Q U I N T E S S E N C E I N T E R N AT I O N A L
ORAL SURGERY
Diagnosis and treatment of ankyloglossia:
A narrative review and a report of three cases
Phoebus Tsaousoglou, DDS, MSc, Dr Med Dent 1/Nikolaos Topouzelis, DDS, MSc, PhD2/Ioannis Vouros, DDS,
MSc, Dr Med Dent 3/Anton Sculean, DMD, MS, PhD, Dr Med Dent, Dr h c 4
Background: Ankyloglossia or tongue-tie is a congenital oral
anomaly with short, tight, and thick lingual frenulum. It may be
asymptomatic or can cause movement limitations of the
tongue, speech and articulation difficulties, breastfeeding diffi-
culties in neonates, as well as periodontal and malocclusion
problems. The etiopathogenesis of ankyloglossia is unknown;
it can occur either as a sole anomaly in the vast majority or in
association with other craniofacial anomalies. Objectives:
The aims of this paper were (1) to provide a comprehensive
review on the criteria for clinical assessment and diagnosis,
etiology and inheritance, and the therapeutic options of anky-
loglossia; and (2) to demonstrate the treatment of ankyloglos-
Key words: ankyloglossia, frenuloplasty, surgical intervention, tongue-tie
The term “ankyloglossia” is derived from the Greek
word “agkilos” for curved and “glossa” for tongue, and
is also known as “tongue-tie”. In this paper the term
“ankyloglossia” will be used. Ankyloglossia, a congenital
oral anomaly, is caused by short frenulum and/or short
1 Periodontist, Department of Periodontology, School of Dental Medicine, Univer-
sity of Bern, Bern, Switzerland.
2 Professor and Chairman, Department of Orthodontics, School of Dentistry, Aris-
totle University of Thessaloniki, Greece.
3 Associate Professor, Department of Preventive Dentistry, Periodontology and
Implant Biology, School of Dentistry, Aristotle University of Thessaloniki, Greece.
4 Professor and Chairman, Department of Periodontology, School of Dental Med-
icine, Department of Periodontology, University of Bern, Bern, Switzerland.
Correspondence: Dr Phoebus Tsaousoglou, Department of Periodon-
tology, School of Dental Medicine, University of Bern, Freiburgstrasse 7,
CH-3010 Bern, Switzerland. Email: phtsaouso@yahoo.com
VOLUME 47 • NUMBER 6 • JUNE 2016
Phoebus
Tsaousoglou
sia by means of frenuloplasty in three cases. Review: The
available evidence from the literature indicates that among
neonates, children, and adults the prevalence of ankyloglossia
is low and in some cases remains undiagnosed. The early clin-
ical assessment, diagnosis, and treatment are beneficial for the
patients and their mothers. Conclusions: Frenuloplasty is a
safe, quick, effective, and economical method and for this rea-
son the parents should not hesitate towards frenulum release.
More clinical studies are needed to confirm the benefits of the
surgical interventions and to compare the results with those
obtained using nonsurgical therapy or with untreated cases.
(Quintessence Int 2016;47:523–534; doi: 10.3290/j.qi.a36027)
genioglossus muscles. It can present with different clin-
ical types, from a severe form with the tongue fused to
the floor of the mouth to a milder form with only an
abnormally short and thick lingual frenulum.1-3 The
structure of the body of lingual frenulum is composed
of connective tissue.4 Normally, after birth and during
the first years of the child’s growth and development,
the lingual frenulum recedes, but in some cases this
frenulum fails to recede or it appears very tight.5,6 As a
consequence, the mobility of the tongue is impaired in
a varying degree, from slight to severe impairment.
Ankyloglossia can be observed in neonates and infants
as well as in children and adolescents, but in some peo-
ple this situation remains undiagnosed despite the
possible associated anatomic or functional problems.
523
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
There is a controversial issue in terms of the clinical
significance of this anomaly. Some authors support that
ankyloglossia is most often asymptomatic whereas
others support that it may cause problems such as
infant breastfeeding difficulties (sore nipples, poor
infant weight gain, early weaning, number of sucks,
pause length between sucking),7-9 dyspnea from for-
ward dislocation of the epiglottis and larynx,10,11 poor
oral hygiene,12 prolonged nipple pain or mastitis of the
mother, speech disorders, swallowing abnormalities,5,13
various mechanical problems (difficulty in licking the
lips, licking an ice cream cone, playing a wind instru-
ment), cuts beneath the tongue, orthodontic and
orthopedic anomalies,14 diastasis of the mandibular
incisors related to the short frenulum, difficulty in
“French” kissing,15 vocalization difficulties, and social
issues related to the mobility of the tongue.3,16 Some
problems, such as social embarrassment, cuts beneath
the tongue, and difficulty in “French” kissing, are most
likely to manifest in the adolescence. There is a dis-
agreement regarding swallowing abnormalities due to
ankyloglossia probably because the maturation of the
swallowing mechanism differs across all age groups. In
babies, swallowing is infantile type; by the 2nd and 4th
years of age it turns into a mature pattern. The per-
sistence of the infantile swallowing pattern might be
due to the inability to elevate the tongue.5,13,17
In terms of speech difficulties in cases with ankylo-
glossia, some children are reported to be able to
develop normal speech whereas some develop speech
insufficiencies as a result of articulation errors or diffi-
culties.5,15
The most common reason for surgical frenulum
division was speech problems (64%), and the majority
of patients (84%) reported benefit from the oper-
ation.18
The aims of the present paper are:
• to provide a comprehensive review on the criteria
for clinical assessment and diagnosis, etiology and
inheritance, and the therapeutic options of ankylo-
glossia
• to demonstrate the treatment of ankyloglossia by
means of frenuloplasty in three cases.
524
ETIOLOGY AND INHERITANCE
The exact etiology and pathogenesis of ankyloglos-
sia is unknown. Ankyloglossia can occur either as a
sole anomaly or in association with other craniofacial
anomalies. In 82% of ankyloglossia cases, this was
reported as a sole anomaly without other abnormalities
or diseases.18 However, some studies have related this
entity with syndromes, such as X-linked cleft palate
syndrome,19-22 Ehlers–Danlos syndrome,4,23 junctional
epidermolysis bullosa inversa,24 Kindler syndrome,25
Simpson–Golabi–Behmel syndrome,26 Van der Woude
syndrome,27 Beckwith–Wiedemann syndrome,28 Smith–
Lemli–Opitz syndrome, and Opitz syndrome.29,30
Ankyloglossia is possible to be manifested as a
result of mutations in T-box genes or from exposure to
teratogenic substances during pregnancy.22,31-33
It is suggested that a significant proportion of anky-
loglossia is inherited and specifically it seems to be
autosomal dominance.34 There are two reports of a
family with isolated ankyloglossia inherited as an auto-
somal dominant trait.35,36
It is worth reporting that maternal cocaine use
increased the risk of ankyloglossia by more than three
times.37
EPIDEMIOLOGY
The incidence of ankyloglossia is relatively rare as it is
referred from medical professionals. More than 70% of
these professionals report that the prevalence of anky-
loglossia is low.38 In the literature, ankyloglossia among
neonates and infants is presented with a prevalence
from 0.02% to 10.7%.3,8,34,37,39-42 This wide fluctuation is
the result of the lack of a uniform definition, objective
grading system, the differences in diagnosis among the
researchers, as well as the possibility of spontaneous
resolution with age. Among different ages, males seem
to be more affected than females, ranging from 4:1 to
1.7:1.34,39,42-45 Ankyloglossia is thought to be less com-
mon in adults as compared to infants,46 leading some
to the hypothesis that certain cases of ankyloglossia
improve with age.16 No racial predilection seems to
VOLUME 47 • NUMBER 6 • JUNE 2016

