Version July 2025
INTRODUCTION —
Ankyloglossia, or tongue-tie, is a condition of limited tongue mobility caused by a restrictive lingual frenulum (picture 1A-B). The definition of ankyloglossia is not standardized, and its clinical significance and optimal management continue to be debated.
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".)
ANATOMY —
There are three types of intra-oral frenula [1,2]:
●Lingual frenulum – The lingual frenulum connects the tongue's ventral surface (underside) to the floor of the mouth. It is a dynamic structure formed by a midline fold in a layer of fascia that inserts around the inner arc of the mandible, forming a diaphragm-like structure across the floor of mouth. This fascia is located immediately beneath the oral mucosa, fusing centrally with the connective tissue on the tongue's ventral surface. The sublingual glands and submandibular ducts are enveloped by the fascial layer, and anterior genioglossus fibers are suspended beneath it [3,4]. Thus, the configuration and contents of the lingual frenulum vary depending on force applied to the tongue.
There is considerable individual variation in the appearance of the lingual frenulum under tension. It may insert on the tip of the mobile tongue or along its undersurface. Thus, ankyloglossia represents a spectrum of variable degrees of impaired tongue movement resulting from a restrictive lingual frenulum. (See 'Ankyloglossia' below and 'Classification and scoring systems' below.)
In some healthy infants, no frenulum is seen connecting the floor of mouth and mobile tongue. In such infants, portions of the genioglossus can be drawn up into the fold, creating what is sometimes called a "posterior" tongue-tie when the tongue is elevated. (See 'Posterior ankyloglossia' below.)
Branches of the lingual nerve are located superficially on the ventral surface of the tongue, immediately beneath the fascia, making them vulnerable to injury during frenotomy procedures [4].
●Maxillary labial frenulum – The maxillary labial frenulum is a normal anatomic structure arising from the maxillary (upper) lip and inserting at the gingival margins of the central incisors [5]. (See 'Upper lip tie' below.)
●Buccal frenula – The buccal frenula are small connective tissue folds between the buccal mucosa and the posterior maxillary (upper) or mandibular (lower) gingiva. They are normal anatomic structures that support suction during breastfeeding. There are no existing criteria to determine whether buccal frenula are restrictive. Surgical division is not recommended [1,2]. (See 'Buccal tie' below.)
EPIDEMIOLOGY
●Prevalence – Ankyloglossia is common. Among healthy newborns, the estimated prevalence is approximately 4 to 7 percent, depending upon the criteria used to define ankyloglossia [6-10]. The prevalence is higher in studies involving newborns with breastfeeding difficulties, among whom approximately 10 to 15 percent have ankyloglossia [9]. It occurs more commonly in males than females, with approximately 55 to 65 percent of cases occurring in males versus 35 to 45 percent in females [10-14].
●Trends in diagnosis and surgery for ankyloglossia – Studies using large nationwide databases of administrative hospital or claims data have shown that the frequency of diagnosing ankyloglossia and/or performing lingual frenotomy have increased dramatically since the late 1990s in North America and Europe [11-15]. In two studies from the United States, there was a nearly 10-fold increase in the diagnosis of ankyloglossia and frenotomy procedures performed in the period from 1997 to 2012 [13], and a further doubling between 2012 and 2016 [11]. A similar study from Denmark reported a nearly 8-fold increase in the number of frenotomies performed annually between 1996 to 2015 [12]. In the United States studies, infants diagnosed with ankyloglossia and/or undergoing frenotomy were more often privately insured and from higher median-income zip codes compared with the general population [1,13,14].
In an observational study from the province of Canterbury, New Zealand, introduction of a standardized clinical pathway for infants with ankyloglossia aimed at supporting breastfeeding and avoiding unnecessary surgery resulted in a marked decrease in the frenotomy rate (11.3 percent in 2015 to 3.5 percent in 2017), without negatively affecting the rate of breastfeeding [16].
●Genetic factors – While most cases of ankyloglossia are sporadic, it occurs more commonly in infants with a family history of tongue tie. Mutations in the T box transcription factor TBX22 may lead to heritable (X-linked) ankyloglossia with or without cleft lip, cleft palate, or hypodontia [17].
