Policy on Management of the Frenulum in Pediatric Patients

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 71

ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM

Purpose

e American Academy of Pediatric Dentistry (AAPD) recog-

nizes that a restrictive oral frenulum may aect a child’s health

by hindering the ability to breastfeed or speak. e frequency

of surgical intervention has increased exponentially over the

last two decades.

1-4

e AAPD recognizes an evidence-based

policy on frenula would make information more accessible

to dentists, physicians, other allied health professionals, and

parents and help reduce the number of unnecessary or

incorrectly-timed procedures.

Methods

This policy, developed by the Council of Clinical Affairs in

2019

, is based on a review of current dental and medical lit-

erature and sources of recognized professional expertise and

stature, including both the academic and practicing health

communities, related to frenula/frenotomies. In addition,

literature searches of PubMed

/MEDLINE, Web of Science,

and Google Scholar databases were conducted using the

terms: ankyloglossia, ankyloglossia AND breastfeeding out-

comes, breastfeeding with ankyloglossia and/or upper lip tie,

gastroesophageal reux, frenotomy, frenulotomy, frenectomy,

frenulectomy, systematic reviews of ankyloglossia other than

breastfeeding, lip-tie, superior labial frenulum, maxillary lip-tie,

breastfeeding cessation, frenum, frenulum, tongue-tie, speech

articulation with lingual frenulum, frenuoplasty, midline

diastema, lactation diculties, nipple pain with breastfeeding,

Hazelbaker Assessment Tool for Lingual Frenulum Function

(ATLFF), Infant Breast-feeding Assessment Tool (IBFAT),

LATCH grading scales, mandibular labial frenulum, perio-

dontal indications for frenectomy, gingival recession associated

with midline diastema; fields: all; limits: within the last 10

years, English. One thousand six hundred twenty-two articles

matched these criteria. Papers for review were chosen from

this list and from references within selected articles. Expert

and/or consensus opinion by experienced researchers and

clinicians also was considered.

Definitions

Ankyloglossia: a congenital developmental anomaly of the

tongue characterized by a short, thick lingual frenulum result-

ing in limitation of tongue movement (partial ankyloglossia)

or by the tongue appearing to be fused to the floor of the

mouth (total ankyloglossia).

6,7

Frenectomy/frenulectomy: the complete removal of the frenum/

frenulum including its attachment to underlying bone.

Frenotomy/frenulotomy: simple cutting or incision of the

frenum/frenulum.

Frenuloplasty: an extensive frenulum excision that usually

involves repositioning of aberrant muscle and is closed by Z-

plasty or a local ap with placement of sutures.

Frenulum: a mucosal attachment containing muscle and

connective tissue fibers which connect intraoral structures

such as the lip and cheek to the alveolar mucosa, gingiva, or

periosteum.

Background

Typically, seven frenula are present in the oral cavity, most

notable the maxillary labial frenulum, the mandibular labial

frenulum, the lingual frenulum, and four buccal (cheek)

frenula.

eir primary function is to provide stability of the

upper lip, lower lip, and tongue.

Frenulum attachments and

their impact on oral motor function and development are

topics of interest within the dental community as well as

various healthcare specialties. Studies have shown dierences

in treatment recommendations among pediatricians, otolaryn-

gologists, lactation consultants, speech pathologists, surgeons,

and dental specialists.

6,12-19

Regardless of the etiology, a 834

percent increase in diagnosed cases of ankyloglossia and an

866 percent increase in frenulum procedures have been re-

ported from 1997 to 2012.

When the data over this time

span is examined more closely, the average percentage of

patients diagnosed with ankyloglossia undergoing surgical

procedures is 33 percent.

Most recently, 35 percent of patients

in 2009 received surgery as did 38 percent in 2012.

In 2020,

a panel of pediatric otolaryngologists released a consensus

statement on the diagnosis, management, and treatment of

ankyloglossia in children less than 18 years old.

Maxillary frenulum

A prominent maxillary frenulum in infants, children, and

adolescents, although a common finding, can be a concern

to parents. e maxillary labial frenulum attachment can be

classied with respect to its anatomical insertion level

Revised

2022

Policy on Management of the Frenulum in

Pediatric Patients

How to Cite: American Academy of Pediatric Dentistry. Policy on

management of the frenulum in pediatric patients. The Reference

Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of

Pediatric Dentistry; 2023:71-6.

ABBREVIATION

AAPD: American Academy of Pediatric Dentistry.

ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM

72 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

1. mucosal (frenal fibers are attached up to the muco-

gingival junction);

2. gingival (frenal bers are inserted within the attached

gingiva);

3. papillary (frenal fibers are extending into the inter-

dental papilla); and

4. papilla penetrating (frenal fibers cross the alveolar

process and extend up to the palatine papilla).

e most commonly observed types are mucosal and gingi-

val.