exist.37,39 A positive family history was noted in 10% to
53% of the subjects.15,41,47,48
The prevalence of speech anomalies in connection
with ankyloglossia fluctuate from 1.1% in Spain to
48.8% in Brazil.49,50
High percentages of infants who experienced
breastfeeding problems have been referred.3,41,48 A very
recent retrospective study demonstrated that 66% of
newborns with breastfeeding difficulties had ankylo-
glossia.51 The degree of the breastfeeding difficulties
among the relevant medical specialists varies. Lactation
consultants believe that ankyloglossia frequently
causes breastfeeding difficulties, whereas 90% of pedi-
atricians and 70% of otolaryngologists believe that
ankyloglossia never or rarely causes a feeding prob-
lem.38 For every day of maternal pain during the initial
3 weeks of breastfeeding there is a 10% to 26% risk of
cessation of breastfeeding.52 Mothers breastfeeding
infants with ankyloglossia have more nipple pain than
mothers feeding normal infants.3,42 Persistent nipple
pain in women breastfeeding infants with ankyloglos-
sia has been observed in a rate from 36% to 80%.3
CLINICAL CHARACTERISTICS
The most important clinical features are described below.
The tongue is often heart or V-shaped at its tip,
which is caused by tethering by the frenulum. Tongue
mobility in ankyloglossia, in general, is restricted. A
typical feature in cases with severe limitation of mobil-
ity is the inability of the tongue to lick the lips. Its pro-
trusion is limited and the tip may not extend over the
lower lip. In some cases, the tongue cannot protrude
more than 1 to 2 mm past the mandibular incisors.53 Its
elevation is also characteristically impaired, from a
complete inability of elevation of the tongue to some
degree of elevation.
The frenulum appears abnormally short and it may
be thin and membranous or fibrous and thickened,
with insertion (attachment) at or near the tongue tip on
one side and with high insertion (attachment) into the
lingual gingivae on the other side.7,41 Lingual gingival
recessions might be present in such cases.54,55
VOLUME 47 • NUMBER 6 • JUNE 2016
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
A protrusive chin or prognathism may be consid-
ered as a result of the low tongue position causing for-
ward and downward pressure and favoring either man-
dibular hyperdevelopment or maxillary
hypodevelopment. 55-58 However, no significant correla-
tion was found between dentofacial anomalies and
ankyloglossia.49 The scientific data do not have the
power to clarify if the ankyloglossia can be considered
a co-factor in the development of malocclusions, espe-
cially Class III malocclusion. In a case report it was
reported that frenectomy led to a favorable occlusion.57
In a case series study, it was suggested that ankyloglos-
sia in association with a Class III malocclusion resulted
in dentofacial anomalies in the maxillary arch.11 More
clinical studies should be carried out in order to eluci-
date the correlation between malocclusion and ankylo-
glossia.55
Sometimes periodontal discrepancies such as a
diastema between the mandibular central incisors are
found as a result of the protrusion of the lingual frenu-
lum.
In addition to the aforementioned clinical features,
another very frequent characteristic is speech difficul-
ties. Nevertheless, a recent systematic review found no
significant evidence regarding ankyloglossia as an etio-
logic factor for speech problems.59
DIAGNOSIS
Diagnosis is based on clinical examination. The appear-
ance and the mobility of the tongue, together with the
attachment, the insertion, and the shortness of the lin-
gual frenulum should be examined and evaluated.
Several authors have reported that they checked the
appearance and the mobility of the tongue with the
Hazelbaker Assessment Tool.60,61 Also, the speech ability
of the patient can be checked by the vocalization of
some letters and words. The vocalization of certain
words by the person can assist in the disclosure of pos-
sible speech problems. Speech sounds that may be
affected by impaired tongue tip mobility include con-
sonants and sounds, such as /s/, /z/, /t/, /d/, /l/, /j/, /zh/,
/ch/, /th/, and /dg/, with more frequent difficulty in
525
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
pronouncing /s/ and /r/.15,49,50,53,62 Last but not least, the
whole appearance of the dentoalveolar structures
should be checked for characteristics such as gingival
recession, diastema, and malocclusion.
CLASSIFICATION
A standardized categorization of cases with ankyloglos-
sia has been considered necessary in order to assess
when a condition constitutes ankyloglossia and its
severity, as well as when surgical intervention is
needed. However, there is not a unique classification in
the literature, and instead many scientists have tried to
implement a measurement system for the degree of
ankyloglossia. Therefore, a lot of classification systems
have been proposed. One of these is based on findings
by Ruffoli et al,58 who clinically and morphofunctionally
examined patients using two techniques, establishing
a classification and categorizing the severity of ankylo-
glossia as mild, moderate, and severe. According to
Kotlow’s criteria, four classes (mild, moderate, severe,
and complete ankyloglossia) can be determined.1 A
recent classification has been reported in which the
tongue mobility limitation is divided in five degrees.63
Another more complicated and extensive system for
assessment of ankyloglossia has been described by
Fernando.64 Moreover, children with ankyloglossia
underwent evaluation of tongue mobility with two
measurement methods: tongue elevation and tongue
protrusion.65 Also, Hazelbaker’s assessment tool for
lingual frenulum function has been demonstrated as
another method for assessment and surgical division
recommendation.60
THERAPY
No consensus exists about the optimal timing of surgi-
cal intervention for ankyloglossia. Some authors have
supported that infancy, and prior to the development
of speech, is the most appropriate age for surgery; oth-
ers wait until a speech problem manifests, usually after
the age of 4 to 5 years; others, that is less effective in
older children; others, that is inappropriate for infants
526
less than 1 year of age or over 12 years of age; others,
that adulthood is the optimal timing of surgical repair;
and others, at any age.5,15,16,38,58,63,66-70 Contrary to these,
a recent review highlights the need for good evaluation
and selection in any case as in half of breastfeeding
babies problems may not occur in an older age.71 More-
over, two recent studies found low evidence regarding
the association between surgical intervention of anky-
loglossia and breastfeeding improvement or
non-breastfeeding difficulties.72,73
The first step in the management of ankyloglossia is
to consider the necessity or not of surgical intervention
based on the possible associated problems: tongue
mobility, breastfeeding in neonates, speech, malocclu-
sion, and gingival recession. Surgical intervention of
ankyloglossia can be carried out either without anes-
thesia or under local or, less often, general anesthesia.18
Three mainly surgical, conventional techniques are
described in the literature:38,53,74-76 frenotomy (frenulot-
omy [partial excision of lingual frenulum]), frenectomy
(frenulectomy [complete excision of lingual frenulum]),
and frenuloplasty (various methods to release the
tongue and correct the anatomic feature, such as hori-
zontal-to-vertical frenuloplasty and four-flap Z-frenu-
loplasty). The term frenotomy should be used when
sutures were not utilized during releasing of frenulum.
Instead, the term frenuloplasty should be used when
incisions and sutures are performed, such as in horizon-
tal-to-vertical and Z-frenuloplasty techniques.18 Other
procedures are the carbon dioxide (CO2) laser,77-79
Nd:YAP laser,80 Er:YAG and Er,Cr:YSGG laser,81 and argon
plasma cutting electrodes.82 Comparing a diode laser
and an Er:YAG laser, the latter was found to be superior
to the former in terms of anesthesia, namely the utiliza-
tion of Er:YAG was possible only with topical anesthesia
without local anesthesia, but at the same time Er:YAG
presented more pain immediately postoperatively.83
Less pain following intervention and fewer nutrition
and speech complications were demonstrated with
Nd:YAG laser in relation to conventional surgical tech-
niques (frenotomy, frenectomy, frenuloplasty).84 A lot
of therapists support the utilization of laser for lingual
frenulum division because it is a more convenient tech-
VOLUME 47 • NUMBER 6 • JUNE 2016