CLINICAL FEATURES
Ankyloglossia
Examination findings — Clinical features of ankyloglossia may include [9,18-20]:
●Abnormally short frenulum, extending from the tip of the tongue to the top of the gum ridge (picture 1A and picture 1B)
●Difficulty lifting the tongue to the maxillary (upper) teeth or gum ridge (picture 2 and figure 1)
●Inability to protrude the tongue more than 1 to 2 mm past the lower central incisors (picture 3 and figure 2)
●Impaired side-to-side movement of the tongue
●Notched or heart shape of the tongue when it is protruded or lifted (figure 3)
●For infants too young to voluntarily protrude the tongue, a frenulum that prevents placement of the examiner's fingers between the underside of the tongue and mandibular alveolus is considered abnormally restrictive
Potential clinical consequences — In many individuals with ankyloglossia, the finding has little to no clinical significance. However, it can be associated with clinical consequences in some patients if tongue movement is severely restricted.
When symptoms related to ankyloglossia develop, they most commonly present in one of the following ways [20,21]:
●Newborn or young infant with breastfeeding difficulty (see 'Breastfeeding difficulties' below)
●Toddler or young child with articulation problems (see 'Articulation difficulties' below)
●Older child or adolescent with mechanical difficulties and/or social embarrassment due to restricted tongue movement (eg, difficulty licking lips, difficulty kissing) (see 'Mechanical and social difficulties' below)
Ankyloglossia does not cause speech delay or sleep apnea [1,2].
Natural history — The natural history of untreated ankyloglossia is unknown [20]. Some postulate that progressive stretching and use of the frenulum leads to spontaneous elongation, but this has not been substantiated in prospective studies [20].
Posterior ankyloglossia — The definition of "posterior" ankyloglossia is not standardized. Some experts use the term to mean a frenulum that inserts into the posterior portion of the mobile tongue, whereas others think of it as a submucosal tethering of the tongue. Some experts question its existence as a real anatomic entity and advocate for abandoning the term "posterior ankyloglossia" [2].
Upper lip tie — All newborns have maxillary labial frenula, which are usually attached at the gingival margins [5]. There is controversy regarding the classification of the maxillary labial frenulum in newborns, particularly with regards to what constitutes an "upper lip-tie" [22]. Existing rating systems have poor reproducibility, even when used by experienced clinicians [23,24]. The clinical significance of an upper lip-tie is uncertain. There are insufficient data to establish an association between upper lip-tie and breastfeeding difficulties [24]. The available observational data have not shown any correlation between maxillary frenulum grade and poor latch or maternal nipple pain [25]. Surgery is rarely warranted for this finding [1,2].
Buccal tie — The term "buccal tie" or "cheek-tie" has been used to describe a perceived tightness in the maxillary and/or mandibular buccal frenula. Surgical division of the buccal frenula is not recommended [1,2]. There are no existing criteria used to determine whether the buccal frenulum is restrictive. In addition, it is illogical that division of the buccal frenulum would be useful in facilitating breastfeeding since it plays a role in augmenting the function of the buccinator muscle during swallowing. (See 'Anatomy' above.)
CLASSIFICATION AND SCORING SYSTEMS —
Various classification and scoring systems have been developed in attempt to objectively characterize the severity of tongue-tie. None of the available tools have been externally validated.
●Anatomic classification – Anatomic classification schemas include the Coryllos and Kotlow classification systems [26,27]:
The Coryllos frenulum classification system characterizes ankyloglossia based upon how the frenulum attaches to the tongue [26]:
•Type 1 – Frenulum is thin and elastic and inserts to the tip of the tongue
•Type 2 – Frenulum is thin and elastic and inserts slightly (2 to 4 mm) behind the tip of the tongue
•Type 3 – Frenulum is thickened and tight or less elastic, attaching from the mid-tongue to the middle of the floor of the mouth
•Type 4 – Frenulum is posterior or not visible; tight inelastic fibers can be felt anchoring the tongue
These classification systems do not address functionality, and the different categories do not consistently correlate with breastfeeding difficulties [28].
