Frenectomy

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Frenectomy

Terminology and Definitions

The term frenectomy (also called frenulectomy) refers to complete surgical removal of a frenum (frenulum) along with its attachment to the underlying bone. It is distinct from related procedures:

Frenotomy - simple incision/release of the frenulum without excision (the most common procedure for neonates with tongue tie)
Frenuloplasty - release of the frenulum combined with plastic reconstruction, often using a Z-plasty technique
Frenectomy - complete removal of the frenulum structure

These procedures are most commonly performed for two distinct anatomical sites: the lingual frenulum (tongue tie/ankyloglossia) and the maxillary labial frenulum (lip tie).

Part 1: Lingual Frenulum (Ankyloglossia / Tongue Tie)

Anatomy

The frenum of the tongue is a triangular fold of mucous membrane extending from the lower midline gingival tissue, along the floor of the mouth, arching to the midline of the undersurface of the tongue. In ankyloglossia, the frenulum attaches too far toward the tongue tip, restricting normal elevation or protrusion.

Epidemiology

Incidence is approximately 4-10% of newborns (varies by definition used)
More common in males (male:female ratio ~1.5-2.6:1)
No racial predilection
In a US database study, affected children were more often male (63.6%), privately insured (60.1%), and from higher-income zip codes (78.1%)
Incidence appears to decrease in older children, suggesting some cases resolve spontaneously as the frenulum stretches or naturally breaks over time

Classification

The most widely used system classifies ankyloglossia into four types:

Type	Description
Type I	Frenulum inserts at the very tip of the tongue (anterior ankyloglossia)
Type II	Frenulum inserts slightly behind the tongue tip
Type III	Frenulum inserts at the mid- to posterior undersurface of the tongue
Type IV	Submucosal frenulum ("posterior tongue tie") - flat and less obvious

Types I and II are considered anterior tongue tie, while Types III and IV are called posterior tongue tie - the latter is a more recently recognized and somewhat controversial category.

Diastasis between lower central incisors due to ankyloglossia, showing the tongue tethered to the floor of mouth

Ankyloglossia with the tongue tethered to the floor of the mouth - Cummings Otolaryngology

Clinical Sequelae

Breastfeeding problems (strongest evidence):

Difficulty achieving a deep latch and seal
Maternal nipple pain and soreness
Reduced milk transfer
Failure of infant to thrive
Recurrent mastitis in the mother

Speech concerns (limited evidence):

Articulation difficulties, especially lingual-dental sounds (t, d) and sibilants (z, s, th)
Many individuals with ankyloglossia develop entirely normal speech without treatment

Mechanical and social effects:

Difficulty licking lips or cleaning teeth with tongue
Diastasis between lower central incisors from frenulum pressure
Difficulty playing wind instruments
Social embarrassment/peer ridicule

Indications for Treatment

Neonates/infants: Poor breastfeeding latch and mechanics, maternal nipple pain, poor weight gain - strongest evidence supports treatment
Older children: Documented articulation difficulties, particularly after speech therapy has been attempted
Adolescents/adults: Mechanical concerns, social concerns, dental hygiene issues
Age under 30 days is associated with higher probability of breastfeeding improvement post-frenotomy

Contraindications (for office-based frenotomy)

Unstable medical conditions (bleeding disorders)
Active dental or oral infection
Orofacial abnormalities (refer to specialist)
Severe "frozen tongue" ankyloglossia requiring Z-plasty - these require general anesthesia and referral to an experienced surgeon

Surgical Technique: Frenotomy (Office-Based)

Equipment:

Straight or curved mosquito hemostat
Surgical scissors (iris or Metzenbaum)
Tongue retractor (small spoon, wooden tongue blade)
Optional: topical anesthetic, lidocaine with epinephrine for bleeding control

Steps:

Immobilize the infant (swaddling, papoose board, parental assistance); crying often improves exposure
Identify the frenulum and the abnormal portion causing restriction
For a thin/lucent membranous frenulum (infants under ~4 months): direct snipping without hemostat is acceptable - bleeding is minimal and comparable to biting the lip
For a thicker, coarser frenulum: apply topical anesthesia (benzocaine syrup on cotton swab - note: FDA has issued a boxed warning against lidocaine/benzocaine in infants for teething due to seizure and methemoglobinemia risk; use only in context of the procedure)
Optional: Clamp the frenulum with the mosquito hemostat to crush tissue at the snip point - this provides some analgesia to the crushed area; then snip through the crushed tissue only
A diamond-shaped wound results after frenotomy - this heals by secondary intention
Control bleeding with a dry or epinephrine-moistened cotton swab; ice may reduce oozing

Post-procedure: Resume normal feeding immediately; no special wound care required.

