Rev. CEFAC. 2020;22(1):e0120 http://dx.doi.org/10.

1590/1982-0216/20202210120

Original articles

Tongue position for lingual frenulum assessment

Roberta Lopes de Castro Martinelli1
https://orcid.org/0000-0002-5791-2575

Irene Queiroz Marchesan2

https://orcid.org/0000-0001-6483-7457

Giédre Berretin-Felix3
https://orcid.org/0000-0002-8614-2805

1
Hospital Santa Therezinha – Brotas, São ABSTRACT
Paulo, Brasil
2
CEFAC Saúde e Educação – São Paulo, Purpose: to compare the movements of elevation and protrusion of the tongue in order
São Paulo, Brasil to determine which position provides better lingual frenulum assessment.
3
Universidade de São Paulo, Faculdade
de Odontologia de Bauru - FOB, Bauru, Methods: a database of 92 audiovisual recordings of subjects over six-years of age
São Paulo, Brasil. diagnosed with ankyloglossia was used to verify the shape of the tip of the tongue
during tongue elevation and protrusion. The Chi-Square Test for Proportion was
Conflict of interests: Nonexistent
applied to verify possible differences between the postures of elevation and protrusion.
The significance level of 5% (p<0.05) was adopted.
Results: the statistical analysis demonstrated that both shapes, i.e., the V-shaped one
and the heart-shaped one are more visible during tongue elevation than during tongue
protrusion.
Conclusion: elevation is the position that allows the best observation of the shape of
the tip of the tongue.
Received on: January 1, 2020 Keywords: Lingual Frenulum; Tongue; Ankyloglossia; Speech, Language and Hearing
Accepted on: January 28, 2020 Sciences
Corresponding address:
Roberta Lopes de Castro Martinelli
Avenida Rui Barbosa, 703 – Centro
CEP: 17380-000 – Brotas, São Paulo,
Brasil
E-mail:[email protected]

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INTRODUCTION concerning the lingual frenulum tend to make the

The lingual frenulum is a dynamic three-dimensional diagnosis difficult and doubtful, interfering with the
structure formed by a central fold in a layer of fascia that reliability of the diagnosis28. Having standardized
extends across the floor of the mouth. The range in the assessment criteria is essential to avoid such
lingual frenulum morphology is created by variability – misunderstandings.
on a spectrum – of several factors1,2. Ankyloglossia is Based on those theoretical assumptions, the
characterized by a restriction of tongue movements1,3. formulated hypothesis was that the tongue elevation
Ankyloglossia is a complex condition impacting is the posture that allows the best observation of the
both mothers and infants. This requires interdisciplinary anatomical characteristic of the lingual frenulum during
approach for assessment and treatment. When ankylo- its assessment. Thus, this study aims to compare the
glossia is characterized by a lingual frenulum attached movements of elevation and protrusion of the tongue,
to the apex of the tongue and visible from the inferior in order to determine which posture provides a better
alveolar crest it can be easily diagnosed. Controversy lingual frenulum assessment.
around the diagnosis of ankyloglossia occur when the
alteration is not so visible. That requires a structural and METHODS
functional assessment of the oral cavity4. Prior authorization of services for the realization of
Several lingual frenulum assessment tools for this study was requested, the signing of the Consent
infants, children, adolescents, and adults have and Informed Form being exempted, for using
been published by professionals, such as dentists, secondary data, and the research was approved by
lactation consultants, midwives, speech-language the Research Ethics Committee of CEFAC Health
pathologists5-22. and Education, CAAE 48132015.3.0000.5538, under
Most authors recommend tongue elevation for opinion number 1,181,172.
diagnosing ankyloglossia 5-6,8,12-14,17-22. A few authors This is a cross-sectional exploratory descriptive
propose tongue protrusion for assessing the lingual retrospective study, in which a database of 92 audio-
frenulum7,11,15. Only one study states that both the visual recordings of subjects over six-years of age
symptoms reported by the mother and clinical evalu- diagnosed with ankyloglossia was used. The lingual
ation during breastfeeding may be sufficient to frenulum assessment was performed by two speech
diagnose ankyloglossia, that is, there is no need to put language pathologies highly experienced in lingual
the finger in the infant´s mouth10. frenulum evaluation. Both therapists assessed the
Tongue movements are essential for the perfor- lingual frenulum by means of the protocol proposed by
mance of orofacial functions. It must be highlighted Marchesan26.
that tongue elevation is needed for proper tongue rest All archives that did not allow accurate analysis of
posture, for adequate nasal breathing, swallowing the tongue’s elevation and protrusion position, as well
and production of the sounds [t], [d], [n], [l] e [ɾ]3,4. as those belonging to subjects previously submitted
An important aspect to remember is that protrusion to surgery for release of the lingual frenulum, or with a
of the tongue is not required for sucking, swallowing, history of neurological and oncological diseases were
breathing, chewing, and speaking. excluded.
In the clinical practice we come across profes- Only audiovisual recordings of tongue elevation and
sionals from several fields who assess lingual frenulum protrusion were considered for the study. The video
by asking the patient to protrude the tongue. If the recordings were analyzed frame by frame by using the
subject can protrude the tongue beyond the vermillion Media Player Classic software, version 1.7.13. For the
border of the lower lip the professionals do not consider latter analysis, the sections of maximum elevation and
frenotomy to be indicated23-25. However, the literature maximum protrusion were selected. The cropped video
cites a set of anatomical and functional characteristics imagens were inserted on a PowerPoint slide.
that must be considered for ankyloglossia diagnosis22-26. The following step consist of a blind evaluation
Brito et al. state that when both the assessment performed by two other speech language therapists,
of lingual frenulum and therapy plan are performed who analyzed the shape of the tongue when elevated
through personal criteria, they may fail, and an inter- and protruded. They classified the shapes as round,
disciplinary approach may be difficult27. Controversies V-shaped or heart-shaped ones (Figure 1).
among health professionals from different fields