●Functional and anatomic scores – Assessment tools that characterize the severity of ankyloglossia based upon both anatomy and function include the HATLFF (Hazelbaker Assessment Tool for Lingual Frenulum Function), BTAT (Bristol Tongue Assessment Tool), FDTBD (Frenotomy Decision Tool for Breastfeeding Dyads), and the NTST (Neonatal Tongue Screening Test) [29-32].
The HATLFF functional score is based on seven different aspects of tongue movement (lateralization, cupping, lift, peristalsis, extension, snap back, and spread), each of which is rated from 0 to 2 points [29]. A HATLFF functional score of 6 to 12 points indicates mild to moderate tongue-tie, and a score of <6 indicates severe tongue-tie.
The BTAT score and its picture version, TABBY (tongue-tie assessment in breastfed babies), include four elements: Togue tip appearance, attachment to the lower gum ridge, lift of the tongue, and protrusion of the tongue [30,33]. Each element is rated from 0 to 2 points. A BTAT/TABBY score ≤3 indicates severe tongue-tie.
●Other tools for assessing breastfeeding effectiveness – Other tools that can be used to assess breastfeeding effectiveness in infants with or without ankyloglossia include the LATCH (Latch, Audible swallowing, Type of nipple, Comfort, Hold) score, IBFAT (Infant Breastfeeding Assessment Tool), and BSES (Breastfeeding Self-Efficacy Scale). These assessments are discussed separately. (See "Initiation of breastfeeding", section on 'Evaluating a latch for effectiveness'.)
MANAGEMENT APPROACH —
In many individuals with ankyloglossia, the finding has little to no clinical significance. However, it can be associated with clinical consequences in some patients if tongue movement is severely restricted.
The following sections outline the approach to determining whether surgical intervention is warranted. Additional details on the surgical procedures themselves are provided below. (See 'Surgical procedures' below.)
Asymptomatic patients — Surgery does not play a role in patients with tongue-tie who are asymptomatic. Preemptive surgery in asymptomatic patients (ie, to prevent future problems with feeding or speech) is generally discouraged [1,2].
Symptomatic patients — When symptoms related to ankyloglossia develop, they most commonly present in one of the following ways [20,21]:
●Newborn or young infant with breastfeeding difficulty (see 'Breastfeeding difficulties' below)
●Toddler or young child with articulation problems (see 'Articulation difficulties' below)
●Older child or adolescent with mechanical difficulties and/or social embarrassment due to restricted tongue movement (eg, difficulty licking lips, difficulty kissing) (see 'Mechanical and social difficulties' below)
Consultation with a lactation specialist and/or speech pathologist may help the infant or child compensate for problems related to ankyloglossia, thereby avoiding surgery.
Breastfeeding difficulties
●Types of feeding problems – Most infants with ankyloglossia are able to breastfeed without difficulty [7]. However, ankyloglossia is associated increased likelihood of experiencing problems such as poor latch, maternal nipple pain, and poor infant weight gain [7,9,34,35]. It is important to recognize that these problems are common in the newborn period, even in the absence of ankyloglossia. (See "Common problems of breastfeeding and weaning", section on 'Nipple and breast pain' and "Common problems of breastfeeding and weaning", section on 'Inadequate milk intake'.)
Studies have not found any association between ankyloglossia and poor feeding in bottle-fed infants, which likely reflects differences in mechanics between breast- and bottle-feeding. (See "Neonatal oral feeding difficulties due to sucking and swallowing disorders".)
●Evaluation – The evaluation of a breastfeeding infant with ankyloglossia includes:
•Reviewing the history, including birth history and careful lactation history. (See "Common problems of breastfeeding and weaning", section on 'History'.)
•Physical examination, with particular focus on the oral structures. The examination aims to identify other potential oral and nasal causes of feeding difficulties (eg, nasal obstruction, cleft palate) and to determine the severity of the tongue tie.
•Scoring tools can be used to complement this assessment. (See 'Classification and scoring systems' above.)
