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National Journal of Maxillofacial Surgery
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Table of Contents
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 280-283  

Treatment of partial ankyloglossia using Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF): A case report with 6-month follow-up

1 Private Practitioner, MDS Pedodontics, HP Govt Dental College, Shimla, Himachal Pradesh, India
2 Consultant Pedodontist, Prime Dental Care, Palampur, India
3 Department of Pedodontics, HPGDC, Shimla, Himachal Pradesh, India
4 Department of Prosthodontics, HPGDC, Shimla, Himachal Pradesh, India

Date of Submission28-Oct-2019
Date of Acceptance11-Feb-2021
Date of Web Publication15-Jul-2021

Correspondence Address:
Dr. Pooja Negi
Room No. 408, 4th Floor, HPGDC, Shimla, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njms.NJMS_69_19

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Ankyloglossia or “tongue-tie,” observed in neonates, children, or adults, is characterized by an abnormally short, thick, fibrosed lingual frenulum which may cause restriction in function of tongue including limitation in tongue movement. The use of Hazelbaker Assessment Tool for Lingual Frenulum Function allows elaborate and extensive scoring of the anomaly. This article reports the surgical management of an 11-year-old patient having ankyloglossia associated with restricted movement of tongue and difficulty in speech. Six months postoperatively, the patient showed uneventful healing and was satisfied with the procedure.

Keywords: Ankyloglossia, children, Hazelbaker Assessment Tool for Lingual Frenulum Function, surgical management

How to cite this article:
Jaikaria A, Pahuja SK, Thakur S, Negi P. Treatment of partial ankyloglossia using Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF): A case report with 6-month follow-up. Natl J Maxillofac Surg 2021;12:280-3

How to cite this URL:
Jaikaria A, Pahuja SK, Thakur S, Negi P. Treatment of partial ankyloglossia using Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF): A case report with 6-month follow-up. Natl J Maxillofac Surg [serial online] 2021 [cited 2021 Dec 5];12:280-3. Available from: https://www.njms.in/text.asp?2021/12/2/280/321456

   Introduction Top

Partial ankyloglossia also called as tongue-tie is a condition caused by abnormally short frenum of the tongue, or the frenum is attached too close to the tip of the tongue.[1] The other category is total ankyloglossia which is rare and occurs when the tongue is completely fused to the floor of the mouth.

The prevalence of ankyloglossia is well established in newborn and is seen in approximately 4%–5% in the newborn population with a 3:1 male-to-female preponderance.[2]

An abnormally tight lingual frenulum often makes the tongue tied down to the floor of the mouth restricting the functions of tongue. It affects speech, feeding, oral hygiene, as well as social environment also. It causes blanching of soft tissue during tongue retrusion and also exerts force on mandibular anteriors.[3]

There is continuing controversy over the diagnostic criteria and treatment of ankyloglossia.[4] Diagnostic criteria established by various studies are based on the length of the lingual frenulum, amplitude of tongue movement,[5] heart-shaped look when the tongue is protruded and/or thickness of the fibrous membrane.[6] As there is no generally agreed definition of tongue-tie, a quantitative instrument has been developed: the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF).[7]

   Case Report Top

An 11-year-old male patient came with the chief complaint of difficulty in speaking and difficulty during the intake of food. He also complained regarding the restricted tongue movement. There was no contributory medical or family history. On intraoral examination, short lingual frenum and restricted tongue movements were observed as seen in [Figure 1]a and [Figure 1]b.
Figure 1: (a and b) Restricted tongue movements with short and thick frenum

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Informed consent and necessary blood investigations were obtained. Recommendation for frenotomy was established using HATLFF [Table 1] under topical anesthesia on tongue's inferior surface. After anesthesia, the tongue was retracted superiorly and stabilized with silk sutures placed at the tip of the tongue. A narrow vertical incision was then made through the mucosa alongside of the frenulum, from beneath the tip of the tongue to just in front of the orifices of the submaxillary ducts [Figure 2]. Blunt dissection was carried down to the floor of the mouth on both sides of the frenum facilitating its removal from lingual and alveolar insertions [Figure 3]. Surgical wound was sutured with catgut suture 4/0 [Figure 4].
Figure 2: Narrow vertical incision made through the mucosa alongside of the frenulum

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Figure 3: Excised triangular tissue held with silk suture at the tongue tip and excision of fiber remnants

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Figure 4: Tension-free closure with silk sutures

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Table 1: Scoring of the patient on the basis Hazelbaker Assessment Tool for Lingual Frenulum Function preoperative

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Postoperative care includes analgesics, mouthwash containing chlorhexidine, as well as recommendations on diet and maintaining good oral hygiene.

