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Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 103-107

Experiences and outcomes of frenotomy in children with ankyloglossia in multiple tertiary centers in Saudi Arabia

1 Department of Surgery, Faculty of Medicine, Umm Al-Qura University, Makkah; Department of Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
2 Department of Academic Clinical, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
3 Department of Academic Clinical, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission18-Sep-2020
Date of Decision06-Nov-2020
Date of Acceptance23-Dec-2020
Date of Web Publication15-May-2021

Correspondence Address:
Osama A Bawazir
Department of Surgery, Faculty of Medicine, Umm Al-Qura University, P. O. Box 715, Makkah 21955
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.JCN_151_20

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Aims: The aim of the study was to examine the experiences and outcomes of frenotomy treatment in neonates and children with ankyloglossia and to explore any subsequent complications. Patients and Methods: This is a retrospective, cross-sectional study of all pediatric cases of ankyloglossia that initially underwent frenotomy over a period of 5 years, in 2015–2020, across a number of departments in three tertiary centers in Jeddah, Saudi Arabia. Results: The most common indications were feeding difficulty in infants under 4 months and speech difficulty in children over 4 months. Following frenotomy, improvements were observed in symptomatic (96%) and asymptomatic (≈70%) children. Overall complications in the frenotomy procedure, including any minor bleeding, were found to be minimal. Conclusion: Ankyloglossia is a common disorder, but its effects on feeding and speaking are difficult to determine objectively, owing to the complexity of individual cases. Most of the babies in the present study improved following frenotomy, which is a simple, time-efficient, low-cost, and safe procedure.

Keywords: Ankyloglossia, children, frenotomy

How to cite this article:
Bawazir OA, Bawazir AO, Bawazir RO, Bawazir FA, Halabi NF. Experiences and outcomes of frenotomy in children with ankyloglossia in multiple tertiary centers in Saudi Arabia. J Clin Neonatol 2021;10:103-7

How to cite this URL:
Bawazir OA, Bawazir AO, Bawazir RO, Bawazir FA, Halabi NF. Experiences and outcomes of frenotomy in children with ankyloglossia in multiple tertiary centers in Saudi Arabia. J Clin Neonatol [serial online] 2021 [cited 2023 Mar 21];10:103-7. Available from: https://www.jcnonweb.com/text.asp?2021/10/2/103/316175

  Introduction Top

Ankyloglossia, or tongue-tie, is a congenital condition involving a thick, tight, or short lingual frenulum, which limits tongue movement and may affect feeding and ultimately speech. The lingual frenulum is a mucous fold rising from under the tongue to the midline of the bottom of the mouth. The incidence rate of ankyloglossia in the general population has been reported to be between 3% and 11%,[1],[2] although it is more frequent in boys, and ethnicity is not a risk factor.[3] While ankyloglossia is asymptomatic most of the time,[4] it is a significant cause of difficulty for breastfeeding. Infant difficulties include a poor latch, problems swallowing air, and restlessness when feeding, with low weight gain, dehydration, and short feeding times.[5] Maternal problems include both pain and discomfort; symptoms such as nipple pain may be so extreme that mothers may decide to discontinue breastfeeding.[6]

Ankyloglossia can cause various mechanical issues, including the delay of speech in older children, a problem eating ice cream in older children and adults, and difficulty playing musical wind instruments; also, in many cases, there is difficulty in removing food from the teeth with the tongue.[7] The most common treatment method for ankyloglossia is surgical excision through a process known as frenotomy[8] (also termed frenectomy and frenulectomy), which is a noninvasive operation with a good success rate. The diagnosis and treatment of this condition, however, has been a tendentious subject for a considerable amount of time, with no consensus reached. While of limited risk, a number of reviews have concluded that the existing data concerning treatment and recovery do not support undertaking frenotomy.[9] Furthermore, some studies have drawn attention to the recent increase in diagnosis and procedures relating to ankyloglossia, raising concern about possible overtreatment.[10],[11] By contrast, it has been suggested that surgical intervention in infants may eliminate the difficulty of sucking, reduce nipple pain for mothers, and militate against speech problems that may subsequently arise.[12],[13]

In this study, we explore the characteristics and outcomes of frenotomy for ankyloglossia in child patients, examining data related to gender, complications, symptom improvement, and timing of surgery.

