Acknowledgments

The Australian Dental Association, in association with an expert multidisciplinary panel of health professionals has developed the

Ankyloglossia and Oral Frena Consensus Statement to provide evidence-based recommendations to guide best practice in caring

for individuals with short, tight labial and lingual frena and ankyloglossia. Working group members are acknowledged below.

Expert working group members

Chair Dr Mihiri Silva (Paediatric Dentist)
BDSc, MDSc, DCD (Paediatric Dentistry), PhD

Australasian Academy of Paediatric Dentistry Dr Kareen Mekertichian (Paediatric Dentist)

(AAPD) BDS, MDSc, FRACDS, MRACDS (Paed Dent), FICD, FPFA

Australian Chiropractors Association (ACA) Dr Russell Mottram (Chiropractor)

B.App.Sc (Chiropractic)

Australian College of Midwives (ACM) Ms Lois Wattis (Clinical Midwife and IBCLC)
BNurs, PGradDipMidwifery, FACM, IBCLC

Australian College of Midwives (ACM) Ms Michelle Simmons (Clinical Midwife Consultant, Westmead)
MNurs, IBCLC

Australian Dental Association (ADA) Prof Laurence Walsh (Specialist in Special Needs Dentistry)
BDSc, PhD, DDSc, GCEd, FRACDS, FFOP (RCPA)

Australian Dental Association (ADA) Dr Philippa Sawyer (Paediatric Dentist)

BDS (USyd), MA (Sports Studies) (UTS), GradCertPedDent (NYU)
PGCertHEd (MQU), Master of Early Childhood (MQU), FICD, FAAPD, FIADT
Diplomate, American Board of Pediatric Dentistry

Australian Dental Association (ADA) Ms Eithne Irving

Deputy CEO & Policy General Manager RN, Grad Dip Neuroscience, MBA

Australian Dental Association (ADA) Dr Mikaela Chinotti (Dentist)

Oral Health Promoter BDS, MPH

Australian Dental & Oral Health Therapists' Ms Nicole Stormon (Oral Health Therapist)
Association (ADOHTA) BOH, AFHEA

Australian and New Zealand Association of Oral and A/Prof David Sherring (Oral and Maxillofacial Surgeon)
Maxillofacial Surgeons (ANZAOMS) MBBS, BDS, DClinDent, FRACDS (OMS)
President ANZAOMS (2017-2019)

Lactation Consultants of Australia & New Zealand Ms Heather Gale (IBCLC, Registered Nurse and Midwife)
(LCANZ) IBCLC/RN/RM/Post grad. Dip Nurse Ed./M. Nursing

Osteopathy Australia (OA) Dr Julie Fendall (Osteopath)

DO MOstSc (Paeds)

Royal Australasian College of Dental Surgeons (RACDS) Dr Kelly Oliver (Paediatric Dentist)
BDSc, DClinDent, FRACDS (Paeds)

Speech Pathology Australia (SPA) Ms Emma Necus (Speech Pathologist)

Speech Pathologist (MSc/Bsc), IBCLC

Dr John Sinn (Neonatologist)

MBBS(Syd), DCH, Dip Paed, MMed (C Epi), FRACP (Paed)

Ankyloglossia and Oral Frena Consensus Statement

First Edition 2020

Published by the Australian Dental Association, PO Box 520, St Leonards, NSW 1590, Australia © Australian Dental Association 2020
Page 2 | Ankyloglossia and Oral Frena Consensus Statement  Back to top
Executive Summary
The Ankyloglossia and Oral Frena Consensus Statement provides a multi-disciplinary, evidence-based consensus regarding the

diagnosis and management of short, tight labial and lingual frena and ankyloglossia.

Working Group
The consensus statement was formed by a multidisciplinary working group of health professionals representing ten

organisations and associations and is intended to guide best practice. It is based on existing evidence, including a systematic

Cochrane Review, an updated broader literature review and the expert opinion of the working group.

Health Problems
Ankyloglossia can cause some individuals to experience functional limitations, such as difficulty breastfeeding. Further

research is needed regarding other reported adverse health outcomes, such as problems with speech, malocclusion, lingual

gingival recession and obstructive sleep apnoea as evidence of a consistent causative relationship is lacking. No evidence

exists to support buccal or labial frena causing problems with feeding or speech.

Diagnosis
The anatomical appearance of oral frena can demonstrate considerable variability without functional issues. Therefore,

diagnosis of ankyloglossia should not be based solely on anatomic appearance. The key pre-requisites for a diagnosis are:

1. Thorough case history.

2. Objective functional assessment of tongue function using a diagnostic system.

3. Complete assessment of functional issues impacted by the suspected ankyloglossia by a qualified professional.

Management
Contemporary management of ankyloglossia includes a range of treatments and requires inter-disciplinary care by multiple

health professionals. Non-surgical management strategies can be effective first-line therapies for management of functional

limitations associated with ankyloglossia.

