Tight Frenulum? When to refer for a frenectomy

Tight Frenulum? When to refer for a frenectomy

Does your client have a short, tight frenulum?

Information related to structure and function of the oral mechanism is crucial in treatment decisions. So why is it that this valuable info, including Ankyloglossia, is often overlooked in speech evaluations? There is of course the time issue and some of our kids may be noncompliant, but I think its more often related to the fact that alot of SLP’s simply don’t know what they are looking for.

The frenulum is a band of connective tissue covered by a thin layer of mucous membrane located under the tongue. A normal frenulum stretches from the undersurface of the tongue in the midline, to the floor of the mouth.

So what are the red flags for a tight frenulum?


In infants: (Red Flags Include)

-breast and bottle feeding challenges

-poor weight gain

-frequent upper respiratory infections, reflux

-drooling, chronic anterior saliva loss

-challenges with using novel spoons, other eating utensils

-excessive residue in the oral area following meals

-inability to transfer from liquids to solids by 12 months of age

In older children: (Red Flags Include)

-A developmental history with one or more of the issues listed above

-Children who are classified as “Picky eaters” or exhibiting food jags

-Children who exhibit marked behavioral changes associated with mealtimes

-Persistent rash in the oral area

-Dentition differences, including an anterior open bite, malocclusion and irregular eruptions of teeth, and / or excessive cavities.

-Tongue thrusting

-Swallowing challenges

-Articulation errors

-Stuttering or dysfluency

-Voicing errors, abrupt changes in pitch, or a monotone vocal quality [/private_free]

Given the fact that the preceding red flags can often occur in the absence of a tight frenulum you must do an oral mechanism exam to either substantiate or rule out its presence.

So in addition to red flags what should you look for in an examination. An arbitrary “stick out your tongue” is not diagnostic. Alot of kids that are “tongue tied” can “stick out their tongue.” When evaluating the frenulum here’s what to look for.


When visually inspecting the tongue look at the range of motion, not the actual appearance. All frenulums are different. If the range of motion of the tongue is not impaired, cosmetic appearance has little relevance.

1.Look at whether the child can extend the tongue beyond the margins of the teeth.

Protrusion with a downward point can be acheived by many kids with tight frenulums. The classic “say ahh” movement in which a child protrudes his / her tongue outward and downward can be acheived by some kids with limited range of motion.

2. Engage the child in tongue tip pointing.

Having a child protrude their tongue “straight out” will be challenging if not impossible for a child with a tight frenulum.

3.Look at the tongue tip with movement attempts.

If there is any bowing or a “heart shape” in the tip, the frenulum is restrictive. In some cases the tongue may not move or it can curl under itself during movement attempts.

4. Look at the ability to elevate the tongue tip toward his nose or upper lip with the mouth open.

Tongue tip elevation with a closed mouth is not acceptable. The child must be able to elevate the tongue tip to the upper lip, toward the nose, with teeth apart. If you see eye rolling, lip pursing, or extraneous head movements be suspicious.

5. Look at lateral movements, circumlocution ability with the tip of the tongue, and retraction skills.

Often kids with restrictive frenulums have poor oral awareness in conjunction with limited range of motion.


In addition to the diagnostic exercises listed above, observe aspects of conversational speech. Older children who have an undiagnosed restrictive frenulum may learn compensatory strategies to compensate for poor articulation. Slow speaking, a quiet vocal volume or a monotone vocal quality are common. Articulation may be precise in isolation and in single words but deteriorate and the conversational level. Lingual sounds may or may not be errant.

So what qualifies as surgery worthy? When should you refer for a frenectomy?

[private_free] If an infant cannot suckle or swallow due to a restrictive frenulum, it should be clipped as soon as possible. Nowadays, most hospitals are savvy at picking up on this issue, but it can be missed. If you have an infant with “latching issues” look at the frenulum and lingual range of motion. In children over the age of six months, surgery may be considered, but always in conjunction with post operative speech therapy. Three to six months of weekly therapy is generally recommended. In some cases, skills improve within weeks. Drooling often resolves quickly. The older the child, the more ingrained the compensatory habits in eating and speech will be, and the longer it will take you to help reestablish appropriate speech and feeding skills.

Even though the procedure is generally quick and performed on an outpatient basis, remember that it still is surgery. Some kids will respond to stretching exercises which may be tried depending on the severity of the tightness. In situations where the “tongue tie” occurs in conjunction with a syndrome or other neurologic disorder, a frenectomy may be a secondary consideration. Always refer to a physician that assesses frenulums and performs the procedure regularly.

It is also relevant to note that the tissue under the tongue can regrow. So even if your client has had a frenectomy, always look at lingual frenulum functioning in your assessment. [/private_free]

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