A pediatrician asked her partner if she had also been seeing an increase in parents being told their newborn had a lingual tongue-tie. “This is the third family today,” she said, “They can’t all have one.” Her partner replied that she had noted the increase too, and was concerned about unnecessary procedures being performed, their potential complications and their cost. “I agree that some babies and Moms would benefit from cutting the tongue-tie, but probably not at this rate,” she remarked.
The anterior 2/3s of the tongue is formed from the 2 lateral lingual swellings fusing with the tuberculum impar and then separating from the mouth’s floor to form the lingual sulcus. Separation failure can result in anchoring of the tongue to varying degrees. Frenula are soft tissue structures which attach and support other oral structures. The lingual frenula attaches the tongue to base of mouth. Labial frenula are located centrally and attach the lips to the alveolar ridges. Often less prominent are the buccal frenula which are on the labial side and are smaller and more lateral to the labial frenula, usually being located around the canine and premolar areas.
Ankyloglossia or “tongue tie” is a “…condition of limited tongue mobility caused by a restrictive lingual frenulum.” The term “anterior” ankyloglossia refers “…to a lingual frenulum that extends to the tip of the tongue or near the tip of the tongue and restrict tongue mobility.” Posterior ankyloglossia for some professionals refers to the frenulum inserting into a posterior position on the tongue, with some people meaning it to insert submucosally. Other professionals do not feel it exists. In a recent consensus statement, the group could not reach actual consensus on this term. Buccal ankyloglossia “…has been used to describe a perceived tightness in the maxillary and/or mandibular buccal frenula.” Tight labial frenula are sometimes referred to as “lip ties.” While there are some classifications for lingual ankyloglossia, the professionals writing a recent consensus article could not recommend a preferred system.
The incidence of tongue-tie ranges from 2.8-10.7% depending on the study, and even up to 59% in healthy newborns in another. “There has been an increase in diagnosis of tongue-tie by 834% from 1997-2012 with a similar increase in the number of frenotomy procedures performed over the same time period.”
Tongue-ties are a hot topic that is very controversial. Consensus on the terminology and how to apply it to studies is lacking and makes it difficult to perform higher quality studies. Usually severe ankyloglossia is easily agreed upon, but moderate or mild causes more problems among professionals and in studies. Therefore studies may show associative effects but data for causal effects and treatment outcomes are often lacking.
Tongue-ties can have effects depending on the age and pattern. It is important to note that ankyloglossia may be present but does not cause any problems at all, and also if ankyloglossia is treated with frenotomy, it also may not fix the problem, as many of the problems listed below are multi-factorial.
- Breastfeeding – this is probably the most common potential clinical problem and also a very common indication for potential frenotomy. Breastfeeding is a serious issue for the maternal-child dyad as well as for public health.Breastfeeding success or lack of is multifactorial with both maternal, infant and society playing multiple roles. Breastfeeding support along with time usually improves most breastfeeding problems. Positioning is one of the most important as significant percentages (70-90% in some studies) of maternal-child dyads with breastfeeding problems are found to have positioning problems. Frenotomy treatment is not a quick fix to breastfeeding problems.
In a consensus statement, professionals said: “Breastfeeding difficulty can often improve with time and nonsurgical intervention by a lactation consultant or speech pathologist who specializes in breastfeeding issues.”
Treatment with standardized clinical pathways for supporting breastfeeding and avoiding unnecessary surgery have shown a decrease from 11.3% to 3.5% without decreasing breastfeeding success.
- Speech articulation – “…the quality of the evidence regarding speech outcomes is low and definite conclusions cannot be drawn.” Frenotomy in infancy is generally not considered an indication for this potential future risk but older aged children are sometimes considered for it.
- Oral hygiene and caries prevention – as the tongue helps to clean the oral cavity, but many people even with ankyloglossia do not have any problems.
- Dental occlusion and craniofacial development – data for causal effects is lacking
- Functional/social – difficulties with daily activities such as kissing, licking foods, wearing dental appliance and playing an instrument are often not listed in the literature but can be concerns for older children, teens and families. These potentially can be reasons for frenotomy
Frenotomy or cutting of the frenulum is the most common procedure, being commonly performed in the outpatient setting. Frenuloplasty or cutting and re-alignment or tissues, or frenectomy or cutting and removal or tissues are other frenular procedures. Frenotomy complications commonly include pain, minor site bleeding, with risks to damaging the salivary ducts located near the lingual frenulum. Other potential complications include scaring, oral aversion, substantial bleeding including hypovolemia, hematoma, infection, oral edema, respiratory difficulty and problems handling oral secretions. Patients with underlying facial or genetic problems should be evaluated carefully before frenotomy is performed as it could cause additional problems. For example with Pierre Robin sequence, freeing the tongue may cause worsening glossoptosis.
Lingual frenula ties have been purported to be associated with “midline diastema between the teeth, increased caries and periodontal disease, gingival regression, difficulty in wearing denture or retainers, difficulty with lip mobility, and possible esthetic or psychological consequences.” Data on lingual frenula ties for breastfeeding is also controversial.
Questions for Further Discussion
1. What are your personal indications for frenotomy?
2. How do you support breastfeeding?
- Disease: Ankyglossia | Tongue Disorders
- Symptom/Presentation: Eating Disorders
- Specialty: Dentistry / Orthodontia | Otolaryngology | Speech and Hearing
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Tongue Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Walsh J, Links A, Boss E, Tunkel D. Ankyloglossia and Lingual Frenotomy: National Trends in Inpatient Diagnosis and Management in the United States, 1997-2012. Otolaryngol Head Neck Surg. 2017;156(4):735-740. doi:10.1177/0194599817690135
Messner AH, Walsh J, Rosenfeld RM, et al. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg. 2020;162(5):597-611. doi:10.1177/0194599820915457
Colombari GC, Mariusso MR, Ercolin LT, Mazzoleni S, Stellini E, Ludovichetti FS. Relationship between Breastfeeding Difficulties, Ankyloglossia, and Frenotomy: A Literature Review. The Journal of Contemporary Dental Practice. 2021;22(4):452-461. doi:10.5005/jp-journals-10024-3073
Walsh J, McKenna Benoit M. Ankyloglossia and Other Oral Ties. Otolaryngol Clin North Am. 2019;52(5):795-811. doi:10.1016/j.otc.2019.06.008
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa