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Ankyloglossia:Doesitmatter?

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Ankyloglossia: does it matter?

M. Lauren Lalakea, MDa,b, Anna H. Messner, MDa,c,*aDivision of Surgery/Otolaryngology/Head & Neck Surgery, Stanford University,

Stanford, CA 94305, USAbDivision of Otolaryngology/Head & Neck Surgery, Santa Clara Valley Medical Center,

751 S. Bascom Avenue, San Jose, CA 95128, USAcLucile Salter Packard Children’s Hospital, Stanford Pediatric Otolaryngology, 725 Welch Road,

Palo Alto, CA 94304-5654, USA

An author nearly 40 years ago aptly commented that ‘‘much entertaining

nonsense has been written about tongue-tie’’ [1]. Tongue-tie (more formally

known as ankyloglossia) is a congenital anomaly characterized by an abnormally

short lingual frenulum, which may restrict mobility of the tongue tip. The clinical

significance of this anomaly and the best method of management have been the

subject of debate for some time [2]. Much of the controversy about management

of ankyloglossia probably is related to the paucity of relevant scientific data

demonstrating efficacy of intervention. To quote a prominent pediatrician (PD),

‘‘much of the information needed for making rational treatment decisions in cases

of tongue-tie is lacking’’ [3]. In a recent edition of a popular pediatric textbook,

only one sentence is devoted to the discussion of ankyloglossia [4]. The purpose

of this article is to summarize fact, fiction, and areas of controversy about

ankyloglossia, to create a greater awareness and understanding of this condition.

Historical context

Historical references to tongue-tie may be found beginning in biblical times:

‘‘. . .and the string of his tongue was loosened and he spoke plain,’’ (Mark 7:35). In

the eighteenth century, several references, as cited by Catlin and De Haan [5] and

Marmet et al [6], recommended clipping the frenulum in tongue-tied infants to

facilitate breast-feeding. Horton et al [7] reported that it was the habit of midwives

in this period to use their fingernails to divide the lingual frenulum of all infants.

Since that time, support for tongue-tie as a cause of feeding or speech problems

0031-3955/03/$ – see front matter D 2003, Elsevier Inc. All rights reserved.

doi:10.1016/S0031-3955(03)00029-4

* Corresponding author. Division of Surgery/Otolaryngology/Head & Neck Surgery, Stanford

University, Stanford, CA 94305, USA.

E-mail address: amessner@stanfordmed.org (A.H. Messner).

Pediatr Clin N Am 50 (2003) 381–397

has waxed and waned. By the early part of the twentieth century, strenuous op-

position was raised to the practice of frenotomy [6,7]. Moreover, by the 1940s,

some authors were quite vehement in their opinion that ankyloglossia should

never be considered causally related to speech difficulties of any type [8]. Current

opinion ranges from the belief that tongue-tie only rarely interferes with feeding or

speech, and generally requires no treatment [3,4]; to enthusiastic support for

frenotomy in the lactation literature [9–11]. Illustrating this diversity of opinion, a

recent article reported the results of a survey of hundreds of US and Canadian PDs,

otolaryngologists (OTOs), lactation consultants (LCs), and speech pathologists

(SPs), and concluded that there was little consensus among and within these

groups with regard to the significance of ankyloglossia or its management [2].

Incidence and natural history

Ankyloglossia is uncommon, but not rare. Incidence figures reported in the

literature vary widely, ranging from 0.02% to 4.8% [5,12–15]. Tongue-tie occurs

more commonly in males—with a male-to-female ratio on the order of 3 to 1, and

shows no racial predilection [13,14]. The variation in reported incidence may be

attributed, in part, to the lack of a uniform definition and objective grading

system for tongue-tie. In addition, some of the variation may reflect age-related

differences in the presence of this anomaly. Contemporary studies conducted in

well-baby nurseries have yielded incidence figures for neonates in the range of

1.7% to 4.8% [12–15]. Tongue-tie is thought to be less common in adults, al-

though there are no exact figures in this regard [3,5].

Ankyloglossia occurs most frequently as an isolated anatomic variation.

Increased prevalence has been noted in infants with a history of maternal cocaine

abuse (incidence = 10.4%, odds ratio = 3.5) [16]. Ankyloglossia also may occur

with increased frequency in association with various congenital syndromes,

including Opitz syndrome, orodigitofacial syndrome, and in association with

X-linked cleft palate [17–19].

There is little definitive information on the natural history of untreated ankylo-

glossia. Certain authors [1,7] have postulated (but not substantiated) that the short

frenulum can elongate spontaneously due to progressive stretching and thinning

of the frenulum with age and use. This explanation might account for the general

perception that this anomaly is more frequently seen in young children, as com-

pared with adults. There is, however, no prospective longitudinal data on the fate

of the congenitally short lingual frenulum. This lack of scientific data complicates

clinical decision making with regard to the need for treatment of ankyloglossia, if

any, and its timing.

Potential manifestations

Opinions range widely regarding the clinical significance of ankyloglossia.

Some authors feel that ankyloglossia is only rarely symptomatic [3,4], whereas

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397382

others believe it may lead to a host of problems, including infant feeding dif-

ficulties, speech disorders, and various mechanical and social issues related to the

inability of the tongue to protrude sufficiently [6,7,20–22]. The ankyloglossia

survey study mentioned above [2] found that as a group, PDs were less likely than

their OTO, SP, and LC colleagues to believe that this anomaly was associated with

symptoms of any kind. Ninety percent of PDs surveyed indicated that ankylo-

glossia is never or rarely a cause of feeding dysfunction, whereas 69% of LCs

stated that ankyloglossia was frequently or always associated with feeding dif-

ficulty. Seventy-seven percent of PDs noted that ankyloglossia is never or rarely a

cause of speech dysfunction, whereas only 40% of OTOs believed similarly. Last-

ly, 67% of OTOs as compared with 21% of PDs believed that tongue-tie is at least

sometimes associated with a variety of social and mechanical issues. Although

some of the above differences may reflect referral biases, it is clear that beliefs

about the significance of ankyloglossia are quite divergent. Information that is

relevant to the potential clinical manifestations of tongue-tie is outlined below.

Effect on feeding

With the increasing popularity of breast-feeding in the past 2 decades, there

has been a resurgence of interest in ankyloglossia as a cause of breast-feeding

problems [6,9]. Although much of the current literature relating to this topic is in

the form of case reports and small uncontrolled case series [6,11,23,24], many LCs

and some physicians believe that ankyloglossia can make breast-feeding difficult

for at least some infants with this condition [2,6,25]. Multiparous mothers who

have breast-fed their unaffected infant(s) successfully in the past note an obvious

difference when nursing a subsequent newborn with tongue-tie. Moreover, mothers

of affected infants frequently report a marked improvement in breast-feeding after

tongue-tie release. Problems reported previously include sore nipples, poor

latching and sucking mechanics, poor infant weight gain, and early weaning.

A recently published prospective study of infants with ankyloglossia has shed

some light on this controversy [14]. Mothers of 36 infants with ankyloglossia

noted at birth and mothers of a matched control group of unaffected newborns

were followed for up to 6 months to determine the incidence of breast-feeding

difficulties. There was no significant difference in the percentage of mothers with

affected infants as compared with mothers in the control group who were able to

successfully breast-feed for at least 2 months (83% and 92%, respectively). Breast-

feeding problems, defined as nipple pain lasting longer than 6 weeks or infant

difficulty latching onto the breast, occurred significantly more frequently in the

ankyloglossia group, however (25%, versus 3% for controls). This study con-

cluded that ankyloglossia may adversely affect breast-feeding in selected infants.

There is general agreement that infants with ankyloglossia do not have trouble

with bottle-feeding, nor with handling solid foods once they are introduced.

Bottle-feeding, however, should not be proposed as a solution for ankyloglossia-

related problems in a mother who otherwise desires to breast-feed. The role of

frenotomy in this situation is discussed later in the article.

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397 383

Effect on speech

The effect of ankyloglossia on speech has not been defined clearly. Although

speech problems historically have been viewed as the hallmark manifestation of

symptomatic tongue-tie, particularly among the lay public, others in the literature

have vociferously denied that any such relationship exists [8]. Current opinion

among speech therapists is evenly divided; 49% of those responding to a survey

on this topic believed that ankyloglossia was never or rarely associated with

speech problems, and an equal number believed that it was sometimes or

frequently associated with speech problems [2].

Anecdotal evidence indicates that some children with ankyloglossia develop

normal speech, and compensate for limited tongue-tip mobility without surgical

repair or need for speech therapy [1,7,21]. In at least some individuals, however,

tongue-tie contributes to articulation errors or difficulty with the rate and range of

articulation, thereby decreasing speech intelligibility [1,7,20,21,26]. Speech

sounds that may be affected by impaired tongue-tip mobility include lingual

sounds and sibilants such as T, D, Z, S, TH, N, and L [1,5,27]. The compensatory

techniques used by children with ankyloglossia typically include restricted mouth

opening while speaking, and alternate tongue placement for sounds requiring

tongue-tip elevation.

An excellent study by Fletcher and Meldrum [20] provided strong evidence

regarding the relationship of tongue mobility to speech articulation. In this study,

normal children, 11 to 12 years of age, underwent careful intraoral measurements

of the relative lengths of the tongue and frenulum, to determine the ratio of ‘‘free’’

tongue to total tongue length. Participants were separated into ‘‘limited lingual

freedom’’ and ‘‘greater lingual freedom’’ groups on this basis. These investigators

found a highly significant increase in the number of articulation errors in the

limited lingual freedom group as compared with the greater lingual freedom

group, and concluded that these findings might be particularly pertinent to the

entity of ankyloglossia.

When present, the severity of the articulation problems in affected individuals

may vary; problems may be so pronounced as to be evident at the single word

level, or be mild enough so as to be noticeable only in connected speech. In our

experience, up to one half of young children with ankyloglossia referred for

otolaryngology evaluation will have articulation difficulties that may be detected

in the context of a formal speech pathology consultation [26]. In addition, among

adults with ankyloglossia, even those with grossly normal speech still may

complain of speech problems, believing that their speech is more effortful than

that of others.

It is important to keep in mind that ankyloglossia is not a cause of speech

delay. Children with ankyloglossia are expected to acquire speech and language

at a normal rate, although some may experience articulation difficulties for

certain speech sounds, as indicated above. Occasionally, parents and others who

care for a child with speech delay may erroneously ascribe the delay to tongue-

tie, and demand surgical intervention in the hope that normal speech and

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397384

language will result. In such a patient, potential causes of speech delay should be

sought carefully, and the patient should be directed for other evaluations as ap-

propriate (eg, audiologic, speech/language, or neurodevelopmental assessments).

Surgical repair may be considered at a later time, once the child has been eval-

uated fully, and other issues have been addressed.

Mechanical and social effects

The potential mechanical and social consequences of ankyloglossia have re-

ceived little attention in the medical literature. Many clinicians are unaware that

tongue-tie may have consequences beyond those of speech and feeding difficul-

ties [2]. Mechanical problems related to tongue-tie may include difficulty with

intraoral toilet (licking the lips and sweeping the teeth free of food debris), local

discomfort or cuts beneath the tongue, dental issues such as a diastasis between

the lower central incisors due to pressure from a tight frenulum, and difficulty

wearing dentures later in life due to poor fit. Other issues that may be associated

with limited lingual range of motion may include decreased facility in playing a

wind instrument, difficulty licking an ice cream cone, and difficulty with ‘‘french

kissing’’ [1,21,28,29]. In addition, as might be expected, these types of symptoms

may be accompanied by a sense of social embarrassment, due to teasing and ridi-

cule from peers [30,31].

In our experience, approximately 50% of older children and adults with

persistent ankyloglossia report one or several of the above complaints when their

presence is sought in the course of obtaining a complete problem-directed history.

These mechanical limitations and social issues may occur even in the absence of

other ankyloglossia-related complaints (ie, without a history of feeding or speech

problems). It is important to note that mechanical and social concerns may not

manifest until later in childhood. Younger children indeed may have symptoms,

but may not recognize or be able to report them. In addition, complaints related to

activities such as playing a wind instrument and kissing, and issues relating to

teasing and ridicule from peers, may not become apparent or relevant until later

childhood and beyond. Finally, owing to a sense of embarrassment regarding

their condition, patients may refrain from expressing or volunteering their

concerns unless questioned directly.

