Int. J. Oral Maxillofac. Surg.

2010; 39: 11301144

available online at http://www.sciencedirect.com

Case Report
Cleft Lip and Palate

Surgical treatment of
ankyloglossia in babiescase
report

A. R. G. Manfro1, R. Manfro2,
M. C. Bortoluzzi3
1
Department of Histology UNOESC SC,
Brazil; 2Department of Implantodontic and
Maxillofacial Surgery SOEBRAS-Passo
S Florianopolis
Fundo RS and SOEBRA
SC, Brazil; 3Department of Maxillofacial
Surgery UNOESC SC, Brazil

A. R. G. Manfro, R. Manfro, M. C. Bortoluzzi: Surgical treatment of ankyloglossia in

babiescase report. Int. J. Oral Maxillofac. Surg. 2010; 39: 11301132. # 2010
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.
Abstract. Ankyloglossia is an anomaly that is characterized by the abnormal insertion
of the lingual frenulum that hinders protrusion and elevation of the tongue towards
the palate, due to the short and thick composition of the frenulum. In babies it can
cause inefficient nursing at the mothers breast, inadequate transfer of milk and pain
in the mothers breast, resulting in early weaning and weight loss. An 8-month-old
baby boy was brought to the clinic by his mother because he found it difficult to suck
and consequently avoiding breast feeding, and was apparently losing weight.
During the clinical exam it was observed that the patient presented little mobility of
the tongue. Owing to the degree of ankyloglossia and the features of malnutrition
present, it was decided to carry out complete removal of the frenulum under general
anesthesia. Although this procedure might increase the risk of morbidity, the
possibility of recurrence and the need to perform further procedures are avoided; the
main advantage is reducing aggravation of the clinical problems.

Ankyloglossia is an oral anomaly characterized by the abnormal insertion of

the lingual frenulum, which compresses
the mucosa, dense connective tissue, and
occasionally, superior fibers of the genioglossus muscle. In this case, protrusion
and elevation of tongue in the direction
of the palate was hindered by the tension
on the short frenulum8. This pathology,
diagnosed at birth, can persist until late
childhood or even adulthood, and presents different patterns of insertion from
the tip of the tongue to the lingual
alveolar ridge4.
The prevalence of ankyloglossia
described in the literature ranges between
0.1% and 10.7%1,4. The main reason for
0901-5027/1101130 + 015 $36.00/0

this wide variation is the lack of definition

among researchers when making diagnosing ankyloglossia. In observational epidemiologic studies of oral mucosa in
general, the prevalence of ankyloglossia
is generally lower (0.14%) than in studies
related only to the prevalence of ankyloglossia (411%). The prevalence is also
higher in studies that investigate newborns
(211%) compared with studies reporting
on children and adults (0.12%)3.
There are asymptomatic cases of this
abnormality, but disorders of language
development can be noted, as a result of
limitation of tongue tip movement9, as
well as mandibular development alterations, affecting facial development and

Keywords: ankyloglossia; frenectomy; general

anesthesia.
Accepted for publication 2 June 2010
Available online 7 July 2010

dental treatment7. Ankyloglossia in

infants is associated with a 2560% incidence of difficulty with breastfeeding,
such as failure to thrive, maternal nipple
damage, maternal breast pain, poor milk
supply, breast engorgement, and refusing
the breast1,4,8. These symptoms have been
associated with ankyloglossia, so it should
be considered a contributing factor when
assessing women with breastfeeding difficulties. Infants with restrictive ankyloglossia cannot extend their tongues over
the lower gum line to form a proper seal
and must use their jaws to keep the breast
in the mouth1,8. In infants with ankyloglossia, this deficiency might require surgical correction9.

# 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Surgical treatment of ankyloglossia in babiescase report

Ankyloglossia can be diagnosed using
the following criteria: impossibility of
touching palate with tongue tip when
the mouth is open; bifid tongue during
protrusion; curvature of the intermediate
part of the tongue, preventing it from
moving forward out of the oral cavity;
and reduced sublingual space7,10.
The treatment options for ankyloglossia
involve observation, language articulation
therapy and three possible surgical techniques: frenotomy, which consists of simply cutting the frenulum; frenectomy,
complete excision of the frenulum; and
frenuloplasty, which involves freeing the
tongue and correcting its anatomy3,7,10.
Depending on the consequences of the
abnormality, radical and urgent treatment
may be required.
Case report

