufficient for treating ankyloglossia encumbered by speech disorders. Collaboration with speech therapists is essential to correct existing misarticulation. The present prospective study was done to examine the effectiveness and challenges of multidisciplinary management in children with ankyloglossia and dysarthria. We evaluated articulation function before surgery and periodically afterwards, in conjunction with postoperative articulation training. 2. Methods 2.1. Patient population Between February 2020 and December 2023, 103 patients with ankyloglossia and dysarthria underwent horizontal-to-vertical frenuloplasties at Shin-Yurigaoka General Hospital, using general anesthesia. All but children under 2 years old and children unable to join the program because of living distance or school were enrolled in postoperative articulation training by speech therapists. Those (n=74) who completed rehabilitation programs by end of December 2024 qualified for study, the protocol of which was approved by our Institutional Review Board (approval number: 20200929-2-➃). Subjects were informed of objectives entailed in an opt-out manner and as such, could decline to participate. 2.2. Study design Our analysis included classification of ankyloglossia (Table 1, Fig.2), Tongue-tie Assessment Score status (Table 2), and tests of articulation function performed pre- and postoperatively. We used a modification of Kotlow’s tongue-tie criteria [5] for disease classification and adopted a simplified version of the Hazelbaker Assessment Tool for Lingual Frenulum Function as our own Tongue-tie Assessment Score [6]. 2.3. Pre- and postoperative articulation testing Articulation tests were conducted preoperatively, establishing baseline values, and postoperatively at 1, 3, and 6 months, as well as at 1 year and on final days of any training required beyond 1 year. Rehabilitation training sessions including tongue-training exercises and articulation exercises generally took place once or twice a month. Patients were also asked to do pronunciation drills at home. To evaluate articulation function, 50 picture cards of common 2- to 3-syllable Japanese words were used, taken from a new version of the articulation test developed by Japan Association of Language and Speech [7]. Patients were interviewed by speech therapists and asked to pronounce the words shown on these cards. The accuracy of word production was gauged through counts of correct pronunciations (word accuracy test). Three aspects of abnormal articulation (omission, substitution, and distortion) were also evaluated, in addition to speech intelligibility and range of tongue mobility. In omission, anticipated sounds are not actually heard (eg, “pay” rather than “play”). Substitution is marked by incorrectly produced sounds construed as other specific words (eg, “wed” instead of “red”). Distortion exists if sounds produced are identifiable as words but seem audibly distorted (eg, nasal or lateral sounds). Intelligibility of speech was evaluated using the following five-point scale: 1: well understood; 2: sometimes not understood; 3: understood, if subject familiar with topic; 4: sometimes understood; or 5: not understood at all. Range of tongue mobility was a metric introduced in July 2020. A four-point scale was similarly applied as follows: 1: upper lip reachable by tongue tip, without compensation; 2: tongue tip elevates within oral cavity, upper lip unreachable; 3: marginal raising of tongue tip within oral cavity; or 4: tongue tip confined, inability to raise within oral cavity. The criteria for completing rehabilitation are achieving correctly pronounced words over 40 out of 50 in a word accuracy test, but improvements in abnormal articulation, intelligibility, and tongue mobility must also be taken into consideration. The decision to complete rehabilitation is made at a monthly joint meeting between the attending pediatric surgeons and speech therapists. 2.4. Statistical analysis The t -test (for two-sample comparisons, assuming variances unequal) served for statistical analysis, setting significance levels of greater ( p <0.001) or lesser ( p <0.05) degree. 3. Results 3.1. Characteristics of study population The 74 eligible participants (boys, 52; girls, 22) ranged from 3-13 years of age (3 years, 15; 4 years, 20; 5 years, 20; 6 years, 14; and 7 to 13 years, 5), with 3-6 year-olds comprising the majority (93.2%). In the course of articulation training, three of them completed the program in 1 month, followed by five in 3 months, 39 in 6 months, 19 in 1 year, and 8 in >1 year. There were 66 patients (89.2%) who required ≥6 months of rehabilitation. Patient categorization by ankyloglossia type was as follows: tongue tip type, 19 (25.7%); anterior membrane type, 28 (37.8%); tower type 21 (28.4%); and posterior type, 6 (8.1%). Overall, tongue-tip type in speech disorders (25.7%) surpassed feeding disorders (14%) in known frequency [4]. Within our study population, the distribution of Tongue-tie Assessment Score was as follows: 1 point, 11; 2 points, 18; 3 points, 27; 4 points, 6; 5 points, 6; 6 points, 3; 7 points, 2; and 8 points, 1. Mean score was 3.0 points (Fig. 3). 3.2. Outcomes of pre- and postoperative articulation testing Results of articulation function tests are detailed in figures that follow, analyzed according to training completion dates as 6-month, 1-year, or >1-year patient groups. In word accuracy testing, counts of correctly pronounced words gradually increased through rehabilitation (preoperative counts: 35.2±9.5, 23.7±9.1, and 20.8±8.6, respectively; endpoint counts: 45.2±6.7, 41.2±11.7, and 42.4±2.3, respectively), all groups eventually achieving counts >40 words, the end goal of rehabilitation (Fig. 4). Counts of abnormal articulations, omissions (Fig. 5), substitutions (Fig. 6), and distortions (Fig. 7), are shown separately. Although omission and substitution issues gradually declined after surgery, distortion increased for 6-month group members (at ~3 months) and for the >1-year group (at ~6 months). In the 1-year rehabilitation group, the distortion improvement we initially witnessed slowed at ~3 months. Both speech intelligibility (Fig. 8) and range of tongue mobility (Figure 9) improved gradually during rehabilitation, with 6-month and 1-year groups approaching peak performances (ie, 1-point scores) upon program completion. Results of testing for articulation function obtained preoperatively and at rehabilitation endpoints are summarized in Table 3. Patients unable to personally participate due to fever or other obstacles and poor-tempered, uncooperative ones were excluded from analysis. In comparing rehabilitation endpoints with preoperative baselines, all groups showed highly significant differences ( p 1-year groups differed to less significant degrees ( p 1-year groups showed no significant differences. 3.3．Effects of patients’ age and disease type on word accuracy test In word accuracy test by age groups (3 y/o, 15; 4 y/o, 20; 5y/o, 20; and 6y/o, 14), the number of words that could be pronounced accurately increased with rehabilitation in all age groups, ultimately reaching or exceeding the target number of 40 words (Fig. 10). In the disease type-specific word accuracy test, (tongue tip type, 19; anterior membrane type, 28; tower type 21; and posterior type, 6), the number of words that could be pronounced accurately with rehabilitation increased in all disease types, exceeding the target number of 40 words (Fig. 11). However, contrary to our expectations, the number of words that could be pronounced accurately in the preoperative test was highest in the tongue-tip type and lowest in the posterior type。 