Diagnosis

Although the diagnosis of ankyloglossia may be suggested by history, it is

confirmed by characteristic physical examination findings. The frenulum may be

thick and fibrous or thin and membranous, and is abnormally short, inserting at or

near the tongue tip (Figs. 1, 2). The tongue may have a notched or heart shape on

protrusion, due to tethering by the frenulum (Fig. 3). Protrusion is limited, and in

some cases, may fail to extend past the lower lip. The tongue may appear to roll

or curl with attempted protrusion as the midportion of the tongue moves forward,

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397 385

while the tip itself is drawn inferiorly by the frenulum with little forward exten-

sion. Affected individuals also characteristically will have difficulty lifting or

elevating the tip of the tongue toward the upper dentition and upper lip. Patients

may be completely unable to lift the tongue, or in those cases when they are able

to elevate the tip to some degree, there is often dimpling noted behind the tongue

tip due to tethering. Side-to-side motion of the tongue may be impaired as well. A

space or diastasis between the lower teeth is occasionally present, due to the

repeated thrusting action of the frenulum through the teeth with attempted tongue

protrusion (Fig. 4).

Fig. 1. One-day-old male with mild ankyloglossia and difficulty latching onto the breast.

Fig. 2. Preschooler with moderate ankyloglossia and articulation problems.

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397386

A variety of schemas have been proposed to verify the presence of ankylo-

glossia and grade its severity. Hazelbaker [32], an LC, devised an ‘‘Assessment

Tool for Lingual Frenulum Function’’ to be used with neonates. This tool eval-

uates seven tongue movements, including lateralization, lift, extension, spread of

anterior tongue, cupping, peristalsis, and snap-back. Each movement is graded on

a 0 to 2 scale; if an infant scores poorly, frenotomy is recommended.

Fig. 3. Heart-shaped tongue on protrusion.

Fig. 4. Four-year-old male with diastasis between his lower central incisors due to ankyloglossia.

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397 387

Kotlow [28] used a measurement termed ‘‘free’’ tongue (distance in mm from

tongue tip to the insertion of the frenulum) to divide tongue-tie into four classes:

mild, moderate, severe, and complete. Unfortunately, this classification scheme

failed to provide any documentation regarding the correlation of ankyloglossia

class to clinical symptoms. Others [20,33] have used more detailed ratios of

lingual dimensions to assess tongue-tie in the older child, and have documented

a relationship between these measures and speech articulation. Owing to lack of

cooperation and difficulties measuring this mobile muscle, however, these in-

vestigators resorted to the use of general anesthesia to accomplish this assessment

in young children [20,33]. Williams and Waldron [27] proposed an alternate

method, designed to measure lingual function, rather than a physical dimension.

These authors recommended measuring the maximum ability of the patient to

elevate the tongue, by asking the patient to touch the tip of his or her tongue to

the upper teeth, and then open the mouth as widely as possible while maintaining

contact. While the patient holds this position, the distance between the upper and

lower central teeth, or interincisal distance, is recorded in millimeters (Fig. 5).

The interincisal distance is thus used as an objective measure of tongue elevation

ability; unfortunately, these authors [27] did not obtain normative data nor did

they document clinical correlation.

Despite the varied attempts listed above to quantify ankyloglossia severity, at

present there is no way to predict—based on examination findings—which

children are likely to have, or to develop, speech or mechanical symptoms related

to their ankyloglossia. Ability to protrude the tongue past the lower lip has been

used by some in the past as a quick rule of thumb to predict which patients will not

require surgical repair [1]. In our personal experience with treating children with

ankyloglossia, however, we have found that those with an associated articulation

disorder (as documented on formal speech pathology assessment) will often be

able to protrude the tongue 15 mm or more beyond the lower dentition [26].

Fig. 5. Interincisal distance. The tongue is placed at the back posterior edge of the upper teeth and

the mouth is maximally opened. Measurement (in millimeters) is taken between the teeth. (From

Lalakea ML, Messner AH. Frenotomy and frenuloplasty: if, when, and how. Op Tech Otolaryngol

2002;13:95; with permission.)

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397388

In our practice, we measure lingual mobility in children who are able to co-

operate for protrusion (measured in millimeters of tip extension past the lower

dentition) (Fig. 6), and elevation (as measured by recording interincisal distance

with the tongue tip maximally elevated and in contact with the upper teeth).

Although these measurements may not predict necessarily the presence or absence

of symptoms, they provide objective documentation of tongue mobility and help

to define the degree of restriction. We have found that protrusion and elevation

values are typically in the range of 15 mm or less in children with ankyloglossia,

and 20 to 25 mm or greater in normal children [26]. Moreover, mobility mea-

surements are a valuable tool in documenting change, particularly preoperatively

and postoperatively.

