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Anatomical classification of lingual frenulum in babies/Classificacao anatomica do frenulo lingual de bebes.


The tongue is an organ that participates in important functions in the oral cavity, such as sucking, swallowing, chewing and speech [1,2]. Its lower side features a fold of mucous membrane that connects the floor of the mouth, called lingual frenulum [3,4].

The frenulum allows free movement of the tongue. During embryonic development, when there is no full apoptosis of the frenulum, the residual tissue may compromise the tongue mobility and, hence, the oral functions, which may lead to ankyloglossia [5].

The ankyloglossia is a congenital oral anomaly that varies from mild to severe degrees, resulting, in different levels, in reduction of tongue movements [6].

The evaluation of the lingual frenulum of babies generally comprises visual observation of the aspects of the frenulum, tongue mobility, non-nutritive sucking, nutritive sucking and swallowing [5,7].

The lingual frenulum can be diagnosed as normal or altered, depending on the criteria used by the evaluator [8]. There is considerable controversy among health professionals regarding the classification of the lingual frenulum altered [9]. Different classifications are found in the literature: lisp [1,10,11]; ankyloglossia [1,12-15]; short frenulum, long frenulum, frontal lisp [1]; short mucosal, long mucosal with mandibular fixing and hypertrophic with fixing the alveolar ridge [12]; short, anterior fixation and short with anterior fixation [4,16] and altered frenulum [8,17,18].

The diagnosis of alterations in the frenulum requires a thorough knowledge of the evaluator on the anatomy of the tongue and the different aspects of the frenulum and adjacent regions. In addition, the professional must know which functions can be influenced by changes in the lingual frenulum [8].

The altered lingual frenulum can cause implications in speech [3,6,12,16,17,19,20], malocclusion and oral hygiene [12]; inadequate latch, trauma and pain in the nipple that contribute to early weaning [3,13,14]; limitation of tongue movements [6,17,18]; suction difficulties [3,6,17,18]; impairment of swallowing [6,17,18], chewing [17,21] and slow weight gain [3].

In the literature revision on the last 14 years, were found 06 articles on the lingual frenulum changes index (Table 1).

Faced with losses generated by an altered lingual frenulum, it was perceived how important an early diagnosis is in order to promote the development of feeding and child communication. In this sense, the objective of this study was to analyze the anatomy of the lingual frenulum of babies attended the Reference Center for Hearing Health/CRESA of the Speech Therapy Department of the Pontifical Catholic University of Goias/PUC Goias.


This research was approved by the Research Ethics Committee of PUC Goias, with process no. 503708 and followed all the rules established by Resolution 466/12 of the National Health Council.

This is a cross-sectional, observational and analytical study with a quantitative approach.

Were included babies between 1 month and 4 months, of both genders, fed in the womb, referred to the evaluation of the lingual frenulum in CRESA/ PUC Goias, from August 2014 to February 2015, whose mothers were willing to authorize and sign the Instrument Consent. Were excluded babies with anatomophysiological changes in the face, pre or post-maturity or with neurological impairment interfering in the sucking and/or swallowing.

Babies were evaluated in clinics in CRESA/PUC Goias. Data collection occurred in the last 7 months, held twice a week.

In evaluation of the lingual frenulum was used the "Lingual frenulum evaluation protocol for infants" [18]. The Anatomical frenulum classification in normal or abnormal was carried out at from the part of the analysis I (item 4) of the Protocol which includes the thickness of the frenulum, the attachment of the frenulum in sublingual face (ventral) of the tongue and the attachment of the frenulum on the floor from the mouth. The orofacial functions (Part II) were observed non-nutritive sucking (language movement) and nutritive sucking (rhythm of sucking, coordination of sucking/swallowing/breathing, biting the nipple and tongue snaps during suction).

The total duration of the intervention was about 20 minutes, including the interview, the assessment with the baby, photos and footage record, feedback of the results to responsible and the delivery of speech-language pathology report with the diagnosis of lingual frenulum.

