Pediatric Frenectomy: Indications and Impact on Speech Development

Pediatric frenectomy is a common surgical procedure performed to correct restrictive oral frenula that may interfere with breastfeeding, oral function, dental development, and speech.

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The relationship between frenulum abnormalities and speech disorders remains controversial, particularly in children. This article reviews current evidence regarding the indications for pediatric frenectomy, its potential impact on speech development, and clinical recommendations for patient selection.

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Understanding the functional implications of ankyloglossia and aberrant labial frenula is essential for evidence-based treatment planning.

✅ Introduction
A frenulum is a fold of connective tissue that attaches soft tissues within the oral cavity. The most clinically relevant oral frenula in pediatric dentistry are the lingual and maxillary labial frenula. Abnormal attachment, thickness, or restriction may result in functional limitations, particularly in infants and children.
Pediatric frenectomy refers to the surgical removal or release of a restrictive frenulum. Although the procedure is frequently performed to improve tongue mobility and oral function, its role in speech development remains a subject of ongoing debate. Clinical decision-making should be based on functional impairment rather than anatomical appearance alone.

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✅ Understanding Oral Frenulum Abnormalities

Ankyloglossia (Tongue-Tie)
Ankyloglossia is characterized by a short, thick, or restrictive lingual frenulum that limits tongue movement. The reported prevalence ranges from approximately 4% to 10% in pediatric populations.
Potential consequences include:
▪️ Breastfeeding difficulties
▪️ Impaired tongue mobility
▪️ Mechanical oral dysfunction
▪️ Challenges with oral hygiene
▪️ Orthodontic concerns
▪️ Potential speech articulation difficulties

Maxillary Labial Frenulum Abnormalities
An enlarged or low-attached maxillary labial frenulum may contribute to:
▪️ Persistent midline diastema
▪️ Gingival recession
▪️ Oral hygiene difficulties
▪️ Esthetic concerns
Unlike lingual frenula, labial frenula rarely affect speech production directly.

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✅ Indications for Pediatric Frenectomy
Current evidence supports performing frenectomy when a restrictive frenulum produces measurable functional limitations.

Breastfeeding Dysfunction
In infants, frenectomy may be indicated when ankyloglossia contributes to:
▪️ Poor latch
▪️ Maternal nipple pain
▪️ Inefficient milk transfer
▪️ Inadequate weight gain
Several studies demonstrate improvement in breastfeeding outcomes following lingual frenotomy when significant restriction is present.

Speech Articulation Disorders
The relationship between tongue-tie and speech remains controversial.

A frenectomy may be considered when:
▪️ Restricted tongue mobility is documented
▪️ Speech articulation errors are directly attributable to tongue restriction
▪️ Evaluation by a speech-language pathologist supports intervention
▪️ Conservative therapy alone has been insufficient

Speech sounds potentially affected include:
▪️ /t/
▪️ /d/
▪️ /n/
▪️ /l/
▪️ /r/
▪️ /s/
▪️ /z/
▪️ /th/
However, many children with ankyloglossia develop normal speech despite anatomical restrictions.

Mechanical and Functional Limitations
Additional indications include:
▪️ Difficulty licking lips
▪️ Problems clearing food from teeth
▪️ Challenges with oral hygiene
▪️ ▪️ Tongue discomfort during movement
▪️ Functional restrictions affecting quality of life

Orthodontic and Periodontal Indications
Maxillary frenectomy may be indicated for:
▪️ Persistent midline diastema after eruption of permanent canines
▪️ Traumatic gingival tension
▪️ Gingival recession associated with frenulum pull

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✅ How Does Frenectomy Affect Speech Development?

Current Scientific Evidence
The impact of pediatric frenectomy on speech development remains an area of active investigation.
Recent systematic reviews indicate that:
▪️ Evidence supporting routine frenectomy solely for speech improvement is limited.
▪️ Many articulation disorders have multifactorial causes unrelated to tongue mobility.
▪️ Speech outcomes appear most favorable when a clear functional restriction is present.
▪️ Combined management involving surgery and speech therapy often yields superior results.
Several studies report improved articulation following frenectomy in selected patients. However, high-quality randomized controlled trials remain limited.

Why Speech Outcomes Vary
Speech production depends on multiple factors:
▪️ Neuromuscular development
▪️ Auditory processing
▪️ Cognitive development
▪️ Motor learning
▪️ Anatomical structures
▪️ Environmental influences
Consequently, correction of a restrictive frenulum alone may not resolve all speech difficulties.

