Running Head: FRENECTOMIES 1

Frenectomies

Shaina Matthews and Kenva Smith

Lamar Institute of Technology

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Ankyloglossia, more commonly called “tongue tie”, is a limitation in lingual mobility

that impedes protrusion and elevation of the tip of the tongue due to the shortness of the

genioglossus muscles. The lingual frenum is a fibro mucous membrane that joins the base of the

tongue to the floor of the mouth. Therefore, a short lingual frenum can restrict the movement of

the tongue resulting in various problems. Although the lingual frenum is notorious for initiating

many complaints, they can also be tight and restrictive in other areas of the mouth, such as the

maxillary anterior frenum. No matter the location, frenectomies are a means of treatment to

improve esthetics, function, and even quality of life. Therefore, this literary review will not only

discuss the nutritional, dental, and speech implications of frenectomies, but also the best age and

method for frenum dissection.

Primarily, there are various classifications used to describe frenum attachments, two of

which are the Coryllos and the Hazelbacker classifications. According to Coryllos classification,

the diagnosis of ankyloglossia is defined by four types of frenum. Type I: fine, elastic, heart

shaped frenum, where the tongue is anchored from the tip to the alveolar ridge. Type II: the

frenum is fine and elastic. It anchors the tongue from 2–4 millimeters of the tip to almost near

the alveolar ridge. Type III: thick, fibrous, and nonelastic; the tongue is anchored from the

middle of the tongue to the floor of the mouth. Type IV: the frenulum cannot be seen, but when

palpation is performed, a fibrous anchoring and/or thick and shiny submucosa from the base of

the tongue to the floor of the mouth can be felt (Ferrés-Amat, E., Pastor-Vera, T., Rodríguez-

Alessi, P., Ferrés-Amat, E., Mareque-Bueno, J., & Ferrés-Padró, E. (2016)). Unlike the Coryllos

anatomical classification, the Hazelbacker classification is concerned with whether or not the

frenum is functional. The Coryllos classification is used in combination with breastfeeding

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problems, whereas the Hazelbacker classification is referenced for frenectomies in newborn

babies.

Frenectomies are sometimes necessary in newborns and infants due to breastfeeding

difficulties. Newborns have breastfeeding difficulties for one or more of the following reasons:

immaturity (preterm infants, before 37 weeks), premature separation of mother and child due to

the hospitalization, or the baby’s lack of sucking reflexes (Ferrés-Amat, E., et. al, 2016). After

birth, this can be where the mother discovers that her baby has problems latching on, and is

therefore unable to get the nutrients needed to grow. It is very important to rule out any possible

abnormalities that cause suckling problems during breastfeeding. A well-known problem where

the newborn shows these oral limitations is ankyloglossia. Ankyloglossia stems from the remains

of embryonic tissues produced in the early stage of development, where it then turns into an

incorrect division of the genioglossus and hypoglossal muscles. Throughout the world, there are

3% of babies born with this condition. Studies have shown that “tongue-tie” can be hereditary,

and that it occurs mainly in male infants.

Apart from the possibility of malnutrition, unproductive suckling tends to cause pain to

the mothers nipples during breastfeeding. Insufficient latching/sucking can pose potential

problems with the infants weight gain, in addition to an increased time for breastfeeding

sessions. When these types of feeding problems exist, a complete morphological and functional

oral examination is done, which incorporates the tongue.

A case study containing a 17-day-old male patient with ankyloglossia is the perfect

example of the issues faced by both the infant and the mother. The information gathered was

from three different incidents during the course of treatment starting from the beginning, then

after two weeks of the procedure, and at the end of treatment. Weight gain, length of feedings,
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and maternal pain were the most important factors that were recorded in this case and were

evaluated and reported 15 days after the end of treatment. The baby’s weight was assessed by

weighing before each meal. The same scale was used each time for accuracy, and the length of

the meal was measured by the mother. The maternal pain during breastfeeding was 10 on the

visual analog scale (VAS; a form of pain meter), poor weight gain was recorded with less than

100 grams weekly, and the length of the feed lasted 60 minutes. A physical examination of the

baby was done paying special attention to the muscle tone and anatomy of the oral cavity as well

as the maxillofacial region. The newborn was diagnosed with ankyloglossia degree II (Coryllos

classification). Throughout breastfeeding sessions, intraoral and extraoral exercises were done to

improve his rooting reflex and stimulate the masseter muscle. Eventually, they decided to

perform a lingual frenectomy by snipping the frenulum with scissors on the then 21-day-old

infant. After the surgery, stimulation was given followed by breastfeeding.