  Patients and Methods Top

This retrospective observational study evaluates the experience of frenotomy for symptomatic ankyloglossia in pediatric patients. A total of 187 children were referred to a pediatric surgery clinic for the management of ankyloglossia. Sixty-nine babies did not meet the inclusion criteria and 118 consecutive patients (diagnosis confirmed by clinical exams) that underwent frenotomy in three tertiary institutions between 2015 and 2020 were analyzed. Information regarding patient medical record number, age (under 4 months or over 4 months), gender, primary symptoms, date of surgery, indication for frenotomy, complications, and symptom resolution were taken from the electronic medical records [[Figure 1] shows the study flowchart].
Figure 1: Study map

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Improvements after frenotomy were measured (in both symptomatic and asymptomatic patients) by improvement of sucking, reduce nipple pain for mothers, and weight gain for babies <4 months and enhancement of speech according to the family assessment and few according to speech therapist assessment.

The ankyloglossia diagnosis was made by a consultant pediatric surgeon, which considered aspects of the lingual frenulum that may affect tongue function and appearance such as position of the tongue close to the teeth, lack of elasticity, and short length.

Follow-up was conducted after 2 weeks, 3, 6, and 12 months. The procedure was considered effective if there were no complications, and patients did not require reintervention.

Surgical techniques

For babies younger than 4 months, the procedure was carried out in a clinic, using xylocain spray as a local anesthetic. The frenulum is crushed by artery forceps then detach with scissors; no suture was used for this age group.

For children older than 4 months, a general anesthesia was used. Pediatric surgeons cut the lingual frenulum by electrocautery, until the tongue base is reached. (Absorbable suture were used to cover the raw area).

Statistical analysis

A statistical analysis was carried out with Stata 16 (Stata Corp, College Station, Texas, USA). Continuous variables were given as mean with standard deviation, and categorical variables were represented as numbers and percentages. Continuous variables were compared using an independent samples t-test and categorical variables with Chi-squared or Fisher's exact tests if the expected frequency was lower than 5. A P < 0.05 was set as statistically significant.

  Results Top

After exclusion of 69 patients, 118 patients who receive frenotomy for ankyloglossia were included in the analysis. Patients were put into two groups according to age and type of anesthesia. Group 1 (n = 65) was those under 4 months and underwent frenotomy under local anesthesia in a clinic setting. Group 2 (n = 53) was those over 4 months and had frenotomy under general anesthesia as a “day case surgery.” The male-to-female ratio was 2.19:1, and the median age in Group 1 was 2.17 months versus 31 months in Group 2. Using an independent samples t-test, there was no statistically significant difference in sex ratio between the two groups (P = 0.33 and P = 0.71, respectively). The main indication for frenotomy in Group 1 was feeding difficulty (78.5%), while speech difficulty was the main indication for Group 2 (58.4%) [Table 1].
Table 1: Comparison of demographic data, indication of surgery, and complications in Groups 1 and 2

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The follow-up period ranged from 3 to 12 months, and 92 patients completed 1 year of follow-up (78%).

The majority of symptomatic patients (96%) showed improvement after frenotomy in both groups (P = 0.88). Furthermore, asymptomatic patients improved in both Group 1 (78%) and Group 2 (62.5%). The mean operation time for Group 1 was 5 ± 2 min and for Group 2 was 11 ± 4 min. Thus, operation time was significantly shorter in Group 1 (P < 0.001).

Complications in the frenotomy procedure were nonsignificantly more prevalent in Group 1 (P = 0.197). Furthermore, two patients in Group 1 had bleeding, which required silver nitrate to impede. No patient had postoperative wound infection. Information regarding frenotomy complications is shown in [Table 1].