Babies, whose frenulum was identified as altered, were referred to the speech therapy with report of lingual frenulum to basic health units corresponding to their respective neighborhoods. In basic health units, they scheduled an appointment with the pediatrician. After this consultation, the patient would be set to the pediatric dentistry clinic for evaluation of the dentist, so these professionals were responsible to define the best procedure for each patient.

The data collection were organized in a spreadsheet of Microsoft[R] Excel 2007 and transferred to Statistical Package for Social Sciences 20/SPSS 20.0. Descriptive analysis was performed, the chi-square test and correlation Kendall's for statistical analysis, and adopted the level of significance of 5% (p [less than or equal to] 0,05).


214 babies were analyzed in the period between August, 2014 and February, 2015. Taking into account the inclusion and exclusion criteria, 166 babies were included in this study. As for the 48 excluded infants, 72.9% (n=35) fed by bottle, 25% (n=12) were over the age of 4 months and 2.1% (n = 1) had Down syndrome, 50% of them were preterm and 8.3% post-term.

As for the age at examination, it was observed that 62.1% (n = 103) of the babies were 1 month old, 21% (n=35) two months, 12.7% (n=21) 3 months and 4,2% (n=7) 4 months old. With regard to the gender, 51% (n=84) were females (Table 2).

In the analysis of lingual frenulum were find that most babies (63%) had frenulum with normal aspect (Figure 1).

In only 1 (0.6%) baby was not possible to view the frenulum. From babies with altered frenulum, 54% (n=33) were male and 46% (n=28) female. There was no statistically significant difference between gender and the anatomy of the frenulum (p=0.38).

Regarding to the thickness of the frenulum, 95.1% (n=157) had thin and 4.8% (n=8) thick frenulum. Among the thick frenulum, 50% (n=4) had a fixation on the middle third/sublingual caruncles and 50% (n=4) between the middle third and the apex/inferior alveolar crest.

Regarding the fixing in the sublingual surface (ventral) of the tongue and floor of mouth, in relation to the normal frenulum, predominated in the fixation in the middle third/sublingual caruncles (28%). In the altered frenulum, the highest frequency was with fixing between the middle third and the apex/inferior alveolar crest (32.2%). (Figure 2).

Among the babies with normal frenulum, 10.8% had changed suction and among the babies with altered frenulum, 14.5% had changed suction (Figure 3).

There was a low correlation, with statistical significance, between the frenulum and suction (p <0.01), whose coefficient was 0.252.


The lingual frenulum classifications are used to evaluate and characterize the structure in normal and altered [22]. Diagnosis and early intervention of the lingual frenulum promote breastfeeding and speech development. Deprivation of lingual movement may compromise sucking [3,6,17,18], chewing [17,21], swallowing [6,17,18], speech [3,6,12,17] and lead to early weaning [3,13,20].

In this study, participated babies aged between 1 month and 4 months, different from previous studies that evaluated only newborns. Only two studies evaluated the anatomical characteristics of the lingual frenulum of babies older than 1 month, 1 on the 1st, on the 6th and 12th month of life and another between 0 and 72 months. In this study predominated the age of 1 month, suggesting an awareness of responsible for babies on the importance of evaluation of the lingual frenulum as well as health professionals who carried out the referrals. The predominant age contributed to the diagnosis and early intervention of lingual frenulum favoring the breastfeeding.

The results found in this study showed a similar sample between female and male. Among the others studies, only one [18] reported gender of the sample, with a prevalence of male. Other reviewed studies only mentioned gender in the prevalence of alteration of the frenulum [10-1518,23].

In clinical evaluation, in only 1 baby was not possible to see the lingual frenulum, in contrast with previous research that evaluated 100 babies and in only 29 was not possible to see the frenulum [18]. In this case, it is recommended to follow the baby until be possible to see the frenulum under the mucosa curtain during the first year of life [18].