4. Discussion Articulation is the production of "spoken words" by various organs above the larynx, namely lips, tongue, hard palate, soft palate, gums, and jaw. The tongue itself assumes a pivotal role, so it is quite reasonable to expect that any mobility restriction (regardless of cause) will likely disrupt articulation. Nonetheless, the question of whether or not lingual frenulum revision improves pronunciation in patients with ankyloglossia and problematic speech has fueled long-standing debate [8–12]. There are some case series that confirm the effectiveness of frenuloplasty in treating ankyloglossia with dysarthria, citing clinically determined improvement rates of 82–90% [13–16]. However, various systematic reviews [17,18] and guidelines [19] hold distinctly opposite views, instead contending that “there has been no association between ankyloglossia and pronunciation or articulation”. Unfortunately, such minor reports (as above) fail to interest systematic reviewers, having too few cases and unblinded approach with no control groups. Our preliminary study documented improvements of articulation at Year 1 post-frenuloplasty through standardized articulation testing [20], but it has also received criticism for its small sample size (n = 5) [19]. Thereafter we have accumulated the number of cases, and confirmed the results by this prospective study. More recently, a randomized trial assessing the influence of frenuloplasty on speech articulation has verified significantly improved speech in two older patient groups (3 to < 4 and 4 to < 5 years old) but not in a younger group (2 to < 3 years) [21]. Likewise, outcomes of a recent systematic review and meta-analysis by Carnino et al. seem to support our premise, having affirmed that “frenectomy for tongue-tie was associated with an improvement in speech articulation” [22]. Our patient cohort (n = 74) was subjected to articulation testing by speech therapists, conducted prior to surgery and postoperatively at 1, 3, and 6 months, as well as at 1 year and on final training days thereafter. Statistical analysis did not include 1- and 3-month rehabilitation groups, which were sparsely populated (3 and 4 patients, respectively). Preoperative dysarthria was mild in these groups, resulting in briefer rehabilitation intervals. Still, 89.2% of our patients required more prolonged postoperative articulation training, lasting from 6 months to 2 years. Results of articulation function testing before surgery and at rehabilitation endpoints are shown in Table 3 . In the 6-month rehabilitation group, there were significant differences in word accuracy test, distortion, intelligibility of speech, and range of tongue mobility (all p < 0.001), although omission did not differ significantly. The 6-month group fared better than the 1-year group both preoperatively and in general, thus improving more quickly. The 1-year rehabilitation group was characterized by highly significant differences in endpoints of word accuracy test, substitution, speech intelligibility, and range of tongue mobility ( p < 0.001), with lesser degrees of significance reached at omission and distortion endpoints (both p 1-year rehabilitation group were registered in word accuracy test, substitution, speech intelligibility, and range of tongue mobility (all p < 0.001). The difference observed in distortion was less impressive ( p < 0.05), and omission did not differ significantly. We attributed the noticeable lag in improvement or worsening of distortion at ~ 3–6 months to a shift to distortion from omissions and substitutions. Distortion is a milder form of error, and children acquire the habit of producing similar sounds, without opening their mouths widely (lateral articulation). Correction of lateral articulation is very difficult, especially as children age [20]. We investigated also the effects of patients’ age and disease type as confounding factors on articulation test. In children aged 3 years and older, age had no significant effect on speech function during rehabilitation. However, contrary to expectations, the performance of the tongue-tip type in the word accuracy test was found to be better than that of other disease types. Omission and substitution showed similar trends also (data not shown). The reason for these paradoxical results is not yet fully understood, but it is speculated that because the tip of the tongue is fixed and cannot move in the tongue-tip type, compensatory pronunciation is acquired by using other parts of the tongue to generate similar sounds. The existence of other confounding factors needs to be analyzed also, and this will be a topic for future consideration. One limitation of this study was the lack of a non-surgically corrected patient group for comparison. Yet, it is our opinion that the random diversion of patients who are otherwise intent on surgical intervention is an unethical practice. Furthermore, language training alone is not as effective. It requires a longer period of time and should be avoided if mobility of the tongue is limited. The same may apply to myofunctional therapy. According to a related systematic review, surgery has proven more beneficial for ankyloglossia than myofunctional therapy, although best results are attained through a combination of both [23]. On a final note, it is important to highlight a longitudinal study addressing anatomic characteristics in infants with tongue-tie. The findings confirm that frenulum shapes are entirely unchanged after 6 or 12 months of observation [24]. Actually, there is no available clinical data to indicate that a short frenulum will self-elongate over time. Infants destined for future speech difficulties are identifiable using our Tongue-tie Assessment Score to ascribe severity. Postponing needed surgery for ankyloglossia until the age of 5 (when dysarthria develops) is thus unsupported, imposing unnecessary medical services and the economic burden attached. 5. Conclusion This prospective study was done to examine the effectiveness and challenges of multidisciplinary management in children with ankyloglossia and dysarthria. We evaluated articulation function before surgery and periodically afterwards, in conjunction with postoperative articulation training. As the result, rehabilitation over 6 months was necessary in about 90% of patients. Word accuracy, speech intelligibility and range of tongue mobility improved gradually in accordance with rehabilitation. In terms of abnormal articulation, omission and substitution increasingly declined after surgery, whereas distortion showed a slowing or heightened tendency at around 3–6 months. Further follow-up studies are needed in the future. As illustrated herein, long-term rehabilitation is essential to correct dysarthria, once acquired. Ankyloglossia warrants correction before a patient learns to speak. Declarations Conflicts of interest The authors have no conflicts of interest to declare (This study was reported at the 62nd Annual Meeting of the Japanese Society of Pediatric Surgery, June 5, 2025, Tokyo, Japan) Conflicts of interest The authors have no conflicts of interest to declare Funding source No funding was secured for our purposes. Author Contribution Y.I. designed the study, performed the surgery , wrote the main manuscript text , and prepared all tables and figures.K.M. and T.S. performed the surgery.G.K., N.T., and M.K. conducted articulation tests, and speech training.All authors reviewed the manuscript Financial disclosure The authors have no financial relationships to disclose regarding this article. Previous communications There are none to report. References Japanese Society of Child Health (2013) The concept of ankyloglossia. Pediatric Health Research 72:754–757 (in Japanese) Ito Y (2023) Anatomy and function of the tongue. In Tongue-tie, 2nd edn. Amazon, Tokyo, pp18-22 Ito Y (2014) Does frenotomy improve breast-feeding difficulties in infants with ankyloglossia? Pediatrics International 56: 497–505 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://aomtinfo.org/wp-content/uploads/2017/02/Ttongue-tie-and-feeding-difficulties.pdf Ito Y (2020) Effectiveness of tongue-tie and lip-tie release in infants with feeding problems: a prospective study of 343 cases. J Jap Soc Ped Surg 56: 1074–1081 (in Japanese with English abstract) Chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.jstage.jst.go.jp/article/jjsps/56/7/56_1074/_pdf Kotlow L (2015) TOTS-Tethered Oral Tissues: The Assessment and Diagnosis of the Tongue and Upper Lip Ties in Breastfeeding. 