AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Management Considerations for Pediatric Oral

Surgery and Oral Pathology
Review Council
Council on Clinical Affairs

Latest Revision
2015

Purpose appropriate medical and dental consultations, anticipating

The purpose of this guideline is to define, describe clinical and preventing emergency situations, and being prepared to
presentation, and set forth general criteria and therapeutic treat emergency situations.3
goals for common pediatric oral surgery procedures and oral
pathological conditions. Dental evaluation
It is important to perform a thorough clinical and radiographic
Methods preoperative evaluation of the dentition as well as extraoral
This guideline was originally developed by the Council on and intraoral soft tissues.3-5 Radiographs can include intraoral
Clinical Affairs and adopted in 2005. This document is a films and extraoral imaging if the area of interest extends be-
revision of the previous version, last revised in 2014. It is yond the dentoalveolar complex. Surgery involving the maxilla
based on a review of the current dental and medical literature and mandible of young patients is complicated by the pre-
related to pediatric oral surgery, including a systematic search sence of developing tooth follicles. Alteration or deviation
®
of the PubMed /MEDLINE database using the terms:
pediatric, oral surgery, extraction, odontogenic infections, im-
from standard treatment modalities may be necessary to avoid
injuring the follicles.6 To minimize the negative effects of
pacted canines, third molars, supernumerary teeth, mesiodens, surgery on the developing dentition, careful planning using
mucocele, eruption cyst, eruption hematoma, attached frenum, radiographs, tomography,7 cone beam computed tomography,8
ankyloglossia, gingival keratin cysts, Epstein pearls, Bohn’s and/or 3-D imaging techniques9 is necessary to provide valu-
nodules, congenital epulis of newborn, dental lamina cysts, able information to assess the presence, absence, location, and/
natal teeth, and neonatal teeth; fields: all; limits: within the or quality of individual crown and root development.6
last 10 years, humans, English, clinical trials. Papers for review
were chosen from the list of articles matching these criteria Growth and development
and from references with selected articles. When data did not The potential for adverse effects on growth from injuries and/
appear sufficient or were inconclusive, recommendations were or surgery in the oral and maxillofacial region markedly
based upon expert and/or consensus opinion by experience increases the potential for risks and complications in the
researchers and clinicians. In addition, the manual Parameters pediatric population. Traumatic injuries involving the maxil-
of Care: Clinical Practice Guidelines for Oral and Maxillo- lofacial region can adversely affect growth, development, and
facial Surgery,1 developed by the American Association of Oral function. Therefore, a thorough evaluation of the growing
and Maxillofacial Surgeons (AAOMS), was consulted. patient must be done before surgical interventions are per-
formed to minimize the risk of damage to the growing facial
General considerations complex.3
Surgery performed on pediatric patients involves a number of
special considerations unique to this population. Several cri- Behavioral evaluation
tical issues deserve to be addressed. Behavioral guidance of children in the operative and periop-
erative periods presents a special challenge. Many children
Preoperative considerations benefit from modalities beyond local anesthesia and nitrous
Informed consent oxide/oxygen inhalation to control their anxiety.2,10 Manage-
Before any surgical procedure, informed consent must be ment of children under sedation or general anesthesia requires
obtained from the parent or legal guardian. For more infor-
mation, refer to AAPD’s Guideline on Informed Consent.2
ABBREVIATIONS
Medical evaluation AAOMS: American Association of Oral and Maxillofacial Surgeons.
Important considerations in treating a pediatric patient in- AAPD: American Academy Pediatric Dentistry.
clude obtaining a thorough medical history, obtaining

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REFERENCE MANUAL V 39 / NO 6 17 / 18