Surgical management should be considered only after non-surgical management has failed to address the functional issue

that led to the diagnosis. Treating clinicians must understand surgical techniques, possess the ability to identify and manage

complications as well as have access to and training in resuscitation equipment appropriate to the age of patients treated.

Appropriate analgesia and anaesthetic use should be considered for individuals of all ages.

Final remarks
The statement highlights the importance of multi-disciplinary care and communication between treating health professionals.

Further research is required to clarify many issues relating to ankyloglossia, particularly the effects of surgical management on

improving functional limitations and the long-term effects of surgical intervention on neonates.

 Back to top | Page 3

Part 1
The purpose of this Ankyloglossia and Oral Frena Despite considerably differing views on the topic, there are

Consensus Statement is to provide a multi-disciplinary, currently no Australian guidelines that inform the diagnosis

evidence-based consensus regarding the diagnosis and and management of ankyloglossia. Therefore, a working

management of short, tight labial and lingual frena and group of relevant key bodies was established to create this

ankyloglossia to guide best practice. consensus statement to provide objective and evidence-

based advice for the assessment and management of

Background
ankyloglossia and other intra-oral frena in neonates, infants,
The lingual frenum refers to the mucous membrane that
children and adults. This statement covers the definition,
connects the ventral surface of the tongue to the floor of
diagnosis, associated health issues and management of
the mouth. Ankyloglossia, commonly referred to as ‘tongue-
ankyloglossia and other oral frena, and complications and
tie,’ describes restricted movement of the tongue causing
post-operative care following surgical management.
functional limitations, accompanied by a visually restricted

lingual frenum. This consensus statement strongly and wholly supports

the World Health Organization (WHO)’s recommendations

Ankyloglossia is a congenital anomaly that has been
for infant and young child feeding, including that mothers
reported in neonates, infants, children and adults. It has
exclusively breastfeed infants for their first six months and
been suggested to be linked with a range of health issues,
the introduction of nutritious complementary foods along
including breastfeeding, speech and dental problems,
with continued breastfeeding until 2 years and beyond to
such as malocclusion. Contemporary management of
achieve optimal growth, development, and health.4
these problems includes a range of treatments and health

professionals.

In recent years, there has been a large increase in the

referral and surgical management of newborns, infants and

children with ankyloglossia. A 420% increase in frenotomy

rates, as derived from Medicare data, was reported in

Australia over the last decade.¹ Surgical management has

also reportedly increased in Canada² and North America.³

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Consensus statement development Prior to meeting, the group was provided with Terms of

To form the multidisciplinary working group to develop the Reference, proposed points for consensus, rapid reviews of

Ankyloglossia and Oral Frena Consensus Statement, the available literature and current Australian and international

Australian Dental Association (ADA) invited relevant health guidelines, policies and position statements, as collated

associations and organisations to partake by nominating by the ADA’s Oral Health Promoter. Group members were

a representative. The statement was developed through encouraged to suggest additional pre-reading that was

meetings (one face-to-face and one teleconference) and not otherwise included in the rapid review. The proposed

additional email correspondence between working group points for consensus included:

members over a period of six months.. • DEFINITION, of terms including lingual frenum,

The final panel included 14 health professionals representing ankyloglossia and ‘posterior’ tongue-tie

the following associations or organisations: • DIAGNOSIS, including the health professionals best

placed to recognise ankyloglossia and the preferred

• Australasian Academy of Paediatric Dentistry (AAPD);
diagnostic tools
• Australian Chiropractors Association (ACA);
• ASSOCIATED HEALTH ISSUES, including breastfeeding
• Australian College of Midwives (ACM); problems, speech and articulation problems,

• Australian Dental Association (ADA); malocclusion, gingival recession, gastroesophageal

reflux disease (GORD), obstructive sleep apnoea (OSA),

• Australian Dental & Oral Health
difficulty transitioning to solid food or muscular tension
Therapists' Association (ADOHTA);
• MANAGEMENT, including treatment setting and
• Australian and New Zealand Association of Oral and practitioner qualifications

Maxillofacial Surgeons (ANZAOMS); • SURGICAL INTERVENTION, including indications and

recommended management pathway prior to surgical

• Lactation Consultants Australia and New Zealand
intervention
(LCANZ);
• ARMAMENTARIUM, including recommended
• Osteopathy Australia (OA);
instrumentation for division of oral frena
• Royal Australasian College of Dental Surgeons (RACDS);
• INFORMED CONSENT, including risks to discuss when
• Speech Pathology Australia (SPA). gaining informed consent

• POST-OPERATIVE CARE, including wound care and pain

management

• COMPLICATIONS associated with treatment

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 The first group meeting was held face-to-face at the ADA An electronic database search to review the literature was

on July 17, 2019. It was chaired by Dr Mihiri Silva, paediatric conducted and the evidence appraised. Details are provided

dentist, and supported by Dr Mikaela Chinotti, dentist and in Part Two and Appendices A and B.