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Int J Environ Res Public Health 19(19):12347, e1-18 https://www.researchgate.net/publication/363927722_Effectiveness_of_Myofunctional_Therapy_in_Ankyloglossia_A_Systematic_Review Martinelli RLC, Marchesan IQ, Berrtin-Felix G (2014) Longitudinal study of the anatomical characteristics of the lingual frenulum and comparison to literature. Rev CEFAC 16:1202–1207 Tables Table 1. Classification of ankyloglossia Type Attachment to tongue Attachment to oral floor Tongue tip Tip (≤5 mm therefrom) Alveolar ridge Anterior membrane ≤1 cm from tip of tongue in infants (anterior half in children) Alveolar ridge Tower Central part of tongue Sublingual folds Posterior (membrane, chord) >1 cm from tip of tongue in infants (posterior half in children) At or behind sublingual folds Table 2. Tongue-tie Assessment Score (for children, revised 2021) (1) Attachment of lingual frenulum to tongue 2: posterior to midpoint 1: anterior to midpoint 0: apex (≤5 mm from tip) (2) Attachment of lingual frenulum to oral floor 2: posterior to sublingual folds 1: at sublingual folds 0: at alveolar ridge (3) Appearance of tongue on protrusion 2: round 1: slight cleft in tip 0: heart shaped (4) Protrusion of tongue 2: over upper lip 1: over lower lip 0: inside lower lip (5) Articulation, mastication, swallowing 2: undisturbed 1: somewhat disturbed 0: markedly disturbed Total score ( ) Scoring ranges: 0-3, severe; 4-5, moderate; 6-7, mild, Surgical indication: ≤7 Table 3. Results of articulation function testing before surgery and at rehabilitation endpoints Test item Duration Preoperative baseline Rehabilitation endpoint P value Word accuracy 6 months 35.2±9.5 (39) 45.2±6.7 (38) * 1 year 23.7±9.1 (19) 41.2±11.7(18) * >1 year 20.8±8.6 (8) 42.4±2.3 (8) * Omission 6 months 2.4±8.3 (39) 0.6±1.8 (37) ns 1 year 4.6±5.9 (19) 0.4±0.6 (18) ** >1 year 2.3±3.1 (8) 0.3±0.7 (8) ns Substitution 6 months 6.5±7.6 (39) 1.8±3.8 (38) * 1 year 14.1±10.7 (19) 2.6±4.3(18) * >1 year 22.4±9.6 (8) 1.1±2.1 (8) * Distortion 6 months 7.1±4.2 (39) 3.8±4.8 (38) * 1 year 12.0±7.4 (19) 6.3±10.9 (17) ** >1 year 7.0±4.1 (8) 6.4±5.8 (9) ** Speech intelligibility † 6 months 1.8±0.5 (38) 1.2±0.4 (34) * 1 year 2.5±1.1 (19) 1.5±0.4 (14) * >1 year 2.3±0.5 (8) 1.4±0.4 (8) * Range of tongue mobility † 6 months 3.3±0.6 (38) 1.3±0.5 (37) * 1 year 3.2±0.7 (17) 1.4±0.8 (16) * >1 year 3.0±0.5 (8) 1.3±0.2 (8) * Test items quantified as counts or † scores, expressed as mean ± standard deviation values with patient totals (n) , * <0.001; ** <0.05; ns, not significant Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Aug, 2025 Read the published version in Pediatric Surgery International → Version 1 posted Editorial decision: Accepted 07 Aug, 2025 Reviews received at journal 07 Aug, 2025 Reviewers agreed at journal 07 Aug, 2025 Reviewers invited by journal 07 Aug, 2025 Editor assigned by journal 07 Aug, 2025 Submission checks completed at journal 07 Aug, 2025 First submitted to journal 04 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7288167","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497305787,"identity":"2677bac4-c08e-44a9-a364-4cc6e73e6bbf","order_by":0,"name":"Yasuo Ito","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYLCCBAYGHjZm/o8PgGwePuK0JDDI8bE3GBuAtLARa42xHM8BMwkQm6AWg+PHn0k8/GGT2CaRkFb5NcdOho2B+eGjG/i0nMkxk0hISANpOXZbdlsy0GFsxsY5+LQcyGEDajkM1JLYdltyGzNQCw+bNF4t558/g2pJZiuW3FZPhJYbCSCHHTZm4znGxvhx22HCWiRvvDG2SEhLk2Nj72GWZtx2HBhBBPzCdz794c0fNjY88s08jB9/bqu252dvfvgYnxaFA0gcZh4wiUc5CMg3IHEYfxBQPQpGwSgYBSMTAAArqkTzC/0jVwAAAABJRU5ErkJggg==","orcid":"","institution":"Shin-Yurigaoka General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yasuo","middleName":"","lastName":"Ito","suffix":""},{"id":497305789,"identity":"5482df82-8dde-414e-b9c9-1e8d854b9483","order_by":1,"name":"Kazuaki Miyaguni","email":"","orcid":"","institution":"Shin-Yurigaoka General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kazuaki","middleName":"","lastName":"Miyaguni","suffix":""},{"id":497305791,"identity":"005c040c-2ec7-461f-bdde-d2aea4565cc5","order_by":2,"name":"Tetsuro Sugihara","email":"","orcid":"","institution":"Shin-Yurigaoka General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tetsuro","middleName":"","lastName":"Sugihara","suffix":""},{"id":497305793,"identity":"9dfb5965-83e1-42d6-9e5e-4acee345fd5f","order_by":3,"name":"Go Kosugi","email":"","orcid":"","institution":"Shin-Yurigaoka General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Go","middleName":"","lastName":"Kosugi","suffix":""},{"id":497305796,"identity":"3117ae34-4993-476b-8695-da7518dc91eb","order_by":4,"name":"Nene Tookaichi","email":"","orcid":"","institution":"Shin-Yurigaoka General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nene","middleName":"","lastName":"Tookaichi","suffix":""},{"id":497305797,"identity":"c8473117-6f19-4680-a734-9897b88b7774","order_by":5,"name":"Myu Kaneko","email":"","orcid":"","institution":"Shin-Yurigaoka General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Myu","middleName":"","lastName":"Kaneko","suffix":""}],"badges":[],"createdAt":"2025-08-04 07:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7288167/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7288167/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00383-025-06149-w","type":"published","date":"2025-08-19T16:29:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89066369,"identity":"fec3b29a-ee91-4c72-8498-e1dc2c961009","added_by":"auto","created_at":"2025-08-14 10:42:39","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29713,"visible":true,"origin":"","legend":"\u003cp\u003eAlgorithm of our management for tongue-tie patients\u003c/p\u003e\n\u003cp\u003eSee Table 2 for tongue-tie assessment score.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/5d7ff53ab243abd2d40a7f60.jpg"},{"id":89066869,"identity":"b10bdad7-97db-4867-8eb4-4abb83a11334","added_by":"auto","created_at":"2025-08-14 10:42:54","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64077,"visible":true,"origin":"","legend":"\u003cp\u003eIllustrated classification of tongue-tie\u003c/p\u003e\n\u003cp\u003e(a) Tongue-tip type; (b) Anterior membrane type; (c) Tower type; (d) Posterior type\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/78498803ff67074f74a65b20.jpg"},{"id":89066551,"identity":"192f4ca0-c590-44a3-a696-35abf4faf1c1","added_by":"auto","created_at":"2025-08-14 10:42:44","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":110397,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Tongue-tie Assessment Score data (n=74)\u003cbr\u003e\nNote: mean of 3.0 points (scored from 0-10)\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/dd8205e20707b359f55b5e42.jpg"},{"id":89066538,"identity":"235e7af6-d003-4ae1-a320-41f627dcf5fb","added_by":"auto","created_at":"2025-08-14 10:42:43","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":166662,"visible":true,"origin":"","legend":"\u003cp\u003ePeriodic word accuracy testing in speech rehabilitation groups\u003c/p\u003e\n\u003cp\u003eGradual rise in counts of correctly pronounced words through training\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/3bea467ea1986a87973809ef.jpg"},{"id":89065912,"identity":"aa7b40e3-c875-4063-87cc-a74fd4626fb7","added_by":"auto","created_at":"2025-08-14 10:42:25","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":165858,"visible":true,"origin":"","legend":"\u003cp\u003eCounts of omission in speech rehabilitation groups\u003c/p\u003e\n\u003cp\u003eGradual declines in omission through training,\u003c/p\u003e","description":"","filename":"Picture5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/2fb09df61a4eb6888c1e510b.jpg"},{"id":89065974,"identity":"1e8e7762-58b8-484d-ad3d-61d58a4f2932","added_by":"auto","created_at":"2025-08-14 