Ankyloglossia in Babies

Clinical Approach of Ankyloglossia in Babies:

Report of Two Cases
Robson Frederico Cunha* / Janaína Zavitoski Silva** / Max Douglas Faria ***

Ankyloglossia is a developmental anomaly of the tongue characterized by a short lingual frenum, resulting
in restricted movement of the tongue. Its etiology is undefined and there is no gender preference. Few stud-
ies are available in the literature and the diagnosis and management of ankyloglossia in infants remains
controversial. We report two cases of infants submitted to lingual frenectomy, emphasizing the management
of ankyloglossia and its implications in breast-feeding.
Keywords: lingual frenectomy, babies, ankyloglossia.
J Clin Pediatr Dent 32(4): 277–282, 2008

INTRODUCTION tomy is indicated when the condition negatively interferes

T
he lingual frenum is a midline tissue fold that con- with suckling.2,3,4,7,8,9 In addition, other etiological factors that
nects the ventral surface of the tongue and the floor of may interfere with suckling such as insufficient muscle
the mouth. Ankyloglossia is a developmental anomaly development and respiratory problems should be ruled out.9
of the tongue characterized by a short lingual frenum, which With respect to the surgical technique, the dissection of
results in restricted movement of the tongue.1,2,3,4 In addition, the lingual frenum is frequently performed with surgical
the lingual apex may appear bifid (heart-shaped), especially scissors or a scalpel under local anesthesia.10 Other
when the tongue touches the palate.5 This anomaly can cause researchers7,9,11 advocate the use of an electrocautery probe
articular (linguodental phonemes) and respiratory disorders, because of its efficacy and the safety of the procedure, mild
can interfere with maxillomandibular growth, and impair bleeding and absence of postoperative complications.
swallowing, mastication, suction and dental hygiene.6 Dif- Recently, the use of a CO2 laser in lingual frenectomies has
ferences exist among investigators regarding the diagnosis been reported, as a safe, effective and ideal technique for use
and performance of lingual frenectomy in infants. This fact in young children.12,13 In addition, a shorter duration of
has clouded the diagnostic assessment of these structures surgery, simplicity of the procedure, absence of postopera-
and the establishment of adequate therapies. tive infection, and the presence of a small or no scar have
The diagnosis of ankyloglossia in infants should be made been reported.
on the basis of anatomical and functional aspects of the lin- In order to contribute to the advancement of both, the
gual frenum. Anatomically, the insertion of the frenum, nor- clinical approach and the treatment of ankyloglossia, the
mally running from the lingual apex to the alveolar ridge, objective of the present study is to report two cases of infants
should be evaluated. Regarding functional aspects, a frenec- with different lingual frenum clinical aspects submitted to
frenectomy at the Baby Clinic of the Araçatuba Dental
School, FOA/Unesp.
* Robson Frederico Cunha Professor of Department of Pediatric
CASE 1
Dentistry, School of Dentistry- UNESP - São Paulo State University,
Araçatuba, Brazil. A 9-month-old boy was referred to the Baby Clinic of the
** Janaína Zavitoski Silva Postgraduated student, School of Dentistry- Araçatuba Dental School, by his pediatrician with the diag-
UNESP- São Paulo State University, Araçatuba, Brazil. nosis of ankyloglossia. The intraoral clinical examination
*** Max Douglas Faria Postgraduated student, School of Dentistry- revealed an edentulous mouth and a short, thin lingual
UNESP- São Paulo State University, Araçatuba, Brazil.
frenum (Figure 1). The mother reported breast-feeding diffi-
Send all correspondence to: Dr. Robson Frederico Cunha -Department of culties having to bottle-feed from 4 months of age. On the
Pediatric Dentistry, School of Dentistry UNESP - São Paulo State Univer- basis of the clinical assessment, as well as the mother and
sity, Araçatuba, Brazil, Rua José Bonifácio, 1193 Bairro: Vila Mendonça, pediatrician’s reports, the diagnosis was established as anky-
Cep: 16015-050, Araçatuba /Brasil. loglossia.
The infant was in good general health. After explanation
Phone: (55) 18 3636-3235 of the pre- and intraoperative aspects, the parents sign the
E-mail: [email protected] informed consent, in order to proceed with the frenectomy,
procedure of choice.