ADA Oral Health Promoter. The meeting was audio recorded All nominees declared no conflicts of interest. No external

and transcribed. funding was provided to the ADA for the development of

The working group was divided into four sub-groups and this statement.

allocated proposed points for consensus, as relevant to their

Glossary
discipline, for discussion. Within groups, members explored
Frenotomy/frenulotomy – division of a frenum without
current standards of care, summarised findings of relevant
suture or revision of the remaining tissues5
publications, shared their expert experience and identified
Frenuloplasty – division of a frenum and closure of the
areas for further investigation. Each group developed a mucosa with sutures5

preliminary consensus regarding the assigned points of Frenectomy/frenulectomy – excision of a frenum5

discussion, which was presented to the working group for Surgical management – surgical intervention of a

debate between all members. Consensus was considered to frenum using techniques including frenotomy/frenulotomy,

be achieved when assent was obtained. frenuloplasty or frenectomy/frenulectomy

Based on the preliminary consensus developed at the Cold steel – term describing surgical procedures

performed using a metal blade instrument, i.e. scalpel,

face-to-face meeting on July 17, 2019, a written draft
scissors
was provided to the working group for comment prior to
Fascia - a sheath, a sheet or any number of dissectible
a teleconference meeting for further discussion to refine
aggregations of connective tissue that forms beneath the
the draft. The teleconference was audio recorded and
skin to attach, enclose or separate muscles and other internal
transcribed. A second draft was disseminated to the working
organs.6
group for comment.
Neonates – babies aged less than 28 days
The final Ankyloglossia and Oral Frena Consensus
Infants – babies aged 1–12 months

Statement draft was provided to the working group prior

to dissemination to the invited and additional health

organisations and associations for the option to become a

signatory.

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Statement of Consensus
Definition Diagnosis

Lingual Frenum - Lingual frenum is the name given to Diagnosis of ankyloglossia should not be based solely

describe the anatomical structure which is “a dynamic on anatomic appearance. The presence of a functional

structure formed by a central fold of fascia that limitation, such as difficulty in breastfeeding, and an

spans the floor of mouth and together with the anatomically restricted lingual frenum should both be

overlying oral mucosa it forms the “roof” of the present for a diagnosis of ankyloglossia. In the absence

sublingual space…the fascia connects around the of a functional limitation, the lingual frenum should be

anterior and lateral ventral surfaces of the tongue, to considered functionally normal.

stabilize tongue position while allowing freedom of

Many adults and children will not experience functional
movement.7”
limitations associated with a short, tight lingual frenum.

Ankyloglossia - Ankyloglossia refers to the restricted Assessment of function should be modified according to age

movement of the tongue causing functional limitations, and life-stage, such as breastfeeding, starting solid foods,

accompanied by a visually restricted lingual frenum. speech and appearance of both the primary and secondary

dentition. In infancy and early childhood, appropriately-

Posterior Tongue Tie - The term ‘posterior’ tongue tie
trained health professionals with an understanding of
was introduced in 2004 through an opinion piece published
neonatal feeding and the biomechanics of nutritive and
in the American Academy of Pediatrics newsletter by
non-nutritive sucking such as International Board Certified
Coryllos, Genna and Salloum,8 classifying the distance of the
Lactation Consultants (IBCLCs), midwives, child health nurses
tongue tip to the leading edge of the frenum.
and/or speech pathologists, are best placed to recognise

There is a lack of evidence from dissection studies to ankyloglossia.

support such an entity.7 Use of this term can result in a

All current diagnostic systems have inherent limitations.
normal lingual frenum being classified as abnormal. The
Some systems describe frenum appearance but provide no
term ‘posterior’ tongue tie should not be used as a medical
diagnostic value. Many remain unvalidated but have been
diagnosis.
shown to influence clinical care. Diagnostic systems that

include assessment of both tongue function and appearance,

such as Martinelli9 and Hazelbaker10 are preferable over those

that classify ankyloglossia purely on anatomic appearance.