nique for the patients, and because there is less bleed-
ing, no need for sutures, faster wood healing, and
minimum scar formation.80,81,83,85,86 On the other hand,
in a case series study it was presented that surgical
techniques offered better organization of muscle fibers
during the healing period in comparison with laser and
electrocautery techniques, although they were less
effective regarding the manipulation of tissues during
the procedure, bleeding, and postoperative pain.87
The use of frenotomy for ankyloglossia has shown
favorable effects according to outcomes of different
studies.12 This type of surgical approach is a relatively
simple, safe, and cost-effective procedure, with appro-
priate results in a short time. Frenotomy is the thera-
peutic approach of choice in newborns with ankylo-
glossia (for breastfeeding difficulties), dividing the
lingual frenulum with small scissors at the thinnest
portion of the frenulum. It is quick and relatively easy to
accomplish with topical anesthesia, and in some cases
even without anesthesia. Usually it does not need local
anesthesia because discomfort and bleeding is mini-
mal.8,74,88,89 Breastfeeding improvement after frenulot-
omy has also been reported.90
Frenuloplasty is the preferred procedure for chil-
dren and adults, generally for most patients older than
1 to 2 years of age. At this age the chances of scarring
and recurrence are reduced. Frenuloplasty may be car-
ried out under general anesthesia for young children
before school age and uncooperative older patients or
under local anesthesia in a private practice for cooper-
ative school age children and adults. It is suggested
that frenuloplasty, as opposed to frenotomy, may
decrease the risk of recurrence.91 Four-flap Z-frenu-
loplasty has been found to be superior to horizon-
tal-to-vertical frenuloplasty in terms of tongue length,
tongue protrusion, and articulation improvement.53
Adequate frenulum division is more important than
the used technique (frenuloplasty or frenotomy), and
adequate division is easier to achieve under general
anesthesia.18
Regarding the need for reoperation, patients treated
under general anesthesia needed fewer reoperations
than those operated with local or no anesthesia.18
VOLUME 47 • NUMBER 6 • JUNE 2016
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
Rare complications have been found after frenot-
omy, frenectomy, and frenulopasty, such as excessive
bleeding, upper airway collapse, infection, diathermy
burn of the lip, crying, ulcer under the tongue, lingual
dysfunction, deglutitory anomalies, and recurrence of
ankyloglossia as a result of scarring.5,13,38,48 Seldom, recur-
rence of ankyloglossia can be caused by scarring, but
when it occurs, the clinical manifestation is less intense
than before the first treatment. Recurrent ankyloglossia
usually responds effectively to revision surgery.38
There is controversy among therapists in terms of
the effects of ankyloglossia in speech and also the effi-
cacy of speech therapy. A large number of speech
pathologists believe that surgical therapy is frequently
or always helpful in this condition.38 Otolaryngologists
believe, twice more so than pediatricians, that ankylo-
glossia may be associated with speech difficulties, and
recommend surgery.38 More and more scientists, espe-
cially the surgeons, suggest speech therapy with partic-
ular tongue exercises to be followed postoperatively.92
Moreover, recently it has been shown that initiation of
the exercises by the patient 1 week earlier might be
useful so that the patient and the tongue adapt to the
movements without any pain, which could be present
after intervention if the usual postoperative exercise
protocol is implemented.63
The recommended tongue exercises postopera-
tively are as follows:15,47,53
1. Push tongue in and out of mouth.
2. Open the mouth as wide as possible and attempt to
touch the tip of the tongue to the back of the max-
illary teeth.
3. Move the tongue from one side of the mouth to the
other, without moving the jaw.
4. Place food of choice on one side of mouth between
the cheek and back teeth. Using the tongue, move
the food from one side of the mouth to the other
and then back again.
5. Consonant sounds of F, V, T, D, N, L, SH, S, ZH, R, and Z.
The above exercises should be performed from 1 week
postoperatively in five repetitions of each exercise,
three to five times per day, for 30 days.
527
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al