●Lactation support – For infants with breastfeeding difficulties (ie, poor latch, maternal nipple pain) in the setting of restricted tongue movement from ankyloglossia, the first step in management is consultation with a lactation specialist [1,2]. The lactation specialist can evaluate for and address other potential causes of the breastfeeding problem. Depending on the mother's anatomy and degree of elasticity of the breast tissue as well as the infant's anatomy and degree of tongue mobility, many infants are able to successfully breastfeed without surgical intervention. (See "Initiation of breastfeeding", section on 'Optimize mechanics of feeding' and "Common problems of breastfeeding and weaning", section on 'Nipple and breast pain'.)
●Persistent difficulty despite lactation support – For infants with a restrictive lingual frenulum causing breastfeeding problems that do not improve with lactation support, we suggest frenotomy. (See 'Frenotomy' below.)
The efficacy of frenotomy in improving breastfeeding outcomes in infants with ankyloglossia is supported by observational studies and a few small clinical trials [36-38]. A 2017 meta-analysis identified five clinical trials including 302 mother-infant dyads who were randomly assigned to frenotomy or control (consisting of usual care, intensive lactation consultation, or sham surgery) [37]. The effect of frenotomy on infant breastfeeding varied in these trials. Two trials evaluated this outcome qualitatively with a parental survey and found that frenotomy improved breastfeeding effectiveness [39,40]. Similarly, a third trial evaluated this outcome with the Infant Breastfeeding Assessment Tool (IBFAT) and found greater improvements in IBFAT scores in the frenotomy group [41]. By contrast, in the two trials using the LATCH score to assess breastfeeding effectiveness, the change in LATCH score in the frenotomy group was similar to that in the control group [42,43]. Maternal nipple pain scores were modestly lower in the frenotomy group (mean difference 0.7 points on a 10-point scale), but the difference was not statistically significant (95% CI 1.35 points lower to 0.13 points higher; based on three trials) [37]. There were no episodes of excessive bleeding, infection, or injury to nearby structures in either group in any of these trials.
Articulation difficulties — Ankyloglossia occasionally impacts speech articulation, but it does not prevent vocalization or cause delay in the onset of speech [44-46]. Affected children are expected to acquire speech and language within the same timeframe as the general population.
It is possible for ankyloglossia to affect speech articulation and intelligibility. However, most children who are referred to speech pathologists for speech concerns thought to be due to ankyloglossia are ultimately found to have age-appropriate speech errors (eg, phonological substitutions, gliding errors) [45,46].
When articulation problems do occur, it is most often due to an extremely short lingual frenulum that extends to the tip of the tongue and prevents the tongue from reaching the upper dental alveolus. Speech sounds that may be affected include sibilants and lingual sounds (eg, "t," "d," "z," "s," "th," "n," "l"). Children who speak languages that involve rolling the "r" (eg, Spanish) may also have difficulty producing this sound.
Formal speech evaluation should be obtained in children who have ankyloglossia and difficulty pronouncing sibilants and lingual sounds. (See "Speech and language impairment in children: Evaluation, treatment, and prognosis".)
Speech therapy can improve articulation problems in some children [20]. In the English language, even the sounds that require the most amount of tongue movement, such as "l" and "th," can be produced with minimal distortion, with the tongue tip pressed down instead of up towards the alveolar ridge ("l") or protruding out ("th"). Similarly, other sounds that require tongue elevation, such as "s" and "z," can also be produced effectively with the tongue tip down. Consequently, ankyloglossia should not have a dramatic impact on speech function in most cases [47,48]. (See "Speech and language impairment in children: Evaluation, treatment, and prognosis", section on 'Efficacy'.)
Pediatric otolaryngologists work in concert with speech pathologists when treating children with ankyloglossia and articulation problems. Often, children are referred to the otolaryngologist after a full speech assessment and a trial of therapy with a request for surgical division of the frenulum. Most otolaryngologists request input from a speech pathologist before surgery to assess the need for surgery and to document the functional nature of the procedure for third-party payers. Finally, speech therapy may be necessary after surgery to retrain tongue musculature and correct preoperative compensatory strategies [20]. (See 'Surgical procedures' below.)
There are few data on the efficacy of frenotomy or frenuloplasty for improving articulation problems in children with ankyloglossia [44-48]. A small prospective study of 30 children who underwent frenuloplasty reported improvements in articulation as assessed by speech pathologists and parent perception [44]. However, other observational studies suggested that surgery had little to no impact on articulation [45,46].
