Lingual Frenotomy Research Articles

Lingual frenotomy for ankyloglossia in infants with breastfeeding difficulties: a longitudinal observational study.

Ankyloglossia, or tongue-tie, is a variation in the anatomy of the lingual frenulum that restricts tongue movement. It is recognised as a cause of breastfeeding difficulty. We prospectively collected data from a specialist tongue-tie assessment clinic and evaluated mothers' experience using a questionnaire. We prospectively collected data from the specialist tongue-tie assessment clinic from January 2023 to October 2023 to assess factors that may influence a lingual frenotomy in an infant. Mothers were invited to complete two questionnaires, one baseline in the clinic waiting room and one follow-up, 4weeks after their clinic visit. These self-reported questionnaires assessed breastfeeding challenges, the mother's motivation for seeking an opinion regarding ankyloglossia, and the continuity of breastfeeding 4weeks following the clinic visit. During these 10months, 157 infants attended the clinic, and 96 frenotomies were performed. One hundred one participants completed baseline questionnaires, and 34 participants completed follow-up questionnaires. When mothers were asked why they wanted their baby assessed for a tongue-tie, the most common answers were difficulty with latch and nipple pain, reported by 45% and 40%, respectively. The average reported pain while breastfeeding was scored at 2.53, graded from 0 to 5 in the baseline questionnaire. This improved to 1.47 amongst women whose infants had a frenotomy. Conclusion: Our study suggests that performing a frenotomy in infants diagnosed with ankyloglossia may positively impact breastfeeding.

Frenotomy Provides Improved Direct Laryngoscopy Exposure in Select Adult Patients With Ankyloglossia.

Objective: To analyze the effects of lingual frenotomy on adults with restrictive ankyloglossia and difficult direct laryngoscopy exposure. Methods: A case series study was conducted. Restriction of tongue protrusion due to ankyloglossia was identified in 2 patients who had a history of suboptimal true vocal fold (TVF) exposure on direct laryngoscopy for phonomicrosurgery. Inadequate exposure of the vocal folds was achieved on direct laryngoscopy attempts with manual tongue protrusion. Mandibular tori were not present in these patients. An intraoperative lingual frenotomy was performed in both patients. Results: After frenotomy and with manual tongue protrusion, direct laryngoscopy exposure was substantially improved allowing for considerably more visualization of the anterior TVFs. Conclusion: Lingual frenulum procedures with manual tongue protrusion should be considered in select adult patients with restrictive ankyloglossia affecting optimal direct laryngoscopy exposure.

Clinical and electromyographic evaluation pre and post lingual frenotomy of an infant with ankyloglossia: A case report

Clinical and electromyographic evaluation pre and post lingual frenotomy of an infant with ankyloglossia: A case report

Effect of lingual frenotomy on the breastfeeding improvement

To evaluate breastfeeding in babies up to six months of age before and after frenotomy surgery in a reference hospital in a city from Santa Catarina state. Methods: An observational quality improvement study, carried out with babies up to six months of age undergoing frenotomy and their mothers in a reference hospital in southern Santa Catarina state. A questionnaire was applied to the mothers in two moments (before and after the surgery), with information regarding breastfeeding, sociodemographic, anthropometric and behavioral characteristics of them and of the babies. Descriptive analyzes were performed and the association between breastfeeding and the independent variables was assessed through Pearson’s chi-square and Fisher’s exact tests, using a 5% significance level. Results: A total of 74 children were studied, with 48 of them returning after surgery. 83.8% were breastfed before surgery and 64.9% after surgery. Before surgery, 58.1% of children effectively took the breast at once. After surgery, this prevalence was 83.3% (p=0.015). Before surgery, 75.9% of the mothers reported not feeling pain, while, after surgery, almost all of them (95.8%) reported this (p=0.004). Most mothers reported improvement in grip (83.3%), increase in the duration of breastfeeding (69.0%), improvement of baby’s breathing (75.0%), and an increase in the frequency of breastfeeding (51.7%). Conclusions: There was a decrease in the prevalence of breastfeeding after frenotomy. However, there was an improvement in the babies ‘grip and breathing and a reduction in the mothers’ pain when breastfeeding. It is emphasized the need to implement multidisciplinary actions in both primary and hospital care to assist mothers in order to prolong the duration of exclusive breastfeeding.