extensive training and expertise.2,11 Special attention should be cessory roots observed in primary canines.16-18 Radiographic
given to the assessment of the social, emotional, and psycho- examination is helpful to identify differences in root anatomy
logical status of the pediatric patient prior to surgery.12 Children prior to extraction.16-18 Care should be taken to avoid placing
have many unvoiced fears concerning the surgical experience, any force on adjacent teeth that could become luxated or
and their psychological management requires that the dentist dislodged easily due to their root anatomy.
be cognizant of their emotional status. Answering questions
concerning the surgery is important and should be done in Maxillary and mandibular molars
the presence of the parent. Primary molars have roots that are smaller in diameter and
more divergent than permanent molars. Root fracture in pri-
Peri- and post-operative considerations mary molars is not uncommon due to these characteristics as
Metabolic management of children following surgery fre- well as the potential weakening of the roots caused by the
quently is more complex than that of adults. Special consider- eruption of their permanent successors.3 Prior to extraction,
ation should be given to caloric intake, fluid and electrolyte the relationship of the primary roots to the developing suc-
management, and blood replacement. Comprehensive cedaneous tooth should be assessed. In order to avoid inad-
management of the pediatric patient following extensive oral vertent extraction or dislocation of or trauma to the permanent
and maxillofacial surgery usually is best accomplished in a successor, pressure should be avoided in the furcation area or
facility that has expertise and experience in the management the tooth may need to be sectioned to protect the developing
of young patients (i.e., a children’s hospital).3,4 permanent tooth.
Molar extractions are accomplished by using slow conti-
Recommendations nuous palatal/lingual and buccal force allowing for the ex-
Odontogenic infections pansion of the alveolar bone to accommodate the divergent
In children, odontogenic infections may involve more than roots and reduce the risk of root fracture.3 When extracting
one tooth and usually are due to carious lesions, periodontal mandibular molars, care should be taken to support the
problems, or a history of trauma.13-15 Untreated odontogenic mandible to protect the temporomandibular joints from
infections can lead to pain, abscess, cellulitis, and difficulty injury.3
eating or drinking. In these children, dehydration is a significant
consideration; prompt treatment of the source of infection is Fractured primary tooth roots
imperative. The presence of a root tip should not be regarded as a positive
With infections of the upper portion of the face, patients indication for its removal. The dilemma to consider when
usually complain of facial pain, fever, and inability to eat or managing a retained primary tooth root is that removing the
drink. Care must be taken to rule out sinusitis, as symptoms root tip may cause damage to the succedaneous tooth, while
may mimic an odontogenic infection. Occasionally in upper leaving the root tip may increase the chance for postopera-
face infections, it may be difficult to find the true cause. Infec- tive infection and delay eruption of the permanent successor.3
tions of the lower face usually involve pain, swelling, and Radiographs can assist in the decision process. Expert opinion
trismus.13 They frequently are associated with teeth, skin, local suggests that if the fractured root tip can be removed easily, it
lymph nodes, and salivary glands.13 Swelling of the lower face should be removed.3 If the root tip is very small, located deep
more commonly has been associated with dental infection.15 in the socket, situated in close proximity to the permanent
Most odontogenic infections can be managed with pulp successor, or unable to be retrieved after several attempts, it is
therapy, extraction, or incision and drainage. 3 Infections of best left to be resorbed.3 The parent must be informed and a
odontogenic origin with systemic manifestations [e.g., elevated complete record of the discussion must be documented. The
temperature (102 to 104 degrees Fahrenheit) facial cellulitis, patient should be monitored at appropriate intervals to eval-
difficulty in breathing or swallowing, fatigue, nausea] require uate for potential adverse effects.
antibiotic therapy. Severe but rare complications of odonto-
genic infections include cavernous sinus thrombosis and Management of unerupted and impacted teeth
Ludwig’s angina.3,13 These conditions can be life threatening There is a wide clinical spectrum of disorders of eruption in
and may require immediate hospitalization with intravenous both primary and permanent teeth in children. These may
antibiotics, incision and drainage, and referral/consultation be syndromic or non-syndromic and include ankyloses,19-23
with an oral and maxillofacial surgeon.3,13 secondary retention,24 or tooth impaction. Clinically, it may
be difficult to differentiate between the various disruptions;
Extraction of erupted teeth however, there have been many reports to assist the clinician
Maxillary and mandibular anterior teeth in making a diagnosis There is increasing evidence that there is
Most primary and permanent maxillary and mandibular cen- a genetic etiology for some of these eruption disruptions which
tral incisors, lateral incisors, and canines have conical single may help in a definitive diagnosis.25 Management will depend
roots. In most cases, extraction of anterior teeth is accom- on whether the tooth/teeth affected is likely to respond to
plished with a rotational movement, due to their single root orthodontic forces. If not, surgical extraction is the preferred
anatomies.3 However, there have been reported cases of ac- treatment option.