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During tongue elevation, it was observed whether elevation. It was also observed whether the tongue
there was concomitant elevation of both the back of could protrude the tongue beyond the vermillion border
the tongue and the floor of the mouth. Those aspects of the lower lip (Figure 2).
could not be observed during protrusion, only during

Figure 1. Images of tongue tip shape when it was elevated and protruded. (A) round; (B) v-shaped (C) heart-shaped.

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Figure 2. Images of other characteristics observed in both elevation and protrusion postures. Normal aspects: without elevation of the
floor of the mouth (A); without elevation of the back of the tongue (B); and protrusion of the tongue beyond the vermillion border of the
lower lip (C). Alterations: elevation of the floor of the mouth (D); elevation of the back of the tongue (E); tongue cannot protrude beyond
the vermillion border of the lower lip (F).

After the analysis, the data were tabulated by using RESULTS

MS-Excel spreadsheets and the software Statistical Ninety-two audiovisual recordings of subjects
Package for Social Sciences (IBM SPSS), version 25.0, diagnosed with ankyloglossia were analyzed, 34
was used for statistical analysis. The Chi-Square Test females (36.96%) and 58 males (63.04%), aged from 6
for Proportion was applied to verify possible differences to 41, 8 years being the median.
between the postures of elevation and protrusion. The Table 1 shows the results from the descriptive statis-
significance level of 5% was adopted. tical analysis of tongue protrusion and elevation. The
statistical analysis demonstrated that both tongue tip
shapes, the V-shaped or the heart-shaped (Figure 3),
are more visible during tongue elevation than during
tongue protrusion (p<0.001).

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Table 1. Frequency and percentage of occurrence of the aspects analyzed in the position of tongue protrusion and elevation in subjects
with ankyloglossia

Protrusion Elevation
Variable p-value
Frequency Percentage Frequency Percentage
V-shaped 21 22.80% 44 47.80% 0.035*
Heart-shaped 8 8.70% 45 48.90% 0.001*
Round 63 68.50% 3 3.30% < 0.001*
Tongue protrudes beyond the vermillion border of the
90 97.83% - - -
lower lip
Elevation of the back of the tongue concomitant with
- - 40 43.50% -
elevation of the tip of the tongue
Elevation of the floor of the mouth concomitant with
- - 29 31.50% -
elevation of the tip of the tongue
Chi-Square Test for Proportions
*Statistical Significance

Figure 3. Characteristics of the tip of the tongue observed in 3 subjects diagnosed with ankyloglossia and their possibility of extending
the tongue beyond the vermillion border of the lower lip, during protrusion. In A and D, tongue protrusion and elevation of subject 1; in B
and E, tongue protrusion and elevation of subject 2; in C and F, tongue protrusion and elevation of subject 3.