The first checkup was 17 days after the surgery. At this time improvements were noticed

such as the baby’s weight increased by 200 grams weekly, feeding time was reduced to 30

minutes, and the mother's pain reduced to 5 (VAS). A second checkup was done 4 weeks later

with the mother’s pain being 0 (VAS), an increase in weight by 200 grams weekly, and the

length of feeding time now down to 15 minutes. The baby was then discharged due to meeting

the appropriate weight gain goal and length of feedings, as well as the mother for her lack of pain

during breastfeeding.

The maxillary labial frenum is another well-known area where abnormalities in the oral

region occur. This frenum is connected to the incisive papilla during the early stages of the

embryonic period. Its high adhesion to the alveolar bone may result in a diastema or gap between
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teeth as well as eruption site abnormalities in the central/deciduous incisors. Treatment is often

required when these types of symptoms surface. This can be difficult since the patients are

usually infants or young school children, which means patient compliance and understanding are

low. Additionally, pediatric patients experience psychological trauma with these types of

procedures due to the stress of the treatment. By the age of 10, if left untreated, anterior

maxillary teeth should erupt to naturally close the diastema. On the other hand, if the erupted

permanent teeth do not close the diastema, this abnormality can cause numerous dental and non-

dental problems if left untreated for adults or even teens. For instance, a common complaint for

patients with maxillary labial frenum was cosmetic problems, seeing as a smile can be a person’s

greatest attribute and can help some feel better about themselves. In addition, a few dental

related problems include malocclusion, open bite, tooth decay, and separation or protrusion of

the bottom central incisors (Bellinger, V., Solari, D., Hogan, M., Rodda, K., Shadbolt, B., and

Todd, D. 2018).

As it relates to speech implications, the research by Bellinger, et. al (2018) stated that

nearly all of a child’s speech should be intelligible by family and friends by the age of 3.

Children with ankyloglossia commonly suffer from speech impediments that are related to the

formation or pronunciation of certain phonemes. Failure to produce these sounds stem from

limited tongue mobility associated with the atypical position of the lingual frenum. For example,

a study with “tongue tied” patients aged 1-12 years were given a pretest (before the frenectomy)

and posttest (after the frenectomy) that incorporated sounds that pose difficulty, such as D, L, N,

S, T, Th, Z. Similarly, another controlled study with three groups of 3yr olds, who were

followed since infancy, contained subjects with ankyloglossia, subjects who had ankyloglossia
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but got frenectomies, and a group that never had ankyloglossia. In both studies, the subjects that

had the frenum dissection showed significant improvement compared to those who did not. This

showed that there were considerable benefits to frenectomies than just breastfeeding.

Considering all the potential problems ankyloglossia and tight frenum generally cause, a

decision on the appropriate age for a patient to undergo frenum dissection is paramount. In their

research, Komori, S., Matsumoto, K., Matsuo, K., Suzuki, H., & Komori, T. (2017) made notice

of a discrepancy where some reports recommended frenectomies be conducted at an early age,

while others suggested the procedure be delayed until later. The main reason for delayed

treatment was the possibility of improvement with growth, in addition to potential scaring.

Instead, it was suggested that initial speech therapy be utilized before undergoing a frenectomy

solely because of the severity of the patient’s articulation function.