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Impacted canines or development of pathology, which may necessitate later

Tooth impaction may occur due to a mechanical obstruc- removal.
tion. Permanent maxillary canines are second to third molars
in frequency of impaction.26 Early detection of an ectopically Supernumerary teeth
erupting canine through visual inspection, palpation, and Supernumerary teeth and hyperdontia are terms to describe an
radiographic examination is important to maximize success of excess in tooth number. Supernumerary teeth are thought to
an intervention.27 Routine evaluation of patients in mid-mixed be related to disturbances in the initiation and proliferation
dentition should involve identifying signs such as lack of ca- stages of dental development.16,36 Although some supernu-
nine bulges and asymmetry in pattern of exfoliation. Abnormal merary teeth may be syndrome-associated (e.g., cleidocranial
angulation or ectopic eruption of developing permanent cus- dysplasia) or of familial inheritance pattern, most supernu-
pids can be assessed radiographically.27 When the cusp tip of merary teeth occur as isolated events.16
the permanent canine is just mesial to or overlaying the distal Supernumerary teeth can occur in either the primary or
half of the long axis of the root of the permanent lateral incisor, permanent dentition.16,37-39 In 33 percent of the cases, a super-
canine palatal impaction usually occurs.26 Extraction of the numerary tooth in the primary dentition is followed by the
primary canines is the treatment of choice to correct palatally supernumerary tooth complement in the permanent denti-
displaced canines or to prevent resorption of adjacent teeth.26 tion.40,41 Reports in incidence of supernumerary teeth can be
One study showed that 78 percent of ectopically erupting as high as three percent, with the permanent dentition being
permanent canines normalized within 12 months after removal affected five times more frequently than the primary dentition
of the primary canines; 64 percent normalized when the start- and males being affected twice as frequently as females.16,37,38
ing canine position overlapped the lateral incisor by more Supernumerary teeth will occur 10 times more often in the
than half of the root; and 91 percent normalized when the maxillary arch versus the mandibular arch.16 Approximately 90
starting canine position overlapped the lateral incisor by less percent of all single tooth supernumerary teeth are found in
than half of the root.26 If no improvement in canine position the maxillary arch, with a strong predilection to the anterior
occurs in a year, surgical and/or orthodontic treatment were region.16,39 The maxillary anterior midline is the most com-
suggested.26,27 A Cochrane review28 and a systematic review29 mon site, in which case the supernumerary tooth is known as
reported no evidence to support extraction of primary canines a mesiodens; the second most common site is the maxillary
to facilitate eruption of ectopic permanent maxillary canines. molar area, with the tooth known as a paramolar. 16,37,39 A
A prospective randomized clinical trial demonstrated that mesiodens can be suspected if there is an asymmetric erup-
extraction of primary canines is an effective measure to correct tion pattern of the maxillary incisors, delayed eruption of the
palatally displaced maxillary canines and is more successful in maxillary incisors with or without any over-retained primary
children with an early diagnosis.30 Consultation between the incisors, or ectopic eruption of a maxillary incisor.37,41 The
practitioner and an orthodontist may be useful in the final diagnosis of a mesiodens can be confirmed with radiographs,
treatment decision. including occlusal, periapical, or panoramic films, 42 or
computed tomography. 7,8 Three-dimensional information
Third molars needed to determine the location of the mesiodens or impacted
Panoramic or periapical radiographic examination is indicated tooth can be obtained by taking two periapical radiographs
in late adolescence to assess the presence, position, and devel- using either two projections taken at right angles to one
opment of third molars.5 AAOMS recommends that a decision another or the tube shift technique (buccal object rule or
to remove or retain third molars should be made before the Clark’s rule)42 or by cone beam computed tomography.8
middle of the third decade.1 Evidence-based research supports Complications of supernumerary teeth can include delayed
the removal of third molars when pathology (e.g., cysts or tu- and/or lack of eruption of the permanent tooth, crowding, re-
mors, caries, infection, pericoronitis, periodontal disease, detri- sorption of adjacent teeth, dentigerous cyst formation, peri-
mental changes of adjacent teeth or bone) is associated and/or coronal space ossification, and crown resorption. 43,44 Early
the tooth is malpositioned or nonfunctional (i.e., an unopposed diagnosis and appropriately timed treatment are important in
tooth).31-33 A systematic review of research literature from 1984 the prevention and avoidance of these complications. Because
to 2013 concluded there is no evidence to support31-34 or refute1 only 25 percent of all mesiodens erupt spontaneously, surgical
the prophylactic removal of disease-free impacted third molars. management often is necessary.41,45 A mesiodens that is conical
Factors that increase the risk for surgical complications (e.g., in shape and is not inverted has a better chance for eruption
coexisting systemic conditions, location of peripheral nerves, than a mesiodens that is tubular in shape and is inverted.43
history of temporomandibular joint disease, presence of cysts The treatment objective for a non-erupting permanent
or tumors)32,33 and position and inclination of the molar in mesiodens is to minimize eruption problems for the perma-
question35 should be assessed. The age of the patient is only a nent incisors.43 Surgical management will vary depending on
secondary consideration.35 Referral to an oral and maxillofacial the size, shape, and number of supernumeraries and the
surgeon for consultation and subsequent treatment may be patient’s dental development.43 The treatment objective for a
indicated. When a decision is made to retain impacted third nonerupting primary mesiodens differs in that the removal of
molars, they should be monitored for change in position and/ these teeth usually is not recommended, as the surgical