a b c

d e f

g h i

Figs 1a to 1j Case 1: the patient before intervention, the surgical steps of the horizon-
tal-to-vertical frenuloplasty technique, and the follow-ups are depicted. (a and b) The
elevation and protrusion status of the patient’s tongue before surgery. (c) Hemostatic
forceps were used to clamp the frenulum and the division was carried out by performing
horizontal incisions above and below the forceps. In this case the submandibular ducts
were close to the lower incision, so this was performed very carefully. (d) The incision of
the frenulum. (e) In order to accomplish adequate release of the tongue, the frenulum
was incised as far as the genioglossus muscle, with very gentle partial division of the
muscle. (f) The borders of the wound were released before suturing. (g) The sutures in
j place. (h) One month after surgery. (i and j) Three months after surgery.

CASE REPORTS speech problems. Apart from the above, he was

Case 1
An 8-year-old boy in mixed dentition was diagnosed
with ankyloglossia. He had Angle Class II/I malocclusion
with crowding of the maxillary and mandibular anterior
teeth and severe overjet and overbite. The patient
underwent orthodontic treatment and wore a remov-
able functional appliance (activator). He had severe
restriction of tongue mobility, with mastication and
referred for surgical treatment of ankyloglossia preven-
tively in order to avoid potential future lingual gingival
recession of the mandibular central incisors (Fig 1).
Case 2
A 12-year-old boy was diagnosed with ankyloglossia.
He was in permanent dentition with malocclusion of
Angle Class I at the right side and Class II at the left side.
The mandibular anterior teeth presented with severe

528 VOLUME 47 • NUMBER 6 • JUNE 2016


a b
d e
crowding, and a congenital lack of the maxillary lateral
incisors was found. He underwent orthodontic therapy
with fixed appliances. He presented severe restriction
of elevation and protrusion and generally of tongue
mobility. Vocalization problems were obvious as well.
The clinical examination revealed ankyloglossia with
thick and short frenulum and for this reason he was
referred for surgical treatment of ankyloglossia (Fig 2).
Case 3
An 8-year-old girl was referred for management of
ankyloglossia by a pediatrician, general surgeon, and
speech pathologist in order to facilitate the improve-
ment of her speech. The clinical examination presented
moderate ankyloglossia with limitations of tongue
mobility. She was in early mixed dentition with Angle
Class II, Division 2 malocclusion, and she presented
with mild crowding of her mandibular anterior teeth
and spacing of the maxillary anterior teeth (Fig 3).
As far as the classification by Ruffoli et al58 is concerned,
regarding the distance between the incisal edges of the
maxillary and mandibular incisor, case 1 was classified
as severe whereas cases 2 and 3 were classified as mod-
erate. However, the values of the last two cases were
almost at the lowest level of the moderate category. No
VOLUME 47 • NUMBER 6 • JUNE 2016
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
c
Figs 2a to 2f The patient before, during,
and after surgical intervention. (a and b)
The disclosure of tongue limitations during
elevation and protrusion assessment. (c)
The incision of the frenulum. (d) The
sutures in place. (e and f) Three months
f after surgery.
digestive problems related to ankyloglossia were
found. Tongue elevation was recorded by measuring
the interincisal distance by maximal mouth opening
while maintaining contact of the tongue tip with the
posterior surface of the central incisor teeth. Tongue
protrusion was measured as the maximum extension of
the tongue tip past the mandibular teeth. These two
measurements were made in millimeters. In order to
keep the records more representative, the assessment
was made by measuring each patient and each one of
the two clinical measurements (tongue elevation and
tongue protrusion) five times, calculating the mean
value.
Before any intervention, the patient’s parents were
informed in detail, and informed consent was obtained
for each patient’s surgery. Surgery was performed
under local anesthesia, implementing frenuloplasty
with the horizontal-to-vertical technique. There were
no surgical or postoperative complications. Follow-up
was performed 1 week, 1 month, and 3 months postop-
eratively. Patients were instructed to carry out recom-
mended tongue exercises, as described above, for 1
month after surgery. After 3 months’ follow-up, signifi-
cant improvement was observed with increased
tongue movement (Table 1). Vocalization was signifi-
cantly improved in all cases with speech problems.
529
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al

a b

Figs 3a to 3c The patient before and after incision of the lingual

frenulum. (a) The restriction of the tongue elevation with a thick
and short frenulum. (b) The sutures of the wound after frenuloplas-
c ty. (c) Three months after surgery.

Table 1 The measurements of tongue elevation and tongue protrusion (mm) pre- and postoperatively

Tongue elevation Tongue protrusion

Postoperative Postoperative
Case Preoperative 1 week 1 month 3 months Preoperative 1 week 1 month 3 months
1 3 9 19 28 4 11 24 31
2 5 13 21 30 7 14 26 34
3 6 12 19 24 6 11 17 23

DISCUSSION improvement in 81% of the patients after frenu-

As far as current literature is concerned, there is neither
a generally accepted classification system to describe
ankyloglossia nor a unanimous system for treatment
management in terms of the indications, timing, and
method of surgical approach.3,41 However, positive
results after surgical treatment have been shown in
several studies. A prospective case study found an
loplasty;15 a randomized prospective study found an
improvement in between 40% and 91% of the patients,
depending on the operative method;53 a case series
study watching the vocal cords with a laryngofiber-
scope during phonation found that the vocal cords
after surgery could be seen in 55.3% of the cases
instead of 14% before surgery.11 Likewise, the surgery
performance on the present cases had positive out-