  Discussion Top

The management of ankyloglossia has received considerable focus in recent years, owing to controversial diagnoses and treatments as a result of a multiplicity of options and modalities and incalcitrant data.

The study found that ankyloglossia was more prevalent in males in the study cohort, with a male-female ratio of 2.22:1, which is broadly supported in the pediatrics literature. For example, Karabulut et al. stated that 70.2% of 127 ankyloglossia pediatric patients were boy, having a boy–girl gender ratio of 2.6:1.[14]

There have been diverging opinions raised regarding the optimal timing for procedures to treat ankyloglossia. A number of authors suggest that surgery could be carried out almost immediately after birth. Indeed, some studies propose, similar to the present study, that nutritional deficiency in a newborn with ankyloglossia can be treated promptly with frenotomy.[5],[15] Others argue that symptomatic newborns should be observed and treated when necessary. Authors that advocate a wait-and-see approach are generally of the view that it may be better to defer treatment since in asymptomatic ankyloglossia cases, tongue movement can show spontaneous recovery, and some children can learn to develop tongue mobility. Mostly, a frenotomy resulted in a substantial increase in the length of the tongue and improvement in consonant articulation. Thus, they generally recommend surgery after 4 years of age.[16]

Ankyloglossia can affect a person in various ways beyond speech impediment as a result of the fundamental mechanical problem such as difficulty playing wind instruments and cleaning teeth with the tongue. Indeed, late-onset symptoms and issues are another principled reason why surgery may be advised for parents when ankyloglossia is detected.[7] Buryk et al. examined thirty infants with ankyloglossia aged between 1 day and 35 days (mean: 6.6 days) and found that frenotomy corrected the feeding immediately and reduced breast pain, and there were no complications in the newborns in the study.[16]

Various surgical treatment modalities and techniques have been introduced for ankyloglossia in children, the most commonly applied being frenotomy and frenuloplasty. However, frenotomy is the most simple procedure, which involves cutting the lingual frenulum. In frenuloplasty, in addition to severing the lingual frenulum, a small separation is made in the genioglossus muscle. Frenotomy is the most popular technique used in infants, and it is straightforward, cost effective, time efficient, and safe and can be carried out with or without local anesthesia.[17],[18] However, frenuloplasty operations for ankyloglossia are likewise very reliable. The most common complication in both these procedures is its recurrence owing to scar formation. Nevertheless, postoperative bleeding, infection, and tongue swelling have been reported in a few cases.[17]

Dollberg et al. found that frenotomy lowered the pain experienced by mothers and often mitigated breastfeeding issues, in a study on 25 infants aged between 1 and 21 days.[5] To the author's knowledge, there have been few randomized controlled studies that have shown breastfeeding enhancement after frenulotomy.[1],[19] Although these studies had significant limitations. In general, there is limited evidence with regard to the advantages and disadvantages of surgery,[9],[20] thus further research is required.

It has been proposed that, in asymptomatic babies, the lingual frenulum can become more elastic over time, and children can adapt and are able to feed and gain weight.[21] The mean age to have the procedure in the present cohort was similar to a number of other studies, which broadly suggests that frenotomy may best be carried out between 1 and 3 weeks after birth.[3],[22] This issue has been considered in Sethi et al.[23] and Walsh and Tunkel,[24] which emphasize the use of clinical judgment in analyzing breastfeeding difficulty before intervention. In the present cohort, the mothers and infants improved, with no complication following surgery, as reflected in a number of other studies.[25],[26]

Study limitations

The study may be limited owing to its retrospective nature and being carried out in a limited number of centers, although the study has uncovered significant findings in the management of pediatric patients with ankyloglossia across the three centers. Furthermore, some patients were lost during follow-up in the study period, but which had a limited effect on the reliability of the results.