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REFERENCE MANUAL V 39 / NO 6 17 / 18

intervention may disrupt or damage the underlying developing lesions sometimes are referred to as eruption hematomas.48,51,56,59
permanent teeth.44 Erupted primary tooth mesiodens typically Because the tooth erupts through the lesion, no treatment is
are left to shed normally upon the eruption of the permanent necessary.48,51,56,59 If the cyst does not rupture spontaneously
dentition.44 or the lesion becomes infected, the roof of the cyst may be
Extraction of an unerupted primary or permanent mesio- opened surgically.7,51,56
dens is recommended during the mixed dentition to allow the
normal eruptive force of the permanent incisor to bring itself Mucocele
into the oral cavity.38 Waiting until the adjacent incisors have The mucocele is a common lesion in children and adolescents
at least two-thirds root development will present less risk to resulting from the rupture of a minor salivary gland excretory
the developing teeth but still allow spontaneous eruption of duct, with subsequent leakage of mucin into the adjacent con-
the incisors.1 In 75 percent of the cases, extraction of the me- nective tissues that later may be surrounded in a fibrous cap-
siodens during the mixed dentition results in spontaneous sule. 49,51,58-60 Most mucoceles are well-circumscribed bluish
eruption and alignment of the adjacent teeth.44,46 If the adja- translucent fluctuant swellings that are firm to palpation,
cent teeth do not erupt within six to 12 months, surgical although deeper and long-standing lesions may range from
exposure and orthodontic treatment may be necessary to aid normal in color to having a whitish keratinized surface.51,58-60
their eruption.45,47 Mucoceles most frequently are observed on the lower lip,
usually lateral to the midline.58 Mucoceles also can be found
Pediatric oral pathology on the buccal mucosa, ventral surface of the tongue, retromolar
Lesions of the newborn region, and floor of the mouth (ranula).58-60 Superficial muco-
Epstein’s pearls, dental lamina cysts, and Bohn’s nodules. Ep- celes and some other mucoceles are short-lived lesions that
stein’s pearls are common, found in about 75 to 80 percent of burst spontaneously, leaving shallow ulcers that heal within a
newborns.48-57 They occur in the median palatal raphe area48-52 few days.51,58-60 Local mechanical trauma to the minor salivary
as a result of trapped epithelial remnants along the line of gland is often the cause of rupture.45,52-54 Many lesions, how-
fusion of the palatal halves.44,46 Dental lamina cysts, found on ever, require treatment to minimize the risk of recurrence.51,58-60
the crests of the dental ridges, most commonly are seen bi-
laterally in the region of the first primary molars.50 They result Pediatric oral pathology management considerations
from remnants of the dental lamina. Bohn’s nodules are rem- Primary and reconstructive management of tumors in children
nants of salivary gland epithelium and usually are found on is affected by anatomical and physiological differences from
