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Frenectomies in the General Dental Practice
By William S. Bike
Frena — tissues that connect lips to gums and the tongue to the floor of the mouth — support both the lips and the tongue.(1) But if frena interfere with function and the tongue’s range of motion — a condition known as ankyloglossia, or tongue-tie(2) — is a frenectomy warranted?
“Frenectomies get a bad name,” said Justin A. Welke, DDS, a pediatric dentist in private practice in Chicago, who said that some medical professionals “deem them to be unnecessary and unhelpful.”
However, having performed more than 3,000 frenectomies, Welke contends that “the procedure is life-changing.”
Jennifer A. Hathaway, DDS, FAGD, a general dentist in Bryan, Texas, has seen that firsthand.
Medical professionals believed that an 18-year-old patient of hers “was developmentally delayed,” Hathaway recalled. “But there wasn’t anything wrong with her brain. She could not speak because her tongue was tied.”
Sometimes, Hathaway noted, with frena that are “too high, tight or attached, newborn babies can’t nurse because that attachment doesn’t let them form a good seal, either on a bottle or on mom’s breast. If you don’t do the frenectomy, they literally can’t eat.”
Frenal Abnormalities
“When discussing frenal abnormalities, we are generally talking about a frenum that is too tight to allow full function of the tongue,” said Trace Favre, DDS, FAGD, a general dentist at Mississippi Dental Arts in Pass Christian, Mississippi. “When the tongue is not able to move properly, the patient may experience issues with sleeping, feeding, speech or several other related problems.”
Richard Baxter, DMD, MS, pediatric dentist owner of the Alabama Tongue-Tie Center in Pelham, Alabama, noted that “a restricted maxillary labial frenum can lead to a diastema or gap in the teeth as well as trouble brushing the teeth, leading to early childhood caries, and it can affect nasal breathing and B, P, M and W sounds. Restricted buccal frena and the mandibular labial frenum can lead to issues with gingival recession, denture retention and fascial tension.”
The American Academy of Pediatric Dentistry, American Association of Oral and Maxillofacial Surgeons, and American Association of Orthodontists all have guidelines and/or recommendations for their specialists about performing frenectomies.(3-5) But Favre noted that general dentists, who sometimes may be wary of the procedure, should not be reluctant to perform frenectomies “with proper training.”
Karl R. Koerner, DDS, FAGD, founder of the Koerner Center for Surgical Instruction in Draper, Utah, calls the idea that pediatric dentists should be exclusively performing frenectomies “ridiculous” because frenal abnormalities “are common in adults and especially a problem with denture cases.”
Favre uses the Kotlow classification system to document the appearance of the frenum in infants and the tongue range of motion ratio (TRMR) in older children and adults. “The most important thing for general dentists is to be able to recognize when a frenum is too tight, and the TRMR is a great place to start.”
“The hardest age group to treat is from around six months to four years old, and that group is probably more manageable for a pediatric dentist to treat because those children are likely to bite down even when assessing,” Baxter said. “If a general dentist does not feel comfortable treating them, referral to a provider who can treat them early is better than leaving them with suboptimal function.”
“A frenectomy procedure on a child requires specialty training on the unique attributes of pediatric health and psychology,” Welke said. “But, for adult patients, general dentists can surely perform frenectomies once they have achieved proper training.”
Training
“Since identifying and treating tongue- and lip-ties are not taught in school, it’s imperative to receive training,” Baxter said, noting he created a course called Tongue-Tied Academy that provides “25 hours of master class–style video lessons and covers history, examination, diagnosis, treatment, research and business aspects.” He also wrote a book about frenectomies called “Tongue-Tied: How a Tiny String Under the Tongue Impacts Nursing, Speech, Feeding, and More.” Baxter donates the proceeds from the book and courses to local and global nonprofits related to clean water, anti–human trafficking efforts, health centers and poverty alleviation.
Koerner noted that frenectomy training is available “in most surgical extraction courses, any oral surgery training, and in most general practice and advanced education in general dentistry residencies.”
Favre recalled that he started his frenectomy training with a lecture and hands-on course by Baxter at an AGD meeting. He also spent a day with a frenectomy provider in a nearby city.
With no frenectomy training requirements at the state or federal levels, training is nonetheless crucial because “it’s essential so no patients are harmed and the best outcomes can be achieved,” Baxter added.
Frenectomy Modalities
Favre noted that various types of laser surgery are the most common way to perform the procedure among dentists, although some ear, nose and throat physicians (ENTs) “are still performing the procedure with scissors — but it is more than just a simple snip or clip. It takes several small cuts to achieve a proper release with a diamond-shaped wound.”
Koerner believes that frenectomies “can easily be done with a blade,” particularly since “only 15% of general practitioners have a laser.”
Laser advocates note that both diode and carbon dioxide (CO2) lasers are used in frenectomies. Welke prefers the latter because diode lasers “aren’t as precise as CO2 lasers, and they also cause more collateral damage to the tissue.”
The diode laser “is essentially a hot glass tip touched to the tissue to burn and cauterize it; it gets to 700°C–1,000°C,” Baxter said, noting that when he used the diode, “I could tell it was painful.” After switching to a CO2 laser, “the procedures were faster” — 10–15 seconds per area as opposed to 60–90 seconds — “and I stopped getting phone calls at night about babies who wouldn’t nurse due to the pain. The CO2 wavelength works better because the laser energy itself comes into contact with the water in the cells of the mucosa, and it vaporizes at 100°C instead of burning at 1,000°C.” He believes a CO 2 laser also offers excellent coagulation, “so it has the best blend of cutting efficiency and hemostasis.”