 Back to top | Page 7

A diagnosis of ankyloglossia may be considered after the There is insufficient evidence to definitively conclude that

following steps are completed: ankyloglossia causes other health problems, including sleep

1. A thorough case history has been taken. disordered breathing, gastroesophageal reflux disease

2. Objective functional assessment of tongue function has (GORD), colic or difficulty transitioning to solid foods.

been completed (using a diagnostic system, such as

Non-surgical management
Martinelli9 or Hazelbaker10 ).
There is evidence that non-surgical management strategies
3. A complete assessment of factors impacted by the
can be an effective first-line therapy for the management of
suspected ankyloglossia by a qualified professional (e.g.
functional limitations related to ankyloglossia.14
breastfeeding observation by an IBCLC).
Non-surgical strategies for management of ankyloglossia

Associated Health Issues include treatment to optimise neonatal and infant feeding

Breastfeeding issues can be associated with ankyloglossia.11 and nutrition and growth, with appropriately-qualified

health professionals, such as IBCLCs, midwives, child health

A minority of children may develop speech problems as a
nurses and/or speech pathologists.
result of ankyloglossia. No available evidence demonstrates

causative association between ankyloglossia and speech Management can include advice on positioning, latch

articulation problems, including a delay in, or lack of speech optimisation, feed frequency, supporting mothers to

development,12 particularly in children who have not had maintain milk supply, and the use of external tools such as

feeding issues. Additionally, no method exists for predicting nipple shields or supplementary nursing systems.

which infants may experience speech difficulties.

There is no evidence to suggest that buccal or labial frena

can lead to problems with feeding or speech.13

Oral problems, such as malocclusion, may arise in a minority

of individuals with a prominent lingual or labial frenum.

Malocclusion, gingival recession and dental caries cannot be

predicted based on the anatomic appearance of the frenum

in infancy or early childhood.

Page 8 | Ankyloglossia and Oral Frena Consensus Statement  Back to top

Figure 1. Suggested management pathway for infants diagnosed with ankyloglossia.

Infant feeding issues

Diagnosis

Ankyloglossia (restricted lingual frenum + functional limitation)

Non-surgical management Review diagnosis and failed

non-surgical management

Surgical management
Feeding support
• Positioning
• Latch optimization
• External tools, e.g.
Nipple shields Post-operative review
• Supply support • Surgical site
• Parent education; speech, • Feeding
transition to solids
Develop oral skills

Continued non-surgical management

Follow up and reassessment

Feeding issues resolved Feeding issues continuing Reassessment of feeding

Feeding issues resolved Feeding issues continuing

 Back to top | Page 9

Surgical Management Surgical management should only be undertaken by

Surgical management of the lingual frenum may be appropriately trained health professionals working in

indicated after: an appropriate clinical setting that can manage possible

1. Diagnosis of ankyloglossia by an appropriately-trained complications. Treating clinicians must understand

health professional using appropriate diagnostic surgical techniques and possess the ability to identify

assessments; and manage complications appropriate to the age of

2. Failure of non-surgical management; and the patient, including access to specialist care. Treating

3. Full informed consent is obtained. health professionals should have training in and access

Surgical management should not take place without the to resuscitation equipment appropriate to the age of the

presence of a well-defined structural problem, which is patients treated. Treating healthcare facilities should have

causing functional issues. Likewise, surgical management well documented and implemented practice protocols

should not be undertaken based on speculation about future for managing complications associated with surgical

problems despite lack of current problems. intervention.

There is insufficient evidence to support the surgical If a patient, parent and/or health professional performing

release of the labial or buccal frena in infants to assist with a procedure identify a complication (including incomplete

breastfeeding difficulties, speech outcomes, or orthodontic division or apparent reattachment due to scar formation),

issues including midline diastema closure.15 then specialist referral, such as to an ear, nose and throat

(ENT) surgeon, paediatrician, paediatric surgeon, paediatric

As part of orthodontic management, a minority of older
plastic surgeon, paediatric dentist or oral maxillofacial
children and adults with intra-oral frena associated with
surgeon is recommended.
malocclusion, may benefit from timely surgical release.
Neonates and Infants

Following receipt of a referral, health professionals who Thorough pre-operative assessment of possible

undertake surgical management are obliged to reassess contraindications for surgery is mandatory. Contraindications

the need for surgical management and review the already for surgical intervention may include orofacial malformations

completed non-surgical care. Treating health professionals such as cleft palate, Pierre Robin Sequence, bleeding

should obtain written consent from patients or parents/ disorders, neuromuscular conditions and vitamin k

guardians. Discussion should include appropriate disclosure deficiency. Routine post-birth vitamin k administration needs

of potential complications of the surgery.