the buccal and lingual aspects of the ridge, away from the those of adult patients. Tumors generally grow faster in pedi-
midline. 48,49,51 Epstein’s pearls, Bohn’s nodules, and dental atric patients and are less predictable in behavior. The same
lamina cysts typically present as asymptomatic one to three physiological factors that affect tumor growth, however, can
millimeter nodules or papules. They are smooth, whitish in play a favorable role in healing following primary reconstruc-
appearance, and filled with keratin. 49,50 No treatment is tive surgery. Pediatric patients are more resilient and heal
required, as these cysts usually disappear during the first three more rapidly than their adult counterparts.2
months of life.49,52 A wide spectrum of oral lesions occurs in children and
adolescents, including soft and hard tissue lesions of the oral
Congenital epulis of the newborn. Congenital epulis of the maxillofacial region. There is limited information on the
newborn, also known as granular cell tumor or Neumann’s tu- prevalence of oral lesions in the pediatric population. The
mor, is a rare benign tumor seen only in newborns. This lesion largest epidemiologic studies in the US place the prevalence
is typically a protuberant mass arising from the gingival mu- rate in children at four to 10 percent with the exclusion of
cosa. It is most often found on the anterior maxillary ridge.53,54 infants. 61,62 Although the vast majority of these lesions re-
Patients typically present with feeding and/or respiratory present mucosal conditions, developmental anomalies, and
problems.54 Congenital epulis has a marked predilection for reactive or inflammatory lesions, it is imperative to be vigilant
females at 8:1 to 10:1.53-55 Treatment normally consists of for neoplastic diseases.
surgical excision.53-55 The newborn usually heals well, and no Regardless of the age of the child, it is important to estab-
future complications or treatment should be expected. lish a working diagnosis for every lesion. This is based on
obtaining a thorough history, assessing the risk factors and
Eruption cyst (eruption hematoma) documenting the clinical signs and symptoms of the lesion.
The eruption cyst is a soft tissue cyst that results from a sepa- Based on these facts, a list of lesions with similar characteris-
ration of the dental follicle from the crown of an erupting tics is rank ordered from most likely to least likely diagnosis.
tooth.49,60 Fluid accumulation occurs within this created fol- The entity that is judged to be the most likely disease becomes
licular space.48,51,56,59 Eruption cysts most commonly are found the working diagnosis and determines the initial manage-
in the mandibular molar region.55 Color of these lesions can ment approach.
range from normal to blue-black or brown, depending on For most oral lesions, a definitive diagnosis is best made
the amount of blood in the cystic fluid.7,51,56,59 The blood is by performing a biopsy of the diseased tissue. By definition, a
secondary to trauma. If trauma is intense, these blood-filled biopsy is the removal of a piece of tissue from a living body