Role of Speech Therapy
Speech-language evaluation is strongly recommended before considering surgical intervention for speech concerns.
Postoperative speech therapy may help patients:
▪️ Develop new tongue movement patterns
▪️ Improve articulation accuracy
▪️ Optimize functional outcomes
The combination of surgery and rehabilitation generally provides the most predictable results when speech impairment is present.

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✅ Surgical Techniques
Several techniques may be used in pediatric frenectomy:

Conventional Scalpel Frenectomy
Advantages:
▪️ Widely available
▪️ Cost-effective
Limitations:
▪️ Greater intraoperative bleeding
▪️ Need for sutures in some cases

Laser Frenectomy
Common laser systems include:
▪️ Diode lasers
▪️ CO₂ lasers
▪️ Er lasers

Potential benefits:
▪️ Reduced bleeding
▪️ Improved visibility
▪️ Minimal postoperative discomfort
▪️ Faster healing
▪️ Reduced need for sutures

Electrosurgery
Electrosurgery may provide effective tissue management but requires careful thermal control to prevent collateral tissue damage.

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💬 Discussion
The decision to perform pediatric frenectomy should be based on functional assessment rather than anatomical appearance alone. Although ankyloglossia has been associated with breastfeeding difficulties and certain speech articulation problems, current evidence does not support universal surgical intervention.
For speech-related concerns, multidisciplinary evaluation involving pediatric dentists, orthodontists, otolaryngologists, lactation consultants, and speech-language pathologists is often necessary. Existing literature suggests that patients with documented tongue mobility restrictions and corresponding articulation deficits may experience improvement after surgery. However, not all speech disorders are attributable to frenulum abnormalities.
Furthermore, overtreatment remains a concern due to increasing public awareness and social media influence regarding tongue-tie management. Evidence-based diagnosis and careful patient selection are therefore essential.

🎯 Clinical Recommendations
For Pediatric Dentists
▪️ Perform comprehensive functional assessments.
▪️ Avoid recommending frenectomy based solely on anatomical appearance.
▪️ Document tongue mobility limitations objectively.
▪️ Consider validated assessment tools when available.

For Speech Concerns
▪️ Obtain evaluation from a speech-language pathologist.
▪️ Confirm that articulation difficulties are directly related to restricted tongue movement.
▪️ Consider postoperative speech therapy when indicated.

For Orthodontic Management
▪️ Delay maxillary labial frenectomy for diastema management until appropriate orthodontic timing has been established.
▪️ Evaluate eruption status of permanent canines before intervention.

For Parents
▪️ Seek professional evaluation when feeding, speech, or oral function concerns arise.
▪️ Understand that surgery may not be necessary in all cases.
▪️ Follow postoperative exercises and therapy recommendations when prescribed.

✍️ Conclusion
Pediatric frenectomy can be a valuable treatment for selected children with clinically significant frenulum restrictions affecting feeding, oral function, periodontal health, or speech articulation. However, current evidence indicates that frenectomy should not be performed solely on the basis of frenulum appearance. The relationship between ankyloglossia and speech disorders is complex and multifactorial. A comprehensive functional assessment and multidisciplinary approach remain essential to achieving optimal outcomes. When speech impairment is directly linked to restricted tongue mobility, frenectomy combined with speech therapy may provide meaningful clinical benefits.

📚 References

✔ American Academy of Pediatric Dentistry. (2024). Policy on management of the frenulum in pediatric dental patients. The Reference Manual of Pediatric Dentistry. Chicago, IL: American Academy of Pediatric Dentistry.
✔ Francis, D. O., Chinnadurai, S., Morad, A., Epstein, R. A., Kohanim, S., McPheeters, M., & Walsh, J. (2015). Treatments for ankyloglossia and ankyloglossia with concomitant lip-tie. JAMA Otolaryngology–Head & Neck Surgery, 141(7), 646–653. https://doi.org/10.1001/jamaoto.2015.0987
✔ Messner, A. H., & Lalakea, M. L. (2002). The effect of ankyloglossia on speech in children. Otolaryngology–Head and Neck Surgery, 127(6), 539–545. https://doi.org/10.1067/mhn.2002.129731
✔ O'Shea, J. E., Foster, J. P., O'Donnell, C. P. F., Breathnach, D., Jacobs, S. E., Todd, D. A., & Davis, P. G. (2017). Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews, 3, CD011065. https://doi.org/10.1002/14651858.CD011065.pub2
✔ Webb, A. N., Hao, W., & Hong, P. (2013). The effect of tongue-tie division on breastfeeding and speech articulation: A systematic review. International Journal of Pediatric Otorhinolaryngology, 77(5), 635–646. https://doi.org/10.1016/j.ijporl.2013.03.008
✔ Yoon, A., Zaghi, S., Ha, S., Law, C. S., Guilleminault, C., & Liu, S. Y. C. (2017). Toward a functional definition of ankyloglossia: Validating current grading scales for tongue-tie by using objective measures. Journal of Oral Rehabilitation, 44(9), 709–721. https://doi.org/10.1111/joor.12536