Of the 165 babies in which it was possible to see the frenulum, it was classified as normal or altered [17,18]. Previous studies have classified the altered frenulum babies as ankyloglossia [1,12-15], lisp [1,10,11] or simply change the frenulum [23]. Part of the studies [10,11,14,15] used Hazelbaker protocol to classify the frenulum and the other part did not mention the criteria and instruments used [12,13,16,17,19,20,23]

As the thickness of the frenulum, the highest incidence was thin frenulum which corroborates other studies [13,17]. The thick frenulum favors breastfeeding difficulties [13], in order to contribute to early weaning.

Most babies had normal frenulum, in accordance with the literature [10,13,14,17,18]. However, it was found 37% of babies with lingual frenulum alterations, this frequency is higher than presented in previous studies [10,13,15,23]. From the raised studies, the highest percentage of lingual frenulum alteration was 22.5% [17,18]. It is believed that this difference is related to the criteria used in the classification of the frenulum in each study and the sample size, which differ in these studies. This research considered the anatomical aspect of the frenulum to classify it as normal or altered. This criterion may have influenced the high index of altered frenulum, since the suction was not considered as a classification parameter and its frequency of alterations was low, which could decrease the altered frenulum index. Regarding the altered frenulum prevailed male babies, in agreement with previous studies [10-15,18,23].

No other analyzed study sub-classified the frenulum from the evaluation of the frenulum fixing tongue and mouth floor, as done in this study. It was found the predominance of frenulum with fixing in the middle third and sublingual caruncles and between the middle third and the apex and the inferior alveolar crest, normal and altered, respectively. Were found a single study [18] that observed, isolated, the fixing of the frenulum in the tongue and in the floor, in which prevailed the frenulum with fixing the tongue in the middle third, and on the floor, in the alveolar crest. As for the other studies, it was found that the sub-classification occurred in the degree of change in severity of the frenulum [11], severity and thickness of the frenulum [13], as total and partial ankyloglossia [12] and the others no sub-classified the frenulum [10,14,15,23].

From babies with normal frenulum, 10.8% had altered suction. Problems like irritability, lips reversed in the suction, inadequates latch and posture were observed during breastfeeding, although not see covered in the protocol. It is believed that several factors interfere with the baby's suckling, beyond the frenulum, as the mother's lack of experience with the practice of breastfeeding, the anatomy of the breast, the latch and the inadequate baby posture, fatigue, among others [24,25].

From the babies with altered frenulum, 14.5% had altered suction. The alteration of the lingual frenulum brings harm to breastfeeding and the baby sucking [3,6,10,13,14,17,18,23], since the participation of tongue movements is essential for this function. In this sense, any limitation on the movement of the tongue can compromise it [5].

The correlation between the lingual frenulum and suction, despite being significant, was low, in accordance with previous studies that mentioned a minority of problems in the breastfeeding of babies with altered lingual frenulum [10,13,23]. However, the change rate was higher than in infants with normal frenulum, justifying the early diagnosis of frenulum. Whatever the etiology of early weaning, it is worth investing in prevention, to take into account the importance of breastfeeding and sucking on the baby's development.


The lingual frenulum were classified as normal and altered, with predominance of the normal lingual frenulum. Alterations in the lingual frenulum corresponded to 37% of babies, with higher incidence in males. Among the normal frenulum, the prevalence was of babies with fixing of the frenulum in the middle third, visible from sublingual caruncles. Regarding the altered frenulum, they were more frequent with fixation between the middle third and the apex and visible from the inferior alveolar crest, the thin thickness was the most observed in both cases.

Despite the low correlation between the frenulum and suction, babies with altered lingual frenulum had more chances in the change of suction, which justified the realization of frenulum evaluation aiming an early intervention and promotion of breastfeeding and speech development.

doi: 10.1590/1982-0216201618522915


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[2.] Cymrot M, Assis F, Texeira A, Castro F, Sales D, Julio F et al. Glossectomia subtotal pela tecnica de resseccao lingual em orificio de fechadura modificada como tratamento de macroglossia verdadeira. Rev Bras Cir Plast. 2012; 27(1):165-9.

