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3.1: Frenolotomy and Frenulectomy for Ankyloglossia (Tongue Tie)

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    Ndivhuwo Diale, Shazia Peer, Jessica McGuire

    Frenulotomy (also referred to as frenotomy) and frenulectomy (frenectomy) are surgical procedures used to correct ankyloglossia, a congenital condition in which the lingual frenulum is too short, causing restricted tongue movement. It is commonly called a tongue tie and it affects 4-11% of neonates1.

    Frenulotomy refers to an incision in the frenulum that frees the tongue from the floor of the mouth. Frenulectomy refers to complete excision of the frenulum. It is more invasive and may be difficult to perform on small children; however, the results are more predictable, and the recurrence rate is lower.


    The tongue is attached to the floor of the mouth by the lingual frenulum. The frenulum’s appearance varies considerably between individuals. Microdissection of cadavers shows that it is a dynamic, layered structure formed by oral mucosa and the underlying floor of mouth fascia, which is mobilized into a midline fold with tongue elevation and/or retraction2.


    Figure 1: Floor of the mouth and ventral surface of the tongue

    The base of the frenulum contains a "V" shaped hump of tissue in the floor of the mouth which houses the two Wharton’s ducts on either side. The sublingual salivary glands empty through tiny ducts on either side of Wharton's ducts. Superficial veins running through the base of the frenulum are known as ranine veins (Figure 1).

    Classification of ankyloglossia (Table 1)

    Type 1 Most extreme form, 100% of the tongue is attached to the lingual frenulum and is tethered to the floor of the mouth anteriorly Screen Shot 2021-06-09 at 5.27.27 PM.png
    Type 2 75% of the tongue is tethered with restricted elevation and extension of the tongue Screen Shot 2021-06-09 at 5.28.05 PM.png
    Type 3 50% of the tongue is tethered. Tongue appears normal, but mobility is limited. Screen Shot 2021-06-09 at 5.28.20 PM.png
    Type 4 Limited tongue mobility due to a posterior, fibrous limitation of the most distal portion of the lingual frenulum Screen Shot 2021-06-09 at 5.28.31 PM.png

    Table 1: Modified grading system developed by Coryllos et al9. Type 2-4 images obtained from Yoon et al10

    Currently, there are no established criteria or grading systems to classify ankyloglossia.

    Several studies have suggested various guidelines based on the following criteria:

    • Length of the frenulum3,4
    • Upward tongue mobility (difficulty lifting the tongue to the upper dental alveolus)5,6
    • Limited tongue protrusion ≤1–2 mm past the lower central incisors7
    • Impaired lateral mobility of the tongue, ‘heart-shaped-tongue-appearance’ and thick fibrous cord palpated on physical examination8

    The classification by Coryllos permits identification of type III and IV frenula, which can go unnoticed with macroscopic examination, by means of palpation (Table 1). For a diagnosis of ankyloglossia in neonates it is necessary to combine both functional and anatomical criteria.

    Indications for surgery

    There has been a surge in frenulotomies performed on neonates in recent years in an attempt to improve breastfeeding. A Cochrane review found that frenulotomy reduced mothers’ nipple pain and had for the most part, positive short-term effects on breastfeeding1.


    • Difficulty feeding, poor latch in breastfeeding babies and poor weight gain
    • Difficulty swallowing
    • Decreased mobility of tongue
    • Speech difficulties
    • Significant dental problems

    A frenulotomy is appropriate in patients with symptomatic type 2-4 ankyloglossia, provided that the frenulum is not fibrotic. Type 1 ankyloglossia, fibrotic frenula and revision cases would benefit from a frenulectomy.

    In neonates and infants, it may be performed under local anesthesia in an outpatient setting. The author has performed this procedure in a 16-week infant. The optimum age to perform a frenulotomy in infants is unclear1 and the age limit to performing the procedure under local anesthesia is equally unclear. Consider a general anesthesia in babies much older than 16 weeks.


    Surgical consent is obtained.

    a. Outpatient Awake Procedure

    • The child is swaddled and restrained by an assistant
    • The child is then placed flat with head in neutral position and mouth open
    Local anesthesia
    • Lignocaine HCl 1% m/v local anesthetic with adrenaline 1:160000 is injected on either side of the frenulum
    • The dose limit is 7 mg/kg and each 1 mL contains 10 mg of lignocaine
    • This is important to bear in mind for small infants


    Figure 3: Example of a grooved retractor


    Figure 4: Grooved retractor manufactured from a teaspoon


    Figure 5: Grooved retractor tenting the frenulum

    • A grooved retractor is used to retract the tongue (Figures 3,4,5)
    • A straight Crile hemostat is used to crimp the frenulum prior to release
    • Sterile curved scissors are then used to release the lingual frenulum at its attachment
    • The incision should be close to the ventral surface of the tongue to avoid injury to the ductal orifices
    • To ensure adequate release of the frenulum, using your finger, gently massage the tongue at the deep end of the cut frenulum.
    • The floor of mouth is compressed with gauze to provide hemostasis, if necessary

    In the awake child, sucking and oral 50% dextrose syrup may also be used to sooth the infant.

    b. General Anesthesia

    • Intermittent mask ventilation or nasal intubation is preferable for adequate access
    • Oral intubation may also be performed
    • Place the child in a supine position with head extended
    • Open the mouth and use the grooved retractor to retract the tongue
    Surgical steps