Indications for intervention

History and physical examination generally are sufficient to confirm the pres-

ence of ankyloglossia, and supplemental evaluations are not required to establish

whether a child may be considered a candidate for surgery. When the presenting

problem relates to breast-feeding difficulty, consultation with a lactation specialist

Fig. 6. Tongue protrusion. Measurement (in millimeters) taken from the lower incisors to the tongue

tip. (From Lalakea ML, Messner AH. Frenotomy and frenuloplasty: if, when, and how. Op Tech

Otolaryngol 2002;13:94; with permission.)

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397 389

is an option—particularly if the degree of restriction appears quite mild—to rule

out other contributing factors. When the patient’s primary complaint is speech

difficulty, a formal speech evaluation may be helpful if the relationship of the

ankyloglossia to the speech disorder is in doubt. A failed trial of speech therapy is

not a requirement before surgical repair is considered.

Patients with ankyloglossia with obvious or definite indications for surgery

include infants with associated breast-feeding difficulties, young children with

characteristic articulation problems, and older children and adults adversely affect-

ed by the mechanical and social manifestations of this condition. There are other

relative indications (discussed below); however, the timing of intervention and the

benefit of surgery in these alternate clinical scenarios are more controversial.

The optimal timing for surgery has not been determined. Some investigators

have advocated surgical intervention prior to the development of speech dif-

ficulties [22,25], whereas others have mandated withholding surgery until age 4

or more, and then offering surgery only to those with a manifest speech problem

[1,3,7]. Current opinion is no less varied; in a recent survey regarding ankylo-

glossia treatment, 34% of OTOs believed that surgery was inappropriate in

children less than 1 year of age, 36% believed surgery could be performed at any

age, and 42% believed surgery to be inappropriate (and perhaps less effective) for

those 12 years of age or older [2].

In our view, given the minor nature of the surgery and the significant potential

for speech difficulties and later social and mechanical problems, it may be

appropriate to consider surgery for those children with significant ankyloglossia

at any age, including infants and toddlers who have yet to demonstrate overt

symptoms. When very young children are referred for evaluation, we inform pa-

rents that there is no way to predict which children will develop symptoms related

to their condition, and which children may remain asymptomatic or later outgrow

their condition. We do, however, present information regarding the potential early

and late consequences of ankyloglossia and solicit parental opinion with respect to

treatment preferences. Although early intervention in all children before the

development of speech problems may be unwarranted, delaying intervention until

obvious difficulties emerge may commit some children unnecessarily to a period

of rehabilitative speech therapy or social embarrassment.

One additional consideration when evaluating an infant with ankyloglossia is

that up to several months of age, a frenotomy can be performed quickly in the

clinic without requiring general anesthesia. In contrast, if surgery is deferred until

the child is older than 1 year of age, general anesthesia in the operating room

usually is required. Cooperative children older than 6 to 7 years of age usually

can undergo repair under local anesthesia, but deferring surgery until this age can

subject a child to an unnecessarily long period of symptoms or social concerns.

Therefore, our practice is to discuss these issues with parents, who may elect

early intervention at their discretion, or may prefer to wait and elect surgery only

if and when symptoms occur.

There are no absolute contraindications to surgery; however, as noted earlier,

children with apparent speech delay should be approached with caution, and

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397390

surgery should be deferred until the child has been evaluated and treated by other

specialists as appropriate.

Alternatives to surgery

Alternatives to surgery include observation or a trial of speech therapy. The

wait-and-see approach may be considered for the young child with minimal

symptoms, because it is possible that the child will outgrow the ankyloglossia, or

compensate sufficiently so that future clinically significant speech or mechanical

problems will not occur.

In the child with speech difficulties, speech therapy may correct articulation

errors successfully in some cases, although SPs vary in their degree of optimism

for this approach [2]. One disadvantage of speech therapy is that it may require a

lengthy period during which time the child may be self-conscious about his or her

impairment. The benefit of speech therapy must be weighed against surgical

treatment that, although invasive, is simple, quick, and effective. Another dis-

advantage is that although speech therapy may allow the child to improve his or

her articulation over time by using various compensatory mechanisms, it may still

leave him or her vulnerable to later manifesting mechanical problems associated

with restricted lingual mobility.

Surgical procedures

Frenotomy, or simple release of the frenulum, and frenuloplasty (release with

plastic repair) are the two most commonly used surgical procedures in the

treatment of ankyloglossia. As noted above, appropriate patient selection and

ideal age for intervention have been topics of much disagreement. Past reports of

complications and the lack of clearly agreed-on measures of success have

contributed to the debate.