An 8-month-old boy was brought in by his

mother, who related the babys inability to
generate and maintain suction during
breast or bottle feeding, rejecting the bottle when it was offered. She also reported
painful breastfeeding and the babys
weight loss.
During the initial clinical examination
poor tongue mobility was observed, especially when attempting to elevate the tongue (Fig. 1). The severity was defined
using the Hazelbaker Lingual Assessment
Tool for Lingual Frenulum Function5,
which was developed to evaluate the
severity of ankyloglossia in newborns,

and is recommended by the Academy of

Breastfeeding Medicine as a method of
evaluating ankyloglossia. The method is
based on appearance (five items) and functional aspects (seven items) and uses a score
system to classify the tongue into three
categories: functionally compromised,
acceptable or perfect. The items related to
appearance are: the appearance of the tongue when it is raised, elasticity of the lingual
frenulum, length of the frenulum when the
tongue is raised, fixation of the lingual
frenulum and tongue, and fixation of the
frenulum to the inferior crest. The items
evaluated regarding function are: lateralization, tongue elevation, tongue extension,
anterior spread of the tongue, peristaltism
and snapback. Each item has a score: significant ankyloglossia is defined as a function of the score (0, 1 or 2) according to the
characteristics of the tongue. A tongue with
a score of 14 (irrespective of the item
appearance) is classified as perfect. A score
of 11 is considered acceptable. A score
under 11 characterizes a functionally compromised tongue. A score below 8 determines the need for surgical treatment.
Examination gave this baby a score of 7
determining a functionally compromised
tongue in of surgical intervention. Oral
and maxillofacial surgeons and anesthesiologists planned the treatment in conjunction
with a specialist in pediatric dentistry.
Owing to the degree of ankyloglossia present, complete removal of the frenulum
with muscle dissection, performed under
general anesthesia was chosen.

[(Fig._1)TD$IG]

Fig. 1. Infants tongue movement is restricted by an abnormal lingual frenulum.

1131

After evaluation by the pediatrician and

anesthesiologist, the patient underwent
general anesthesia, followed by local infiltration of 0.9 ml of 4% articaine with
1:200,000. A 5-0 simple catgut suture
thread placed in an atraumatic needle
was used to immobilize the tongue in its
position. This thread was passed through
the tongue tip and fixed with Halsted
forceps. This surgical instrument was used
to provide tongue traction and facilitate
the surgical procedures. Resection of the
lingual frenulum was performed with a
No. 15 surgical scalpel fitted to a No. 3
handle. A pair of Metzenbaum scissors
was used to perform muscle dissection
until normal tongue mobility for an 8month-old infant was achieved. The surgical wound was sutured with 5-0 simple
catgut.. Immediately after surgery it was
noted that tissue mobility had been reestablished (Fig. 2).
The patient was discharged on the same
day and his mother was instructed to
encourage him to suck in order to exercise
the tongue.
At the 1 week follow-up, the babys
mother reported that he had no postoperative complaints and his ability to suck had
improved. 30 days after surgery, the
patient showed movement and strength
consistent with his age, and had no difficulty with breastfeeding.
Discussion

Ankyloglossia is the most frequent developmental abnormality of the tongue,

occurring in 0.220% of patients1. There
are various consequences of this abnormality, ranging from a mild reduction in
tongue movement to a mandibular growth
deficiency. In breastfed infants it can
cause poor sucking at the breast, inadequate transfer of milk and make the
mothers nipples painful, resulting in early
weaning4,6, and weight loss in the baby.
Marmet et al.8 confirmed that a short
lingual frenulum prevents the normal
movements of breastfeeding, because it
is impossible for the baby to compress
the mothers breast, resulting in regurgitation, and in extreme cases, inanition,
because the movements required for sucking are inhibited.
Depending on the consequences of the
abnormality, early treatment is essential
and radical measures must be taken.
Although frenotomy is a more conservative procedure, it offers the undesirable
possibility of fibers becoming reattached,
requiring complementary procedures to
release the tongue satisfactorily, such as
section of superficial genioglossus muscle

1132
[(Fig._2)TD$IG]

Manfro et al.
Ethical approval

Not required.

References

Fig. 2. Clinical photograph taken after surgery. Note that proper tissue mobility is achieved
immediately after surgery.

fibers, dissection of the lateral edge of the

incision and gingivectomy. Frenectomy is
a more invasive procedure and more difficult to perform in very young children, in
an ambulatory environment, but its results
are more predictable, decreasing the recurrence rate7. Berg2 reported that frenectomy is normally performed in 13-yearold children, under general anesthesia, in
most cases. It should be performed as soon
as possible, because if performed later, the
child might have incorrect swallowing and
disturbed speech muscle movement patterns. There are no conclusive parameters
about the age for performing the surgical
technique in the literature9. Randomized
clinical trials, prospective studies and
long-term follow-up studies are necessary
to determine the optimum age for surgery.
In situations in which the newborn presents difficulty with breastfeeding associated with weight loss, frenectomy is
the treatment option, and must be performed as quickly as possible to prevent

conditions of malnutrition or problems

with physical and/or motor development.
The main treatment options for ankyloglossia are frenectomy and frenotomy, but
because of the limited quantity and quality
of available data it is impossible to determine the best surgical treatment and ideal
age for therapy10.
In conclusion, this study describes the
case of a baby with ankyloglossia who had
started to reject breastfeeding and had lost
weight; a typical situation for the indication of a radical treatment such as frenectomy, even though it needs to be performed
under general anesthesia.

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Competing interests

Address:
Aline Rosler Grings Manfro
Av
XV de Novembro
371/1001
CEP 89600-000
Centro Joacaba/SC
Brazil
Tel.: +55 049 3521 3080

None declared.

doi:10.1016/j.ijom.2010.06.007

Funding

None.