The labial and lingual frenula are normal anatomical structures, but when their attachment is abnormal or restrictive, they can interfere with oral function, facial development, and esthetics.
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✅ Diagnosis of Frenulum Abnormalities
1. Abnormal Maxillary Labial Frenulum
➤ Clinical Diagnosis:
° Low attachment (near the interdental papilla)
° Midline diastema
° Blanching of the papilla when the frenulum is pulled
➤ Evaluation Tools:
° Visual and tactile inspection
° Kotlow Classification for insertion level
° Periapical radiographs to assess spacing
➤ Classification (Miralles et al., 2009):
° Mucosal, gingival, papillary, penetrating
2. Lingual Frenulum (Ankyloglossia or "Tongue-Tie")
➤ Clinical Diagnosis:
° Limited tongue mobility
° Difficulties in breastfeeding, speech, or swallowing
° Heart-shaped appearance of the tongue tip
➤ Assessment Tools:
° Hazelbaker Assessment Tool (function and anatomy)
° Observation during oral functions (e.g., protrusion, suction)
° Referral to multidisciplinary specialists when needed
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✅ Consequences of Untreated Frenulum Issues
° Persistent midline diastema
° Periodontal recession due to tissue pulling
° Speech disorders (e.g., lisps, articulation delay)
° Breastfeeding difficulties in infants
° Orofacial myofunctional disorders
° Orthodontic complications later in life
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1. Labial Frenulum
➤ Management:
° Monitoring (especially in children under age 6 with physiological spacing)
° Surgical Frenectomy indicated when:
- Diastema persists after eruption of permanent incisors
- Orthodontic treatment is planned
- Gingival recession or tension is observed
° Traditional scalpel technique
° Electrosurgery
° Diode laser (minimizes bleeding, faster healing)
2. Lingual Frenulum (Tongue-Tie)
➤ Management:
° Frenotomy: simple incision, typically for infants
° Frenectomy: complete removal, suitable for older children or severe cases
° Pre- and post-surgical myofunctional therapy
° Multidisciplinary approach: pediatric dentist, lactation consultant, speech-language pathologist
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° Assess frenula during the infant’s first dental or pediatric visit
° Treat ankyloglossia early if it impacts feeding or oral function
° Avoid surgery for purely esthetic reasons in primary dentition
° Use laser technology for anxious children or those needing fast recovery
° Always include functional assessment before deciding on surgery
💬 Discussion
Frenulum-related conditions are common in children but often overlooked. Evidence suggests that function-based assessment should take precedence over anatomical appearance when making treatment decisions. Early intervention in cases like tongue-tie can greatly improve oral and facial development. Diode lasers have significantly improved surgical outcomes in children, making the procedures less invasive and more tolerable. Still, collaboration between specialties remains the gold standard for long-term success.
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° Early identification of abnormal frenula prevents future complications.
° Treatment decisions must prioritize function over appearance.
° Conservative surgical techniques are preferred in pediatric cases.
° A team-based approach enhances treatment outcomes, especially in tongue-tie.
° Parental education and regular follow-up are essential to successful management.
📚 References
✔ American Academy of Pediatric Dentistry (AAPD). (2023). Guideline on Management of the Frenulum in Pediatric Patients. https://www.aapd.org/research/oral-health-policies--recommendations/
✔ Baxter, R., & Dupont, J. (2020). Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More. Alabama Tongue-Tie Center.
✔ Hazelbaker, A. (2010). Assessment Tool for Lingual Frenulum Function (ATLFF). Columbus, OH.
✔ Kotlow, L. A. (2004). Oral diagnosis of abnormal frenum attachments in neonates and infants: evaluation and treatment of the maxillary and lingual frenum using the Erbium:YAG laser. Journal of the Laser and Health Academy, 2(3), 1–7.
✔ Miralles, R., et al. (2009). Clinical classification of upper labial frenulum insertions in children. Revista Chilena de Odontopediatría, 3(1), 23–27.
✔ Nakhash, A., et al. (2021). Surgical interventions for ankyloglossia in children: A systematic review and meta-analysis. International Journal of Pediatric Otorhinolaryngology, 145, 110714. https://doi.org/10.1016/j.ijporl.2021.110714
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