10:42:27","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":141032,"visible":true,"origin":"","legend":"\u003cp\u003eCounts of substitution in speech rehabilitation groups\u003c/p\u003e\n\u003cp\u003eGradual declines in substitution through training\u003c/p\u003e","description":"","filename":"Picture6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/136c809944c0176c22ccc4c2.jpg"},{"id":89066108,"identity":"1585b2fb-e97c-44e6-8aee-ba1ca5d17a4e","added_by":"auto","created_at":"2025-08-14 10:42:35","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":152862,"visible":true,"origin":"","legend":"\u003cp\u003eCounts of distortion in speech rehabilitation groups\u003c/p\u003e\n\u003cp\u003eGradual declines in distortion showing upturn ~3-6 months after surgery\u003c/p\u003e","description":"","filename":"Picture7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/6a4b22528cc63f077dfc47b9.jpg"},{"id":89066329,"identity":"40a212ef-4980-45e9-a64f-94282a602be9","added_by":"auto","created_at":"2025-08-14 10:42:38","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":144492,"visible":true,"origin":"","legend":"\u003cp\u003eTimelines of speech intelligibility in rehabilitation groups\u003c/p\u003e\n\u003cp\u003eGradually improved speech intelligibility through training, scored as follows: 1: well understood; 2: sometimes not understood; 3: understood, if subject familiar with topic; 4: sometimes understood; or 5: not understood at all.\u003c/p\u003e","description":"","filename":"Picture8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/64cb1459344710195b238c36.jpg"},{"id":89066836,"identity":"acb1fb68-d55a-4971-996b-b2d9d959e43f","added_by":"auto","created_at":"2025-08-14 10:42:53","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":144245,"visible":true,"origin":"","legend":"\u003cp\u003eTimelines of tongue mobility in rehabilitation groups\u003c/p\u003e\n\u003cp\u003eGreatly improved range of tongue mobility through training, scored as follows: 1: upper lip reachable by tongue tip, without compensation; 2: tongue tip elevates within oral cavity, upper lip unreachable; 3: marginal raising of tongue tip within oral cavity; or 4: tongue tip confined, inability to raise within oral cavity.\u003c/p\u003e","description":"","filename":"Picture9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/80ec9fc0244ca7f43ff05ad0.jpg"},{"id":89066163,"identity":"501cee9b-f5ae-4f3a-acfb-45653ad05206","added_by":"auto","created_at":"2025-08-14 10:42:35","extension":"jpg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":171814,"visible":true,"origin":"","legend":"\u003cp\u003ePeriodic word accuracy testing in different age groups\u003c/p\u003e\n\u003cp\u003eGradual rise in counts of correctly pronounced words in all age groups through training, ultimately reaching or exceeding the target number of 40 words\u003c/p\u003e","description":"","filename":"Picture10.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/95e407ce033c1384c774e13e.jpg"},{"id":89066217,"identity":"37bff5d9-590b-4392-93c5-433f12281142","added_by":"auto","created_at":"2025-08-14 10:42:36","extension":"jpg","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":198257,"visible":true,"origin":"","legend":"\u003cp\u003ePeriodic word accuracy testing in different disease types\u003c/p\u003e\n\u003cp\u003eTongue-tip type showing better results than other types contrary to expectations.\u003c/p\u003e","description":"","filename":"Picture11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/e5f4b91764953b2a3e409957.jpg"},{"id":89847225,"identity":"9e63f015-ddc3-49f2-bbd1-e7b73c9067e1","added_by":"auto","created_at":"2025-08-25 16:42:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2064208,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7288167/v1/ee8926e6-bd32-4e1c-8bbb-23ec3355c910.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of Frenuloplasty and Postoperative Speech Rehabilitation in Patients with Ankyloglossia and Dysarthria","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eRecommendations of the Japanese Children's Health Association (2013) have stated that \u0026ldquo;ankyloglossia or tongue-tie is not related to feeding disorders and does not require surgery in infancy\", while also stipulating \"if dysarthria is present at the age of 5, when the development of articulation skills is achieved, the need for surgery should be considered \"[1]. Many medical institutions throughout Japan have since adopted this guidance for treatment of ankyloglossia.\u003c/p\u003e\u003cp\u003eBecause the tongue is a muscularized motor organ that cannot fully exert its function if a short frenulum limits the range of motion [2], our clinic has instead advocated frenotomy in early infancy under local anesthesia [3,4] (Fig.\u0026nbsp;1). However, the reality is that many of our clinic patients are already impaired and arrive with speech problems. From our perspective, lingual frenuloplasty itself (under general anesthesia) is insufficient for treating ankyloglossia encumbered by speech disorders. Collaboration with speech therapists is essential to correct existing misarticulation.\u003c/p\u003e\u003cp\u003eThe present prospective study was done to examine the effectiveness and challenges of multidisciplinary management in children with ankyloglossia and dysarthria. We evaluated articulation function before surgery and periodically afterwards, in conjunction with postoperative articulation training.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e2.1. \u0026nbsp; \u0026nbsp; \u0026nbsp; Patient population\u003c/p\u003e\n\u003cp\u003eBetween February 2020 and December 2023, 103 patients with ankyloglossia and dysarthria underwent horizontal-to-vertical frenuloplasties at Shin-Yurigaoka General Hospital, using general anesthesia. All but children under 2 years old and children unable to join the program because of living distance or school were enrolled in postoperative articulation training by speech therapists. Those (n=74) who completed rehabilitation programs by end of December 2024 qualified for study, the protocol of which was approved by our Institutional Review Board (approval number: 20200929-2-➃). Subjects were informed of objectives entailed in an opt-out manner and as such, could decline to participate.\u003c/p\u003e\n\u003cp\u003e2.2. Study design\u003c/p\u003e\n\u003cp\u003eOur analysis included classification of ankyloglossia (Table 1, Fig.2), Tongue-tie Assessment Score status (Table 2), and tests of articulation function performed pre- and postoperatively. We used a modification of Kotlow\u0026rsquo;s tongue-tie criteria [5] for disease classification and adopted a simplified version of the Hazelbaker Assessment Tool for Lingual Frenulum Function as our own Tongue-tie Assessment Score [6].\u003c/p\u003e\n\u003cp\u003e2.3. Pre- and postoperative articulation testing\u003c/p\u003e\n\u003cp\u003eArticulation tests were conducted preoperatively, establishing baseline values, and postoperatively at 1, 3, and 6 months, as well as at 1 year and on final days of any training required beyond 1 year. Rehabilitation training sessions including tongue-training exercises and articulation exercises generally took place once or twice a month. Patients were also asked to do pronunciation drills at home.\u003c/p\u003e\n\u003cp\u003eTo evaluate articulation function, 50 picture cards of common 2- to 3-syllable Japanese words were used, taken from a new version of the articulation test developed\u003c/p\u003e\n\u003cp\u003eby Japan Association of Language and Speech [7]. Patients were interviewed by speech therapists and asked to pronounce the words shown on these cards. The accuracy of word production was gauged through counts of correct pronunciations (word accuracy test).