Ankyloglossia: Clinical and Sociodemographic Predictors of Diagnosis and Management in the United States, 2004 to 2019.

The past 2 decades have seen a rapid increase in the diagnosis of ankyloglossia. Patients are often managed by lingual frenotomy. The objective is to define the clinical and socioeconomic factors that determine which patients receive frenotomy. A retrospective analysis of commercially insured children. Optum Data Mart database. Trends in frenotomy including provider and setting were described. Multiple logistic regression was used to determine predictors of frenotomy. Diagnosis of ankyloglossia increased from 2004 to 2019 (from 3377 in 2004 to 13,200 in 2019), while lingual frenotomy similarly increased from 1483 in 2004 to 6213 in 2019. The proportion of inpatient frenotomy procedures increased from 6.2% to 16.6% from 2004 to 2019, with pediatricians having the highest odds of performing inpatient frenotomies (odds ratio:4.32, 95% confidence interval:4.08, 4.57). Additionally, during the study period, the proportion of frenotomies performed by pediatricians increased from 13.01% in 2004 to 28.38% in 2019. In multivariate regression analyses, frenotomy was significantly associated with the male sex, white non-Hispanic ethnicity, higher parental income and education, and a greater number of siblings. Ankyloglossia has been increasingly diagnosed in the past 2 decades, and amongpatients with ankyloglossia, frenotomy is increasingly performed. This trend was driven at least in part due to increasing rates of pediatricians as proceduralists. After accounting for maternal and patient-level clinical factors, socioeconomic differences in the management of ankyloglossia were observed.

Efficacy of Various Laser Wavelengths in the Surgical Treatment of Ankyloglossia: A Systematic Review.

Ankyloglossia, commonly known as tongue-tie, is the most common disorder of tongue morphology characterized by aberrant attachment of the lingual frenum. This study aimed to provide a comprehensive literature review and evaluate the effectiveness of various laser wavelengths in the surgical treatment of patients with ankyloglossia. An electronic screening of PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) databases was conducted on 8 November 2021. The following search terms were used to review the available data on the subject of interest: (ankyloglossia OR tongue tie OR short lingual frenulum OR lingual frenectomy OR lingual frenulectomy OR lingual frenotomy OR lingual frenulotomy) AND laser. The use of lasers in ankyloglossia treatment resulted in shorter procedure time, reduced indications for general anesthesia, reduced administration of postoperative analgesics, fewer sutures or none needed, reduced postoperative bleeding, and improved healing. Despite many advantages, this method has its clinical limitations: it requires the use of expensive equipment; well-trained personnel familiar with lasers; and personal protective equipment for the patient, caregiver, operator, and assistant. The laser procedure does not eliminate the need for myofunctional exercises and work with a speech therapist.

Survey of Pediatric Otolaryngology Frenotomy Practice Patterns.

