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Introduction
Ankyloglossia, commonly referred to as tongue-tie, is a congenital oral variation characterised by a short, inelastic lingual frenulum. The lingual frenulum is a fibro-mucosal fold that connects the ventral (underside) surface of the tongue and the mucosa of the sublingual space. Ankyloglossia is commonly diagnosed in neonates, with an estimated incidence of 4%-11%.
This anomaly can lead to breastfeeding difficulties, speech articulation deficits, oral hygiene challenges, and malocclusion or orofacial growth disturbances. Timely diagnosis and treatment can enhance functional outcomes.1
Aetiology
Ankyloglossia results from the incomplete embryological separation of the tongue from the floor of the mouth. Tongue formation begins in week four of gestation, emerging from a trifecta of pharyngeal arches (1st, 2nd, and 3rd). The lingual frenulum guides myogenic migration (movement of muscle-forming cells) of the tongue, tethering and positioning as it elongates.
In normal development, frenulum regression occurs through apoptosis (controlled cell death). Incomplete apoptosis or the remainder of excessive fibrotic tissue in the frenulum results in tongue restriction and reduced mobility.2
Risk factors
Risk factors for ankyloglossia include:
- Male sex: higher prevalence at a 3:1 ratio due to X-linked genetic influences affecting frenulum development
- Positive family history: genetic factors, including MTHFR gene mutations, play a significant role in increasing susceptibility
- Syndromic associations: conditions such as Beckwith-Wiedemann syndrome or Opitz syndrome have an increased incidence due to underlying developmental anomalies
- Associated craniofacial abnormalities: frequently coexist alongside oral clefts and other structural anomalies
- Preterm birth: due to incomplete development of oral and tongue structures in early gestation
- Low birth weight: developmental delays may contribute to abnormal formation of the frenulum
- Maternal smoking: disrupts normal fetal development during pregnancy
- Multiple pregnancies: increased incidence in twins or higher-order multiples, potentially due to altered intrauterine conditions affecting tongue and frenulum development3
Clinical features
History
Typical symptoms of ankyloglossia depend on the age of presentation.
Neonates and infants
Feeding difficulties associated with ankyloglossia include:
- Poor latch during breastfeeding
- Maternal nipple pain or damage
- Bottle-feeding leakage or difficulty generating suction
- Frequent feeding, prolonged feeding times, or early fatigue
- Aerophagia (excessive swallowing of air)
- Poor weight gain
Oral dysfunction may manifest as:
- Difficulty moving the tongue beyond the lower gum line
- Inability to elevate or lateralise the tongue
Children or adults
Typical features include:
- Speech difficulties (e.g. articulation of “t”, “d”, “l”, “r”, “s”, “n”)
- Oral hygiene issues (difficulty clearing food, increased risk of dental decay)
- Mechanical difficulties (e.g. difficulty licking lips, playing wind instruments)
- Myofascial tension leading to headaches or jaw pain
- Compensatory behaviours (e.g. altering tongue position to accommodate restricted movement)
- Disordered orofacial development (malocclusion and sleep-disordered breathing)
Clinical examination
Clinical findings are dependent on the severity of ankyloglossia but may include:
- A short, thick, or fibrotic frenulum
- Difficulty protruding the tongue beyond the lower teeth and lip
- Inability to elevate the tongue towards the hard palate or maxillary incisors
- Heart-shaped or forked tongue when protruded
- Decreased range of motion with lateral tongue movement
Diagnosis
The Coryllos system is an anatomically based classification system that quantifies the severity of ankyloglossia.
Table 1. Coryllos system4
| Classification | Details |
| Type I | Frenulum attachment to the tongue tip |
| Type II | Frenulum attachment 2-4 mm behind the tongue tip |
| Type III | Frenulum attachment to the mid-tongue |
| Type IV | Frenulum attachment at the base of the tongue |
Management
Clinical controversies
There is a lack of universal consensus on the management of ankyloglossia, with divided and contentious opinions on diagnosis and treatment decisions. Patients and/or parents should be appropriately counselled on treatment options and outcomes.
Importantly, not all patients with ankyloglossia experience functional issues. For instance, feeding difficulties are often multifactorial, involving issues such as poor latch, maternal supply, or oversupply. Children with initial speech concerns can develop compensatory adaptations over time.
Surgical intervention carries the potential for harm, and there is no guarantee of success or improvement. Surgery is only indicated for functional impairments that are resistant to conservative management.1
The current best practice is to focus on function, not just appearance.