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Tongue-Tie in Babies: How a Short Lingual Frenulum Affects Breastfeeding and When Treatment Is Needed

Tongue-tie (ankyloglossia) is a common congenital condition in infants that can significantly affect breastfeeding during the first months of life. It occurs when the lingual frenulum is unusually short, thick, or tight, restricting normal tongue movement.

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Although some babies with tongue-tie feed without difficulty, others experience poor latch, ineffective milk transfer, and early breastfeeding challenges, which may lead to frustration for both infants and parents.

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In recent years, increased awareness has led to more frequent diagnoses; however, not all cases require treatment. Current evidence emphasizes the importance of evaluating functional impairment rather than anatomical appearance alone, especially when breastfeeding difficulties persist despite proper support.

This article provides parents with evidence-based information on how a short lingual frenulum affects breastfeeding, how to recognize key signs and symptoms, and when professional evaluation and treatment may be necessary, helping families make informed decisions in collaboration with healthcare providers.

✅ What Is a Short Lingual Frenulum (Tongue-Tie)?
A short lingual frenulum, medically known as ankyloglossia, is a congenital condition in which the tissue connecting the tongue to the floor of the mouth is short, thick, or tight, limiting normal tongue movement.
In infants, restricted tongue mobility can interfere with effective breastfeeding, oral development, and comfort for both baby and mother.

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✅ How to Identify Tongue-Tie in Babies
Parents and healthcare providers may notice:

▪️ Limited tongue movement (difficulty lifting or protruding the tongue)
▪️ Tongue appears heart-shaped when crying or lifted
▪️ Tongue cannot reach the roof of the mouth
▪️ Difficulty maintaining latch during breastfeeding
Early identification is essential to avoid feeding complications.

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✅ Signs and Symptoms Related to Breastfeeding

1. In Babies
▪️ Poor latch or frequent unlatching
▪️ Prolonged feeding times
▪️ Clicking sounds while nursing
▪️ Inadequate weight gain
Excessive gassiness or reflux-like symptoms

2. In Mothers
▪️ Nipple pain or cracking
▪️ Incomplete breast emptying
▪️ Mastitis or blocked ducts
▪️ Decreased milk supply over time
Persistent breastfeeding difficulties despite proper positioning may indicate tongue-tie.

✅ Treatment Options: When and How to Treat

➤ Conservative Management
▪️ Lactation consultant support
▪️ Positioning and latch optimization
▪️ Monitoring weight gain and feeding efficiency

➤ Surgical Treatment
When symptoms persist, a frenotomy may be recommended:

▪️ Quick, minimally invasive procedure
▪️ Often performed without anesthesia in young infants
▪️ Minimal discomfort and rapid recovery
▪️ Immediate improvement in breastfeeding in many cases
Treatment is recommended only when functional problems are present, not solely based on appearance.

📊 Comparative Table: Tongue-Tie Management in Infants

Aspect	Advantages	Limitations
Conservative management	Non-invasive, supports natural adaptation	May not resolve severe functional limitations
Frenotomy	Rapid improvement in breastfeeding, minimal discomfort	Not indicated in asymptomatic infants
Multidisciplinary evaluation	Accurate diagnosis based on function	Requires access to trained professionals

💬 Discussion: Is Every Tongue-Tie a Problem?
Not all tongue-ties require treatment. Current evidence emphasizes that ankyloglossia should be treated only when it causes functional impairment, especially breastfeeding difficulties.
Overdiagnosis and unnecessary procedures should be avoided. A multidisciplinary evaluation involving pediatricians, dentists, and lactation consultants ensures appropriate decision-making.

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👨‍👩‍👧 Recommendations for Parents

▪️ Seek evaluation if breastfeeding is painful or ineffective
▪️ Consult a certified lactation consultant
▪️ Avoid self-diagnosis based on appearance alone
▪️ Ask about functional assessment tools (e.g., Hazelbaker Assessment Tool)
▪️ Follow post-procedure exercises if frenotomy is performed

Early, evidence-based intervention improves outcomes and parental confidence.