Mechanical and social difficulties — Mechanical and social difficulties related to restricted tongue movements from ankyloglossia may include:
●Impaired oral hygiene (ie, inability to effectively lick the lips or sweep food debris from the teeth, which may result in periodontal disease) (see "Gingivitis and periodontitis in children and adolescents", section on 'Gingivitis')
●Difficulty licking or kissing, which may cause social embarrassment in older children and adolescents
●Splaying of the lower central incisors
Frenotomy/frenuloplasty may be offered if the tongue-tie is bothersome and significantly impacts quality of life. (See 'Frenotomy' below and 'Frenuloplasty' below.)
SURGICAL PROCEDURES —
The following sections describe the two most commonly performed procedures for ankyloglossia (frenotomy and frenuloplasty). The approach to determining whether surgical intervention is warranted is outlined above. (See 'Management approach' above.)
General considerations — The goal of surgery is to increase the mobility of the tongue, not to improve its contour. Even after surgery, the tip of the tongue may have a notch or be heart-shaped.
Indications for surgery may include breastfeeding difficulty, articulation problems, or mechanical/social problems. Global speech delay is not an indication for surgical release of tongue-tie. Preemptive surgery in asymptomatic patients (ie, to prevent future problems with feeding or speech) is generally discouraged [1,2].
For infants with ankyloglossia-related breastfeeding problems, there is consensus that surgery should be performed as soon as it becomes clear that the problems are not improving with lactation support [2]. The optimal timing of surgery for indications other than breastfeeding is uncertain [20,49,50]. Some advocate waiting until the child is at least four years old because of the chance that the frenulum may spontaneously elongate as it is used, whereas others advocate surgery before speech or other problems worsen [20,51].
Frenotomy — Frenotomy (sometimes called frenulotomy) is the simple release or division of the frenulum. Most frenotomies are performed in the office setting without general anesthesia.
●Procedural details – When performed in young infants, frenotomy can be done with nonpharmacologic comfort measures alone (eg, sucrose, swaddling). (See "Management and prevention of pain in neonates", section on 'Nonpharmacologic measures'.)
In cooperative older children and adolescents, frenotomy may be performed under local anesthesia.
The procedure is performed under direct vision, rather than by blindly snipping the frenulum. This ensures completeness and avoids injury to nearby structures. The infant is restrained by swaddling or in a Papoose board, with an assistant holding the child's head. The area is illuminated with a headlight or an office microscope. The tongue is elevated with forceps, a grooved retractor, or two gloved fingers on the underside of the tongue (picture 4 and picture 5). Simple division of the frenulum rarely leads to significant bleeding. Pressure with a gauze sponge for a few minutes controls any capillary ooze. Allowing the infant to feed immediately after the procedure also helps.
Increasingly, some practitioners perform frenotomy using carbon dioxide or diode lasers, particularly when the procedure is performed by oral surgeons, dentists, and pediatricians. Laser frenotomy ensures a bloodless incision; however, it adds additional cost to the procedure and based on the available data, there does not appear to be any advantage of laser frenotomy over conventional frenotomy [2,52].
●Complications – Potential complications of lingual frenotomy include hemorrhage, airway obstruction, injury to salivary structures, oral aversion, scarring, and recurrence. These complications are rare but do occur and should be discussed with parents/caregivers during informed consent, as should the possibility that breastfeeding may not improve after surgery. Most studies report little discomfort and few adverse effects [39,42,53-56]. Relative contraindications to infant frenotomy include, but are not limited to, retrognathia, micrognathia, neuromuscular disorder, hypotonia, and coagulopathy [2].
●Postprocedure care – The infant may feed immediately after the procedure [20]. We suggest against performing postoperative "tongue exercises" (eg, massaging or stretching of the tongue and floor of mouth). These exercises have not been shown to be beneficial and may cause oral aversion [1,57].