[3.] Hall DMB, Renfrew MJ. Tongue-tie: common problem or old wives tale. Arch. Dis. Child. 2005; 90:1211-5.

[4.] Comite de Motricidade Orofacial da Sociedade Brasileira de Fonoaudiologia. Documento oficial 04/2007. Sao Paulo: Sociedade Brasileira de Fonoaudiologia; 2007.

[5.] Martinelli RLC, Marchesan IQ, Rodrigues AC, Berretin-Felix G. Protocolo de avaliacao do frenulo da lingua em bebes. Rev. CEFAC. 2012; 14(01):138-45.

[6.] Melo NSFO, Lima AAS, Fernandes A, Silva RPGVC. Anquiloglossia: relato de caso. RSBO. 2011; 8(1):102-7.

[7.] Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF): Use in a lactation consultant private practice [thesis]. Pasadena (CA): Pacific Oaks College; 1993.

[8.] Marchesan IQ. Protocolo de avaliacao do frenulo da lingua. Rev. CEFAC. 2010; 12(6):977-89.

[9.] Marchesan IQ. Frenulo lingual: proposta de avaliacao quantitativa. Rev. CEFAC. 2004; 6(3):288-93.

[10.] Ricke LA, Baker NJ, Madlon-Kay DJ, Defor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. JABFP. 2005; 18(1):1-7.

[11.] Emond A, Ingram J, Johnson D, Blair P, Whitelaw A, Copeland M et al. Randomised controlled trial of early frenotomy in breastfed infant with mild-moderate tongue-tie. Arch Dis Child Fetal Neonatal. 2014; 99:189-95.

[12.] Podesta MCE, Del Arco MSN, Melendez PGT, Gonzalez BAC. Diagnostico clinico de anquiloglossia, posibles complicaciones y propuesta de solucion quirurgica. Gac. Odontol. 2001; 3(2):13-7.

[13.] Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E. Ankyloglossia incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg. 2000; 126(1):36-9.

[14.] Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessement, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002; 110(5):1-6.

[15.] Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics. 2011; 128(2):280-8.

[16.] Marchesan IQ. Frenulo da lingua: classificacao e interferencia na fala. Rev. CEFAC. 2003; 5(4):341-5.

[17.] Martinelli RLC, Marchesan IQ, Berretin-Felix G. Estudo Longitudinal das caracteristicas anatomicas do frenulo lingual comparados com afirmacoes da literatura. Rev. CEFAC. 2014; 16(4):1202-7.

[18.] Martinelli RLC, Marchesan IQ, Berretin-Felix G. Protocolo de avaliacao do frenulo lingual para bebes: relacao entre aspectos anatomicos e funcionais. Rev. CEFAC. 2013; 15(3):599-610.

[19.] Ortiz GR, Magana FG, Lopez BSG. Aquiloglossia parcial (incompleta) reporte de um caso y revision de la literatura. Rev ADM. 2009; 65(2) 42-7.

[20.] Braga LAS, Silva J, Pantuzzo CL, Motta AR. Prevalencia de alteracao no frenulo lingual e suas implicacoes na fala de escolares. Rev CEFAC. 2009; 11(3):378-90.

[21.] Silva MC, Costa MLVCM, Nemr K, Marchesan IQ. Frenulo de lingua alterado e interferencia na mastigacao. Rev. CEFAC. 2009; 11(supl-3):363-9.

[22.] Witwytzkyj LP, Cordeiro MC, Coelho TTT. Analise clinica das propostas de classificacao do frenulo da lingua por indice e porcentagem. Rev. CEFAC. 2014; 16(2):537-45.

[23.] Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Pediatrics Child Health. 2005; 41(5- 6):246-50.