18,19

However, a maxillary frenulum is a dynamic structure

that presents changes in position of insertion, architecture, and

shape during growth and development.

Evidence suggests

apical migration of the insertion as the alveolar process grows

and descends and the frenulum remains in place.

19,20

Infants

have the highest prevalence of papillary penetrating pheno-

type.

In severe instances, a restrictive maxillary frenulum

attachment has been associated with breastfeeding and bottle-

feeding difficulties among newborns.

21-24

However, in a

prospective study, anatomical classification of the maxillary

frenulum alone was not correlated with breastfeeding success

or diculty, pain, or maternally-reported poor latch.

Studies

suggest a restrictive maxillary frenulum may inhibit an airtight

seal on the maternal breast through flanging of both lips.

22-

24,26

For this reason, future studies focusing on assessment of

upper lip exibility and the ability to ange rather than just

anatomical point of insertion may provide more information.

e maxillary frenulum can contribute to reux in babies due

to the intake of air from a poor seal at the breast or bottle

leading to colic or irritability.

24,27

With the lack of understand-

ing of the function of the labial frenulum, the universality of

the labial frenulum, and level of attachment in most infants,

the release of the maxillary frenulum based on appearance

alone cannot be endorsed.

Although a causal relationship

between a hyperplastic maxillary frenum and facial caries has

not been substantiated, anticipatory guidance for patients with

restrictive tissues may include additional oral hygiene measures

(e.g., swabbing the vestibule after feeding).

Surgical removal of the maxillary midline frenulum may be

related to presence or prevention of midline diastema forma-

tion, prevention of post orthodontic relapse, esthetics, and

psychological considerations.

16-18,30

Treatment options for

midline diastema and sequence of care vary with patient age

and can include orthodontics, restorative dentistry, frenectomy,

or a combination of these.

Treatment is suggested (1) when

the attachment exerts a traumatic force on the gingiva caus-

ing the papilla to blanch when the upper lip is pulled, or (2) if

the attachment causes a diastema wider than two millimeters,

which is known to rarely close spontaneously during further

development.

18,30,31

When a diastema persists into the perma-

nent dentition, the objectives for treatment involve managing

both the diastema and its etiology.

Pediatric dentists and

orthodontists generally agree that most diastemas in the primary

and mixed dentitions are normal, are multifactorial, and tend

to close with maturity; therefore, any surgical manipulation of

the frenulum is not recommended before the permanent canines

erupt and only following orthodontic closure of the space

30,32

or in conjunction with orthodontic treatment

. This was

recently armed in a systematic review.

Certain surgical inter-

ventions, when performed too early, may result in orthodontic

relapse due to scarring.

A recent retrospective cohort study

saw a decrease in maxillary midline diastema width when la-

ser labial frenectomy was performed in both the primary and

mixed dentitions.

Whether or not this early treatment can

prevent the need for orthodontic closure of a persistent di-

astema in adolescence would best be demonstrated by a

prospective investigation utilizing controls with long-term

follow up, which was not present in this study.

Mandibular labial frenulum

A high frenulum sometimes can present on the labial aspect

of the mandibular ridge. is most often is seen in the perma-

nent central incisor area but also can be found by the canine.

e mandibular labial frenulum occasionally inserts into the

free or marginal gingival tissue.

Movements of the lower lip

can cause the frenulum to pull on the bers inserted into the

free marginal tissue, which creates pocket formation that, in

turn, can lead to food and plaque accumulation.

Surgical

intervention can be considered to prevent subsequent inam-

mation, recession, pocket formation, and possible loss of

alveolar bone and/or teeth.

However, if factors causing

gingival/periodontal inammation are controlled, the degree

of recession and the need for treatment decreases.

13,15

Lingual frenulum

The World Health Organization has recommended mothers

worldwide exclusively breastfeed infants for the child’s first

six months to achieve optimum growth, development, and

health.

ereafter, they may be given complementary foods

and continue breastfeeding up to the age of two years or

beyond.

The American Academy of Pediatrics in 2018

rearmed its recommendation of exclusive breastfeeding for

about six months, followed by continued breastfeeding as

complementary foods are introduced, with continuation of

breastfeeding for one year or longer as mutually desired by

mother and child.

Lingual frenula, in addition to the maxil-

lary labial frenula, have been associated by some practitioners

with impedance to successful breastfeeding, thereby leading to

recommendations for frenulotomy. e most common symp-

toms that babies experience from tongue-and lip-tie are poor

or shallow latch on the breast or bottle, slow or poor weight

gain, reux and irritability from swallowing excessive air, pro-

longed feeding time, milk leaking from the mouth due to a

poor seal, and clicking or smacking noises when nursing/

feeding; maternal symptoms include painful nursing.