Table 2 shows that most subjects with ankyloglossia This finding demonstrates that the protrusion position
(97.83%) can extend the tongue beyond the vermillion does not allow for an accurate identification of
border of the lower lip during protrusion (Figure 3). ankyloglossia.

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Table 2. Comparison of all variables between tongue elevation and the extending of the tongue beyond the vermillion border of the lower
lip, during protrusion in subjects with ankyloglossia

Variable n Percentage p-value

V-shaped observed during tongue elevation 44 47.83%
Extending the tongue beyond the vermilion border of lower lip < 0.001*
90 97.83%
during protrusion
Heart-shaped observed during tongue elevation 45 48.91%
Extending the tongue beyond the vermilion border of lower lip < 0.001*
90 97.83%
during protrusion
Round observed during tongue elevation 3 3.26%
Extending the tongue beyond the vermilion border of lower lip < 0.001*
90 97.83%
during protrusion
Elevation of the back of the tongue concomitant with elevation
40 43.48%
of the tip of the tongue
< 0.001*
Extending the tongue beyond the vermilion border of lower lip
90 97.83%
during protrusion
Elevation of the floor of the mouth concomitant with elevation
29 31.52%
of the tip of the tongue
< 0.001*
Extending the tongue beyond the vermilion border of lower lip
90 97.83%
during protrusion
Chi-Square Test for Proportions
*Statistical Significance

DISCUSSION state that elevation is the best posture to assess the

lingual frenulum.
This study aimed to compare the position of
Another relevant datum is that 97.83% of the
elevation and protrusion of the tongue to determine
subjects with ankyloglossia were able to extend the
which position provides better lingual frenulum
tongue beyond the vermillion border of the lower lip,
assessment. during protrusion (Table 1).
Of the 92 subjects aged from 6 to 41 diagnosed A comparison of all variables between tongue
with ankyloglossia, whose audiovisual recordings were elevation and the extending of the tongue beyond the
analyzed, 58 were males (63.04%). This finding agrees vermillion border of the lower lip, during protrusion, in
with studies that report higher prevalence of ankylo- subjects with ankyloglossia, demonstrated a statisti-
glossia in males than in females29,30. cally significant difference (p<0.001), as shown in
The statistical analysis demonstrated that both Table 2. Thus, protrusion is not a relevant posture for
tongue tip shapes, the V-shaped and the heart-shaped, ankyloglossia diagnosis.
(Figure 3) are more visible during tongue elevation than An important aspect to remember is that tongue
protusion is not required for oral functions, such as
during tongue protrusion (p<0.001). These findings
sucking, swallowing, breathing, chewing, and speaking.
demonstrated that tongue elevation is the position that
On the other hand, tongue elevation is essential for
allows for the best observation of the shape of the tip of
swallowing, for producing many speech sounds, and
the tongue, being possible to identify, more accurately,
for proper tongue rest posture28,34-36.
the presence of V-shaped or heart-shaped tip in
It is important to emphasize that a proper lingual
subjects with ankyloglossia. Thus, those findings agree
frenulum assessment must consider a set of charac-
with proposals of most assessment tools5,6,8,12-14,17-22,31-33.
teristics for the diagnosis of tongue movement
A study on the anatomy of the lingual frenulum restriction36. Unlike tongue protrusion, tongue elevation
states that the elevation of the anterior and middle parts allows for the assessment of the lingual frenulum, since
of the tongue and/or retraction creates tension in the this position favors the visualization of the anatomical
fascial layer of the floor of the mouth, drawing the fascia characteristics regarding thickness, attachment of the
and the overlying mucosa up into a midline sagittal fold tongue to the floor of the mouth, and shape of the tip of
that forms the lingual frenulum1. Thus, it is possible to the tongue36.