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 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

for diagnostic study and is considered the gold standard of 6. Complete the surgical pathology form including patient
diagnostic tests.63 The two most common biopsies are the inci- demographics, the submitting dentist’s name and ad-
sional and excisional types. Excisional biopsies usually are per- dress, and a brief but accurate history. It is important to
formed on small lesions, less than one centimeter in size, for have legible records so that the diagnosis is not delayed.
the total removal of the affected tissue. An incisional biopsy is Clinical photographs and radiographs often are very
performed when a malignancy is suspected, the lesion is large useful for correlating the microscopic findings.
in size or diffuse in nature, or a multifocal distribution is
present. Multiple incisional biopsies may be indicated for Although the following list is not inclusive, examples of
diffuse lesions, in order to obtain a representative tissue sample. common oral lesions that may be biopsied include:
Fine needle aspiration, the cytobrush technique, and exfoliative 1. Gingival hyperplasia that is nonresponsive to oral hy-
cytology may assist in making a diagnosis, but they are giene measures.
considered adjunctive tests because they do not establish a 2. Pyogenic granuloma and other reactive gingival lesions.
definitive diagnosis.64,65 3. Mucocele.
It is considered the standard of care that any abnormal 4. Squamous papilloma or oral wart.
tissue removed from the oral and maxillofacial region be sub- 5. Irritation fibroma.
mitted for histopathologic examination. Exceptions to this 6. Inflamed operculum.
rule include carious teeth that do not have soft tissue attached, 7. Periapical cyst or granuloma which may or may not be
extirpated pulpal tissue, and clinically normal tissue, such as attached to an extracted tooth.
tissue from gingival recontouring.66 Gross description of all 8. Hyperkeratosis of uncertain cause.
tissue that is removed should be entered into the patient record. 9. Smokeless tobacco keratosis.
In general, a soft tissue biopsy should be performed when a 10. Benign migratory glossitis with an atypical or stationary
lesion persists for greater than two weeks despite removal of pattern.
the suspected causative factor or empirical drug treatment. It 11. Persistent oral ulcers.
is also imperative to submit hard or soft tissue for evaluation to 12. Mucocutaneous diseases.
a pathologist if the differential diagnosis includes at least one 13. Dental follicle cyst or dentigerous cyst.
significant disease or neoplasm. Histopathologic examination 14. Odontoma.
not only furnishes a definitive diagnosis, but it provides
information about the clinical behavior and prognosis and Structural anomalies
determines the need for additional treatment or follow-up. Frenum attachments and their impact on oral motor function
Another valuable outcome is that it allows the clinician to and development have become a topic of emerging interest
deliver evidence-based medical/dental care and increases the among the community as well as various specialties of health-
likelihood for a positive result. Furthermore, it presents im- care providers. Studies have shown differences in treatment
portant documentation about the lesion for the patient record, recommendations among pediatricians, otolaryngologists, lac-
including the procedures taken for establishing a diagnosis.63 tation consultants, speech pathologists, surgeons, and dental
Many oral biopsies are within the scope of practice for a specialists.67-75 Clear indications and timing of surgical treat-
pediatric dentist to perform. However, if the tissue is excised, ment remain controversial due to lack of consensus regarding
the following steps should be taken for optimum results:63,66 accepted anatomical and diagnostic criteria for degree of
1. Select the most representative lesion site and not the restriction and relative impact on growth, development, feed-
area that is the most accessible. ing, or oral motor function.67-75 Although, the etiology of this
2. Remove an adequate amount of tissue. If the biopsy is condition remains unknown, there appears to be a higher
too small or too superficial, a diagnosis may be com- predilection in males towards anomalies of frenum attachments,
promised. whether it is ankyloglossia or hypertrophic/restrictive maxillary
3. Avoid crushing or distorting the tissue. Damage is most labial frenum.68,74,76
often observed from the forces of the tissue forceps,
tearing the tissues or overheating the tissue from the use Ankyloglossia/restrictive mandibular lingual frenum
of electrosurgery or laser removal. Ankyloglossia is a developmental anomaly of the tongue
4. Immediately place the tissue in a fixative, which for most characterized by a short, thick lingual frenum resulting in
samples is 10 percent formalin. It is critical not to dilute limitation of tongue movement (partial ankyloglossia) or by
the fixative with water or other liquids because tissue the tongue appearing to be fused to the floor of the mouth
autolysis will render the sample nondiagnositic. (total ankyloglossia). 70,77 Studies with different diagnostic
5. Proper identification of the specimen is essential. The criteria report prevalence of ankyloglossia between four and
formalin container should be labelled with the name 10.7 percent of the population.67,68 Several diagnostic classi-
of the patient and the location. Multiple tissue samples fications have been proposed based on anatomical and func-
from different locations should not be placed in the tional criteria, but none has been universally accepted.67
same container, unless they are uniquely identified, such Ankyloglossia has been associated with breastfeeding dif-
as tagged with a suture. ficulties among neonates, limited tongue mobility and speech

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REFERENCE MANUAL V 39 / NO 6 17 / 18