Page 10 | Ankyloglossia and Oral Frena Consensus Statement  Back to top

to be confirmed in neonates and infants undergoing surgical Complications

management. The surgical management of ankyloglossia carries the risk of

If surgical intervention is deemed necessary, the age of both acute and chronic complications.

the patient influences the surgical approach. Cold steel

Acute complications can include deep ulceration, bleeding,
frenotomy using scissors is recommended in neonates. Laser
haematoma, airway compromise, swelling, restricted tongue
or cold steel may be appropriate in infants. Risks associated
movement and iatrogenic injury.
with the use of laser surgery include eye exposure, inhalation

of plume and aspiration of coolant spray, plume and/or Chronic complications can include ‘recurrent ankyloglossia’

blood. due to scar tissue formation, sub-mandibular salivary gland duct

injury, oral aversion, ranula, tongue paraesthesia and infection.

Age-appropriate analgesia for pain control or management

should be instituted. Management of intra-operative pain Although it may be regarded a simple procedure to perform,

is an important consideration as neonates and infants can complications can be potentially life-threatening. Reports

experience pain from cold steel or laser surgery. exist of large volume blood loss causing hypovolemic shock in

neonates;16,17 a condition that can present initially with subtle

Neonates receiving surgical management should undergo
symptoms18 but rapidly progress in neonates.
treatment in an established healthcare facility or tertiary

setting with access to neonatal resuscitation equipment Following surgical management, there is no guaranteed

and the ability to manage acute airway and/or bleeding improvement of the functional limitation for which surgery was

complications. sought. Patient issues may worsen, or new issues may develop

post-operatively.
Children and Adults

Surgical management in adults should be considered elective

treatment.

The use of cold steel or laser surgery may be suitable

in children and adults, with consideration of appropriate

anaesthesia and analgesia.

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Table 1. Reported complications following surgical management of lingual and labial frena
Article Study Design and Complications
Participants (N)
Hale et al. 2020.17 Observational, cohort study • Poor feeding
N = 16 • Apnoea or other breathing difficulty
• Pain
• Bleeding
• Weight loss
• Pallor/Anaemia
• Excess scarring
• Delayed diagnosis of alternative underlying medical
condition
Dixon B et al. 2018.19 Observational, cohort study • Severe bleeding
N = 367 • Submandibular oedema
• Oral aversion
• Division of the submandibular salivary ducts
Suter V, Bornstein M. 2009.20 Systematic review • Excessive bleeding
• Recurrent ankyloglossia due to excessive scarring
• Upper airway collapse
• Functional disturbances; lingual dysfunction and
deglutitory anomalies
Zaghi S et al. 2019.21 Observational, cohort study • Lingual paraesthesia
N = 420 • Salivary gland inflammation and swelling
• Increased salivation and jetting of saliva
• Sleep-disordered breathing
Varadan M et al. 2019. 22
Critical review • Excessive bleeding or haemorrhage
• Retention cyst or ranula
• Sublingual haematoma
• Reattachment/recurrence of frenal attachment
• New speech disorder or worsened existing speech disorder
• Paraesthesia of the tongue and neighbouring soft tissues
Tracy LF et al. 2017.16 Case report • Large volume blood loss causing hypovolemic shock. Case
N=2 1 required cardiopulmonary resuscitation, while Case
2 underwent emergent operative treatment to control
bleeding. Both cases required blood transfusions.
Maciag M et al. 2016.23 Case report • Ludwig’s angina
N=1
Genther DJ et al. 2015.24 Case report • Prominent glossoptosis in supine position
N=1
- Near complete obstruction of the pharyngeal airway
- Nasogastric tube and gastrostomy tube for feeding
Isaiah A, Pereira KD. 2013.25 Case report • Infected hematoma
N=1
Opara PI et al. 2012.26 Case report • Large volume blood loss
N=2

Page 12 | Ankyloglossia and Oral Frena Consensus Statement  Back to top

Post-operative care Training

Post-operative care to minimise complications and support No training courses exist that allows any member of a

patients and families to overcome functional problems that health profession to register as a specialist or ‘expert’ in the

initiated the surgical intervention is essential. Care should treatment of ankyloglossia. Individuals must not advertise

be appropriate to the procedure performed as well as the themselves as registered specialists in ankyloglossia or

diagnosis and functional limitation originally established. tongue tie management specifically.

Administration of pharmacological analgesics to neonates The Health Practitioner Regulation National Law

should be provided in consultation with a neonatologist or Act 2009 Section 115 (1) states that “A person must not

paediatrician. Non-pharmacological analgesic strategies can knowingly or recklessly take or use - (c) a specialist title for

include skin-to-skin contact, sucrose with or without a pacifier a recognised specialty unless the person is registered under

and breastfeeding or the provision of expressed breastmilk or this Law in the specialty.”

colostrum.