The postoperative period was uneventful. After 1 week, the tongue was evaluated and early mobilization was indicated to minimize scarring and improve tongue range of motion [Figure 5]. The patient is asked to perform tongue exercises that are designed to improve protrusion, elevation, and side-to-side motion 3 or more times daily. The patient was referred to a speech therapist to have his tongue movement and speech articulation improved.
Figure 5: Follow-up after 1 week

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Although some improvement in tongue mobility occurred in the early postoperative period, a noticeable gain in mobility has been noted 1 month postoperatively with further improvements 3 months after surgery [Figure 6]. Postoperative assessment reveals improved results postsurgerical intervention [Table 2].
Figure 6: Follow-up after 1 month after surgery showing easier lingual mobility

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Table 2: Hazelbaker Assessment Tool for Lingual Frenulum Function postoperative

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   Discussion Top

Ankyloglossia, partial or complete, causes specific speech disorders in certain individuals. It does not prevent or delay the onset of speech but interferes with articulation which is consistent with our case. It causes blanching of soft tissue during tongue retrusion and also exerts force on mandibular anteriors.[3] Moreover, it interferes in toothbrushing process, consequently, favoring the risk of plaque accumulation, tissue inflammation onset, and gingival recession.[8] It also results in improper chewing and swallowing of food which in turn increases the gastric distress and bloating, snoring, and bed wetting at sleep. Dental caries may also occur due to restricted tongue's action on the teeth and spreading of saliva. Malocclusion like open bite due to thrust created by tongue-tie spreading of lower incisors and tooth mobility due to long-term tongue thrust.

Tuerk and Lubit proposed two dental deformities as a consequence of ankyloglossia which are open-bite deformity and mandibular prognathism. The inability to raise the tongue to the roof of the palate encourages the continuation of the infantile swallow, prevents the development of the adult swallow, and leads to an open-bite deformity. The lack of a free upward and backward movement of the tongue which may result in an exaggerated anterior thrusting of the tongue against the anterior body of the mandible produces mandibular prognathism.[9] Horton et al. reported that the prominent lower frenulum may lead to repeated lower denture plate dislodgment when the tongue is elevated. The above possibility was also noted by other authors.[10]

While evaluating the effect of ankyloglossia on speech, it is important to focus on lingual-alveolar sounds. Mobility of the tongue is measured in millimeters the tip of the tongue extended past the lower dentition, while elevation is measured by recording interincisal distance with the tongue tip maximally elevated and in contact with the upper teeth. If there is ankyloglossia, the protrusion and elevation values of 15 mm or less will be recorded and 20–2 mm for normal individuals[11] which applied to our case as well. The myofunctional therapy is a program of specific exercises that strengthen the muscles of the tongue.[12]

The ankyloglossia correction at early ages reduces the risks of complications to nursing babies, and surgical intervention should be performed when there is interference in deglutition and speech.[13]

   Conclusion Top

Tongue-tie or ankyloglossia, frequently seen in infants and young children, causes various functional and esthetic complications that may affect the physical and mental health of the individual. Timely detection followed by quick intervention prevents problems not only related to feeding and speech but also involving growth and posture.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Ramya V, Manisundar N, Balaji A. Management of ankyloglossia with scalpel and electrosurgery method. Indian J Multidiscip Dent 2012;2:472-4.  Back to cited text no. 1
  [Full text]  
Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: Prevalence and effect on breast-feeding. J Am Board Fam Pract 2005;18:1-7.  Back to cited text no. 2
Verdine VA, Khan R. Management of ankyloglossia – Case reports. IOSR J Dent Med Sci 2013;6:31-3.  Back to cited text no. 3
Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health 2005;41:246-50.  Back to cited text no. 4
Jorgenson RJ, Shapiro SD, Salinas CF, Levin LS. Intraoral findings and anomalies in neonates. Pediatrics 1982;69:577-82.  Back to cited text no. 5
Chu MW, Bloom DC. Posterior ankyloglossia: A case report. Int J Pediatr Otorhinolaryngol 2009;73:881-3.  Back to cited text no. 6
The Assessment Tool for Lingual Frenulum Function (ATLFF): Use in a Lactation Consultant Private Practice. Pasadena, California: Pacific Oaks College; 1993.  Back to cited text no. 7
YaredK FG, Zenobio EG, Pacheco W. Aetiologiamultifatorial da recessão periodontal. R Dent Press Ortodon Ortop Facial 2006;11:45-51.  Back to cited text no. 8
Tuerk M,' Lubit EC. Ankyloglossia. Plast Reconstr Surg Transplant Bull 1959;24:271-6.  Back to cited text no. 9
Horton CE, Crawford HH, Adamson JE, Ashbell TS. Tongue-tie. Cleft Palate J 1969;6:8-23.  Back to cited text no. 10
Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: Clinical suggestions for diagnosis and management. Pediatr Dent 2005;27:40-6.  Back to cited text no. 11
Ferrés-Amat E, Pastor-Vera T, Ferrés-Amat E, Mareque-Bueno J, Prats-Armengol J, Ferrés-Padró E. Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Med Oral Patol Oral Cir Bucal 2016;21:e39-47.  Back to cited text no. 12
Babu HM. Surgical management of ankyloglossia: A case report. Int J Contemp Dent 2010;1:58-61.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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