24,37

An anatomical dissection study determined the lingual

frenulum in neonates is not formed by a discrete submucosal

midline string or band as previously thought; rather, it is a

dynamically formed midline fold created in a layer of fascia

spanning the floor of the mouth and characterized by

ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 73

morphology that varies with tongue movement similar to

that in adults.

This fascia runs from the inner surface of

the mandible to join with the connective tissue on the ventral

surface of the tongue. It is the height of the fascial attachment

on the ventral surface of the tongue that alters the visual

prominence of the frenulum when placed under tension as seen

when elevated.

The lingual frenulum does not have direct

connection to the posterior tongue (also known as the tongue

base). erefore, the term “posterior tongue-tie” is misleading

and anatomically incorrect. Ankyloglossia can perhaps be

considered an imbalance of the fascial roles, where its provision

of tongue stability impacts tongue movement.

A methodological review of the term ankyloglossia shows

the use of multiple diagnostic criteria, leading the reported

prevalence of ankyloglossia to vary between 4.2 and 10.7 per-

cent of the population.

13,19

Several diagnostic classifications

have been proposed based on anatomical and functional criteria,

but none has been universally accepted.

13,39

No single ana-

tomical variable of the frenulum has been shown in isolation

to correlate directly with impaired tongue function. As such,

the use of grading systems simply describes appearance rather

than serving as an objective tool to diagnose or categorize the

frenulum as ankyloglossia.

The tongue’s ability to elevate

rather than protrude is the most important quality for nursing,

feeding, speech, and development of the dental arches.

40,41

Ankyloglossia has been associated with breastfeeding and

bottle-feeding difficulties among neonates, limited tongue

mobility and speech difficulties, malocclusion, and gingival

recession.

6,12,13,15-19,31

An ultrasound study has shown that patterns

of tongue motions diered both in infants with ankyloglossia

(with breastfeeding problems) and those without ankyloglos-

sia,

but because no anatomical variables of the lingual

frenulum were included in that study, it is not possible to cor-

relate frenum morphology to changes demonstrated on the

ultrasound

. A short frenulum can inhibit tongue movement

and create deglutition problems.

13,42,43

Systematic literature

review articles acknowledge the role of frenotomy/frenectomy

for demonstrable frenal constriction in order to reduce maternal

nipple pain

and improve successful breastfeeding when the

procedure is provided in conjunction with support of other

allied healthcare professionals.

6,13,15,16,19

A Cochrane review

noted the included randomized control trials were small and

had multiple limitations. Due to those limitations, the review

was unable to determine whether frenotomy in infants younger

than 30 days who had ankyloglossia and feeding difficulties

correlated with longer-term breastfeeding success. Similarly,

the Canadian Agency for Drugs and Technologies in Health

(CADTH) questioned whether frenectomy provides a mean-

ingful incremental benet over other treatments or procedures

to improve breastfeeding, particularly in the longterm due to

studies’ designs.

Because breastfeeding is a complex relation-

ship dyad, ankyloglossia may be only one of multiple possible

deciencies contributing to diculty breastfeeding.

2,45

ere-

fore, predicting which infants will have improved breastfeeding

following frenectomy may be dicult.

44,46

Some studies show

a decrease in surgical intervention in infants with feeding

difficulties when a team of allied healthcare professionals is

involved using consistent multidisciplinary assessment and

incorporating alternative intervention strategies.

47-49

Limitations in tongue mobility and pathologies of speech

have been associated with ankyloglossia.

13,50,51

However,

opinions vary among health care professionals regarding the

correlation between ankyloglossia and speech disorders. Speech

articulation is largely perceptual in nature; variation in speech

assessment outcomes is very high among individuals and spe-

cialists from dierent medical backgrounds.

e diculties

in articulation for individuals with ankyloglossia are evident

for consonants and sounds like / s /, / z /, / t /, / d /, / l /, / sh /,

/ ch /, / th /, and / dg /, and rolling an R is especially chal-

lenging.

6,50

Because parents often do not report speech issues

accurately, an evaluation by a speech-language pathologist

skilled in assessing tongue-ties (although consensus on assess-

ment techniques has not been established) is suggested prior to

recommending a tongue-tie release.

Speech therapy in con-

junction with frenuloplasty, frenulotomy, or frenulectomy can

be a treatment option to improve tongue mobility and

speech.

50,51

One pilot study reported children with moderate

and moderate-to-severe speech and language impairment at-

tained better speech and language outcomes after frenulectomy

when compared with children with mild and mild-to-moderate

impairments.

However, other studies hint at the subjective

improvement when parents were surveyed.