Assess current frenotomy practice patterns of pediatric otolaryngologists via a cross-sectional survey. Survey study. A 31-question electronic survey assessing frenotomy practice patterns was distributed to all American Society of Pediatric Otolaryngology (ASPO) members. Descriptive statistics were used to summarize responses and demographics of respondents. Of all ASPO members, 41% (240/588) completed the survey. Most respondents, 185 (77%), reported increased frenotomy referrals over the last 5 years and 144 (60%) described the current number of referrals as "too many." The two primary lingual frenotomy indications identified in infants were: breastfeeding/nipple pain (92%) and inability to latch (83%). For older children, speech difficulty (87%) was the primary indication. Maxillary frenotomy indications in infants varied amongst respondents. For analgesia during in-office frenotomy procedures, respondents used glucose/sucrose drops (48%), topical lidocaine (29%), or no pain control measure (27%). For post-procedure care, respondents recommended continuing lactation support (45%), massaging/stretching the wound (38%), or none (40%). Most respondents, 143 (60%), reported having seen a complication from frenotomy, and the most reported frenotomy complications were frenulum re-attachment and excessive bleeding. In the last 5 years, otolaryngologists have seen an increase in referrals for frenotomy. Pediatric otolaryngologists have varying practice patterns with regards to ankyloglossia diagnosis and treatment. The reported indications for frenotomy varied amongst pediatric otolaryngologists especially with respect to maxillary frenotomy. Practice patterns also varied with respect to procedural pain control and frenotomy aftercare recommendations. More frenotomy research is needed to establish a standard of care for patients with ankyloglossia. 4 Laryngoscope, 132:2505-2512, 2022.

A Retrospective Cohort Study of the Impact of Upper Lip Tie Release on Breastfeeding in Infants.

Objectives: Lingual frenotomies for the purpose of improving infant breastfeeding remain controversial, whereas maxillary frenotomies are even more so given the scant data and differing opinions on the matter. This study aimed at further elucidating the effect that maxillary frenula have on breastfeeding difficulties in infants. Methods: A retrospective chart review was performed on infants approximately aged 0-3 months who presented to a tongue tie/breastfeeding clinic from January to December of 2019. All analyzed infants had both lip and tongue ties classified by a clinician. Data on pre-frenotomy pain scores, lingual Coryllos classification, maxillary Kotlow classification, post-frenotomy complications, and breastfeeding success were captured. Results: Of the 316 infants, 224 underwent their first procedure at the tongue tie/breastfeeding clinic. Two hundred eleven out of 224 infants received a lingual frenotomy only, whereas the remaining 13 (5.8%) underwent both lingual and maxillary frenotomy procedures. Of the group of 211, 207 (98.1%) had successful feeding after 1 procedure; the remaining 4 underwent revision procedures to achieve successful feeding. All maxillary frenulum releases (n = 13) led to successful feeding without the need for revision procedures. Coryllos and Kotlow classification scores were significantly higher in the infants receiving both a maxillary and lingual frenulum release as compared with those receiving solely a lingual frenulum release. Conclusions: The majority (98.1%) of infants receiving a lingual frenulum release alone had successful feeding after only one procedure, and only 5.8% of all infants receiving any intervention required a maxillary frenulum release for successful feeding, calling into question the relative necessity of performing maxillary frenulum releases for breastfeeding difficulties.

The effects of lingual frenotomy on breastfeeding: an integrative review

Purpose: to investigate what effects lingual frenotomy has on breastfeeding. Methods: based on the research question - “Is there a relationship between the improvement in breastfeeding and the lingual frenotomy?” -, a bibliographical survey was carried out in three databases, using the following descriptors: ankyloglossia, lingual frenum, breastfeeding and frenotomy. Frenotomy is a free term. Original articles with babies up to 6 months old who had difficulties breastfeeding due to ankyloglossia and who had been submitted to lingual frenotomy were chosen. An instrument was developed, containing the following information: name of the authors, year of publication, country of origin, the objective of the study, type of study, sample, main results, and conclusion. Literature Review: of the 243 articles screened, four met the inclusion criteria for this study. It was observed that, after lingual frenotomy, some changes may take place in breastfeeding patterns, such as an increase in the number of suctions and a decrease in the time of pause in between series of suctions. Conclusion: the lingual frenotomy can be an important procedure in the treatment of babies with ankyloglossia, possibly helping improve the latch and breastfeeding.

Tongue-tie: incidence and outcomes in breastfeeding after lingual frenotomy in 2333 newborns.