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThree aspects of abnormal articulation (omission, substitution, and distortion) were also evaluated, in addition to speech intelligibility and range of tongue mobility. In omission, anticipated sounds are not actually heard (eg, \u0026ldquo;pay\u0026rdquo; rather than \u0026ldquo;play\u0026rdquo;). Substitution is marked by incorrectly produced sounds construed as other specific words (eg, \u0026ldquo;wed\u0026rdquo; instead of \u0026ldquo;red\u0026rdquo;). Distortion exists if sounds produced are identifiable as words but seem audibly distorted (eg, nasal or lateral sounds).\u003c/p\u003e\n\u003cp\u003eIntelligibility of speech was evaluated using the following five-point scale: 1: well understood; 2: sometimes not understood; 3: understood, if subject familiar with topic; 4: sometimes understood; or 5: not understood at all.\u003c/p\u003e\n\u003cp\u003eRange of tongue mobility was a metric introduced in July 2020. A four-point scale was similarly applied as follows: 1: upper lip reachable by tongue tip, without compensation; 2: tongue tip elevates within oral cavity, upper lip unreachable; 3: marginal raising of tongue tip within oral cavity; or 4: tongue tip confined, inability to raise within oral cavity.\u003c/p\u003e\n\u003cp\u003eThe criteria for completing rehabilitation are achieving correctly pronounced words over 40 out of 50 in a word accuracy test, but improvements in abnormal articulation, intelligibility, and tongue mobility must also be taken into consideration. The decision to complete rehabilitation is made at a monthly joint meeting between the attending pediatric surgeons and speech therapists.\u003c/p\u003e\n\u003cp\u003e2.4. Statistical analysis\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003et\u003c/em\u003e-test (for two-sample comparisons, assuming variances unequal) served for statistical analysis, setting significance levels of greater (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) or lesser (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05) degree.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1. Characteristics of study population\u003c/p\u003e\n\u003cp\u003eThe 74 eligible participants (boys, 52; girls, 22) ranged from 3-13 years of age (3 years, 15; 4 years, 20; 5 years, 20; 6 years, 14; and 7 to 13 years, 5), with 3-6 year-olds comprising the majority (93.2%). In the course of articulation training, three of them completed the program in 1 month, followed by five in 3 months, 39 in 6 months, 19 in 1 year, and 8 in \u0026gt;1 year. There were 66 patients (89.2%) who required ≥6 months of rehabilitation.\u003c/p\u003e\n\u003cp\u003ePatient categorization by ankyloglossia type was as follows: tongue tip type, 19 (25.7%); anterior membrane type, 28 (37.8%); tower type 21 (28.4%); and posterior type, 6 (8.1%). Overall, tongue-tip type in speech disorders (25.7%) surpassed feeding disorders (14%) in known frequency [4].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWithin our study population, the distribution of Tongue-tie Assessment Score was as follows: 1 point, 11; 2 points, 18; 3 points, 27; 4 points, 6; 5 points, 6; 6 points, 3; 7 points, 2; and 8 points, 1. Mean score was 3.0 points (Fig. 3).\u003c/p\u003e\n\u003cp\u003e3.2. Outcomes of pre- and postoperative articulation testing\u003c/p\u003e\n\u003cp\u003eResults of articulation function tests are detailed in figures that follow, analyzed according to training completion dates as 6-month, 1-year, or \u0026gt;1-year patient groups. In word accuracy testing, counts of correctly pronounced words gradually increased through rehabilitation (preoperative counts:\u0026nbsp;35.2±9.5, 23.7±9.1, and 20.8±8.6, respectively; endpoint counts: 45.2±6.7, 41.2±11.7, and 42.4±2.3, respectively), all groups eventually achieving counts \u0026gt;40 words, the end goal of rehabilitation (Fig. 4).\u003c/p\u003e\n\u003cp\u003eCounts of abnormal articulations, omissions (Fig. 5), substitutions (Fig. 6), and distortions (Fig. 7), are shown separately. Although omission and substitution issues gradually declined after surgery, distortion increased for 6-month group members (at ~3 months) and for the \u0026gt;1-year group (at ~6 months). In the 1-year rehabilitation group, the distortion improvement we initially witnessed slowed at ~3 months.\u003c/p\u003e\n\u003cp\u003eBoth\u0026nbsp;speech intelligibility (Fig. 8) and range of tongue mobility (Figure 9) improved gradually during rehabilitation,\u0026nbsp;with 6-month and 1-year groups approaching peak performances (ie, 1-point scores) upon program completion.\u003c/p\u003e\n\u003cp\u003eResults of testing for articulation function obtained preoperatively and at rehabilitation endpoints are summarized in Table 3. Patients unable to personally participate due to fever or other obstacles and poor-tempered, uncooperative ones were excluded from analysis. In comparing rehabilitation endpoints with preoperative baselines, all groups showed highly significant differences (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001) for word accuracy, substitution, speech intelligibility, and range of tongue mobility. Omission in the 1-year group and distortion in 1-year and \u0026gt;1-year groups differed to less significant degrees (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.05), whereas omission in 6-month and \u0026gt;1-year groups showed no significant differences.\u003c/p\u003e\n\u003cp\u003e3.3．Effects of patients’ age and disease type on word accuracy test\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn word accuracy test by age groups (3 y/o, 15; 4 y/o, 20; 5y/o, 20; and 6y/o, 14), the number of words that could be pronounced accurately increased with rehabilitation in all age groups, ultimately reaching or exceeding the target number of 40 words (Fig. 10).\u003c/p\u003e\n\u003cp\u003eIn the disease type-specific word accuracy test, (tongue tip type, 19; anterior membrane type, 28; tower type 21; and posterior type, 6), the number of words that could be pronounced accurately with rehabilitation increased in all disease types, exceeding the target number of 40 words (Fig. 11). However, contrary to our expectations, the number of words that could be pronounced accurately in the preoperative test was highest in the tongue-tip type and lowest in the posterior type。\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eArticulation is the production of \"spoken words\" by various organs above the larynx, namely lips, tongue, hard palate, soft palate, gums, and jaw. The tongue itself assumes a pivotal role, so it is quite reasonable to expect that any mobility restriction (regardless of cause) will likely disrupt articulation. Nonetheless, the question of whether or not lingual frenulum revision improves pronunciation in patients with ankyloglossia and problematic speech has fueled long-standing debate [8\u0026ndash;12].\u003c/p\u003e\u003cp\u003eThere are some case series that confirm the effectiveness of frenuloplasty in treating ankyloglossia with dysarthria, citing clinically determined improvement rates of 82\u0026ndash;90% [13\u0026ndash;16]. However, various systematic reviews [17,18] and guidelines [19] hold distinctly opposite views, instead contending that \u0026ldquo;there has been no association between ankyloglossia and pronunciation or articulation\u0026rdquo;. Unfortunately, such minor reports (as above) fail to interest systematic reviewers, having too few cases and unblinded approach with no control groups. Our preliminary study documented improvements of articulation at Year 1 post-frenuloplasty through standardized articulation testing [20], but it has also received criticism for its small sample size (n\u0026thinsp;=\u0026thinsp;5) [19]. Thereafter we have accumulated the number of cases, and confirmed the results by this prospective study.\u003c/p\u003e\u003cp\u003eMore recently, a randomized trial assessing the influence of frenuloplasty on speech articulation has verified significantly improved speech in two older patient groups (3 to \u0026lt;\u0026thinsp;4 and 4 to \u0026lt;\u0026thinsp;5 years old) but not in a younger group (2 to \u0026lt;\u0026thinsp;3 years) [21]. Likewise, outcomes of a recent systematic review and meta-analysis by Carnino et al. seem to support our premise, having affirmed that \u0026ldquo;frenectomy for tongue-tie was associated with an improvement in speech articulation\u0026rdquo; [22].