  Conclusion Top

Ankyloglossia is a common disorder, but its effect is difficult to assess on feeding or speaking owing to case complexity and incalcitrant data. Most of the children in the present cohort were found to improve with frenotomy, which is a simple, low-cost, time-efficient, and safe operation. Broadly, in terms of speech, a frenotomy resulted in enhancement of speech according to the family assessment. We demonstrated that, for mothers whose infants were referred for ankyloglossia, surgery had a limited impact on breastfeeding. Thus, we suggest that mothers are informed about the various contingencies of breastfeeding with ankyloglossia and are asked to consider the possible outcomes before initiating treatment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Berry J, Griffiths M, Westcott C. A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeed Med 2012;7:189-93.  Back to cited text no. 1
Ingram J, Johnson D, Copeland M, Churchill C, Taylor H, Emond A. The development of a tongue assessment tool to assist with tongue-tie identification. Arch Dis Child Fetal Neonatal Ed 2015;100:F344-8.  Back to cited text no. 2
Ata N, Alataş N, Yılmaz E, Adam AB, Gezgin B. The relationship of ankyloglossia with gender in children and the ideal timing of surgery in ankyloglossia. Ear Nose Throat J. 2019 Sep 26:145561319867666. doi: 10.1177/0145561319867666.  Back to cited text no. 3
Paradise JL. Evaluation and treatment for ankyloglossia. JAMA 1990;262:2371.  Back to cited text no. 4
Dollberg S, Botzer E, Grunis E, Mimouni FB. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: A randomized, prospective study. J Pediatr Surg 2006;41:1598-600.  Back to cited text no. 5
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Kapoor V, Douglas PS, Hill PS, Walsh LJ, Tennant M. Frenotomy for tongue-tie in Australian children, 2006-2016: An increasing problem. Med J Aust 2018;208:88-9.  Back to cited text no. 10
Lisonek M, Liu S, Dzakpasu S, Moore AM, Joseph KS, Canadian Perinatal Surveillance System (Public Health Agency of Canada). Changes in the incidence and surgical treatment of ankyloglossia in Canada. Paediatr Child Health 2017;22:382-6.  Back to cited text no. 11
Nicholson WL. Tongue-tie (ankyloglossia) associated with breastfeeding problems. J Hum Lact 1991;7:82-4.  Back to cited text no. 12
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Karabulut R, Sönmez K, Türkyilmaz Z, Demiroğullari B, Ozen IO, Bağbanci B, et al. Ankyloglossia and effects on breast-feeding, speech problems and mechanical/social issues in children. B-ENT 2008;4:81-5.  Back to cited text no. 14
Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics 2011;128:280-8.  Back to cited text no. 15
Messner AH, Lalakea ML. Ankyloglossia: Controversies in management. Int J Pediatr Otorhinolaryngol 2000;54:123-31.  Back to cited text no. 16
Heller J, Gabbay J, O'Hara C, Heller M, Bradley JP. Improved ankyloglossia correction with four-flap Z-frenuloplasty. Ann Plast Surg 2005;54:623-8.  Back to cited text no. 17
Yeh ML. Outpatient division of tongue-tie without anesthesia in infants and children. World J Pediatr 2008;4:106-8.  Back to cited text no. 18
Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M, et al. Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Arch Dis Child Fetal Neonatal Ed 2014;99:F189-95.  Back to cited text no. 19
Schlatter SM, Schupp W, Otten JE, Harnisch S, Kunze M, Stavropoulou D, et al. The role of tongue-tie in breastfeeding problems-A prospective observational study. Acta Paediatr 2019;108:2214-21.  Back to cited text no. 20
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Power RF, Murphy JF. Tongue-tie and frenotomy in infants with breastfeeding difficulties: Achieving a balance. Arch Dis Child 2015;100:489-94.  Back to cited text no. 22
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Walsh J, Tunkel DE. Tongue-tie and frenotomy: what evidence do we have and what do we need? Med J Aust 2018;208:67-8.  Back to cited text no. 24
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  [Figure 1]

  [Table 1]


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