✍️ Conclusion
A short lingual frenulum can significantly affect breastfeeding, but not all cases require surgical treatment. Proper diagnosis should focus on function rather than anatomy alone. When breastfeeding problems persist, timely evaluation and individualized management can greatly improve feeding success and quality of life for both baby and parents.

📚 References

✔ American Academy of Pediatrics. (2024). Identification and management of ankyloglossia in infants. Pediatrics, 153(1), e2023062345.
✔ Francis, D. O., Chinnadurai, S., Morad, A., et al. (2015). Treatment of ankyloglossia and breastfeeding outcomes. Pediatrics, 135(6), e1458–e1466.
✔ O’Shea, J. E., Foster, J. P., O’Donnell, C. P., et al. (2017). Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews, (3), CD011065.
✔ Walsh, J., Tunkel, D. (2017). Diagnosis and treatment of ankyloglossia in newborns and infants. JAMA Otolaryngology–Head & Neck Surgery, 143(10), 1032–1039.

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Clinical Indications for Frenectomy in Pediatric Dentistry: Evidence-Based Guidelines

Frenectomy is a common surgical procedure in pediatric dentistry aimed at correcting abnormal frenum attachments that interfere with oral function, growth, and development.

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Video 🔽 What is frenectomy? Step by step surgical procedure ... The frenectomy is performed under local anesthesia and has a short postoperative period without major complications. This surgical procedure can be performed on pediatric and adult patients.

While frenula are normal anatomical structures, pathological frenal attachments may compromise breastfeeding, speech articulation, oral hygiene, periodontal health, and orthodontic stability. Current evidence emphasizes that frenectomy should be indicated based on functional impairment rather than anatomy alone.

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✅ Clinical Indications for Frenectomy in Children

1. Breastfeeding Difficulties (Ankyloglossia)
A restrictive lingual frenum may impair tongue mobility, leading to:
▪️ Poor latch
▪️ Maternal nipple pain
▪️ Inadequate milk transfer
Early frenectomy has been shown to improve breastfeeding outcomes when functional limitation is confirmed.

2. Speech Disorders
Although controversial, frenectomy may be indicated when:
▪️ Persistent articulation disorders are present
▪️ Speech therapy alone is insufficient
▪️ Tongue mobility is objectively restricted
Speech assessment by a speech-language pathologist is essential prior to surgery.

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3. Periodontal and Oral Hygiene Concerns
Abnormal labial frenula may:
▪️ Cause gingival tension and recession
▪️ Interfere with plaque control
▪️ Compromise periodontal health
Frenectomy is recommended when gingival trauma or inflammation persists despite good oral hygiene.

4. Orthodontic Indications
A high or thick maxillary labial frenum may contribute to:
▪️ Midline diastema
▪️ Orthodontic relapse
Frenectomy is typically performed after orthodontic space closure, unless periodontal or functional issues are present earlier.

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5. Functional and Mechanical Limitations
Indications also include:
▪️ Difficulty in mastication
▪️ Altered tongue posture
▪️ Limited lip mobility affecting speech or feeding
Functional limitation remains the primary criterion for intervention.

📊 Comparative Table: Clinical Indications for Frenectomy in Pediatric Dentistry

Aspect	Advantages	Limitations
Breastfeeding improvement	Enhances latch, milk transfer, and maternal comfort	Not effective if feeding issues are unrelated to tongue restriction
Speech function	May improve articulation when tongue mobility is severely limited	Speech outcomes vary; surgery alone is often insufficient
Periodontal health	Reduces gingival tension and recession risk	Does not replace proper oral hygiene or periodontal care
Orthodontic stability	Helps prevent midline diastema relapse	Timing is critical; premature surgery may be unnecessary

💬 Discussion
Current guidelines discourage routine frenectomy based solely on frenal appearance. Evidence-based practice supports a multidisciplinary diagnostic approach, involving pediatric dentists, orthodontists, lactation consultants, and speech therapists. Advances in laser technology have improved surgical outcomes; however, the decision to perform frenectomy must remain clinically justified. Overdiagnosis and unnecessary procedures remain concerns in pediatric populations.

