Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Ankyloglossia (tongue-tie) in infants and children

Glenn C Isaacson, MD, FAAP
Section Editor
Anna H Messner, MD
Deputy Editor
Carrie Armsby, MD, MPH


Ankyloglossia, or tongue-tie, is a congenital anomaly in which a short, lingual frenulum or a highly-attached genioglossus muscle restricts tongue movement (ie, restrictive lingual frenulum) (picture 1A-B) [1]. The definition of ankyloglossia is not standardized and there is wide variation of opinion regarding its clinical significance and optimal management [2,3].

Ankyloglossia will be discussed here. Other congenital anomalies of the tongue are discussed separately. (See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx".)


The reported prevalence of ankyloglossia varies from <1 percent to 10 percent, depending upon the study population and criteria used to define ankyloglossia [1,4-13]. A uniform definition and objective grading system for tongue-tie are lacking, though standardized measurement techniques and norms have been proposed (figure 1 and figure 2) [14,15].

In most series, the frequency of tongue-tie is higher among boys with a male to female ratio of 1.5:1 to 2.6:1 [4]. While most cases of ankyloglossia are sporadic, mutations in the T box transcription factor TBX22 may lead to heritable (X-linked) ankyloglossia with or without cleft lip, cleft palate, or hypodontia [16].


Ankyloglossia — Clinical features of ankyloglossia may include [1,14,17]:

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: May 23, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  1. Mueller DT, Callanan VP. Congenital malformations of the oral cavity. Otolaryngol Clin North Am 2007; 40:141.
  2. Messner AH, Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol 2000; 54:123.
  3. Brinkmann S, Reilly S, Meara JG. Management of tongue-tie in children: a survey of paediatric surgeons in Australia. J Paediatr Child Health 2004; 40:600.
  4. Hall DM, Renfrew MJ. Tongue tie. Arch Dis Child 2005; 90:1211.
  5. Cinar F, Onat N. Prevalence and consequences of a forgotten entity: ankyloglossia. Plast Reconstr Surg 2005; 115:355.
  6. Messner AH, Lalakea ML, Aby J, et al. Ankyloglossia: incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg 2000; 126:36.
  7. Segal LM, Stephenson R, Dawes M, Feldman P. Prevalence, diagnosis, and treatment of ankyloglossia: methodologic review. Can Fam Physician 2007; 53:1027.
  8. Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health 2005; 41:246.
  9. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract 2005; 18:1.
  10. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002; 110:e63.
  11. Garcia-Pola MJ, Garcia-Martin JM, Gonzalez-Garcia M. Prevalence of oral lesions in the 6-year-old pediatric population of Oviedo (Spain). Med Oral 2002; 7:184.
  12. Flinck A, Paludan A, Matsson L, et al. Oral findings in a group of newborn Swedish children. Int J Paediatr Dent 1994; 4:67.
  13. Sedano HO, Carreon Freyre I, Garza de la Garza ML, et al. Clinical orodental abnormalities in Mexican children. Oral Surg Oral Med Oral Pathol 1989; 68:300.
  14. Lalakea ML, Messner AH. Ankyloglossia: does it matter? Pediatr Clin North Am 2003; 50:381.
  15. Ruffoli R, Giambelluca MA, Scavuzzo MC, et al. Ankyloglossia: a morphofunctional investigation in children. Oral Dis 2005; 11:170.
  16. Kantaputra PN, Paramee M, Kaewkhampa A, et al. Cleft lip with cleft palate, ankyloglossia, and hypodontia are associated with TBX22 mutations. J Dent Res 2011; 90:450.
  17. Muntz HR, Gray SD. Congenital malformations of the mouth and pharynx. In: Pediatric otolaryngology, 4th ed, Bluestone CD, Casselbrant ML, Stool SE, et al (Eds), Saunders, Philadelphia 2003. p.1149.
  18. WALLACE AF. TONGUE TIE. Lancet 1963; 2:377.
  19. Horton CE, Crawford HH, Adamson JE, Ashbell TS. Tongue-tie. Cleft Palate J 1969; 6:8.
  20. Pransky SM, Lago D, Hong P. Breastfeeding difficulties and oral cavity anomalies: The influence of posterior ankyloglossia and upper-lip ties. Int J Pediatr Otorhinolaryngol 2015; 79:1714.
  21. Douglas PS. Rethinking "posterior" tongue-tie. Breastfeed Med 2013; 8:503.
  22. Kotlow LA. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. J Hum Lact 2013; 29:458.
  23. Wright JE. Tongue-tie. J Paediatr Child Health 1995; 31:276.
  24. Lalakea ML, Messner AH. Ankyloglossia: the adolescent and adult perspective. Otolaryngol Head Neck Surg 2003; 128:746.
  25. Ketty N, Sciullo PA. Ankyloglossia with psychological implications. ASDC J Dent Child 1974; 41:43.
  26. National Institute for Health and Clinical Excellence (NICE) interventional procedure guidance [IPG149]. Division of ankyloglossia (tongue-tie) for breastfeeding. Available at: https://www.nice.org.uk/guidance/ipg149/chapter/1-Guidance (Accessed on June 09, 2016).
  27. Joseph KS, Kinniburgh B, Metcalfe A, et al. Temporal trends in ankyloglossia and frenotomy in British Columbia, Canada, 2004-2013: a population-based study. CMAJ Open 2016; 4:E33.
  28. Forlenza GP, Paradise Black NM, McNamara EG, Sullivan SE. Ankyloglossia, exclusive breastfeeding, and failure to thrive. Pediatrics 2010; 125:e1500.
  29. Dollberg S, Botzer E, Grunis E, Mimouni FB. Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study. J Pediatr Surg 2006; 41:1598.
  30. Geddes DT, Langton DB, Gollow I, et al. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics 2008; 122:e188.
  31. Power RF, Murphy JF. Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Arch Dis Child 2015; 100:489.
  32. Messner AH, Lalakea ML. The effect of ankyloglossia on speech in children. Otolaryngol Head Neck Surg 2002; 127:539.
  33. Williams WN, Waldron CM. Assessment of lingual function when ankyloglossia (tongue-tie) is suspected. J Am Dent Assoc 1985; 110:353.
  34. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics 2015; 135:e1458.
  35. O'Shea JE, Foster JP, O'Donnell CP, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev 2017; 3:CD011065.
  36. Kummer AW. Ankyloglossia: To Clip or Not to Clip? That's the Question. http://leader.pubs.asha.org/article.aspx?articleid=2278327 (Accessed on February 05, 2017).
  37. Webb AN, Hao W, Hong P. The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Int J Pediatr Otorhinolaryngol 2013; 77:635.
  38. Chinnadurai S, Francis DO, Epstein RA, et al. Treatment of ankyloglossia for reasons other than breastfeeding: a systematic review. Pediatrics 2015; 135:e1467.
  39. Fiorotti RC, Bertolini MM, Nicola JH, Nicola EM. Early lingual frenectomy assisted by CO2 laser helps prevention and treatment of functional alterations caused by ankyloglossia. Int J Orofacial Myology 2004; 30:64.
  40. Froom SR, Stewart J. Novel local anaesthetic analgesic technique for tongue-tie. Anaesthesia 2007; 62:97.
  41. Ghaheri BA, Cole M, Fausel SC, et al. Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope 2017; 127:1217.
  42. Masaitis NS, Kaempf JW. Developing a frenotomy policy at one medical center: a case study approach. J Hum Lact 1996; 12:229.
  43. Griffiths DM. Do tongue ties affect breastfeeding? J Hum Lact 2004; 20:409.
  44. Interventional procedures overview - division of anklyloglossia (tongue-tie) for breastfeeding. www.nice.org.uk/ip279overview (Accessed on June 25, 2008).
  45. Amir LH, James JP, Beatty J. Review of tongue-tie release at a tertiary maternity hospital. J Paediatr Child Health 2005; 41:243.
  46. Isaacson G. Pediatric intracapsular tonsillectomy with bipolar electrosurgical scissors. Ear Nose Throat J 2004; 83:702, 704.
  47. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. Frenectomy for the Correction of Ankyloglossia: A Review of Clinical Effectiveness and Guidelines, CADTH Rapid Response Reports, 2016.
  48. Tecco S, Baldini A, Mummolo S, et al. Frenulectomy of the tongue and the influence of rehabilitation exercises on the sEMG activity of masticatory muscles. J Electromyogr Kinesiol 2015; 25:619.