The Journal of Clinical Pediatric Dentistry Volume 32, Number 4/2008 277
Ankyloglossia in Babies

Figure 1. Clinical aspect of short and thin lingual frenum. Figure 2. Topical anesthesia with Emla ointment.

The infant was placed on a dental chair and the topical hydrogenated castor oil, carboxipolymethylene, sodium
anesthetic Emla® ointment (AstraZeneca of Brazil, Cotia) hydroxide and purified water.
was applied with gauze for 3 min (Figure 2). Emla® (Eutec- During this procedure, it is important to keep part of the
tic mixture of lydocaine and prylocaine) contains the fol- gauze outside the child’s mouth to avoid accidental slippage.
lowing ingredients per gram: lydocaine (25 mg), prylocaine After, the anesthesia, the assistant stretches the lingual
(25 mg), and excipients q.s.p. (1 g) such as: polyoxyethylene frenum using the index finger allowing the surgeon to per-

Figure 3. Incision of lingual frenum in the midpoint with the Figure 4. Immediate post surgical aspect of lingual frenum.
scissors.

278 The Journal of Clinical Pediatric Dentistry Volume 32, Number 4/2008
 Ankyloglossia in Babies

trolled using compression with sterile gauze and without the

need to suture (Figure 4).
Suckling is encouraged after the surgical procedure in
order to promote hemostasis and wound healing and to pro-
vide greater comfort to the child. The postoperative instruc-
tions for the parents included observation of the child, who
might be upset during the first hours after surgery. No anal-
gesics were required in this case. The follow-up examination
performed 7 and 30 days after surgery showed no abnormal
characteristics and the mother reported that the child was
feeding normally. Twelve months after the surgical proce-
dure, the clinical aspect was within normal limits and the
infant presented normal development of both, feeding and
babbling of words (Figure 5).
Figure 5. Clinical aspect of lingual frenum after twelve months.
CASE 2
A 3-month-old boy was referred by his physician to the Baby
form the incision at the thinnest and most ischemic region, Clinic of the Araçatuba Dental School, FOA/Unesp, because
with the midpoint of the frenum serving as a guide. The scis- of suckling difficulties and a suspicion of ankyloglossia.
sors should be inserted at an angle of approximately 45º and During the intraoral examination, an extremely short, thick
should penetrate until reaching the limit between the lingual and fibrous frenum was noticed on the ventral surface of the
frenum and the floor of the mouth (Figure 3). Bleeding is tongue, forming a strong connection between the lingual
mild due to the poor irrigation of the area and is readily con- apex and the alveolar ridge (Figure 6).

Figure 6. Clinical aspect of thick and fibrous frenum. Figure 7. Incision of the thick and fibrous frenum with the scissors.

Figure 8. Immediate post surgical. Aspect of lingual frenum with Figure 9. Post surgical aspect of lingual frenum after twelve months.
mild bleeding.

The Journal of Clinical Pediatric Dentistry Volume 32, Number 4/2008 279
Ankyloglossia in Babies