To determine the prevalence of ankyloglossia in newborns with breastfeeding problems and to assess the effectiveness of frenotomy in the maintenance of exclusive breastfeeding at 1 month, 3 months and 6 months in newborns at an Andorran Hospital. A descriptive, cross-sectional, population-based, retrospective study of newborns over a 5-year period (2016-2020) was performed. Nine medical history variables (presence or absence of ankyloglossia and type of frenulum, surgical intervention or not, first degree hereditary component, gender, Rh and blood group, type of breastfeeding, causes of cessation and duration of breastfeeding) related to perinatal and feeding history were collected confidentially and anonymously. The Coryllos classification was used for the diagnosis of ankyloglossia. Descriptive analysis of the data, Chi-square test and prevalence ratios were calculated. A total of 2333 newborns were included in the study (50.02% males and 49.98% females). The prevalence of ankyloglossia was 7.84% (n = 183). Of the infants examined, 136 underwent lingual frenotomy. The number of infants who maintained exclusive breastfeeding, both surgically and non-surgically treated, was no statistically significant differences at 1 month (p = 0.65), 3 months (p = 0.61) and 6 months (p = 0.49). Lingual frenotomy was only performed on patients with ankyloglossia associated with ineffective suction that causes BF difficulties. The realization or not of frenotomy was not a determining factor for the maintenance of breastfeeding at 1 month, 3 months and 6 months. On the contrary, it was a determining factor for the prolongation of mixed feeding. Ankyloglossia related to breastfeeding difficulties should be treated by a multidisciplinary team.

Prevalence of ankyloglossia and factors that impact on exclusive breastfeeding in neonates

ABSTRACT Objective: to determine the prevalence of ankyloglossia in neonates and verify factors that interfere with exclusive breastfeeding and cause difficulties in breastfeeding. Methods: an observational longitudinal study conducted at a public maternity hospital in Teresina, Piauí, Brazil. The sample comprised 397 mother-child pairs. Ankyloglossia was diagnosed with the part I of the Baby Lingual Frenulum Assessment Protocol with Scores. Six months after the children were born, the mothers were interviewed and answered questions on the indication and performance of frenotomy and time of breastfeeding. Descriptive analysis of the data, chi-square test and bivariate and multivariate Poisson regression were conducted (p < 0.05). Results: the prevalence of ankyloglossia was 4.3% (n = 17). The attendance rate for the second moment of the research was 70.8% (n = 281). Of the examined children, 14 were indicated for lingual frenotomy, but only one was submitted to the procedure. The time of exclusive breastfeeding of children with ankyloglossia was equal to that of children with a normal lingual frenulum (p-value = 0.876). Ankyloglossia was not associated with breastfeeding difficulties (PR = 1.0 95%CI 0.8-1.1, p-value = 0.441), neither was it a factor for not breastfeeding exclusively for 6 months (PR = 1.1 95%CI 0.9-1.2, p-value = 0.390). Conclusions: the prevalence of ankyloglossia in the studied population was 4.3%. Baby bottle use in the first month of life and breastfeeding difficulties were hindering factors for exclusive breastfeeding.

Prevalence of ankyloglossia and factors that impact on exclusive breastfeeding in neonates