Although all methods of frenum dissection are effective, some factors need to be

considered in order to make the best choice for the patient, such as age, location of frenum, and

recovery. The frenectomy procedure is done either with the use of lasers or surgically, with blunt

scissors or a scalpel (Ferrés-Amat, E., et. al, 2016; Komori, S., et al. 2017). A surgical approach

on a child aged 3 years or younger must often include general anesthesia for patient compliance

and comfort, whereas topical anesthetic is usually sufficient in older children. Sutures are

required for hemostasis when the surgical method is utilized. In comparison, laser dissection is

done with either a CO2 or Er:YAG laser. Pain management through topical anesthetic is

sufficient with the lasers, however the Er:YAG may require local anesthetic with a

vasoconstrictor for hemostatic control (Komori, S., et al. 2017).

The research revealed that treatment with lasers produced significantly less postoperative

pain and discomfort from chewing and speaking than with the surgical treatment method. Other
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advantages over the surgical method are its simplicity, reduction in treatment time, and increased

patient cooperation. However, the precision and care needed when cutting the maxillary labial

frenum presents as a disadvantage to frenum dissection by lasers. Because of its location, using

too much power can damage the alveolar bone. Furthermore, the operator should be cautious of

damage to the eyes, since the laser will be pointed upward, toward the upper lip.

No matter the location of the frenectomy or method of dissection, postoperative

instructions on extension exercises are given to discourage re-adhesion of the frenum. For

infants, sucking stimulation is recommended before and after the surgical intervention to

evaluate the effectiveness of the procedure. Patients are also given prophylactic antibiotics and

analgesics to combat potential pain and infection.

In summary, a tight frenulum can result in nutritional, dental, and speech complications.

Nutritional complications are usually noted during infancy when the baby has difficulty suckling

and/or swallowing because of ankyloglossia. The subsequent outcomes are extended feeding

times, malnutrition, and pain to the mother’s nipples during breastfeeding. Apart from the

nutritional implications, ankyloglossia also makes pronunciation of specific sounds, such as S,

TH, and Z, difficult due to the limited mobility of the tongue. Dental issues associated with tight

frenulum include malocclusion, open bite, tooth decay, and separated or protruded mandibular

central incisors. The tight frenulum is corrected surgically, with scissors/scalpel or with lasers.

Lasers are generally easier, faster and more well tolerated than the surgical approach. The best

age or time for a child to have a frenectomy is still unclear. Some reports recommend frenum

dissection be conducted at an early age, whereas others suggest the procedure be delayed. Future

research is needed to confirm whether or not it is better to wait for the tight frenulum to correct

itself or if children should undergo frenectomies as an infant or toddler. Finally, it is important

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that a dental hygienist is able to clinically recognize ankyloglossia and tight frenum in pediatric

and adult patients so that the hygienist can both educate and give anticipatory guidance to the

patient or the parent. In turn, this will allow the patient to make an informed decision about their

personal oral health.

References
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1. Bellinger, V., Solari, D., Hogan, M., Rodda, K., Shadbolt, B., & Todd, D. (2018).

Tongue-tie division in the newborn: Follow-up at 9 and 38 months. Breastfeeding

Review, 26(1), 13–22. Retrieved from https://search-ebscohost-

com.libproxy.lamar.edu/login.aspx?direct=true&db=ccm&AN=129442392&site=eds-

live

2. Ferrés-Amat, E., Pastor-Vera, T., Rodríguez-Alessi, P., Ferrés-Amat, E., Mareque-

Bueno, J., & Ferrés-Padró, E. (2016). Management of Ankyloglossia and Breastfeeding

Difficulties in the Newborn: Breastfeeding Sessions, Myofunctional Therapy, and

Frenotomy. Case reports in pediatrics, 2016, 3010594. doi:10.1155/2016/301059

3. Ghaheri, B. A., Cole, M., Fausel, S. C., Chuop, M., & Mace, J. C. (2017). Breastfeeding

improvement following tongue-tie and lip-tie release: A prospective cohort study. The

Laryngoscope, 127(5), 1217–1223. doi:10.1002/lary.26306

4. Komori, S., Matsumoto, K., Matsuo, K., Suzuki, H., & Komori, T. (2017). Clinical Study

of Laser Treatment for Frenectomy of Pediatric Patients. International journal of clinical

pediatric dentistry, 10(3), 272–277. doi:10.5005/jp-journals-10005-1449