Future Directions
Post-operative breastfeeding support for the mother-infant
Further research, preferably through randomised controlled
dyad is essential. All neonates and infants who undergo
trials (RCT)'s or high quality observational studies employing
surgical management of ankyloglossia due to breastfeeding
objective outcomes, is required. Further understanding of
difficulties should receive breastfeeding support from an
many aspects is required, particularly the effects of surgical
appropriately qualified health professional.
management on improving functional limitations and the

Contemporary post-operative care increasingly includes long-term effects of surgical intervention on neonates,

stretching of the soft tissue wound following division of a as memories of pain may be recorded biologically, and

frenum to prevent ‘reattachment’ of wound margins. There consequently alter brain development and subsequent

is no scientific evidence to support these stretches, which behaviour.28

are commonly referred to as ‘active wound management’

stretches. Stretching of surgical wounds is not recommended

as it prolongs healing time and increases risk of scarring

and infection.27 The lack of a scientific reason for carrying

out these stretches is a medico-legal risk for clinicians who

recommend and use this approach.

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Part Two
Supporting Evidence

Search Strategy Table 3: Embase search terms:

An electronic search was conducted in August 2019 using 1. ankyloglossia/

the Medline (Ovid) and Embase Databases. 2. (ankylogloss* or tongue-tie* or tonguetie*).tw,kw,dq.

The search strategy was developed with the assistance of 3. tongue frenulum/ or labial frenum/

4. (frenulum or frenum or frena).tw,kw,dq. and

an experienced librarian (Tables 2 and 3). In addition, hand
((abnormal* or surger* or surgical* or operat* or
repair).tw,kw,dq,hw. or su.fs.)
searching of the reference lists of selected studies and a
5. (Frenulectom* or Frenectom* or frenotom*).tw,kw,dq.
number of paediatric journals was performed. Unpublished
6. frenotomy.hw.
studies were sought by contacting experts in the field and
7. oral surgery/
by searching the ProQuest Dissertations and Theses global
8. treatment outcome/
database.
9. exp speech disorder/
Table 2: Medline (Ovid) search terms: 10. speech intelligibility/

1. Ankyloglossia/ 11. (speech or dental or caries or malocclusion* or mal-

occlusion*).tw,kw,dq,hw.
2. (ankylogloss* or tongue-tie* or tonguetie*).tw,kf.
12. exp infant feeding/
3. Lingual Frenum/ab, su or Labial Frenum/ab, su
13. (breastfeeding or breast-feeding).tw,kw,dq.
4. (frenulum or frenum or frena).tw,kf. and ((abnormal*
14. feeding difficulty/
or surger* or surgical* or operat* or repair).tw,kf,hw.
or (su or ab).fs.)
15. malocclusion/ or exp tooth occlusion/ or dental caries/
5. (Frenulectom* or Frenectom* or frenotom*).tw,kf.
16. (1 or 2 or 3 or 4 or 5 or 6) and (8 or 9 or 10 or 11 or
6. treatment outcome/ 12 or 13 or 14 or 15)

7. exp Speech Disorders/ 17. (1 or 2) and 7

8. Speech Intelligibility/ 18. 16 or 17

9. (speech or dental or caries or malocclusion* or

mal-occlusion*).tw,kf,hw.
Can non-surgical management be effective in
10. Breast Feeding/
improving breastfeeding?
11. (breastfeeding or breast-feeding).tw,kf.
Evidence from two prospective cohort studies demonstrates
12. malocclusion/ or dental occlusion, traumatic/ or open
bite/ or dental caries/ that early feeding support can reduce the need for surgical
13. (1 or 2 or 3 or 4 or 5) and (6 or 7 or 8 or 9 or 10 or
11 or 12) intervention in cohorts of babies referred for frenotomy.19 A

14. limit 13 to case reports summary of the findings from these studies can be found in

15. 13 not 14 Appendix A.

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 Can surgical management be effective in improving Further research in the form of cohort and clinical trials is

breastfeeding? required to determine whether a clear relationship exists.

A Cochrane review conducted in 2017 reported frenotomy

Does ankyloglossia cause dental caries?
to not consistently improve infant feeding and to be more
One review of the literature34 investigated the notion
likely to improve (short term) nipple pain with long term
that short, tight lingual or labial frena cause increased
follow-up data limited due to high contamination of control
risk of early childhood caries (ECC). It reported no high-
groups.29 The review advised that few randomised controlled
quality evidence to support a correlation between
studies have reported improvements in breastfeeding
ankyloglossia or maxillary lip-tie and an increased risk
effectiveness after frenotomy,29 however, all have significant
of early childhood caries.34 No studies were found that
limitations. No new systematic reviews or RCTs have been
reported caries incidence for children or adults with short,
released following the 2017 Cochrane review. A summary of
tight lingual or labial frena.
findings can be found in Appendix A.