Conservative management
Conservative management of ankyloglossia includes:
- Lactation support: positioning, latch optimisation if breastfeeding technique is the primary concern
- Speech therapy: for mild cases not requiring surgical intervention or speech articulation difficulties
- Parental education and monitoring: counselling that dysfunctions can self-resolve
- Myofunctional therapy: exercises to improve tongue mobility
- ENT or maxillofacial assessment: in cases of severe restriction impacting function5
Surgical management
Surgical intervention can provide significant benefits in appropriate cases.
Indications
Indications for consideration include:
- Significant breastfeeding difficulties (pain, poor latch, failure to thrive)
- Severe restriction impacting speech or oral function
- Resistance to conservative management
Surgical procedures
Surgical procedures may include:
- Frenotomy (simple incision of frenulum): rapid intervention with minimal bleeding and no anaesthetic required; more suited to neonates as less well tolerated in young children
- Frenuloplasty (extensive release with suturing): for severe or fibrotic ties, often under anaesthetic
- CO2 laser frenectomy (tissue ablation): minimal bleeding, precise and accurate6
Post-operative interventions
Post-operative interventions include:
- Immediate breastfeeding in neonates or infants, to provide analgesia and promote healing
- Tongue stretching exercises to prevent reattachment
- Follow-up for speech and language assessment to determine the need for further intervention
- Early oral evaluation for complication identification to assess wound healing and functional improvement7
Complications
Untreated ankyloglossia
Speech and communication
- Difficulty articulating specific sounds or verbal intelligibility
- Delayed speech development
- Compensatory articulation strategies
Orofacial and dental development
- High-arched palate and narrow maxilla from low tongue posture
- Malocclusion patterns due to disrupted oral muscle balance (e.g. open bite, crossbite)
- Poor oral hygiene owing to reduced natural cleaning action of the tongue
- Increased incidence of dental caries and gingivitis
Airway and sleep
- Obstructive sleep-disordered breathing or sleep fragmentation
- Promotion of chronic mouth breathing from lower tongue tone
- Poor oral rest posture contributing to long-term airway instability
Feeding and nutrition
- Impaired breastfeeding due to poor latch and milk transfer
- Maternal nipple pain and early cessation of breastfeeding
- Difficulty transitioning to solid foods
- Choking, gagging, or selective eating
- Feeding aversion and prolonged mealtimes
Psychosocial and developmental
- Increased maternal stress and impaired early parent-infant bonding due to breastfeeding challenges
- Behavioural disturbances and irritability due to feeding and speech complexity
- Self-consciousness or social anxiety due to a difference in speech vocalisation or visible tongue restriction
Surgical management
Complications of surgical management in ankyloglossia can include:
- No improvement in symptoms
- Pain
- Bleeding
- Wound infection/abscess formation
- Reattachment (requires repeat procedure if adhesions form)
- Poor feeding
- Floor of mouth cyst formation
- Submandibular oedema (if Wharton’s duct obliteration)8
Reviewer
Dr Theodore Athanasiadis, MBBS, PhD, FRACS, Laryngologist
Consultant Otolaryngologist at Flinders Medical Centre
Laryngology Fellowship Director at Flinders Medical Centre
Editor
Dr Jamie Scriven
References
- Evans L, Lawson H, Oakeshott P, et al. Tongue-tie and breastfeeding problems. British Journal of General Practice. 2023. Available from: [LINK].
- Ganesan K, Girgis S, Mitchell S. Lingual frenotomy in neonates: past, present, and future. British Journal of Oral and Maxillofacial Surgery. 2019. Available from: [LINK].
- Becker S, Brizuela M, Mendez MD. Ankyloglossia (Tongue-Tie). StatPearls. 2023. Available from: [LINK].
- Coryllos E, Genna C, Salloum AC. Congenital tongue-tie and its impact on breastfeeding. American Academy of Pediatrics Section on Breastfeeding. 2004. Available from: [LINK].
- Shekher R, Lin L, Zhang R, et al. How to Treat a Tongue-tie: An Evidence-based Algorithm of Care. Plastic and Reconstructive Surgery Global Open. 2021. Available from: [LINK].
- Oganyan S, Khamidova M, Davtyan A, et al. Comparative Analysis of Methods for Surgical Treatment of Ankyloglossia: A Review Article. Open Dentistry Journal. 2023. Available from: [LINK].
- Smart S, Grant H, Tseng RJ. Beyond surgery: Pre- and post-operative care in children with ankyloglossia. International Journal of Paediatric Dentistry. 2025. Available from: [LINK].
- Solis-Pazmino P, Kim GS, Lincango-Naranjo E, et al. Major complications after tongue-tie release: A case report and systematic review. International Journal of Pediatric Otorhinolaryngology. 2020. Available from: [LINK].
Image references
- Figure 1. Gzzz. Ankyloglossia (tongue-tie) due to a short lingual frenulum, in a 4 years old child. License: [CC BY-SA 4.0]. Available from: [LINK].
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