\u003c/p\u003e\u003cp\u003eOur patient cohort (n\u0026thinsp;=\u0026thinsp;74) was subjected to articulation testing by speech therapists, conducted prior to surgery and postoperatively at 1, 3, and 6 months, as well as at 1 year and on final training days thereafter. Statistical analysis did not include 1- and 3-month rehabilitation groups, which were sparsely populated (3 and 4 patients, respectively). Preoperative dysarthria was mild in these groups, resulting in briefer rehabilitation intervals. Still, 89.2% of our patients required more prolonged postoperative articulation training, lasting from 6 months to 2 years.\u003c/p\u003e\u003cp\u003eResults of articulation function testing before surgery and at rehabilitation endpoints are shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eIn the 6-month rehabilitation group, there were significant differences in word accuracy test, distortion, intelligibility of speech, and range of tongue mobility (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), although omission did not differ significantly. The 6-month group fared better than the 1-year group both preoperatively and in general, thus improving more quickly.\u003c/p\u003e\u003cp\u003eThe 1-year rehabilitation group was characterized by highly significant differences in endpoints of word accuracy test, substitution, speech intelligibility, and range of tongue mobility (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with lesser degrees of significance reached at omission and distortion endpoints (both \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eSignificant differences in the \u0026gt;\u0026thinsp;1-year rehabilitation group were registered in word accuracy test, substitution, speech intelligibility, and range of tongue mobility (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The difference observed in distortion was less impressive (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and omission did not differ significantly.\u003c/p\u003e\u003cp\u003eWe attributed the noticeable lag in improvement or worsening of distortion at ~\u0026thinsp;3\u0026ndash;6 months to a shift to distortion from omissions and substitutions. Distortion is a milder form of error, and children acquire the habit of producing similar sounds, without opening their mouths widely (lateral articulation). Correction of lateral articulation is very difficult, especially as children age [20].\u003c/p\u003e\u003cp\u003eWe investigated also the effects of patients\u0026rsquo; age and disease type as confounding factors on articulation test. In children aged 3 years and older, age had no significant effect on speech function during rehabilitation. However, contrary to expectations, the performance of the tongue-tip type in the word accuracy test was found to be better than that of other disease types. Omission and substitution showed similar trends also (data not shown). The reason for these paradoxical results is not yet fully understood, but it is speculated that because the tip of the tongue is fixed and cannot move in the tongue-tip type, compensatory pronunciation is acquired by using other parts of the tongue to generate similar sounds. The existence of other confounding factors needs to be analyzed also, and this will be a topic for future consideration.\u003c/p\u003e\u003cp\u003eOne limitation of this study was the lack of a non-surgically corrected patient group for comparison. Yet, it is our opinion that the random diversion of patients who are otherwise intent on surgical intervention is an unethical practice. Furthermore, language training alone is not as effective. It requires a longer period of time and should be avoided if mobility of the tongue is limited. The same may apply to myofunctional therapy. According to a related systematic review, surgery has proven more beneficial for ankyloglossia than myofunctional therapy, although best results are attained through a combination of both [23].\u003c/p\u003e\u003cp\u003eOn a final note, it is important to highlight a longitudinal study addressing anatomic characteristics in infants with tongue-tie. The findings confirm that frenulum shapes are entirely unchanged after 6 or 12 months of observation [24]. Actually, there is no available clinical data to indicate that a short frenulum will self-elongate over time. Infants destined for future speech difficulties are identifiable using our Tongue-tie Assessment Score to ascribe severity. Postponing needed surgery for ankyloglossia until the age of 5 (when dysarthria develops) is thus unsupported, imposing unnecessary medical services and the economic burden attached.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis prospective study was done to examine the effectiveness and challenges of multidisciplinary management in children with ankyloglossia and dysarthria. We evaluated articulation function before surgery and periodically afterwards, in conjunction with postoperative articulation training.\u003c/p\u003e\u003cp\u003eAs the result, rehabilitation over 6 months was necessary in about 90% of patients. Word accuracy, speech intelligibility and range of tongue mobility improved gradually in accordance with rehabilitation. In terms of abnormal articulation, omission and substitution increasingly declined after surgery, whereas distortion showed a slowing or heightened tendency at around 3\u0026ndash;6 months. Further follow-up studies are needed in the future.\u003c/p\u003e\u003cp\u003eAs illustrated herein, long-term rehabilitation is essential to correct dysarthria, once acquired. Ankyloglossia warrants correction before a patient learns to speak.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflicts of interest\u003c/h2\u003e\u003cp\u003eThe authors have no conflicts of interest to declare\u003c/p\u003e\n\u003cp\u003e(This study was reported at the 62nd Annual Meeting of the Japanese Society of Pediatric Surgery, June 5, 2025, Tokyo, Japan)\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConflicts of interest\u003c/h2\u003e\u003cp\u003eThe authors have no conflicts of interest to declare\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding source\u003c/h2\u003e\u003cp\u003eNo funding was secured for our purposes.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.I. designed the study, performed the surgery , wrote the main manuscript text , and prepared all tables and figures.K.M. and T.S. performed the surgery.G.K., N.T., and M.K. conducted articulation tests, and speech training.All authors reviewed the manuscript\u003c/p\u003e\u003ch2\u003eFinancial disclosure\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors have no financial relationships to disclose regarding this article.