The surgical steps were identical as those described in the and mucosa and it is contraindicated for patients with allergy
previous case. The surgical scissors penetrated the tissue to lydocaine, prylocaine or any component of the product or
reaching the limit between the lingual frenum and the floor to other amide-type local anesthetics. This topical anesthetic
of the mouth (Figure 7). Bleeding was mild and controlled was chosen because it causes rapid and effective analgesia of
with compression without the need to suture (Figure 8). Dur- the oral mucosa, a desired feature in interventions involving
ing the postoperative control visit after 7 days, the mother children of young age. In addition, this anesthetic is safe
reported that the infant presented no local or general prob- because low plasma concentrations are reached.23
lems, feeding difficulties or phonetic disturbances. Exami- If the frenum is thick and fibrous, a second application of
nation of the patient 12 months after the surgical procedure the anesthetic is required. Anesthetic cream is preferred
showed normal characteristics in the surgical area (Figure 9). since it is visible to the surgeon and provides greater anes-
thetic safety. However, other researchers have recommended
DISCUSSION the use of 0.5% or 1% ophthalmic anesthetic.24 Some authors
Several studies have reported a low incidence of ankyloglos- do not perform anesthesia before surgery.2,3,14
sia ranging from 0.2 to 4.8%,7,8,14,15 with pediatricians being During the surgical procedure, the tongue can be
the physicians responsible for referral of these patients to the stretched with a specifically designed instrument, called
dentist. The lack of consensus regarding diagnostic indica- tongue lifter.10,18,25 In the case of adults or adolescents, a
tors for surgical intervention may explain such low rates. In suture line transfixed to the lingual apex might be used.26
order to establish a more precise diagnosis of ankyloglossia Although no reports are available in the literature, the tongue
the participation of a multidisciplinary team involving pedi- can be stretched using the index fingers as in the present
atricians, dentists and speech therapists is recommended.16 cases. This approach was chosen because of the ease and
Lingual frenectomy is indicated for the treatment of safety afforded to the surgeon and the patient during surgery,
ankyloglossia in infants suffering from sucking2,3,4,7,8,9 and and because of the limited space available to maneuver,
breastfeeding problems17,18,19 such as insufficient infant adapt and stabilize a tongue lifter inside the newborn’s oral
weight gain, reduced maternal milk supply, sore nipples and cavity. The assistant stretched the tongue using the index fin-
repeated bouts of maternal mastitis.10,20 For older children, gers facilitating the incision to release the frenum, with min-
the indications for frenectomy include articulation difficul- imal bleeding.
ties confirmed by a speech pathologist, mechanical limita- In both cases, the tongue was stretched using the assis-
tions such as inability to lick the lips, to perform internal tant’s index fingers.2,11,27 It is important that the assistant be
oral hygiene or to play a wind instrument.18,21 The procedure trained in the management of this structure,28 especially
is simple, safe2,14,22 and fast and the child can be easily man- when the infant has teeth. The incision is made with straight
aged. In addition, future complications such as phonetic dis- surgical scissors9,10 under local anesthetic since they provide
orders, diastema and periodontal problems can be prevented. the surgeon with greater safety and precision. However,
In both cases reported, the indications for frenectomy were other researchers have used the electrocautery.7,11 When the
breastfeeding and suckling difficulties, noting an immediate frenum is thicker, more than one incision may be required,29
improvement in breastfeeding according to the mothers’ being careful not to damage the surrounding anatomical
report. structures. The procedure involves minimal bleeding and it is
The parents should receive instructions regarding the sur- a low-risk procedure. The baby can usually breast-feed
gical procedure and pre- and postoperative care measures.4 immediately after the frenotomy, and the mother may notice
Preoperative care includes keeping the infant in a fasting an immediate difference in the effectiveness and comfort of
state to prevent problems of regurgitation during surgery. In breastfeeding,18 If the baby seems to need help sucking prop-
addition, nursing the child immediately after the surgical erly after frenotomy, the mother may benefit from consulta-
procedure is indicated, with a preference for breast-feeding tion with myofunctional therapists, speech and/or feeding
since the components of maternal milk benefit hemostasis therapists, or lactation consultants to seek experienced help
and sooth the infant, thus reassuring the mother.2,4 Postoper- for these particular situations.9
ative care is fundamental to relieve the parents’ tension if the No consensus exists in the literature regarding the inci-
child became irritated. Since the procedure is simple and sion limit of the lingual frenum. In both cases, the frenum
minimally invasive, and considering the postoperative was sectioned until its limit with the floor of the mouth,
results observed in our clinical practice, analgesic medica- whereas others indicate a 2 to 3 mm incision in the thinner
tion is not required. portion of the lingual frenum between the tongue and lower
The type of anesthesia varies according to the thickness alveolar ridge.30
of the lingual frenum and age of the patient. Since the Neither of the patients submitted to frenectomy presented
frenum is generally a thin and transparent fold of mucous immediate or late postoperative complications. The
membrane in infants, only topical anesthesia is indicated guardians reported that the child was a little upset during the
through the use of a dermatological anesthetic cream (Emla, first hours, but fed normally and slept well, thus demon-
AstraZeneca) applied with sterile gauze for 3 to 5 min. The strating the importance of breast-feeding after this surgical
Emla (5%) anesthetic cream consists of lydocaine and pry- procedure since it promotes hemostasis and wound healing
locaine. It is indicated for superficial anesthesia of the skin and confers comfort to the child.2,4,25 In addition, the mother