ABSTRACT Objective: to determine the prevalence of ankyloglossia in neonates and verify factors that interfere with exclusive breastfeeding and cause difficulties in breastfeeding. Methods: an observational longitudinal study conducted at a public maternity hospital in Teresina, Piauí, Brazil. The sample comprised 397 mother-child pairs. Ankyloglossia was diagnosed with the part I of the Baby Lingual Frenulum Assessment Protocol with Scores. Six months after the children were born, the mothers were interviewed and answered questions on the indication and performance of frenotomy and time of breastfeeding. Descriptive analysis of the data, chi-square test and bivariate and multivariate Poisson regression were conducted (p < 0.05). Results: the prevalence of ankyloglossia was 4.3% (n = 17). The attendance rate for the second moment of the research was 70.8% (n = 281). Of the examined children, 14 were indicated for lingual frenotomy, but only one was submitted to the procedure. The time of exclusive breastfeeding of children with ankyloglossia was equal to that of children with a normal lingual frenulum (p-value = 0.876). Ankyloglossia was not associated with breastfeeding difficulties (PR = 1.0 95%CI 0.8-1.1, p-value = 0.441), neither was it a factor for not breastfeeding exclusively for 6 months (PR = 1.1 95%CI 0.9-1.2, p-value = 0.390). Conclusions: the prevalence of ankyloglossia in the studied population was 4.3%. Baby bottle use in the first month of life and breastfeeding difficulties were hindering factors for exclusive breastfeeding.

Conservative Management of Ankyloglossia by Diode Laser: A Case Report

Ankyloglossia or tongue-tie is a congenital condition that results when the inferior lingual frenulum is too short and is attached to the tip of the tongue, limiting its normal movements. Ankyloglossia can lead to different problems such as difficulties in breastfeeding, speech impediments, poor oral hygiene, malocclusion, inability to deglutition, thus being an undesired problem in normal life activity. Among various methods of treatment of ankyloglossia, laser-assisted lingual frenotomy is the simplest, safest, and less traumatic with the most promising results. Here, a case of ankyloglossia and its management by frenotomy with diode laser is reported in a four-year-old female child. After performing partial frenectomy (frenotomy) using a diode laser of 980nm there was an immediate tongue protrusion and slight improvement of phonetics of the patient immediately and altogether improved after six months.

Effect of Lingual Frenotomy on Tongue and Lip Rest Position: A Nonrandomized Clinical Trial

Introduction The tongue plays an important role in the development of craniofacial structures. At rest, the light and constant pressure of the tongue against the hard palate, counterbalanced by the pressure provided by proper lip sealing, serves as a guide for maxillary growth. Ankyloglossia makes tongue coupling against the hard palate difficult, impacting maxillary development, which may lead to breathing disorders. Objective To verify the effect of lingual frenotomy on the resting position of the tongue and lips in infants with ankyloglossia. Methods The sample consisted of 334 infants aged between 1 and 60 days old diagnosed with ankyloglossia. The groups were divided in: a) experimental group (EG), which consisted of infants whose mothers agreed with lingual frenotomy; b) control group (CG), which consisted of infants whose mothers either refused lingual frenotomy or were waiting for surgery. Both the position of the lips and of the tongue at rest were assessed while the infants were sleeping during the quiet sleep phase. For mothers who refused their infants to undergo the surgical procedure, a follow-up of the infants was proposed to verify possible interference of the frenulum with the resting position of the tongue and lips. Infants whose mothers agreed with surgery were referred for lingual frenotomy. Results Regarding the position of the tongue and lips at rest at the initial and final assessments, the statistical analysis demonstrated significant differences between both groups. Conclusion Lingual frenotomy enabled infants diagnosed with ankyloglossia to maintain both tongue coupling against the hard palate and closed lips at rest.

Frenotomy Revision Rate in Breastfeeding Infants: The Impact of Early Versus Late Follow-Up.