difficulties, malocclusion, and gingival recession.67-75,78 A short The most commonly observed types are mucosal and gin-
frenum can inhibit tongue movement and create deglutition gival.74 However, it is also reported that a maxillary frenum
problems.67,79,80 During breastfeeding, a restrictive frenum can is a dynamic structure that presents changes in position of
cause ineffective latch, inadequate milk transfer and intake, insertion, structure, and shape during growth and develop-
and persistent maternal nipple pain, all of which can affect ment.74 Infants have the highest prevalence of papillary pene-
feeding adversely. 67-82 Systematic literature review articles trating phenotype.74,88 In severe instances, maxillary frenum
acknowledge the role of frenectomy procedure in improved attachment has been associated with breastfeeding difficulties
breastfeeding and reduction in maternal nipple pain when among newborns.52,71,89 Hyperplastic labial frenum that inserts
provided in conjunction with support of other allied health- into free or marginal gingiva has been suggested to interfere
care professionals.67-70,73 with proper oral hygiene measures and potentially lead to
Limitations in tongue mobility and speech pathology facial-cervical caries as well as initiation and progression of
have been associated with ankyloglossia.67,83,84 Speech articu- gingival/periodontal disease due to interference with adequate
lation is largely perceptual in nature, and differences in oral hygiene. 89-91 However, further research is required to
pronunciation are often evaluated subjectively. There is very substantiate the cause-and-effect relationship.
high variability in the speech assessment outcomes among When treatment is considered due to higher caries risk, anti-
individuals and specialists from different medical back- cipatory guidance and other preventive measures should be
grounds. 68 The difficulties in articulation are evident for emphasized. Surgical removal of maxillary midline frenum is
consonants and sounds like /s/, /z/, /t/, /d/, /l/, /j/, /zh/, /ch/, also related to presence or prevention of midline diastema
/th/, /dg/, and it is especially difficult to roll an r.68,83 Speech formation, prevention of post orthodontic relapse, esthetics,
therapy in conjunction with frenuloplasty or frenectomy and psychological considerations. 71-74,92 Treatment options
can be a treatment option to improve tongue mobility and and sequence of care vary with patient age and can include
speech.83,84 There has been varied opinion among health care orthodontics, restorative dentistry, surgery, or a combination
professionals regarding the correlation between ankyloglossia of these.92 Treatment is suggested when the attachment exerts
and speech disorders.59,64 Further evidence is needed to de- a traumatic force on the gingiva causing the papilla to
termine the benefit of surgical correction of ankyloglossia and blanch when the upper lip is pulled or if it causes a diastema
its relation to speech pathology as there are many children and wider than two millimeters, which is known to rarely close
individuals with ankyloglossia who do not suffer from speech spontaneously during further development. 74,78,92 When a
difficulty.67,73,85 diastema is present, the objectives for treatment involve
There is limited evidence to show that ankyloglossia and involve managing both the diastema of permanent teeth and
abnormal tongue position may affect skeletal development and its etiology.92 If orthodontic treatment is indicated, the need
be associated with Class III malocclusion.61,80,86 A complete for frenectomy should be assessed and coordinated with ortho-
orthodontic evaluation, diagnosis, and treatment plan are dontic closure of the diastema to achieve stable results.7,78,92
necessary prior to any surgical intervention.86
Localized gingival recession on the lingual aspect of the Mandibular labial frenum
mandibular incisors has been associated with ankyloglossia A high frenum sometimes can present on the labial aspect
in some cases where frenal attachment causes gingival retrac- of the mandibular ridge. This is most often seen in the
tion.67,70 As with most periodontal conditions, elimination of permanent central incisor area and frequently occurs in indiv-
plaque-induced gingival inflammation can minimize gingival iduals where the vestibule is shallow. 70 The mandibular
recession without any surgical intervention.67 When recession anterior frenum, as it is known, occasionally inserts into the
continues even after oral hygiene management, surgical inter- free or marginal gingival tissue.70 Movements of the lower lip
vention may be indicated.67,70 cause the frenum to pull on the fibers inserting into the free
marginal tissue, which in turn, can lead to food and plaque
Maxillary frenum accumulation.70 Early treatment can be considered to prevent
A prominent maxillary frenum in infants, children, and ado- subsequent inflammation, recession, pocket formation, and
lescents, although a common finding, is often a concern. possible loss of the alveolar bone and/or tooth.70 However, if
The maxillary labial frenal attachment can be classified with factors causing gingival/periodontal inflammation are con-
respect to its anatomical insertion level. trolled, the degree of recession and need for treatment
1. Mucosal (frenal fibers are attached up to the mucogin- decreases.67,70
gival junction).
2. Gingival (fibers are inserted within the attached gingiva). Frenectomy procedure
3. Papillary (fibers are extending into the interdental Although there is limited evidence in the literature to promote
papilla). the timing, indication, and type of surgical intervention,
4. Papilla penetrating (fibers cross the alveolar process and frenectomy for functional limitations should be considered
extend up to the palatine papilla).74,88 on an individual basis. 67,68,80,82,84,93 When indicated,
frenuloplasty/frenotomy (various methods to release the frenum
and correct the anatomic situation) or frenectomy (simple

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 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

cutting of the frenulum may be a successful approach to alle- 2. American Academy of Pediatric Dentistry. Guideline on
viate the problem.67,68,74,94 Each of these procedures involves informed consent. Pediatr Dent 2015;37(special issue):
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