\u003c/p\u003e\n\u003ch2\u003ePrevious communications\u003c/h2\u003e\n\u003cp\u003eThere are none to report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJapanese Society of Child Health (2013) The concept of ankyloglossia. Pediatric Health Research 72:754–757 (in Japanese)\u003c/li\u003e\n\u003cli\u003eIto Y (2023) Anatomy and function of the tongue. In Tongue-tie, 2nd edn. Amazon, Tokyo, pp18-22\u003c/li\u003e\n\u003cli\u003eIto Y (2014) Does frenotomy improve breast-feeding difficulties in infants with ankyloglossia? Pediatrics International 56: 497–505 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://aomtinfo.org/wp-content/uploads/2017/02/Ttongue-tie-and-feeding-difficulties.pdf\u003c/li\u003e\n\u003cli\u003eIto Y (2020) Effectiveness of tongue-tie and lip-tie release in infants with feeding problems: a prospective study of 343 cases. J Jap Soc Ped Surg 56: 1074–1081 (in Japanese with English abstract) Chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.jstage.jst.go.jp/article/jjsps/56/7/56_1074/_pdf\u003c/li\u003e\n\u003cli\u003eKotlow L (2015) TOTS-Tethered Oral Tissues: The Assessment and Diagnosis of the Tongue and Upper Lip Ties in Breastfeeding. Oralhealth March https://www.oralhealthgroup.com/features/tots-tethered-oral-tissues-the-assessment-and-diagnosis-of-the-tongue-and-upper-lip-ties-in/\u003c/li\u003e\n\u003cli\u003eHazelbaker AK (1994) The Assessment Tool for Lingual Frenulum Function (ATLFF): Use in a Lactation Consultant Private Practice. https://www.academia.edu/82969400/The_Assessment_Tool_for_Lingual_Frenulum_Function_ATLFF_Use_in_a_Lactation_Consultant_Private_Practice\u003c/li\u003e\n\u003cli\u003eImai T, Kato M, Takeshita K et al (2010) New Edition of the Articulation Test, Chiba Test Center Co., Ltd., Tokyo (in Japanese) https://www.chibatc.co.jp/cgi/web/index.cgi?c=catalogue-zoom\u0026amp;pk=38\u003c/li\u003e\n\u003cli\u003ePlummer RN (1956) Tongue tie speech, Ariz Med 13(4):139\u003c/li\u003e\n\u003cli\u003eBlock JR (1968) The role of speech clinician in determining indications for furenulotomy in cases of ankyloglossia. N.Y. State Dent J 34:479 − 81\u003c/li\u003e\n\u003cli\u003eLalakea LM, Messner AH (2002) Frenotomy and frenoplasty: If, when, and how. Otolaryngol. Head Neck Surg 13:93 − 7\u003c/li\u003e\n\u003cli\u003eSalt H, Claessen M, Johnston T et al (2020) Speech production in young childrenwith tongue-tie. Int J Ped Otorhinolaryngol 134:110035\u003c/li\u003e\n\u003cli\u003eMelong J, Bezuhly M, Hong P (2024) The effect of tongue-tie release on speech articulation and intelligibility. Ear, Nose \u0026amp; Throat Journal 103NP450-NP454.\u003c/li\u003e\n\u003cli\u003eIto S (1988) Clinical study on speech disorders and speech therapy of ankyloglossia. Kokubyo Gakkai Zasshi 55: 159–184 (in Japanese with English abstract)\u003c/li\u003e\n\u003cli\u003eMessner AH, Lalakea ML (2002) The effect of ankyloglossia on speech in children. Otolaryngol. Head Neck Surg 127: 539 − 45\u003c/li\u003e\n\u003cli\u003eBaxter R, Merkel-Walsh RM, Baxter BS et al (2020) Functional improvements of speech, feeding, and sleep after lingual frenectomy tongue-tie release: A prospective cohort study. Clinical Pediatrics e1-8 https://tonguetieal.com/wp-content/uploads/2020/05/Baxter-et-al-2020- Feeding-Speech-Sleep-Improvements.pdf\u003c/li\u003e\n\u003cli\u003eDaggumati S, Cohn JE, Brennan MJ et al (2019) Speech and language outcomes in patients with ankyloglossia undergoing frenulectomy: A retrospective pilot study. OTO Open 3(1):2473974X19826943 Chrome -extension:// efaidnbmnnnibpcajpcglclefindmkaj/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6572914/pdf/10.1177_2473974X19826943.pdf\u003c/li\u003e\n\u003cli\u003eWebb AN, Hao W, Hong P (2013) The effect of tongue-tie division on breast feeding and speech articulation- a systematic review. Int J Ped Otorhinolaryngol 77: 635–646\u003c/li\u003e\n\u003cli\u003eWang J, Yang X, Hao S et al (2022) The effect of ankyloglossia and tongue-tie division on speech articulation: A systematic review. Int J Paediatr Dent 32:144–156\u003c/li\u003e\n\u003cli\u003eAustralian Dental Association (2020) Ankyloglossia and oral frena consensus statement. June 5 https://www.ada.org.au/Dental-Prof essionals/Publications/Ankyloglossia-Statement/Ankyloglossia-and-Oral-Frena-Consensus-Statement_J.aspx\u003c/li\u003e\n\u003cli\u003eIto Y, Shimizu T, Nakamura T et al (2015) Effectiveness of tongue-tie division for speech disorder in children. Pediatrics International 57: 222–226 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://aomtinfo.org/wp-content/uploads/2017/02/Ttongue-tie-and-speech-disorder.pdf\u003c/li\u003e\n\u003cli\u003eZhao H, He X, Wang J (2024) Efficacy of infants release of ankyloglossia on speech articulation: A randomized trial. Ear Nose Throat J 103: 787–793\u003c/li\u003e\n\u003cli\u003eCarnino JM, Rodriguez Lara F et al (2024) Speech outcomes of frenectomy for tongue-tie release: A systematic review and meta-analysis. Ann Otol Rhinol Laryngol 133: 566–574\u003c/li\u003e\n\u003cli\u003eGonzalez Garrido MdP, Garcia-Munoz C, Rodriguez-Huguet M et al (2022) Effectiveness of myofunctional therapy in ankyloglossia: a systematic review. Int J Environ Res Public Health 19(19):12347, e1-18 https://www.researchgate.net/publication/363927722_Effectiveness_of_Myofunctional_Therapy_in_Ankyloglossia_A_Systematic_Review\u003c/li\u003e\n\u003cli\u003eMartinelli RLC, Marchesan IQ, Berrtin-Felix G (2014) Longitudinal study of the anatomical characteristics of the lingual frenulum and comparison to literature. Rev CEFAC 16:1202–1207\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eClassification of ankyloglossia\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"568\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 225px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttachment to tongue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttachment to oral floor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eTongue tip\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 225px;\"\u003e\n \u003cp\u003eTip (\u0026le;5 mm therefrom)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eAlveolar ridge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eAnterior membrane\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 225px;\"\u003e\n \u003cp\u003e\u0026le;1 cm from tip of tongue in infants (anterior half in children)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eAlveolar ridge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eTower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 225px;\"\u003e\n \u003cp\u003eCentral part of tongue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eSublingual folds\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003ePosterior (membrane, chord)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 225px;\"\u003e\n \u003cp\u003e\u0026gt;1 cm from tip of tongue in infants (posterior half in children)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp\u003eAt or behind sublingual folds\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eTongue-tie Assessment Score (for children, revised 2021)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"431\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e(1) \u0026nbsp;Attachment of lingual frenulum to tongue\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;2: posterior to midpoint\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1: anterior to midpoint\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;0: apex (\u0026le;5 mm from tip)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(2) \u0026nbsp;Attachment of lingual frenulum to oral floor\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;2: posterior to sublingual folds\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1: at sublingual folds\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;0: at alveolar ridge\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(3) \u0026nbsp;Appearance of tongue on protrusion\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;2: round\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1: slight cleft in tip\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;0: heart shaped\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 202px;\"\u003e\n \u003cp\u003e(4) \u0026nbsp;Protrusion of tongue\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;2: over upper lip\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1: over lower lip\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;0: inside lower lip\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(5) \u0026nbsp;Articulation, mastication, swallowing\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;2: undisturbed\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1: somewhat disturbed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;0: markedly disturbed\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cu\u003eTotal score \u0026nbsp; \u0026nbsp;( \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; )\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eScoring