Purpose: The protocol for postoperative follow-up time after lingual frenotomy in breastfeeding infants with ankyloglossia was changed from 2 weeks to 1 week at our institution. This study examined the impact of this change in practice on frenotomy revision rate. Materials and Methods: A retrospective chart review of breastfeeding infants who underwent lingual frenotomy for ankyloglossia from January 2016 to December 2017 was performed. Subjects were divided into 1-week (1-9 days) and 2-week (10-20 days) follow-up groups. Statistical analyses were performed to investigate the relationship between revision rate and postoperative follow-up time, as well as additional patient characteristics. Results: Of the 369 patients included in the study, 34 (9.2%) underwent frenotomy revision. The individual revision rates of the 1- and 2-week follow-up cohorts were 5.2% and 12.7%, respectively. The difference in revision rate was statistically significant (p = 0.022), and logistic regression revealed the odds of revision for the 2-week cohort to be 2.67 times (95% confidence interval: 1.207-5.918) greater than the 1-week cohort (p = 0.015). Conclusion: This study demonstrates a significant association between a shorter postoperative follow-up time and decreased frenotomy revision rate. With earlier follow-up, manual adjustment can be performed sooner in the postoperative period as needed, which may prevent scarring or healing complications that usually necessitate full revision. Our findings support a shift to a shorter postoperative follow-up time as a means of improving frenotomy outcomes.

The Effectiveness of Frenotomy on Speech in Adults

There is no publication concerning tongue-tie (TT) in adults, surprisingly. It is generally known that TT is mainly diagnosed in newborns and infants. It seems unlikely that TT does not cause functional disorders in adults, especially considering that TT has been present in organism since childhood. Thus, there is insufficient information about the influence of TT on adults′ speech production. The purpose of this study was the functional evaluation of lingual frenotomy on tongue mobility and speech in the adult Polish population. Methods: Methods were based on visual observation and examination of the oral cavity accompanied by visual and auditory examination of articulation. Χ2 test, Kruskal–Wallis, analysis of variance (ANOVA), and Student’s t-test were used for statistical analyses. Conclusions: Tongue-tie is a serious condition in adults. Implementing surgical procedures to treat it improves the tongue′s mobility in every direction and improves speech clarity. The frenotomy should be implemented in patients suffering from malocclusion because the equilibrium of all the face muscles and skeleton is often disturbed and may lead to unstable functional effects of orthodontic and orthognathic treatment.

Lingual frenotomy in univiteline twin babies: case report

Ankyloglossia is an anatomical variation that has been associated with a variety of problems such as: suckling, swallowing and speaking. In this perspective, frenotomy is a surgical procedure commonly performed on babies to correct ankyloglossia. In this sense, the objective of this work is to report a clinical case of ankyloglossia in which the frenotomy procedure was performed on twin newborns, who had difficulty breastfeeding, carried out in the Extension Project “Língua Solta”, from the Federal University of Pernambuco. The evaluation of the lingual frenulum followed the protocol recommended by Martinelli, 2013. After application of the protocol, newborns showed the need to perform frenotomies. The surgeries were performed and, after 7 days, the babies showed significant improvement in breastfeeding. The diagnosis made, through the protocol and experienced professionals, is of fundamental importance for the success of the surgery. In addition, early intervention contributes to improved breastfeeding and development of the newborn.

Factors associated with frenotomy after a multidisciplinary assessment of infants with breastfeeding difficulties