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CONCLUSION 12. Martinelli RLC, Marchesan IQ, Lauris JR, Honório

HM, Gusmão RJ, Berretin-Felix G. Validation of the
Elevation is the position that allows the best obser-
Lingual Frenulum Protocol for infants. Int J Orofacial
vation of the shape of the tip of the tongue, allowing
Myology. 2016;42:5-13.
for a more accurate identification of the presence
of V-shaped and heart-shaped tips in subjects with 13. Martinelli RLC, Marchesan IQ, Lauris JR, Honório
ankyloglossia. HM, Gusmão RJ, Berretin-Felix G. Validade e
confiabilidade da triagem: “teste da linguinha”.
Rev. CEFAC. 2016;18(6):1323-31.
REFERENCES 14. Walker RD, Messing S, Rosen-Carole C, McKenna
1. Mills N, Pransky SM, Geddes DT, Mirjalili SA. What Benoit M. Defining tip-frenulum length for
is a tongue tie? Defining the anatomy of the in-situ ankyloglossia and its impact on breastfeeding:
lingual frenulum. Clin Anat. 2019;32(6):749-61. a prospective cohort study. Breastfeed Med.
2. Mills N, Keough N, Geddes DT, Pransky SM, Mirjalili 2018:13(3):204-10.
SA. Defining the anatomy of the neonatal lingual 15. Ingram J, Copeland M, Johnson D, Emond A. The
frenulum. Clin Anat. 2019;32(6):824-35. development and evaluation of a picture tongue
3. Zaghi S, Valcu-Pinkerton S, Jabara M, Norouz- assessment tool for tongue-tie in breastfed babies
Knutsen L, Govardhan C, Moeller J et al. Lingual (TABBY). Int Breastfeed J. 2019;14:31.
frenuloplasty with myofunctional therapy: Exploring 16. Fernando C. Tongue-tie - from confusion to
safety and efficacy in 348 cases. Laryngoscope clarity: a guide to the diagnosis and treatment of
Investig Otolaryngol. 2019;4(5):489-96. ankyloglossia. Tandem. 1998.
4. Walsh J, McKenna Benoit M. Ankyloglossia 17. Lee SK, Kim YS, Lim CY. A pathological
and other oral ties. Otolaryngol Clin North Am. consideration of ankyloglossia and lingual
2019;52(5):795-811. myoplasty. Taehan Chikkwa Uisa hyophoe Chi
5. Hazelbaker AK. The assessment tool for lingual 1989;27:287-308.
frenulum function (ATLFF): use in a lactation 18. Kotlow LA. Ankyloglossia (tongue-tie): a diagnostic
consultant private practice [thesis]. Pasadena, CA: and treatment quandary. Quintessence Int
Pacific Oaks College; 1993. 1999;30:259-62.
6. Coryllos E, Genna CW, Salloum AC. Congenital 19. Marchesan IQ. Frênulo lingual: proposta
tongue-tie and its impact in breastfeeding. de avaliação quantitativa. Rev. CEFAC.
Breastfeeding: Best for mother and baby 2004;6(3):288-93.
Newsletter. 2004;1-6 20. Ruffoli R, Giambelluca MA, Scavuzzo MC, Bonfigli
7. Griffiths DM. Do tongue ties affect breastfeeding? J D, Cristofani R, Gabriele M et al. Ankyloglossia: a
Hum Lact. 2004;20(4):409-14. morphofunctional investigation in children. Oral
8. Hogan M, Westcott C, Griffiths M. Randomized, Diseases. 2005;11:170-4.
controlled trial of division of tongue-tie in infants 21. Marchesan IQ. Protocolo de avaliação do frênulo
with feeding problems. J Paediatr Child Health. da língua. Rev. CEFAC. 2010;12(6):977-89.
2005;41(5-6):246-50. 22. Yoon A, Zaghi S, Weitzman R, Ha S, Law CS,
9. Srinivasan A, Dobrich C, Mitnick H, Feldman P. Guilleminault C, Liu SY. Toward a functional
Ankyloglossia in breastfeeding infants: the effect definition of ankyloglossia: validating current
of frenotomy on maternal nipple pain and latch. grading scales for lingual frenulum length and
Breastfeed Med. 2006;1(4):216-24. tongue mobility in 1052 subjects. Sleep Breath.
10. Baeza CE, de Alba Romero C, Morales AM, Querol Sleep Breath. 2017 Sep;21(3):767-775.
N. Diagnosing Ankyloglossia: do we need to put the 23. Wallace AF. Tongue-tie. Lancet. 1963;2:377-8.
finger in the mouth? Journal of Human Lactation. 24. Sedano HO, Carreon Freyre I, Garza de la Garza
2013;29(1):95-6 ML, Gomar Franco CM, Grimaldo Hernandez C,
11. Ingram J, Johnson D, Copeland M, Churchill Hernandez Montoya ME et al. Clinical orodental
C, Taylor H, Emond A. The development of a abnormalities in Mexican children. Oral Surg Oral
tongue assessment tool to assist with tongue-tie Med Oral Pathol.1989;68:300-11.
identification. Arch Dis Child Fetal Neonatal Ed. 25. Obrigatoriedade do Teste da Linguinha em
2015;100(4):F344-8. recém-nascidos entra em vigor. TV Senado,

