What is the treatment for tongue tie (ankyloglossia)?

Treatment of Tongue Tie (Ankyloglossia)

Surgical division (frenotomy/frenuloplasty) is the definitive treatment for ankyloglossia when it causes functional impairment, particularly breastfeeding difficulties in infants or speech articulation problems in children, with the procedure showing good evidence for improved outcomes in these specific contexts.

Indications for Treatment

The decision to treat ankyloglossia should be based on functional impairment rather than anatomical appearance alone:

In Infants

• Breastfeeding difficulties are the primary indication for intervention in neonates, though controlled trials remain limited 1
• Good evidence exists that division of anterior tongue-tie leads to improved breastfeeding outcomes 2
• The association between tongue-tie and breastfeeding problems is recognized, but optimal treatment timing requires individualized assessment 1

In Children and Adults

• Speech articulation disorders represent a key indication, particularly when tongue mobility is demonstrably limited 1, 3
• The degree of discomfort and severity of speech problems are subjective and difficult to categorize 1
• Limitations in tongue mobility are present in affected individuals, but the clinical significance varies 1

Important Caveat

Not all tongue-ties require surgical intervention - it remains controversial which cases need surgery versus observation 1. The lack of an accepted universal definition and classification makes this determination challenging 1.

Surgical Treatment Options

Three main surgical approaches exist, though no specific method can be definitively favored due to limited comparative evidence 1:

1. Frenotomy (Simple Division)

• Involves cutting the lingual frenulum
• Can be performed under local anesthesia 4
• Simpler procedure with minimal complications 1

2. Frenectomy (Complete Removal)

• Complete excision of the frenulum
• More extensive than frenotomy 1

3. Frenuloplasty (Surgical Reconstruction)

• Involves plastic reconstruction of the frenulum
• More complex surgical approach 1, 3

Expected Outcomes and Timeline

Speech Improvement Pattern

When tongue-tie division is performed for speech disorders, improvement follows a predictable pattern 3:

• Substitution errors: Improve relatively early (decrease from 19 preoperatively to 10 at 1 month, 7 at 3-4 months, and 1 at 1-2 years) 3
• Omission errors: Also improve early (decrease from 5 preoperatively to 3 at 1 month, 2 at 3-4 months, and 1 at 1-2 years) 3
• Distortion errors: Require more time for improvement and may persist as defective speaking habits (13 preoperatively, 8 at 3-4 months, but 11 at 1-2 years in some patients) 3

Post-Surgical Management

Speech therapy is essential following surgical correction, particularly for children with established speech patterns 4. The surgery alone does not guarantee complete resolution of articulation problems 3.

Critical Diagnostic Considerations

Before proceeding with surgery, clinicians must:

• Assess actual functional limitation rather than relying solely on anatomical appearance 1, 5
• Evaluate tongue range of motion and its impact on specific functions (feeding, speech, oral hygiene) 5
• Consider that no uniformly accepted classification system exists, making standardized assessment difficult 1
• Recognize that gingival recessions are NOT caused by ankyloglossia - there is no evidence supporting this association 1

Common Pitfalls to Avoid

• Over-treatment: Not every anatomical tongue-tie requires intervention; functional impairment must be demonstrated 1
• Delayed speech therapy: Surgery should be accompanied by appropriate speech therapy sessions, especially in older children with established speech patterns 4
• Unrealistic expectations: Distortion-type speech errors may persist longer and require extended therapy even after successful surgery 3
• Inadequate follow-up: Outcomes should be assessed at multiple time points (1 month, 3-4 months, and 1-2 years) to track improvement trajectory 3

Evidence Limitations

Almost no controlled prospective trials exist for surgical interventions in tongue-tie patients, preventing conclusive recommendations about the optimal method 1. The lack of standardized definitions and classifications makes study comparisons nearly impossible 1. Clinical decisions must therefore rely on functional assessment and patient-specific factors rather than rigid protocols.