50,54

Nevertheless,

further evidence is needed to determine the benet of surgical

correction of ankyloglossia and its relation to speech pathology

as many children and individuals with ankyloglossia may be

able to compensate and do not appear to suer from speech

diculty.

13,16,39,55-57

A high-arched palate, reduced palate width, and elongated

soft palate have been associated with tongue-tie.

40,41

Evidence

relating ankyloglossia and abnormal tongue position to skeletal

development of Class III malocclusion is limited.

58,59

A com-

plete orthodontic evaluation, diagnosis, and treatment plan

are necessary prior to any surgical intervention.

Localized gingival recession on the lingual aspect of the

mandibular incisors has been associated with ankyloglossia in

some cases where frenal attachment causes gingival retraction.

As with most periodontal conditions, elimination of plaque-

induced gingival inammation can minimize gingival recession

without any surgical intervention.

When recession continues

even after oral hygiene management, surgical intervention may

be indicated.

13,15

Treatment considerations

Although evidence in the literature to promote the timing,

indication, and type of surgical intervention is limited,

frenulotomy/frenulectomy for functional limitations and symp-

tomatic relief may be considered on an individual basis.

6,13,42,51,

60,61

Evaluation for other potential head and neck sources

(e.g., nasal obstruction, airway obstructions, reux, craniofacial

anomalies) for breastfeeding problems before performing a

ORAL HEALTH POLICIES: MANAGEMENT OF THE FRENULUM

74 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

frenulotomy on a patient who has feeding difficulties

may

prevent unnecessary surgeries especially in very young neonates

less than two weeks of age. When indicated, frenuloplasty,

frenulectomy, and frenulotomy may be a successful approaches

in alleviating the problem.

6,9,13,18

Each of these procedures in-

volves surgical incision or excision, establishing hemostasis, and

wound management.

With regards to anatomy, the lingual

nerve has been shown to pass immediately beneath the fascia

on the ventral surface of the tongue with smaller branches

continuing into the lingual frenum.

As such, sensory input

necessary for tongue shape may be compromised if the lingual

nerve is damaged.

Additional complications may occur

during or following frenulum surgical procedures and include

excessive bleeding, formation of a mucus retention cyst, re-

attachment, hematoma formation, numbness or paresthesia,

infection, scar tissue formation, and restriction in tongue move-

ment.

Dressing placement or the use of antibiotics is not

necessary.

In older patients, postoperative care may include

maintaining a soft diet, regular oral hygiene, and analgesics

as needed. Postoperative pain has been reported in some

studies and found to persist as a moderate level (6.5 on a scale

of 10) for three days.

Although otolaryngologists’ expert

opinion

and the CADTH

do not support a standard post-

procedure regimen including stretching, massaging, or other

exercises to prevent reattachment of the frenulum, others have

concluded that exercises after tongue-tie release have elicited

functional improvements in speech, feeding, and sleep.

54,65

ese studies have been limited by patient numbers and lack of

control groups. Postoperative pain, especially in the neonate,

may further inhibit postsurgical stretching and exercises and

can lead to oral aversion.

Oral exercises have been advocated

as a safe and potentially eective adjunct to improve tongue

movements with or without surgical intervention in school-

aged patients.

e use of electrosurgery or laser technology for frenulotomies/

frenulectomies has demonstrated a shorter operative working

time, improved hemostasis, reduced intra- and postoperative

pain and discomfort, fewer postoperative complications (e.g.,

swelling, infection), no need for suture placement, and in-

creased patient acceptance.

68,69

ese procedures require extensive

training as well as skillful technique and patient management,

especially in the neonate.

6,9,13,18,51,70-73

As with all surgical

procedures, an informed consent is essential. Informed consent

includes relevant information regarding assessment, diagno-

sis, nature and purpose of proposed treatment, and potential

benets and risks of the proposed treatment, along with pro-

fessionally-recognized or evidence-based alternative treatment

options – including no treatment – and their risks.

Policy statement

e AAPD supports additional research on the causative as-

sociation between ankyloglossia and diculties in breastfeeding

or speech articulation, between a hyperplastic labial frenulum

and increased risk of caries or periodontal disease, and upper

lip restriction and difficulties with breastfeeding/latch. The

AAPD recognizes that causes other than ankyloglossia are more

common for breastfeeding diculties and that, while frenulo-

tomy for an infant with ankyloglossia can lead to an improve-

ment in breastfeeding, not all infants with ankyloglossia require

surgical intervention.

Due to the broad dierential diagnosis,

a team-based approach including consultation with other

specialists can aid in treatment planning. Further randomized

controlled trials and other prospective studies of high

methodological quality are necessary to determine the indications

and long-term eects of frenulotomy/frenulectomy.

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