doi: 10.1590/1982-0216/20202210120 | Rev. CEFAC. 2020;22(1):e0120

8/8 | Martinelli RLC, Marchesan IQ, Berretin-Felix G

2014. Disponível em: https://www.youtube.com/

watch?v=NqHAGjukTCo Acesso em: 29 nov. 2019.
26. Marchesan IQ. Protocolo de avaliação do frênulo
da língua. Rev. CEFAC. 2010;12(6):977-89.
27. Brito SF, Marchesan IQ, Bosco CM, Carrilho
ACA, Rehder MI. Frênulo lingual: classificação
e conduta segundo ótica fonoaudiológica,
odontológica e otorrinolaringológica. Rev. CEFAC.
2008;10(3):343-51.
28. Marchesan IQ, Teixeira AN, Cattoni DM. Correlações
entre diferentes frênulos linguais e alterações na
fala. Distúrb. Comun. 2010;22(3):195-200.
29. Ata N, Alataş N, Yılmaz E, Adam AB, Gezgin B. The
relationship of ankyloglossia with gender in children
and the ideal timing of surgery in ankyloglossia. Ear
Nose Throat J. 2019 Sep 26:145561319867666.
[Epub ahead of print]
30. Caloway C, Hersh CJ, Baars R, Sally S, Diercks
G, Hartnick CJ. Association of feeding evaluation
with frenotomy rates in infants with breastfeeding
difficulties. JAMA Otolaryngol Head Neck Surg.
2019 Jul 11. [Epub ahead of print]
31. Martinelli RLC. Relação entre as características
anatômicas do frênulo lingual e as funções de
sucção e deglutição em bebês [dissertação].
Bauru (SP): Faculdade de Odontologia de Bauru,
Universidade de São Paulo; 2013.
32. Cunha RF, Silva JZ, Faria MD. Clinical approach of
ankyloglossia in babies: report of two cases. J Clin
Pediatr Dent. 2008;32(4):277-81.
33. Karabulut R, Sönmez K, Türkyilmaz Z, Demirogullari
B, Ozen IO, Bagbanci B et al. Ankyloglossia and
effects on breastfeeding, speech problems and
mechanical/social issues in children. B-ENT.
2008;4(2):81-5.
34. Cockley L, Lehman A. The Ortho missing link: could
it be tied to the tongue. JAOS. 2015;15(1):18-21.
35. Martinelli RLC, Marchesan IQ, Berretin-Felix G. Rest
position of the tongue in infants with and without
lingual frenulum alteration. Int J Orofacial Myology.
2016;42:43-8.
36. Martinelli RLC, Marchesan IQ. Frênulo lingual.
In: Silva HJ, Tessitore A, Motta AR, Cunha DA,
Berretin-Felix G, Marchesan IQ (orgs). Tratado
de Motricidade Orofacial. São José dos Campos:
Pulso Editorial. 2019.

Rev. CEFAC. 2020;22(1):e0120 | doi: 10.1590/1982-0216/20202210120