🔎 Recommendations
Perform frenectomy only when functional impairment is clearly documented
Use validated assessment tools for tongue mobility and function
Collaborate with speech therapists and lactation specialists
Avoid prophylactic frenectomy in asymptomatic children
Ensure proper postoperative exercises and follow-up

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✍️ Conclusion
Frenectomy in pediatric dentistry is a valuable therapeutic procedure when appropriately indicated. Modern evidence supports a functional, patient-centered approach, ensuring that surgical intervention improves quality of life, oral function, and long-term outcomes. Careful diagnosis and interdisciplinary collaboration are essential to avoid overtreatment and maximize clinical success.

📚 References

✔ American Academy of Pediatric Dentistry. (2023). Policy on management of the frenulum in pediatric dental patients. Pediatric Dentistry, 45(6), 81–85.
✔ Buryk, M., Bloom, D., & Shope, T. (2011). Efficacy of neonatal release of ankyloglossia: A randomized trial. Pediatrics, 128(2), 280–288. https://doi.org/10.1542/peds.2011-0077
✔ Kotlow, L. A. (2015). Diagnosis and treatment of ankyloglossia and tied maxillary fraenum in infants. Journal of Pediatric Dental Care, 21(2), 1–9.
✔ Messner, A. H., & Lalakea, M. L. (2002). Ankyloglossia: Controversies in management. International Journal of Pediatric Otorhinolaryngology, 64(1), 1–10. https://doi.org/10.1016/S0165-5876(02)00054-0
✔ Suter, V. G. A., & Bornstein, M. M. (2009). Ankyloglossia: Facts and myths in diagnosis and treatment. Journal of Periodontology, 80(8), 1204–1219. https://doi.org/10.1902/jop.2009.090086

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What is frenectomy? Step by step surgical procedure

In the oral cavity we can find two types of frenulum: the lingual and the labial. The alterations of the braces can cause aesthetic and phonetic problems. Treatment is sometimes multidisciplinary: pediatric dentist and speech therapist.

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The frenectomy is performed under local anesthesia and has a short postoperative period without major complications. This surgical procedure can be performed on pediatric and adult patients.

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We share complete information about frenectomy, effectiveness and the step-by-step procedure regarding a clinical case. In addition to the case of a laser frenectomy in pediatric patients.

📌 Watch video "What is a Frenectomy?"

Youtube/ Joseph R Nemeth DDS

📌 Read and download the article in PDF 1:

👉 "Surgical techniques for the treatment of ankyloglossia in children: a case series" 👈

Junqueira MA, Cunha NN, Costa e Silva LL, Araújo LB, Moretti AB, Couto Filho CE, Sakai VT. Surgical techniques for the treatment of ankyloglossia in children: a case series. J Appl Oral Sci. 2014 Jun;22(3):241-8. doi: 10.1590/1678-775720130629. PMID: 25025566; PMCID: PMC4072276.

📌 Read and download the article in PDF 2:

👉 "Frenectomy for the Correction of Ankyloglossia: A Review of Clinical Effectiveness and Guidelines" 👈

Frenectomy for the Correction of Ankyloglossia: A Review of Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2016 Jun 15. PMID: 27403491.

📌 Read and download the article in PDF 3:

👉 "Treatment of ankyloglossia with dental laser in paediatric patients: Scoping review and a case report" 👈

Garrocho-Rangel A, Herrera-Badillo D, Pérez-Alfaro I, Fierro-Serna V, Pozos-Guillén A. Treatment of ankyloglossia with dental laser in paediatric patients: Scoping review and a case report. Eur J Paediatr Dent. 2019 Jun;20(2):155-163. doi: 10.23804/ejpd.2019.20.02.15. PMID: 31246095.

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Oral Surgery: Use of laser in lingual frenectomy in pediatric patients

The frenectomy is the surgical act that is performed on the labial or lingual frenulum. This procedure is performed when the frenulum generates limits the movements of the lip or tongue.

Among the benefits of using laser in frenectomy are: a quick surgical procedure, and a shorter and less painful post-operative period. Other benefits are: it promotes hemostasis and sterilizes the surgical site.

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We share an interesting clinical case of a 7-year-old girl referred by the orthodontist for a lingual frenectomy. In the article we can find the benefits of using laser in frenectomy.

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Benefits of Tongue Tie Surgery

👉 READ AND DOWNLOAD "Diode Laser Lingual Frenectomy in Pediatric Dentistry: Case Report" IN FULL IN PDF👈

Irineu Gregnanin Pedron., et al. “Diode Laser Lingual Frenectomy in Pediatric Dentistry: Case Report". Scientific Archives Of Dental Sciences 4.1 (2021): 29-33.

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