ranges: 0-3, severe; 4-5, moderate; 6-7, mild, Surgical indication: \u0026le;7\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Results of articulation function testing before surgery and at rehabilitation endpoints\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest item\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative baseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRehabilitation endpoint\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 106px;\"\u003e\n \u003cp\u003eWord accuracy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e35.2\u0026plusmn;9.5 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e45.2\u0026plusmn;6.7 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e23.7\u0026plusmn;9.1 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e41.2\u0026plusmn;11.7(18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026gt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e20.8\u0026plusmn;8.6 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e42.4\u0026plusmn;2.3 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 106px;\"\u003e\n \u003cp\u003eOmission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e2.4\u0026plusmn;8.3 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.6\u0026plusmn;1.8 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e4.6\u0026plusmn;5.9 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.4\u0026plusmn;0.6 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026gt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e2.3\u0026plusmn;3.1 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e0.3\u0026plusmn;0.7 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003ens\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 106px;\"\u003e\n \u003cp\u003eSubstitution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e6.5\u0026plusmn;7.6 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.8\u0026plusmn;3.8 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e14.1\u0026plusmn;10.7 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e2.6\u0026plusmn;4.3(18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026gt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e22.4\u0026plusmn;9.6 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.1\u0026plusmn;2.1 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 106px;\"\u003e\n \u003cp\u003eDistortion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e7.1\u0026plusmn;4.2 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e3.8\u0026plusmn;4.8 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e12.0\u0026plusmn;7.4 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e6.3\u0026plusmn;10.9 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026gt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e7.0\u0026plusmn;4.1 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e6.4\u0026plusmn;5.8 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 106px;\"\u003e\n \u003cp\u003eSpeech intelligibility\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e1.8\u0026plusmn;0.5 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.2\u0026plusmn;0.4 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e2.5\u0026plusmn;1.1 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.5\u0026plusmn;0.4 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026gt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e2.3\u0026plusmn;0.5 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.4\u0026plusmn;0.4 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 106px;\"\u003e\n \u003cp\u003eRange of tongue mobility\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e3.3\u0026plusmn;0.6 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.3\u0026plusmn;0.5 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e3.2\u0026plusmn;0.7 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.4\u0026plusmn;0.8 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026gt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003e3.0\u0026plusmn;0.5 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003e1.3\u0026plusmn;0.2 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTest items quantified as counts or \u003csup\u003e\u0026dagger;\u003c/sup\u003escores, expressed as mean \u0026plusmn; standard deviation values with patient totals (n)\u003cstrong\u003e, *\u003c/strong\u003e\u0026lt;0.001;\u003cstrong\u003e\u0026nbsp;**\u003c/strong\u003e\u0026lt;0.05; ns, not significant\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"ankyloglossia, tongue-tie, dysarthria, speech disorder, frenuloplasty, speech therapy","lastPublishedDoi":"10.21203/rs.3.rs-7288167/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7288167/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eTo assess the effectiveness of frenuloplasty and postoperative rehabilitation as remedies for speech disorders in children with ankyloglossia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eArticulation testing was done before and after surgery in 74 patients with ankyloglossia and dysarthria who underwent frenuloplasties. Overall evaluations included disease classification, Tongue-tie Assessment Score status, correctly pronounced word counts (word accuracy test), abnormal articulation profiling (omission, substitution, and distortion), speech intelligibility rating, and range of tongue mobility. Articulation testing took place at preoperative baseline and postoperatively at 1, 3, and 6 months, as well as at 1 year and on final days of any training required beyond 1 year. Test results were appraised in phases, examining patient groups at 6 months (n\u0026thinsp;=\u0026thinsp;39), 1 year (n\u0026thinsp;=\u0026thinsp;19), and \u0026gt;\u0026thinsp;1 year (n\u0026thinsp;=\u0026thinsp;8) of rehabilitation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eRehabilitation\u0026thinsp;\u0026ge;\u0026thinsp;6 months was necessary in 89.2% (66/74) of patients. Counts of correctly pronounced words gradually rose as a result. Both speech intelligibility and range of tongue mobility also steadily improved. In terms of abnormal articulation, omission and substitution increasingly declined after surgery, whereas distortion showed a slowing or heightened tendency at ~\u0026thinsp;3\u0026ndash;6 months.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eLong-term rehabilitation is required to correct dysarthria, once acquired. Ankyloglossia should be corrected before patients learn to speak.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Frenuloplasty and Postoperative Speech Rehabilitation in Patients with Ankyloglossia and Dysarthria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-14 09:58:39","doi":"10.21203/rs.3.rs-7288167/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-08-07T17:36:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-07T17:35:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"340165079514415562491512844803786995236","date":"2025-08-07T17:34:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-07T17:30:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-07T16:16:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-07T15:07:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2025-08-04T07:23:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"cb4e67fd-3dd2-432a-95cc-74b384af4eb7","owner":[],"postedDate":"August 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T16:33:25+00:00","versionOfRecord":{"articleIdentity":"rs-7288167","link":"https://doi.org/10.1007/s00383-025-06149-w","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2025-08-19 16:29:13","publishedOnDateReadable":"August 19th, 2025"},"versionCreatedAt":"2025-08-14 09:58:39","video":"","vorDoi":"10.1007/s00383-025-06149-w","vorDoiUrl":"https://doi.org/10.1007/s00383-025-06149-w","workflowStages":[]},"version":"v1","identity":"rs-7288167","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7288167","identity":"rs-7288167","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}