Frenotomy

Frenotomy (Fig. 7) also has been termed ‘‘clipping’’ of the frenulum, and is

most appropriate for the treatment of ankyloglossia in infants (eg, for breast-

feeding problems) because it is rapid and relatively easy to accomplish. The pro-

cedure may be performed at the bedside in the newborn nursery, or in the office

with local or no anesthesia. Practitioners who typically perform frenotomy in-

clude OTOs, dentists, and PDs. Interestingly, 22% of a group of 425 US and Ca-

nadian PDs who responded to a survey for a recent paper on this topic indicated

that they had performed frenotomy, although only 10% reported that they had

been taught this skill in residency [2].

Although some practitioners use local anesthesia, in our experience, the

discomfort associated with the release of thin and membranous frenula is brief

and quite minor. The infant is positioned in front of the clinician with his or her

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397 391

head directed toward the clinician’s left (if the clinician is right handed). Two

gloved fingers of the clinician’s left hand are placed below the tongue on either

side of midline, to retract it upward toward the palate, exposing the frenulum.

Small sterile scissors are used to release the frenulum, beginning at its free border

and proceeding posteriorly directly adjacent to the tongue to avoid injury to the

(more inferiorly placed) submandibular ducts in the floor of mouth. Occasionally,

complete release may be accomplished with a single scissor cut, but more

frequently, especially when the frenulum is quite tight, two or three sequential

cuts are required; each cut provides some release, allowing improved retraction

and visualization for subsequent cuts, if necessary. Bleeding is generally slight,

although the amount of blood may appear greater due to mixing with saliva. If

needed, bleeding can be controlled easily with a brief period of pressure applied

with a 2� 2-inch gauze. The incision is not sutured, and the infant is allowed to

feed immediately following the procedure. Acetaminophen may be used for pain

control, but often is not required. Antibiotic therapy is unnecessary. The patient

may be seen in follow-up in 1 to 2 weeks as needed; generally by that time the

incision has healed completely. Once the practitioner has sufficient experience

with the procedure, telephone follow-up may be appropriate as long as the patient

is doing well.

Frenuloplasty

Frenuloplasty (Fig. 8) is the preferred procedure for most patients greater than

1 to 2 years of age, because it allows for more complete release of the tongue-tie.

In addition, because a plastic closure is performed, some surgeons believe that the

chance of scarring and recurrent ankyloglossia is reduced. In young children, the

Fig. 7. Frenotomy. (From Lalakea ML, Messner AH. Frenotomy and frenuloplasty: if, when, and how.

Op Tech Otolaryngol 2002;13:95; with permission.)

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397392

procedure is performed using a brief general anesthetic, whereas in older children

and adults, it can be accomplished easily in the clinic using a local anesthetic. The

frenulum is released in a manner identical to that used for frenotomy. Occasion-

ally, limited division of the genioglossus muscle may be required to effect

adequate release. The resulting wound is closed with sutures. Some surgeons use

a z-plasty flap closure, and others prefer to close the diamond-shaped defect

created by the initial horizontally oriented release in a vertical manner (hori-

Fig. 8 A-C. Horizontal to vertical frenuloplasty. (A) the incision line; (B) the resulting defect; and

(C ) the closure line. (From Lalakea ML, Messner AH. Frenotomy and frenuloplasty: if, when, and

how. Op Tech Otolaryngol 2002;13:96; with permission.)

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397 393

zontal-to-vertical plasty). Both methods cover the exposed raw surface and result

in additional lengthening of the frenulum. Frenuloplasty is only slightly more

involved than is simple frenotomy, and requires only minutes to perform.

Bleeding is generally minimal, and is controlled with pressure or cautery. Patients

are advised to resume a normal diet as tolerated. As a rule, patients report little in

the way of postoperative discomfort, and may use acetaminophen as needed for

pain. Antibiotics are not required. When patients are old enough to comply, we

ask them to perform a series of tongue exercises several times daily for the first

4 to 6 weeks postoperatively, with the expectation that this practice may en-

hance mobility, assist in retraining of tongue musculature, and reduce the poten-

tial for scarring.