Frenuloplasty — Frenuloplasty is a release of ankyloglossia with plastic repair. It is reserved for:
●Ankyloglossia in older children who are unable to cooperate in the office
●Ankyloglossia that is not relieved by simple division of the frenulum
●Revision surgery
Frenuloplasty requires general anesthesia. In this procedure, the tongue is elevated with forceps and the frenulum is divided in the sagittal plane as in frenotomy. Submucosal dissection continues into the genioglossus muscle in the midline until a full release is achieved (picture 6). Good illumination and magnification with loupes or an operating microscope permit division of the frenulum without injury to the nearby submandibular ducts. Midline dissection decreases the risks of injury to the lingual nerves.
Frenuloplasty dissection produces an elliptical tissue defect on the floor of the mouth. If left open, scarring and recurrent tethering of the tongue may result. The wound is usually closed with multiple simple absorbable sutures in the coronal plane to achieve a double V-Y advancement. Single or multiple Z-plasties have been advocated to prevent scar contracture. There are no comparative trials demonstrating an advantage to these more complicated repairs [58]. (See "Z-plasty".)
Following surgery, a normal diet can be resumed as tolerated. In older children undergoing frenuloplasty for articulation problems, continued speech therapy and specific tongue exercises are commonly used postoperatively [59].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breastfeeding and infant nutrition".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Basics topic (see "Patient education: Common breastfeeding problems (The Basics)")
●Beyond the Basics topic (see "Patient education: Common breastfeeding problems (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Prevalence – Ankyloglossia, or tongue-tie, refers to limited tongue mobility caused by a restrictive lingual frenulum (picture 1A-B). This finding is observed in approximately 4 to 7 percent of healthy newborn infants. (See 'Epidemiology' above.)
●Examination findings – Clinical features of ankyloglossia include inability to lift the tongue to the maxillary dental alveolus (picture 2), impaired protrusion of the tongue (picture 3), impaired side-to-side movement of the tongue, and a notched or heart shape to the tongue when it is protruded (figure 3). (See 'Examination findings' above.)
●Potential clinical consequences – In many individuals with ankyloglossia, the finding has little to no clinical significance. However, it can be associated with clinical consequences in some patients if tongue movement is severely restricted. These include (see 'Potential clinical consequences' above):
•Breastfeeding difficulties in infancy (see 'Breastfeeding difficulties' above)
•Articulation problems in early childhood (see 'Articulation difficulties' above)
•Mechanical/social difficulties (eg, impaired oral hygiene, difficulty licking or kissing) in later childhood and adolescence (see 'Mechanical and social difficulties' above)
Ankyloglossia does not cause speech or language delay or sleep apnea.
●Classification and severity scores – The Coryllos classification system characterizes ankyloglossia according to how the frenulum attaches to the tongue; it does not address functionality. The Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) and Bristol Tongue Assessment Tool (BTAT) are assessment tools that characterize the severity of ankyloglossia based upon both the appearance and function of the tongue and frenulum. (See 'Classification and scoring systems' above.)
●Management of the clinical consequences of ankyloglossia (See 'Symptomatic patients' above.)
•Breastfeeding difficulties – For infants with ankyloglossia who are experiencing breastfeeding difficulties (ie, poor latch, maternal nipple pain), the first step in management is consultation with a lactation specialist. For affected infants who continue to have problems with breastfeeding despite lactation support, we suggest frenotomy (Grade 2C). Ongoing conservative management is a reasonable alternative. If frenotomy is undertaken, it should be performed by appropriately trained personnel. (See 'Breastfeeding difficulties' above and 'Frenotomy' above.)
•Articulation problems – Evaluation by a speech pathologist is an essential component of the management of children with articulation problems and concomitant ankyloglossia. Speech therapy can improve articulation problems in some children and should be trialed before considering surgery. For children who undergo frenotomy, speech therapy will likely also be necessary after surgery to retrain tongue musculature and correct preoperative compensatory strategies. (See 'Articulation difficulties' above.)
•Mechanical and social difficulties – These may include impaired oral hygiene, difficulty licking or kissing, and splaying of the lower central incisors. Frenotomy may be offered as an option in some cases if the tongue-tie is bothersome and significantly impacts quality of life. (See 'Mechanical and social difficulties' above and 'Frenotomy' above.)