ObjectiveFrenotomy for ankyloglossia has increased nearly 10-fold over the past few decades despite insufficient evidence that the procedure improves breastfeeding outcomes. There is no universally accepted method for identifying patients who may benefit from the procedure. The objective of this study is to determine if comprehensive feeding evaluations and targeted interventions can identify children who should undergo procedures, and to identify factors associated with lip or tongue frenotomy to treat breastfeeding difficulties. MethodsThis observational quality improvement study followed infant-mother dyads between March 2018 and December 2019 referred to our tertiary care center for breastfeeding difficulties. Speech and language pathologists performed comprehensive feeding evaluations on infants prior to surgical consultation for frenotomy. Infants’ oral anatomy and function and their ability to breast and bottle feed were assessed, and techniques for mothers to address feeding difficulties without a procedure were offered prior to surgical consultation. Infants either found success over a short observation period or underwent procedures (lip and/or tongue frenotomy). Results153 patients (mean age 47.0 days (stdev 39.0 days, 56.2% male) were referred for surgical division of the lingual frenulum. Following development of a program utilizing pediatric speech language pathologists to perform feeding evaluations prior to surgical consultation, 69.9% of patients subsequently did not undergo surgical procedures. 11 (23.9%) underwent labial frenotomy alone and 30 (65.2%) underwent both labial and lingual frenotomies. Frenotomy was associated with significantly increased worry subscale of the Feeding Swallow Impact Survey (FSIS) and decreased mean Breastfeeding Self Efficacy Scale score (p = 0.0001, p = 0.006, respectively). Tongue appearance was significantly associated with having a procedure, while lip appearance was not. The Bristol Breastfeeding Assessment Tool (BBAT) was lower in children undergoing tongue and/or lip frenotomy (p = 0.0006), while the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) appearance and function scores were lower in children undergoing lingual frenotomy with or without lip frenotomy (p = 0.0008, p = 0.0009, respectively). ConclusionsThe majority of patients referred for ankyloglossia may benefit from nonsurgical intervention strategies based on findings from comprehensive feeding evaluation. Frenotomy is associated with higher maternal feeding-related worry and reduced breastfeeding self-efficacy scores. While tongue appearance is associated with frenotomy, functional assessment is critical for identifying patients who may also benefit from lip frenotomy.

Understanding the Lingual Frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery.

Lingual frenotomy has become an increasingly common surgical procedure, performed for a broad range of indications from birth through adulthood. This study utilizes histology to define the structure and tissue composition of the lingual frenulum and floor of mouth (FOM) fascia. En bloc specimens of anterior tongue, lingual frenulum, and FOM tissues were harvested from ten embalmed adult cadavers. An additional three fresh tissue cadaveric specimens were frozen with the tongue supported in an elevated position, to enable harvesting and paraffin embedding of the elevated lingual frenulum as a discrete specimen. All 13 specimens were prepared as ten-micron coronal sections using stains to determine the general morphology of the lingual frenulum, its relationship to neighbouring structures (Mason's Trichrome), presence of elastin fibers (Verhoeff-van Gieson), and collagen typing (Picrosirius Red). Our results have shown a submucosal layer of fascia spanning horizontally across the FOM was present in all specimens, with variability in fascial thickness and histologic composition. This FOM fascia suspends the sublingual glands, vessels, and genioglossus from its deep surface. The elevated lingual frenulum is formed by a central fold of this FOM fascia together with the overlying oral mucosa with variability in fascial thickness and composition. With tongue elevation, the fascia mobilizes to a variable extent into the fold forming the frenulum, providing a structural explanation for the individual variability in lingual frenulum morphology seen in clinical practice.

Primum non nocere: lingual frenotomy for breastfeeding problems, not as innocent as generally accepted.

The frenotomy or surgical release of the lingual frenulum is performed with increasing frequency. Restricted tongue mobility, ankyloglossia, is the main indication for this procedure. This clinical diagnosis is often used as synonym for tongue-tie which is blamed for many feeding difficulties resulting in an increase in performed frenotomies. Until recently, little was known about the anatomical structure and normal variation of the tongue-tie. Different grading systems have been developed. Some are exclusively based on appearance of the tongue-tie; others also include functional elements. There is, however, no established relation between the tongue-tie score and the observed feeding problems or outcomes following frenotomy. Therefore, caution is warranted before submitting babies to this procedure.Conclusion: This narrative review aims to give an overview of current knowledge and concerns regarding the tongue-tie, which need to be considered before referral for a frenotomy. What is Known: • The presence of a tongue-tie is associated with a higher frequency of breastfeeding problems. • Hence, frenotomy is advocated and increasingly performed in infants with breastfeeding problems. Current tongue-tie classifications do not allow to predict breastfeeding problems. What is New: • New anatomy insights caution for possible complications resulting from this seemingly innocent practice of frenotomy. • Frenotomy should only be performed after multidisciplinary evaluation of feeding problems, following exclusion and remediation of other causative factors.