    Figure 6: Hemostat clamped parallel to tongue


    Figure 7: Middle finger retracting lower lip to avoid injuring it while lingual frenulum is released


    Figure 8: Diamond-shaped wound following frenulotomy


    Figure 9: In revision cases, or older children, interrupted absorbable sutures can be placed to prevent the release from adhesing back down onto the floor of mouth

    • Inject or apply topical pledgets soaked with 1:80000 lignocaine with adrenaline to either side of frenulum
    • Use the grooved retractor to retract the ventral tongue to fully expose the lingual frenulum (Figure 5)
    • Clamp a straight Crile hemostat onto frenulum parallel to the tongue at its ventral surface (Figure 6)
    • Wait a few seconds, and then release the hemostat
    • Use sterile iris scissors to release the lingual frenulum at its attachment (Figures 6-8)
    • Make the incision close to the ventral surface of the tongue to avoid the submandibular and sublingual salivary gland ducts which open onto the floor of the mouth
    • To break down deeper fibrous bands, gentle finger / peanut dissection is recommended (encountered more often in thicker frenula and revision cases)
    • The genioglossus muscle is the posterior limit of the frenulum incision
    • Compress the floor of mouth with gauze to provide hemostasis
    • In revision cases, or with older children, interrupted absorbable sutures can be placed to prevent the release from adhesing back down onto the floor of mouth. Take care near the papilla of the submandibular ducts (Figure 9)
    Complications of surgery (rare)
    • Bleeding
    • Infection
    • Swelling
    • Discomfort
    • Injury to Wharton’s duct
    • Scarring requiring revision


    This is recommended in older children and revision cases to improve speech.

    Surgical Steps


    Figure 10: Incisions outlined


    Figure 11: Vertical incision along frenulum



    Figures 12a, b: Two incisions at 900 to vertical incision


    Figures 13a, b: Two flaps are elevated


    Figure 14: Transpose the 2 flaps adjacent to each other to close in the form of a Z-plasty


    Figures 15a, b: Sutures flaps to complete the Z-plasty

    • Place a silk stitch through the tongue tip to retract the tongue and hold it in place (Figure 10)
    • Apply lignocaine with adrenaline injection of 1:80 000 or topical pledgets to either side of frenulum
    • Draw the Z-plasty incisions (Figure 10)
    • Make a vertical/longitudinal incision along the length of the frenulum (Figure 11)
    • Make 2 incisions at 900 to the first vertical one (Figures 12a, b)
    • Two rectangular flaps are now created and elevated (Figures 13a, b)
    • Transpose the 2 flaps adjacent to each other to close in the form of a Z-plasty (Figure 14)
    • Suture with interrupted 5.0 vicryl (Figures 15a, b)


    1. O'Shea JE, Foster JP, O'Donnell CP, Breathnach D, Jacobs SE, Todd DA, Davis PG. Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews. 2017(3)
    2. Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E. Ankyloglossia: incidence and associated feeding difficulties, Arch Otolaryngol Head Neck Surg. 126 (2000) 36–9
    3. Kotlow LA, Ankyloglossia (tonguetie): a diagnostic and treatment quandary, Quintessence Int. 30 (1999) 259–62
    4. Marmet C, Shell E, Marmet R, Neonatal frenotomy may be necessary to correct breastfeeding problems, J Hum Lact. 6 (1990) 117–21
    5. Hogan M, Westcott C, Griffiths M, Randomized, controlled trial of division of tongue-tie in infants with feeding problems, J Paediatr Child Health. 41 (2005) 246–50
    6. Masaitis NS, Kaempf JW. Developing a frenotomy policy at one medical center: a case study approach. J. Hum. Lact. 12 (1996) 229–32
    7. Chu MW, Bloom DC. Posterior ankyloglossia: a case report, Int J Pediatr Otorhinolaryngol. 73 (2009) 881–3
    8. Harris EF, Friend GW, Tolley EA. Enhanced prevalence of ankyloglossia with maternal cocaine use, Cleft Palate Craniofac J. 29 (1992) 72–6
    9. Coryllos E, Genna CW, Salloum AC. Congenital tongue-tie and its impact on breastfeeding. AAP section on breastfeeding. 2004; Vol. Summer‐8‐27%20Newsletter.pdf
    10. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY. Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional–morphological study. Orthodontics & craniofacial research. 2017 Nov;20(4):237-44


    Ndivhuwo Diale MBChB, MMed, FCORL
    Sefako Makgatho Health Sciences
    University, Gauteng Province, South Africa

    Shazia Peer MBChB, MMed, FCORL
    A-Professor, Pediatric Otolaryngologist
    Red Cross War Memorial Children’s Hospital, Cape Town, South Africa

    Jessica McGuire MBChB, MMed, FCORL
    Pediatric Otolaryngology
    Red Cross War Memorial Children’s Hospital, Cape Town, South Africa

    Pediatric Section Editor

    Nico Jonas MBChB, FCORL, MMed
    Pediatric Otolaryngologist
    Addenbrooke’s Hospital Cambridge, United Kingdom

    Author and Editor

    Johan Fagan MBChB, FCS(ORL), MMed
    Professor and Chairman
    Division of Otolaryngology
    University of Cape Town
    Cape Town, South Africa