Frenuloplasty (Z-Plasty)

Used for severe restriction. The diamond-shaped defect created by frenotomy is sutured closed by transposing two triangular tissue flaps - this lengthens the frenulum and prevents re-adhesion. Requires suturing skills and regional or general anesthesia.

Surgical Outcomes

Evidence from multiple cohort studies and RCTs shows that frenotomy for anterior ankyloglossia in newborns:

Reduces maternal nipple pain during breastfeeding
Improves breastfeeding mechanics and milk transfer
Increases probability of resumed breastfeeding if previously stopped
73% of mothers who had stopped breastfeeding before frenotomy resumed after the procedure (in one trial with ~4 months follow-up)
Better outcomes when performed in infants under 30 days vs. over 30 days

A 2017 Cochrane meta-analysis of 5 RCTs found frenotomy consistently reduced short-term maternal nipple pain, though a consistently positive effect on overall breastfeeding duration was not confirmed.

For posterior tongue tie, speech, and social-mechanical concerns - evidence remains limited and controlled trials are lacking.

Cummings Otolaryngology Head and Neck Surgery, Chapter 207

Part 2: Maxillary Labial Frenulum (Lip Tie)

Types 1, 2, and 3 of the maxillary upper lip frenulum in newborns

Types 1, 2, and 3 of the maxillary upper lip frenulum - Cummings Otolaryngology

Background

All newborns have some degree of upper labial frenulum. Its evolution over time is poorly understood. Lip tie (tight maxillary frenulum) is increasingly diagnosed and treated, often together with ankyloglossia. It has been described as a condition where the frenulum limits upper lip mobility and function.

Clinical assessment - the "blanching test": Pull the upper lip superiorly and forward to inspect for blanching of the palatine papilla, indicating a tighter attachment.

Classification (4-grade system)

Grade 1: No tissue attachment of the lip to gingival tissue
Grade 2: Attachment to free gingival margin
Grade 3: Attachment between free margin and anterior papilla
Grade 4: Attachment onto the palate

(There is significant intra- and inter-rater inconsistency in grading, even among experts)

Sequelae

Breastfeeding difficulties - prevents deep latch and adequate seal; maternal nipple pain
In older children: dental caries on anterior surfaces of maxillary central incisors (different from baby-bottle caries, which presents lingually); reduced access for tooth brushing and plaque removal
Midline diastema - a hypertrophic maxillary frenulum may be an etiologic factor (along with genetic factors) for a space between the upper central incisors

Frenectomy Technique (Maxillary)

The surgical approach has changed little since Angle's 1907 description:

The complete removal of the maxillary frenulum involves excision of its attachment to the underlying periosteum
The wound may be left open, or primary closure may be attempted
Timing relative to orthodontics is controversial: if performed before orthodontic treatment (generally after the 6 upper permanent anterior teeth have fully erupted), speed of diastema closure may be affected. Some evidence suggests frenectomy before orthodontics accelerates tooth movement; others find no difference

Laser Frenectomy

Both CO₂ and diode lasers have been used for labial and lingual frenectomy. A 2026 systematic review and meta-analysis (PMID: 41369715) compared diode laser vs. conventional scalpel for labial frenectomy and found evidence in favor of the laser technique for certain outcomes (healing, bleeding, patient comfort).

Summary: Frenectomy vs. Frenotomy vs. Frenuloplasty

Procedure	Definition	Typical Setting	Anesthesia
Frenotomy	Simple snip/incision of frenulum; no excision	Office/bedside	Topical or none (neonates)
Frenectomy	Complete excision of frenulum + periosteal attachment	Office or OR	Local or general
Frenuloplasty (Z-plasty)	Release + plastic reconstruction with transposed flaps	OR	General or regional

Recent Evidence (2025-2026)

Three recent systematic reviews are relevant:

Frenectomy for ankyloglossia in breastfeeding (PMID: 41204347, 2025): Meta-analysis in children under 5 confirming breastfeeding benefits
Diode laser vs. scalpel for labial frenectomy (PMID: 41369715, 2026): Meta-analysis of RCTs; laser associated with favorable outcomes vs. conventional scalpel
Frenotomy for ankyloglossia and feeding in infants (PMID: 42050812, 2026): Part 2 of a comprehensive systematic review on effectiveness, technique, and safety - reinforces evidence for the procedure in feeding-challenged infants

Sources: Cummings Otolaryngology Head and Neck Surgery, Chapter 207 | Pfenninger and Fowler's Procedures for Primary Care, Chapter 82

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