530 VOLUME 47 • NUMBER 6 • JUNE 2016


comes, with improvement in all cases. In terms of
tongue elevation and tongue protrusion assessments,
improvements of more than three times were found. A
prospective controlled trial demonstrated that the
measurements in millimeters of tongue elevation and
tongue protrusion when ankyloglossia was present
were nearly half the length of control persons.7
Many professionals have dealt with this topic,
including otolaryngologists, pediatricians, pediatric sur-
geons, dentists, oral and maxillofacial surgeons, perio-
dontists, lactation consultants, and speech patholo-
gists. According to the literature, it is obvious that the
significance of ankyloglossia, including clinical assess-
ment, etiopathogenesis, diagnosis, and management
of ankyloglossia, should be a matter of interdisciplinary
approach with some controversies among the scien-
tists in the subsection issues. The broad referral status
from different professionals regarding the treatment of
ankyloglossia is also supported by the three cases pre-
sented in this report. The first case was referred by an
otolaryngologist and orthodontist, the second by a
speech pathologist and orthodontist, and the third by
pediatrician, general surgeon, and speech pathologist.
In a considerable proportion of neonates, breast-
feeding problems are noticed.3,41 The influence of anky-
loglossia on performing oral hygiene has often been a
matter of discussion. In consequence of poor oral and
dental hygiene due to the difficulties in cleaning, caries
lesions, periodontal pockets, and gingival recessions
have been reported.92,93 In such cases the division of
frenulum is essential.
Gingival recessions have been reported as a result
of short and thick lingual frenulum.94 As seen in Fig 1,
the frenulum of the patient in Case 1 was attached high
to the lingual gingivae of the mandibular incisors, and
might have potentially contributed to the development
of recession. This was an additional reason to release
the frenulum. In contrast, in the other two cases the
frenulum was attached physiologically in the lingual
gingivae. Gingival recessions have a multifactorial etiol-
ogy and may be caused by primary and secondary fac-
tors. Main factors are associated with mechanical fac-
tors, such as toothbrushing trauma, and/or localized
VOLUME 47 • NUMBER 6 • JUNE 2016
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
Fig 4 A patient in whom the
ducts were not involved in the
lingual frenulum.
plaque-induced inflammatory lesions, and/or general-
ized forms of destructive periodontal disease.95 High
muscle attachment and frenal pull, alveolar bone dehis-
cences, iatrogenic reasons, and other factors have been
recognized as secondary factors.94,96,97 The influence of
high frenal attachment in gingival recession is unclear
and there are disagreements in the literature.94,98-100 In
particular, there is not enough evidence to support the
theory that a high frenal lingual attachment due to a
short and high attached lingual frenulum can cause
lingual recession simultaneously with or without gingi-
val inflammation, and therefore, a direct association is
not unambiguous. Additionally, a systematic review
found no evidence of association between gingival
recessions and ankyloglossia.55 However, some authors
support that insertion of lingual frenulum in attached
gingivae and papilla have strong association with gin-
gival recession.81 There is a case report concerning lin-
gual recession due to high lingual frenal attachment.54
Recently, mild recession in lingual gingivae around
mandibular central incisors has been presented.87
Additionally, it has been suggested that as a result
of a strong lingual frenulum insertion in the attached
gingivae, a diastema between the central incisors may
develop.7,55,63,98,101 Consequently, it may be anticipated
that an open interdental space without any interproxi-
mal contact might cause periodontal problems due to
food impaction.102,103
A factor that has to be considered very carefully, in
cases where the frenulum is attached high in lingual
gingivae, is whether the submandibular ducts interfere
or not with the frenulum. Sometimes the ducts are
located in the middle of the frenulum, a fact that makes
the division of the frenulum in surgery more difficult. In
531
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
the first case, the submandibular ducts are located in
the middle of the lingual frenulum (Figs 1a and 1c), in
contrast with another case where the ducts do not
interfere with the frenulum (Fig 4).
One of the possible complications of surgical pro-
cedures is scarring at the incision site leading to recur-
rent ankyloglossia. In an effort to avoid this complica-
tion, it is recommended that the patients perform
tongue exercises for some months postoperatively.
Specific exercises have been proposed by some authors
and for this reason it is recommended to motivate both
patients and their parents to meticulously follow the
instructions for the exercises after surgery.7,15,53 It may
also be anticipated that tongue exercises could help
the patient to increase the range of tongue motion.
Moreover, early mobilization of the tongue is encour-
aged to minimize scarring and tongue mobility. Usu-
ally, signs of improvement in mobility are not observed
prior to the first or second month postoperatively, and
this can extend to the third or fourth month.
The association between ankyloglossia and speech
problems is still not completely clear. The definition of
speech problems is mainly a subjective issue.7 In order
to clarify the effectiveness of the surgical treatment of
ankyloglossia on the therapy of speech problems, more
studies are needed. Furthermore, it would be of interest
to compare the treatment outcomes of speech prob-
lems between surgical release of ankyloglossia and
nonsurgical treatment carried out by speech patholo-
gists. In all three cases described in this report, the
vocalization was substantially improved after surgery.
Regarding the prevalence of ankyloglossia, the fol-
lowing two points need to be emphasized: Firstly, the
prevalence of ankyloglossia is lower in studies looking
for general findings on oral mucosa than in studies
looking for the prevalence of ankyloglossia
alone.3,8,41,42,44,104-107 Secondly, the prevalence is lower in
the studies investigating children, adolescents, or
adults than those investigating neonates, which may
suggest that mild forms of ankyloglossia are perhaps
resolved with growth.3,8,39,41,42,44,49,104,108
Systematic reviews have recently indicated a lack of
evidence on this topic, since the great majority of stud-
532
ies are either case reports or systematic reviews based
on case reports. Moreover, there is high diversity and
heterogeneity in methodology as well as in the charac-
teristics of the interventions.72,73 Therefore, more ran-
domized controlled trials are needed to confirm the
benefits of the surgical interventions on the various
problems observed in cases with ankyloglossia. Studies
comparing operated and not-operated cases with
ankyloglossia are also required, taking into account
obvious ethical issues.
CONCLUSIONS
Ankyloglossia is observed in a considerable number of
infants, children, and adults. Even today there is major
controversy among scientists regarding diagnosis,
management, therapy, and subsequent clinical bene-
fits. On the other hand, the surgical approach is a rela-
tively simple and safe procedure, leading to satisfactory
results in a short time.
REFERENCES
1. Kotlow LA. Ankyloglossia (tongue-tie): a diagnostic and treatment quandary.
Quintessence Int 1999;30:259–262.
2. Jamilian A, Fattahi FH, Kootanayi NG. Ankyloglossia and tongue mobility. Eur
Arch Paediatr Dent 2014;15:33–35.
3. Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E. Ankyloglossia: Incidence
and associated feeding difficulties. Arch Otolaryngol Head Neck Surg
2000;126:36–39.
4. Chu MW, Bloom DC. Posterior ankyloglossia: a case report. Int J Pediatr Oto-
rhinolaryngol 2009;73:881–883.
5. Wright J. Tongue-tie. J Paediatr Child Health 1995;31:276–278.
6. Bhattad MS, Baliga MS, Kriplani R. Clinical guidelines and management of
ankyloglossia with 1-year follow up: report of 3 cases. Case Rep Dent
2013;2013:185803.
7. Lalakea ML, Messner AH. Ankyloglossia: does it matter? Pediatr Clin North Am
2003;50:381–397.
8. Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of
tongue-tie in infants with feeding problems. J Paediatr Child Health 2005;41:
246–250.
9. Martinelli RL, Marchesan IQ, Gusmão RJ, Honório HM, Berretin-Felix G. The
effects of frenotomy on breastfeeding. J Appl Oral Sci 2015;23:153–157.
10. Mukai S, Mukai C, Asaoka K. Ankyloglossia with deviation of the epiglottis and
larynx. Ann Otol Rhinol Laryngol Suppl 1991;153:3–20.
11. Mukai S, Mukai C, Asaoka K. Congenital ankyloglossia with deviation of the
epiglottis and larynx: Symptoms and respiratory function in adults. Ann Otol
Rhinol Laryngol 1993;102:620–624.
12. Segal LM, Stephenson R, Dawes M, Feldman P. Prevalence, diagnosis, and
treatment of ankyloglossia: methodologic review. Can Fam Physician 2007;53:
1027–1033.
VOLUME 47 • NUMBER 6 • JUNE 2016