Confounding factors such as regular consumption of

Does a short, tight lingual frenum influence speech
cariogenic foods and drinks and/or inadequate oral hygiene
problems?
practices should be considered in association with caries
The 2013 systematic review by Webb, Hao and Hong
development.
reported no causative association between ankyloglossia

and speech articulation problems.12 Evidence released since Does ankyloglossia cause lingual gingival recession?

has not demonstrated otherwise.30,31 There is no evidence The notion that lingual gingival recession may be due to

to recommend division for all individuals with a short, tight high frenal attachment is a subject of controversy in the

lingual frenum.30,32,33 A summary of the findings from these literature. Further research is required to determine whether

studies can be found in Appendix B. a clear relationship exists.20

Is ankyloglossia related to the development of

malocclusion?

A systematic (critical) review of the impact of ankyloglossia

on malocclusion evaluated four case reports/series that

found limited evidence that tongue-tie represents a

(co)-factor in the development of malocclusions.20

 Back to top | Page 15

 Does ankyloglossia cause obstructive sleep apnoea

(OSA)?

Three observational studies35,36,37 evaluating short lingual

frenulum and obstructive sleep apnoea in children were

identified. All studies reported a short lingual frenulum being

related to obstructive sleep apnoea in children; however,

none demonstrated a definitive cause and effect relationship.

Does ankyloglossia cause gastroesophageal reflux

disease (GORD)?

The group supports Douglas’s 201738 review of the

relationship between ankyloglossia and GORD. No gold

standard diagnostic tool exists for the diagnosis of GORD

in neonates or infants.39,40 Evidence41,42,43 associating

ankyloglossia with GORD in neonates or infants is subjective

and anecdotal. It does not demonstrate causation and is not

strong enough to provide a basis for decisions to surgically

treat ankyloglossia.

Does musculoskeletal therapy, including chiropractic

or osteopathic care, assist breastfeeding practices in

infants with ankyloglossia?

Few studies support manual interventions to correct

infant musculoskeletal dysfunctions linked to suboptimal

breastfeeding;44,45,46 however, there is no evidence linking

musculoskeletal therapy to ankyloglossia management alone.

Page 16 | Ankyloglossia and Oral Frena Consensus Statement  Back to top

Appendix A. Summary of studies investigating the impact of
surgical and non-surgical management of intra-oral frena on
breastfeeding.

Study Design Participants (N) Intervention Outcomes Risk of Bias

Colaway Observational, N = 115 infants Individual Reduced need for surgical • Poorly defined control group
2019 14
cohort breastfeeding intervention - Breast feeding
• Inconsistent follow-up
evaluation and established with non-surgical
support intervention for 62.6% of
participants initially referred for
surgical intervention
Dixon Observational, N = 367 infants Community level Frenotomy rate reduced from • Non-validated questionnaire
2018 19
cohort education and 11.3% in 2015 to 3.5% in mid-
breastfeeding 2017
support

Schlatter Observational, N = 776 mother- Frenotomy; method LATCH score improved from 6.9 • Selective outcome reporting
201911 cohort infant dyads not advised to 9.5* following frenotomy
• Control group included but
results not reported

Ramoser Observational, N = 329 patients Scissors frenotomy 106/126 short-term and 114/138 • Selective outcome reporting
2019 47
case control (295 infants and 34 long-term improvements
• Potential recall bias
children)
• Improvement outcomes do not
distinguish breastfeeding from
speech/language

• Unblinded

• No control group

• Parental reporting; cannot

discount placebo effect

*Mann-Whitney U test
N = number of participants

 Back to top | Page 17

Appendix B. Summary of studies investigating impact of
intra-oral frena on speech problems

Study Design Participants (N) Intervention Outcomes Risk of Bias

Webb 2013 12
Systematic 4 observational Subjects with No causative association between • Non-randomised - selection bias
review studies ankyloglossia ankyloglossia and speech
underwent articulation • Non-blinded
tongue-tie • Lack of comparison or control group
division
• Small sample sizes

• Lack of statistical analysis of outcomes

• Results based on parental recall –

potential recall bias
Walls 201431 Observational, N = 104 children Frenotomy Infants who underwent frenotomy • Non-randomised – selection bias
case-control within the first demonstrated improved speech
month of life outcomes (Likert 4.52) compared • Subjective outcomes
to those who did not undergo • Ankyloglossia based on anatomy only
frenotomy (Likert 3.60)
• No professional evaluation of survey

