Ankyloglossia: A Comprehensive Narrative Review of Contemporary Concepts in Diagnosis and Management

Abstract

Background: Ankyloglossia (tongue-tie) is a congenital condition in which a short, thick, or anteriorly placed lingual frenulum restricts tongue mobility, with potential adverse consequences including difficulties with breastfeeding, speech, dental development, and quality of life. Although the condition has been recognised for centuries, clinicians continue to debate its definition, prevalence, and when treatment is truly warranted. Reported prevalence varies from 0.1% to 10.7%, a range attributable largely to heterogeneity in diagnostic criteria and assessment tools rather than true population differences. In the United States alone, diagnoses quadrupled between 2003 and 2012, yet no universally accepted classification system or management pathway has emerged. This fragmentation across paediatrics, neonatology, otolaryngology, speech-language pathology, lactation consultancy, and paediatric dentistry creates diagnostic inconsistency and variable treatment that may harm families through both unnecessary surgery and unaddressed functional impairment. Methodology: A comprehensive narrative review was conducted. A systematic literature search was performed in 2026 across PubMed/MEDLINE, Scopus, and Google Scholar, using MeSH terms and free-text keywords including "ankyloglossia," "lingual frenulum," "tongue-tie," "frenotomy," "frenulotomy," "frenectomy," "frenuloplasty," "breastfeeding AND frenulum," and "pediatric oral surgery." The primary date range was 2000 to 2026; landmark studies published before 2000 were included through backward citation tracking where they represented foundational evidence. Results: The Kotlow anatomical classification and the Zaghi functional grading system are the most reproducible frameworks for clinical and research use. Surgical management comprising frenotomy, frenuloplasty, or frenectomy, remains the cornerstone for moderate-to-severe presentations, with laser-assisted techniques offering meaningful advantages in haemostasis, post-operative comfort, and cooperative behaviour in children. Integrated myofunctional therapy improves long-term functional outcomes when combined with surgical release. Conclusion: Ankyloglossia is a clinically significant but diagnostically inconsistent condition in the paediatric population. Conservative management with lactation support and Orofacial Myofunctional Therapy (OMT) should precede surgical referral. Significant evidence gaps remain, particularly regarding speech outcomes and long-term surgical results; high-quality multicentre randomised controlled trials with standardised diagnostic criteria and validated outcome measures are much needed.