13. Sánchez-Ruiz I, González Landa G, Pérez González V, et al. Section of the
sublingual frenulum. Are the indications correct? Cir Pediatr 1999;12:161–164.
14. Jang SJ, Cha BK, Ngan P, Choi DS, Lee SK, Jang I. Relationship between the
lingual frenulum and craniofacial morphology in adults. Am J Orthod Dento-
facial Orthop 2011;139:e361–e367.
15. Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children.
Otolaryngol Head Neck Surg 2002;127:539–545.
16. Paradise JL. Evaluation and treatment for ankyloglossia. JAMA 1990;262:2371.
17. Peng CL, Jost-Brinkmann PG, Yoshida N, Chou HH, Lin CT. Comparison of
tongue functions between mature and tongue-thrust swallowing: an ultra-
sound investigation. Am J Orthod Dentofacial Orthop 2004;125:562–570.
18. Klockars T, Pitkäranta A. Pediatric tongue-tie division: indications, techniques
and patient satisfaction. Int J Pediatr Otorhinolaryngol 2009;73:1399–1401.
19. Björnsson A, Arnason A, Tippet P. X-linked cleft palate and ankyloglossia in an
Icelandic family. Cleft Palate J 1989;26:3–8.
20. Gorski SM, Adams KJ, Birch PH, Chodirker BN, Greenberg CR, Goodfellow PJ.
Linkage analysis of X-linked cleft palate and ankyloglossia in Manitoba Men-
nonite and British Columbia Native kindreds. Hum Genet 1994;94:141–148.
21. Forbes SA, Richardson M, Brennan L, et al. Refinement of the X-linked cleft
palate and ankyloglossia (CPX) localisation by genetic mapping in an Icelan-
dic kindred. Hum Genet 1995;95:342–346.
22. Braybrook C, Lisgo S, Doudney K, et al. Craniofacial expression of human and
murine TBX22 correlates with the cleft palate and ankyloglossia phenotype
observed in CPX patients. Hum Mol Genet 2002;11:2793–2804.
23. De Felice C, Toti P, Di Maggio G, Parrini S, Bagnoli F. Absence of the inferior
labial and lingual frenula in Ehlers-Danlos syndrome. Lancet 2001;357:
1500–1502.
24. Wright JT, Fine JD, Johnson LB, Steinmetz TT. Oral involvement of recessive
dystrophic epidermolysis bullosa inversa. Am J Med Genet 1993;47:
1184–1188.
25. Hacham-Zadeh S, Garfunkel AA. Kindler syndrome in two related Kurdish
families. Am J Med Genet 1985;20:43–48.
26. Neri G, Gurrieri F, Zanni G, Lin A. Clinical and molecular aspects of the Simpson
GolabiBehmel syndrome. Am J Med Genet 1998;79:279–283.
27. Burdick AB, Ma LA, Dai ZH, Gao NN. Van der Woude syndrome in two families
in China. J Craniofac Genet DevBiol 1987;7:413–418.
28. Patterson GT, Ramasastry SS, Davis JU. Macroglossia and ankyloglossia in
Beckwith-Wiedemann syndrome. Oral Surg Oral Med Oral Pathol 1988;65:
29–31.
29. Meinecke P, Blunck W, Rodewald A. Smith-Lemli-Opitz syndrome. Am J Med
Genet 1987;28:735–739.
30. Brooks JK, Leonard CO, Coccaro PJ Jr. Opitz (BBB/G) syndrome: Oral manifes-
tations. Am J Med Genet 1992;43:595–601.
31. Herr A, Meunier D, Müller I, et al. Expression of mouse Tbx22 supports its role
in palatogenesis and glossogenesis. Dev Dyn 2003;226:579–586.
32. Morita H, Mazerbourg S, Bouley DM, et al. Neonatal lethality of LGR5 null mice
is associated with ankyloglossia and gastrointestinal distension. Mol Cell Biol
2004;24:9736–9743.
33. Karahan S, Kul BC. Ankyloglossia in dogs: a morphological and immunohisto-
chemical study. Anat Histol Embryol 2009;38:118–121.
34. Klockars T, Pitkäranta A. Inheritance of ankyloglossia (tongue-tie). Clin Genet
2009;75:98–99.
35. Keizer D. Casuistische mededelingen dominant erfeljik ankyloglosson. Nederl
T Geneesk 1952;96:2203–2205.
36. Klockars T. Familial ankyloglossia (tongue-tie). Int J Pediatr Otorhinolaryngol
2007;71:1321–1324.
37. Harris EF, Friend GW, Tolley EA. Enhanced prevalence of ankyloglossia with
maternal cocaine use. Cleft Palate Craniofac J 1992;29:72–76.
38. Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int J
Pediatr Otorhinolaryngol 2000;54:123–131.
39. Jorgenson RJ, Shapiro SD, Salinas CF, Levin LS. Intraoral findings and anoma-
lies in neonates. Pediatrics 1982;69:577–582.
VOLUME 47 • NUMBER 6 • JUNE 2016
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
40. Friend GW, Harris EF, Mincer HH, Forg TL, Carruth KR. Oral anomalies in the
neonate by race and gender in an urban setting. Pediatr Dent 1990;12:
157–161.
41. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and
effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002;110:1–6.
42. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: preva-
lence and effect on breastfeeding. J Am Board Fam Pract 2005;18:1–7.
43. Sawyer DR, Taiwo EO, Mosadomi A. Oral anomalies in Nigerian children.
Community Dent Oral Epidemiol 1984;12:269–273.
44. García-Pola MJ, García-Martín JM, González-García M. Prevalence of oral
lesions in the 6-year-old pediatric population of Oviedo (Spain). Med Oral
2002;7:184–191.
45. Cinar F, Onat N. Prevalence and consequences of a forgotten entity: ankylo-