Surgical outcome

The results of frenotomy and frenuloplasty for ankyloglossia are highly fa-

vorable, provided that surgical indications are met and patients are appropriately

selected for intervention. In children and adults, tongue mobility measures

predictably improve in the first 1 to 3 months following surgery, and tend to

remain stable after that time. Postoperatively, patients may be expected to gain

10 mm or more of tongue protrusion and tongue elevation on average, as com-

pared with preoperative measures of mobility [26]. In addition, significant sub-

jective gains may be anticipated as well; a majority of parents/patients report that

they are highly satisfied with these procedures.

Frenotomy has been reported to result in immediate improvement in problems

related to breast-feeding in a majority of cases [6,9,30]. There are multiple

anecdotal reports in the lactation literature describing rapid resolution of maternal

nipple pain, better latching, and enhanced infant weight gain [10,11,23,24]. In

our practice, it is not uncommon for mothers to note a marked difference in

nursing mechanics as early as the first feeding after frenotomy. Frenotomy is

not a panacea for all breast-feeding problems, however; when the degree of

ankyloglossia is minimal, or there is doubt as to the contribution of tongue-tie

to nursing problems, it may be wise to obtain a lactation consultation or to

counsel the mother appropriately regarding expectations before proceeding

with frenotomy.

Speech results following frenuloplasty are good, assuming that patients who

are chosen for surgery have articulation problems characteristic of tongue-tie, and

not speech and language delay or an unrelated speech issue. More than 75% of

such children will have demonstrable improvements in articulation as judged by

an SP postoperatively as compared with preoperatively [26]. Supplemental

speech therapy may be required in the remaining minority to effect retraining

of tongue musculature and correction of preoperative compensatory strategies.

Although surgery alone may not be fully corrective in all patients, it may allow

those with a residual speech deficit to progress more quickly in a program of

speech therapy. Because lingual mobility improves quite reliably, one additional

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397394

benefit of surgery in this setting is that it presumably will reduce the chances of

other, later-presenting mechanical and social problems as well.

Frenuloplasty appears to be equally effective in the treatment of mechanical

problems related to tongue-tie, even when surgery is not performed until late

childhood [21]. Following frenuloplasty, patients frequently report greater facility

with activities such as licking the lips, licking an ice cream cone, using the tongue

to sweep the teeth free of debris, kissing, and playing a wind instrument, as well as

a decrease in local discomfort and cuts beneath the tongue. Interestingly, patients

often will note improvement in some of these activities even when they failed to

perceive a limitation preoperatively. For example, a patient may be aware only in

hindsight that he or she was unable to lick the lips, when comparing this newfound

ability to his or her preoperative status; a patient who has never experienced

normal lingual mobility may not fully recognize the extent of his or her limitations

until presented with a new frame of reference. Approximately half of our own

adolescent and adult patients with uncorrected ankyloglossia have commented that

they wished their condition had been repaired earlier in childhood.

Complications of frenotomy and frenuloplasty reported historically include

infection, excessive bleeding, recurrent ankyloglossia due to excessive scarring,

one case of a new speech disorder developing postoperatively, and ‘‘tongue

swallowing’’ or glossoptosis due to excessive tongue mobility [1,7,8,29]. Con-

temporary literature suggests that complications of frenotomy and frenuloplasty

are rare. In our experience, and that of others [2,30], frenotomy is quite safe when

performed by those who are comfortable and familiar with the procedure. Simi-

larly, frenuloplasty has had an excellent safety record in the current literature; no

complications were recorded in a recent series of 158 procedures [21].

Among the potential complications of surgery for tongue-tie, recurrent

ankyloglossia is the most common [2]. Some surgeons believe that recurrence

is less likely with frenuloplasty as compared with simple frenotomy. When it

occurs, recurrent ankyloglossia is generally less severe than at original presenta-

tion, and may respond favorably to revision surgery.

Summary

Ankyloglossia is an uncommon oral anomaly that can cause difficulty with

breast-feeding, speech articulation, and mechanical tasks such as licking the lips

and kissing. For many years the subject of ankyloglossia has been controversial,

with practitioners of many specialties having widely different views regarding its

significance. In many children, ankyloglossia is asymptomatic; the condition may

resolve spontaneously, or affected children may learn to compensate adequately

for their decreased lingual mobility. Some children, however, benefit from sur-

gical intervention (frenotomy or frenuloplasty) for their tongue-tie. Parents

should be educated about the possible long-term effects of tongue-tie while their

child is young (< 1 year of age), so that they may make an informed choice

regarding possible therapy.

M.L. Lalakea, A.H. Messner / Pediatr Clin N Am 50 (2003) 381–397 395

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