[24.] Castro KF, Souto CMRM, Rigao TVC, Garcia TR, Bustorff LACV, Braga VAB. Intercorrencias mamarias relacionadas a lactacao: estudo envolvendo puerperas de uma maternidade publica de Joao Pessoa, PB. Mundo Saude. 2009; 33(4):433-9.

[25.] Silvestre AALA. Identificacao das dificuldades iniciais encontradas no aleitamento materno entre maes e bebes a termo [trabalho de conclusao de curso]. Goiania (GO): Pontificia Universidade Catolica de Goias, CEAFI; 2011.

Enajes Silva Soares Marcione (1)

Fernanda Gomes Coelho (1)

Cejana Baiocchi Souza (1)

Ellia Christinne Lima Franca (1)

(1) Pontificia Universidade Catolica de Goias / PUC Goias, Goiania- Goias, Brasil.

Source of help: Catholic University of Goias Conflict of interest: non-existent

Received on: December 30, 2015

Accepted on: June 17, 2016

Mailing address:

Fernanda Gomes Coelho

Rua JC 67 Qd. 147 Lt. 15

Jardim Curitiba III


CEP: 74481-550

Table 1. Distribution of publications of indices of alterations of
lingual frenulum of babies, according the author, year, objectives,
sample, age and results

Authors/Year                   Objective              Sample/Age

MESSNER; LALAKEA;        To analyze                Were examined 1.041
ABY; MACMAHON, 2000      the incidence of         babies, from 0 to 30
[13]                     ankyloglossia and               days.
                         difficulties of
                         breastfeeding in
                         babies with

BALLARD; AUER; KHOURY    To identify the         3.032 babies, from 0
2002 [14]                incidence, gender,        to 30 days, were
                         age and the impact of         examined
                         the ankyloglossia in
                         breastfeeding babies
                         and the efficacy of
                         the frenuloplasty
                         with respect to
                         solving specific

RICKE; BAKER; MADLON-    To determine whether      3.490 babies were
KAY; DEFOR; 2005 [10]    breast-fed infants      examined, the age was
                         with altered lingual       not mentioned.
                         frenulum have
                         decreased rates of
                         breastfeeding at 1
                         week and 1 month of
                         age, to determine the
                         prevalence of lingual
                         frenulum altered in
                         babies; to test the
                         usefulness of the
                         Hazelbaker protocol
                         in assessing the
                         severity of altered
                         frenulum in

HOGAN; WESTCOTT;         To determine whether,    Were examined 1.866
GRIFFITHS, 2005 [23]     in babies with          babies, from 0 to 30
                         altered lingual                 days.
                         frenulum and a
                         feeding problem, the
                         medical treatment
                         (referral to a
                         lactation consultant)
                         or immediate division
                         works best and
                         enables the babies to
                         feed normally.

MARTINELLI; MARCHESAN;   To verify the             Were examined 100
BERRETIN-FELIX, 2013     anatomical features     babies, with 30 days.
[18]                     of the lingual
                         frenulum influence in
                         sucking and
                         swallowing functions
                         in term infants, in
                         order to propose
                         adjustments in the
                         protocol proposed by
                         Martinelli et al,

MARTINELLI; MARCHESAN;   To evaluate                71 babies were
BERRETIN-FELIX, 2014     anatomical features     examined at 1, on the
[17]                     of the lingual          6th and 12th month of
                         frenulum of babies on           life.
                         the 1st, on the 6th
                         and 12th month of
                         life, comparing with
                         the literature.

Authors/Year                Results of alterations of lingual

MESSNER; LALAKEA;        Fifty newborns (4.8%) were identified
ABY; MACMAHON, 2000      with ankyloglossia, 36 males and 14
[13]                     females. Breastfeeding difficulties were
                         experienced by 9 (25%) of the mothers of
                         babies with ankyloglossia

BALLARD; AUER; KHOURY    123 babies with ankyloglossia were
2002 [14]                identidied, 70 presented symptoms of
                         poor latch and 53 nipple pain. After
                         frenuloplasties, it was observed an
                         improvement in the latch in all cases
                         and maternal pain levels fell
                         significantly. The proportional of males
                         for females was 15:1.