glossia. Plast Reconstr Surg 2005;115:355–356.
46. Ketty N, Sciullo PA. Ankyloglossia with psychological implications. J Dent
Child 1974;41:43–46.
47. Lalakea ML, Messner AH. Ankyloglossia: the adolescent and adult perspective.
Otolaryngol Head Neck Surg 2003;128:746–752.
48. Griffiths DM. Do tongue ties affect breastfeeding? J Hum Lact 2004;20:
409–414.
49. GarcíaPola MJ, González García M, García Martín JM, Gallas M, Seoane Lestón
J. A study of pathology associated with short lingual frenum. ASDC J Dent
Child 2002;69:59–62.
50. Queiroz Marchesan I. Lingual frenulum: classification and speech interference.
Int J Orofacial Myology 2004;30:31–38.
51. Pransky SM, Lago D, Hong P. Breastfeeding difficulties and oral cavity anom-
alies: the influence of posterior ankyloglossia and upper-lip ties. Int J Pediatr
Otorhinolaryngol 2015;79:1714–1717.
52. Schwartz K, d’Arcy H, Gillespie B, Bobo J, Longeway M, Foxman B. Factors
associated with weaning in the first 3 months postpartum. J Fam Pract 2002;
51:439–444.
53. Heller J, Gabbay J, O’Hara C, Heller M, Bradley JP. Improved ankyloglossia
correction with four-flap Z-frenuloplasty. Ann Plast Surg 2005;54:623–628.
54. Ewart NP. A lingual mucogingival problem associated with ankyloglossia: a
case report. N Z Dent J 1990;86:16–17.
55. Suter VG, Bornstein MM. Ankyloglossia: facts and myths in diagnosis and
treatment. J Periodontol 2009;80:1204–1219.
56. Couly G. The tongue, a natural orthodontic appliance ‘for better and for
worse’. Rev Orthop Dento Faciale 1989;23:9–17.
57. Defabianis P. Ankyloglossia and its influence on maxillary and mandibular
development: a seven year follow-up case report. Funct Orthod 2000;17:
25–33.
58. Ruffoli R, Giambelluca MA, Scavuzzo MC, et al. Ankyloglossia: a morphofunc-
tional investigation in children. Oral Dis 2005;11:170–174.
59. Webb AN, Hao W, Hong P. The effect of tongue-tie division on breastfeeding
and speech articulation: a systematic review. Int J Pediatr Otorhinolaryngol
2013;77:635–646.
60. Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF): use
in a lactation consultant private practice. Pasadena: Master’s Thesis, 1993.
61. Edmunds J, Hazelbaker A, Murphy JG, Philipp BL. Tongue-tie. J Hum Lact
2012;28:14–17.
62. Ito Y, Shimizu T, Nakamura T, Takatama C. Effectiveness of tongue-tie division
for speech disorder in children. Pediatr Int 2015;57:222–226.
63. Ferrés-Amat E, Pastor-Vera T, Ferrés-Amat E, Mareque-Bueno J, Prats-Armen-
gol J, Ferrés-Padró E. Multidisciplinary management of ankyloglossia in
childhood. Treatment of 101 cases. A protocol. Med Oral Patol Oral Cir Bucal
2016;21:e39–e47
64. Fernando C (ed). Tongue tie - from confusion to clarity: a guide to the diag-
nosis and treatment of ankyloglossia. Sydney: Tandem Publications, 1998.
65. Williams WN, Waldron CM. Assessment of lingual function when ankyloglos-
sia (tongue-tie) is suspected. J Am Dent Assoc 1985;110:353–356.
66. Berg KL. Tongue-tie (ankyloglossia) and breastfeeding: a review. J Hum Lact
1990;6:109–112.
533
Q U I N T E S S E N C E I N T E R N AT I O N A L
Tsaousoglou et al
67. Nicholson WL. Tongue-tie (ankyloglossia) associated with breastfeeding
problems. J Hum Lact 1991;7:82–84.
68. Notestine G. The importance of the identification of ankyloglossia (short lin-
gual frenulum) as a cause of breastfeeding problems. J Hum Lact 1990;6:
113–115.
69. Catlin FI, De Haan V. Tongue-tie. Arch Otolaryng 1971;94:548–557.
70. Warden PJ. Ankyloglossia: a review of the literature. Gen Dent 1991;39:
252–253.
71. Power RF, Murphy JF. Tongue-tie and frenotomy in infants with breastfeeding
difficulties: achieving a balance. Arch Dis Child 2015;100:489–494.
72. Chinnadurai S, Francis DO, Epstein RA, Morad A, Kohanim S, McPheeters M.
Treatment of ankyloglossia for reasons other than breastfeeding: a systematic
review. Pediatrics 2015;135:e1467–e1474.
73. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and
breastfeeding outcomes: a systematic review. Pediatrics 2015;135:e1458–
e1466.
74. Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: clinical
suggestions for diagnosis and management. Pediatr Dent 2005;27:40–46.
75. Velanovich V. The transverse-vertical frenuloplasty for ankyloglossia. Mil Med
1994;159:714–715.
76. Brinkmann S, Reilly S, Meara JG. Management of tongue-tie in children: a
survey of paediatric surgeons in Australia. J Paediatr Child Health 2004;40:
600–605.
77. Bullock N Jr. The use of the CO2 laser for lingual frenectomy and excisional
biopsy. Compend Contin Educ Dent 1995;16:1118,1120,1122–1123.
78. Fiorotti RC, Bertolini MM, Nicola JH, Nicola EM. Early lingual frenectomy assist-
ed by CO2 laser helps prevention and treatment of functional alterations
caused by ankyloglossia. Int J Orofacial Myology 2004;30:64–71.