However, Hathaway noted that, for some practices, the diode laser may still be indicated because, “the CO2 laser is really expensive; that’s the biggest hangup,” she said. “There are pros and cons to both of them. Find whatever you’re comfortable with, but get good training through a certified course.”
Diode lasers cost around $3,000, and CO2 lasers are around $35,000, Welke noted. Before making that purchase, he suggested, “first attend a conference and do some hands-on training. The American Laser Study Club offers excellent conferences and courses.”
Lebret et al. did a thorough study of frenectomies using lasers vs. conventional surgery in the Journal of Oral Medicine and Oral Surgery.(6)
“Around 10%–25% of your patients have a restricted tongue or lip and could benefit from the procedure, and, in many cases, have life-changing effects,” Baxter said.
Identifying Patients in Need
How should the general dentist identify patients in need of frenectomies?
“If you’re looking at the airway, you can see the tongue tie,” Hathaway said. “If you’re doing cosmetic dentistry and dentures, you’re already used to listening to people’s speech patterns, so you can identify the need that way. You can tell if it’s an abnormal speech pattern, and you can ask them: ‘Does your speech pattern bother you? Do you have any swallowing issues?’ They usually know if it’s bad, but they have to make the decision to keep living with it or make the change. And, in the case of a denture, if that muscle in the front pulls it up, then we really need to trim the muscle.”
“Assess whether the frenum looks and feels tight,” Welke advised. “Ask if there are symptoms such as feeding and speech issues, head and neck pain, temporomandibular disorders, open-mouth breathing, and poor-quality sleep.”
“Learning the TRMR is a simple way to get started,” Favre said.
Baxter has created a Tongue Restriction Questionnaire, “which includes the most common symptoms,” he said.
In July 2024, the American Academy of Pediatrics released news of a report published in the August issue of Pediatrics alleging that frenectomies are overused and are sometimes unnecessary.(7) The article states that parents should consult with lactation specialists, and often changing the baby’s feeding position results in successful latching.
Hathaway disagreed, saying, “I would say that frenectomies are underused. I think that, with the current baby formula shortage, more people will try breastfeeding, and if you don’t do a frenectomy on a baby with ties, the baby literally can’t eat.”
“There are many pediatricians who are against tongue-tie releases, but they are the same pediatricians who present no solutions to their patients in term of ways to improve feeding for babies,” Welke added. “Dentists like myself who have performed thousands of these procedures know when to treat and when not to treat.”
The experts took issue not only with the article’s conclusions, but with the research as well.
“The article danced around some issues; it didn’t have any pictures of the different kinds of ties we see,” Hathaway said.
Favre noted that “the last example in the article was a mom who actually improved with a laser release — it just speculates that a snip or clip may have been sufficient. All in all, it is a poorly written article with a lack of data to back up the claims it makes.”
Baxter says the article “purposefully left out research that supports tongue-tie treatment. They simply did not report it or cite it because it did not fit their narrative.”
A Team Approach
Dentists who perform frenectomies recommend a team approach.
“Working with a functional professional — such as a lactation consultant, speech or feeding therapist, or myofunctional therapist — is essential because all tied patients have compensations and need help to various degrees to overcome these old habits,” Baxter advised.
Hathaway works with a pulmonologist for airway considerations. Favre also noted that “interdisciplinary collaboration is necessary for success.”
Marketing
Collaboration is also part of marketing. Favre noted that, while he lists frenectomies on his website, he mainly gets referrals from other medical professionals.
“The best marketing method is word-of-mouth from previous patients,” Baxter said. “After proper training, announcing that you are open to helping these families on your website and social media often is enough to get started. From there, word will spread, and you will have more patients than you can serve.”
“There are many patients looking for help with frenectomy care,” Welke said. “Marketing should be done by dentists via their practice website or even creating a practice dedicated to only frenectomies.” Welke has done this and calls his practice the Chicago Tongue-Tie Center.
“It’s hard to find another procedure in dentistry that is more rewarding than helping babies nurse or eat better, kids speak better and with more confidence, or patients sleep more soundly,” Baxter said.
William S. Bike is a freelance writer and editor based in Chicago. He is a former director of advancement communications for the University of Illinois Chicago College of Dentistry. To comment on this article, email impact@agd.org.
References
1. “Frenum (Frenulum in Mouth).” Cleveland Clinic, my.clevelandclinic.org/health/body/frenum-mouth-frenulum. Last reviewed 12 Dec. 2023. Accessed 20 July 2024.
2. “Tongue-Tie (Ankyloglossia).” Mayo Clinic, 15 May 2018, mayoclinic.org/diseases-conditions/tongue-tie/ symptoms-causes/syc-20378452.
3. “Policy on Management of the Frenulum in Pediatric Patients.” American Academy of Pediatric Dentistry, aapd.org/globalassets/media/policies_guidelines/p_mgmt_frenulum.pdf. Revised in 2022. Accessed 3 Aug. 2024.
4. “What is a Frenectomy?” American Association of Oral and Maxillofacial Surgeons, myoms.org/what-we-do/oral-soft-tissue-surgery/what-is-a-frenectomy/. Last updated July 2023. Accessed 3 Aug. 2024.
5. Procedures: Frenectomy, Fiberotomy & Gingivoplasties. American Association of Orthodontists, St. Louis, Missouri. Brochure.
6. Lebret, Clément, et al. “Perioperative Outcomes of Frenectomy Using Laser Versus Conventional Surgery: A Systematic Review.” Journal of Oral Medicine and Oral Surgery, vol. 27, no. 3, 2021, doi: 10.1051/ mbcb/2021010.
7. Thomas, Jennifer, et al. “Identification and Management of Ankyloglossia and Its Effect on Breastfeeding in Infants: Clinical Report.” Pediatrics, vol. 154, no. 2, August 2024, e2024067605.