RICKE; BAKER; MADLON-    80% of babies with altered frenulum have
KAY; DEFOR; 2005 [10]    successful in the breastfeeding in 1
                         week, with 3 times more chance to use
                         bottle. By 1 month, altered frenulum
                         babies were as likely as controls to be
                         bottle fed only. There was 148 (4.24%)
                         of babies with altered lingual frenulum,
                         103 males and 45 females. The Hazelbaker
                         is not useful to identify if babies with
                         lingual frenulum alteration has
                         difficulties to breastfeeding.

HOGAN; WESTCOTT;         Were identified 10,7% (n=201) babies
GRIFFITHS, 2005 [23]     with ankyloglossia, 124 males and 77
                         females, of whom 88 had breastfeeding or
                         bottlefeeding problems. Chirurgical
                         intervention resulted in improved
                         feeding in 54 (95%) of babies. This
                         procedure was significantly better for
                         feeding improvement than the intensive
                         support of the feeding consultant.

MARTINELLI; MARCHESAN;   Among 100 evaluated babies, 29 was not
BERRETIN-FELIX, 2013     possible to see the frenulum. Of the 71
[18]                     (71%) whom was possible to see it, 16
                         (22.5%) had anatomical features that
                         restricted the tongue movement in
                         nutritive and not nutritious sucking,
                         and 55 (77.5%) remaining considered

MARTINELLI; MARCHESAN;   16 (22.5%) babies were diagnosed with
BERRETIN-FELIX, 2014     altered frenulum. It was found that the
[17]                     lingual frenulum did not modify in the
                         first year of life.

Table 2. Frequency of chronological age and gender of babies attended
In Reference Center In Hearing Health/CRESA between August, 2014 and
February, 2015.

Sociodemographic    n       %

Age (months)

1 month            103   (62,1%)
2 months           35     (21%)
3 months           21    (12,7)
4 months            7    (4,2%)


Female             84     (51%)
Male               82     (49%)

Figure 1. Classification lingual frenulum of babies attended in the
Reference Center in Hearing Health/CRESA between August, 2014 and
February, 2015

Altered   37%
Normal    63%

Note: Table made from pie chart.

Figure 2. Distribution of the anatomic aspects of lingual frenulum in
babies attended in the Reference Center in Hearing Health/CRESA Puc
Goias between August, 2014 and February, 2015

Altered (apex / sublingul caruncles)   0,6%

Altered (apex / inferior alveolar      4,2%

Altered (middle third and the apex     32,2%
/ inferior alveolar crest)

Normal (middle third / inferior        13%
alveoar crest)

Normal (middle third and the apex      22%
/ sublingual caruncles)

Normal (middle third / sublingual      28%

Note: Table made from bar graph.

Figure 3. Distribution of changes in suction in normal and altered
frenulum in babies attended in Reference Center in Hearing Health/
CRESA--Puc Goias between August, 2014 and February, 2015

                                  Suction normal   Suction altered

Normal (middle third/sublingual      24,8%              3,0%

Normal (middle third and the         9,7%               3,6%
apex/sublingual caruncles)

Normal (middle third/inferior        18,2%              4,2%
alveolar crest)

Altered (middle third and the        18,8%              12,7%
apex/inferior alveolar crest)

Altered (apex/inferior alveolar      0,6%

Altered (apex/sublingual             3,4%               1,8%

Note: Table made from bar graph.
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Title Annotation:Original articles. Texto en ingles
Author:Marcione, Silva Soares; Coelho, Fernanda Gomes; Souza, Cejana Baiocchi; Franca, Ellia Christinne Lim
Publication:Revista CEFAC: Atualizacao Cientifica em Fonoaudiologia e Educacao
Date:Sep 1, 2016
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