79. Puthussery FJ, Shekar K, Gulati A, Downie IP. Use of carbon dioxide laser in
lingual frenectomy. Br J Oral Maxillofac Surg 2011;49:580–581.
80. De Santis D, Gerosa R, Graziani PF, et al. Lingual frenectomy: a comparison
between the conventional surgical and laser procedure (Epub ahead of print,
1 Aug 2013). Minerva Stomatol.
81. Lamba AK, Aggarwal K, Faraz F, Tandon S, Chawla K. Er, Cr:YSGG laser for the
treatment of ankyloglossia. Indian J Dent 2015;6:149–152.
82. Verco PJ. Case report and clinical technique: Argon beam electrosurgery for
tongue ties and maxillary frenectomies in infants and children. Eur Arch Pae-
diatr Dent 2007;8:15–19.
83. Aras MH, Göregen M, Güngörmüş M, Akgül HM. Comparison of diode laser
and Er:YAG lasers in the treatment of ankyloglossia. Photomed Laser Surg
2010;28:173–177.
84. Kara C. Evaluation of patient perceptions of frenectomy: a comparison of
Nd:YAG laser and conventional techniques. Photomed Laser Surg 2008;26:
147–152.
85. Olivi G, Signore A, Olivi M, Genovese MD. Lingual frenectomy: functional
evaluation and new therapeutical approach. Eur J Paediatr Dent 2012;13:
101–106.
86. Junqueira MA, Cunha NN, Costa e Silva LL, et al. Surgical techniques for the
treatment of ankyloglossia in children: a case series. J Appl Oral Sci 2014;22:
241–248.
87. Reddy NR, Marudhappan Y, Devi R, Narang S. Clipping the (tongue) tie. J
Indian Soc Periodontol 2014;18:395–398.
534
88. Srinivasan A, Dobrich C, Mitnick H, Feldman P. Ankyloglossia in breastfeeding
infants: The effect of frenotomy on maternal nipple pain and latch. Breastfeed
Med 2006;1:216–224.
89. Wallace H, Clarke S. Tongue tie division in infants with breast feeding difficul-
ties. Int J Pediatr Otorhinolaryngol 2006;70:1257–1261.
90. Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. Frenu-
lotomy for breastfeeding infants with ankyloglossia: effect on milk removal
and sucking mechanism as imaged by ultrasound. Pediatrics 2008;122:
e188–e194.
91. Gray SD, Parkin JL. Congenital malformations of the mouth and pharynx. In:
Bluestone CD, Stool SE, Kenna MA (eds). Pediatric Otolaryngology, 3rd ed.
Philadelphia: WB Saunders, 1996:989–991.
92. Sane VD, Pawar S, Modi S, Saddiwal R, Khade M, Tendulkar H. Is use of laser
really essential for release of tongue-tie? J Craniofac Surg 2014;25:e279–e280.
93. Carmen F (ed). Tongue tie, from confusion to clarity. Sydney: Tandem Publi-
cations, 1998.
94. Trott JR, Love B. An analysis of localized gingival recession in 766 Winnipeg
High School students. Dent Pract Dent Rec 1966;16:209–213.
95. Wennström JL, Zucchelli G, Pini Prato GP. Mucogingival therapy: Periodontal
plastic surgery. In: Lang NP, Lindhe J (eds). Clinical Periodontology and
Implant Dentistry, 5th ed. Oxford: Blackwell Munksgaard Publishing, 2008:
955–1028.
96. Löst C. Depth of alveolar bone dehiscences in relation to gingival recessions.
J Clin Periodontol 1984;11:583–589.
97. Lindhe J, Nyman S. Alterations of the position of the marginal soft tissue fol-
lowing periodontal surgery J Clin Periodontol 1980;7:525–530.
98. Stoner JE, Mazdyasna S. Gingival recession in the lower incisor region of
15-year-old subjects. J Periodontol 1980;51:74–76.
99. Powell RN, McEniery TM. A longitudinal study of isolated gingival recession in
the mandibular central incisor region of children aged 6–8 years. J Clin Peri-
odontol 1982;9:357–364.
100. Younes SA, El Angbawi MF. Gingival recession in the mandibular central
incisor region of Saudi schoolchildren aged 10–15 years. Community Dent
Oral Epidemiol 1983;11:246–249.
101. Priyanka M, Sruthi R, Ramakrishnan T, Emmadi P, Ambalavanan N. An over-
view of frenal attachments. J Indian Soc Periodontol 2013;17:12–15.
102. Larato DC. Relationship of food impaction to interproximal intrabony lesions.
J Periodontol 1971;42:237–238.
103. Jernberg GR, Bakdash MB, Keenan KM. Relationship between proximal tooth
open contacts and periodontal disease. J Periodontol 1983;54:529–533.
104. Sedano HO, Carreon Freyre I, Garza de la Garza ML, et al. Clinical orodental
abnormalities in Mexican children. Oral Surg Oral Med Oral Pathol 1989;68:
300–311.
105. Flinck A, Paludan A, Matsson L, Holm AK, Axelsson I. Oral findings in a group
of newborn Swedish children. Int J Paediatr Dent 1994;4:67–73.
106. Vörös-Balog T, Vincze N, Bánóczy J. Prevalence of tongue lesions in Hungarian
children. Oral Dis 2003;9:84–87.
107. Mumcu G, Cimilli H, Sur H, Hayran O, Atalay T. Prevalence and distribution of
oral lesions: A cross sectional study in Turkey. Oral Dis 2005;11:81–87.
108. Sedano HO. Congenital oral anomalies in Argentinian children. Community
Dent Oral Epidemiol 1975;3:61–63.
VOLUME 47 • NUMBER 6 • JUNE 2016
Copyright of Quintessence International is the property of Quintessence Publishing Company
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.