• Small sample size

• Results based on parental recall –

potential recall bias

• No baseline data to determine

improvement

• Reason for frenotomies not advised

Daggumati Observational, N = 188 children Frenulectomy Children with moderate and • Small sample size
201932 moderate-to-severe speech and
language impairment attained • Poor follow up, non-randomised –
better outcomes (100%) post- selection bias
frenotomy compared to mild
• Retrospective - potential recall bias
and mild-to-moderate impaired
children (82%); • Multiple evaluating providers
P = 0.015
• Ankyloglossia not graded using
diagnostic system

• Population not treated under same

conditions
Ito 201533 Observational, N = 5 children 1 frenuloplasty Improved articulation in 4 of 5 • Very small sample size
case series under general participants (80%)
anaesthetic, 4 • Non-blinded
frenulotomy • No control group
without local
anaesthetic • Variability in provision of speech
therapy

• Inhomogeneous sample

N = number of participants

Page 18 | Ankyloglossia and Oral Frena Consensus Statement  Back to top

Appendix C. Ankyloglossia Working Group Terms of Reference
Role/Purpose 2. Roles and Responsibilities

The role of the Ankyloglossia working group (the working The Working Group is accountable for:

group) is to work with other key bodies to reach a consensus • Fostering collaboration.

on the management of Ankyloglossia so that the public can • Removing obstacles to the successful delivery working

access objective and evidence-based advice. groups outcomes.

• Maintaining at all times the focus of the working group

The Ankyloglossia working group sets out to achieve the
on the agreed scope, outcomes and benefits.
following:
• Monitoring and managing the factors outside the
• Develop a consensus statement regarding ankyloglossia
working group’s control that are critical to its success.
diagnosis and management to assist in ensuring best

practice and appropriate referral pathways. The membership of the working group will commit to:

• Formulate consensus statement in combination with • Attending all meetings and if necessary, nominate a

advisory panel members regarding diagnosis and proxy.

management of Ankyloglossia for neonates, infants, • Wholeheartedly championing the working group within

children and adults. and outside of work areas.

• Gain support of key governing bodies. • Sharing all communications and information across all

• Disseminate statement information, including uploading working group members.

the statement to the Australian Dental Association • Making timely decisions and take timely action so as to

website. not hold up the project.

• Provide accurate facts to educate the general public, • Notifying members of the working group, as soon as

in particular new parents, regarding ankyloglossia and practical, if any matter arises which may be deemed to

its diagnosis and management to allow them to make affect the development of the consensus statement.

informed decisions.
Members of the advisory group will expect:

1. Term • That each member will be provided with complete,

The Working Group will exist from the first face-to- accurate and meaningful information in a timely

face meeting and will be ongoing until such time as the manner.

objectives listed above have been achieved. • To be given reasonable time to make key decisions.

• To be alerted to potential risks and issues that could

 Back to top | Page 19

 impact the project, as they arise.

• Open and honest discussions, without resorting to any

misleading assertions.

• Ongoing ‘health checks’ to verify the overall status and

‘health’ of the working group.

3. Meetings

• All meetings will be chaired by Dr Mihiri Silva

• The first meeting will be held in person.

Any subsequent meetings required to finalise the

working group outcomes will be held by teleconference/

videoconference.

• If required subgroup meetings will be arranged outside

of these times at a time convenient to subgroup

members.

• A meeting quorum will be 50% of the members of the

working group.

• Decisions will be made by consensus (i.e. members are

satisfied with the decision even though it may not be

their first choice).

• Meeting agendas and minutes will be provided by the

secretariat, Australian Dental Association, this includes:

- preparing agendas and supporting papers.

- preparing meeting notes and information.

4. Amendment, Modification or Variation

This Terms of Reference may be amended, varied or

modified in writing after consultation and agreement by

working group members.

Page 20 | Ankyloglossia and Oral Frena Consensus Statement  Back to top

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Notes

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Signatories for the Ankyloglossia and Oral Frena Consensus Statement

Australasian Academy of Paediatric Dentistry (AAPD)

Australasian Council of Dental Schools (ACDS)

Australian Chiropractic Association (ACA)

Australian College of Midwives (ACM)

Australian Dental and Oral Health Therapists Association (ADOHTA)

Australian and New Zealand Academy of Periodontists (ANZAP)

Dental Hygienists Association of Australia Ltd (DHAA)

Lactation Consultants of Australia and New Zealand (LCANZ)

Osteopathy Australia (OA)

Royal Australasian College of Dental Surgeons (RACDS)

Speech Pathology Australia (SPA)

The Australian and New Zealand Association of Oral and Maxillofacial Surgeons (ANZAOMS)

ada.org.au/ankyloglossia >

Page 26 | Ankyloglossia and Oral Frena Consensus Statement  Back to top