280 The Journal of Clinical Pediatric Dentistry Volume 32, Number 4/2008
 Ankyloglossia in Babies

noticed an immediate difference in the movement of the 12. Fiorotti RC, Bertolini MM, NicolA JH, NicolA EM. Early lingual
child’s tongue.2 No difference in wound healing was frenectomy assisted by CO2 laser helps prevention and treatment of
functional alterations caused by ankyloglossia.Int J Orofacial Myology,
observed between these two patients and their different feed- 30: 64–71, 2004.
ing types, although breast-feeding is always recommended. 13. Kato J, Wijeyeweera RL. The effect of CO(2) laser irradiation on oral
Bleeding is generally superficial and is easily controlled soft tissue problems in children in Sri Lanka.Photomed Laser Surg, 25:
by applying pressure with gauze. The incision is not sutured 264–268, 2007.
unless a vessel is affected and bleeding occurs.2,4, 28,31 Litera- 14. Ruffoli R, Giambelucca MA, Scavuzzo MC et al. Ankyloglossia: a mor-
phofunctional investigation in children. Oral diseases, 11: 170–174,
ture reports have indicated the possibility of infection, 2005.
excess bleeding and recurrent ankyloglossia.9 15. Klockars T. Familial ankyloglossia (tongue-tie). Int J Pediatr Otorhino-
Lingual frenectomy in infants is a fast and safe surgical laryngol, 1–4, 2007.
procedure, with uneventful wound healing,2,14,22 and improves 16. Horton CE et al. Tongue-tie. Cleft Palate J, 6: 8–23, 1969.
comfort, effectiveness and ease of feeding for the mother 17. Messner AH, Ankyloglossia: incidence and associated feeding difficul-
ties, Arch Otolaryngol Neck Surg, 126: 36–39, 2000.
and infant.10 In addition, in the cases studied the parents 18. Palmer, B. Frenums, tongue-tie, ankyloglossia. Available at:
showed great satisfaction and comfort regarding the surgical http://www.brianpalmerdds.com/pdf/frenum_pdf.pdf. Accessed Febr
procedure, mainly because of the outcomes observed and the 28, 2008.
immediate recovery of the child’s oral functions. 19. Segal LM, Stephenson R, Dawes M, Feldman P. Prevalence, diagnosis,
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ACKNOWLEDGMENT 20. Marmet C, Shell E, Marmet R. Neonatal frenotomy may be necessary
We wish to thank FUNDUNESP (grant n. 00295/08DFP) for to correct breastfeeding problems. J Hum Lact, 6: 117–121, 1990.
the financial aid in english language revision. 21. Wright JE. Tongue-tie. J Paediatr Child Health, 31: 276–278, 1995.
22. Dollberg S, Botzer E, Grunis E, Mimouni FB. Immediate nipple pain
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