Tongue-Tie: When Surgery Is Needed (and When It Isn't)

At Bites Odontopediatría I see many babies referred for a tongue-tie evaluation. And honestly, many of them don't need surgery. This is one of the uncomfortable truths of pediatric dentistry today: ankyloglossia is being over-diagnosed, and by extension over-operated, in Chile and worldwide.

I want to explain how our multidisciplinary team decides when a frenectomy is truly indicated and when it isn't.

The problem with anatomical diagnosis

The traditional way to diagnose ankyloglossia is to look at the tongue. If the frenulum looks short, if the tongue forms a heart shape when lifted, if it doesn't extend far when stuck out, it gets labeled "tongue-tie" and surgery is often indicated.

The problem with that approach is that anatomy doesn't predict function. Surgery is decided by function, not by the photo. That's why a thorough diagnosis matters, ideally led by a speech therapist specialized in orofacial motor function.

What actually matters: the functional signs

When a mother consults me because she was told her baby has a tongue-tie, my first question isn't "can I see it?". It's "how is breastfeeding or complementary feeding going? Does the baby rest with the mouth open and the tongue low?". The functional signs I evaluate:

In the mother:

• Persistent nipple pain, especially at the start of each feed.
• Cracks, lesions, or nipples flattened after nursing.
• Recurrent mastitis or blocked ducts with no clear cause.
• The feeling that the baby never gets full and asks to feed very often.

In the baby:

• Weight gain below the expected curve on exclusive breastfeeding.
• Very long or very frequent feeds.
• Audible clicking while nursing (the baby loses the seal).
• Inability to lift the tongue toward the palate when crying.
• Coughing or choking during feeds.
• Significant reflux (it can be secondary to air swallowing from a poor seal).

If several of these signs appear together and persist, clinical suspicion is high. If there are just one or two isolated ones, another cause is more likely: positioning at the breast, letdown management, work with a lactation consultant.

What I evaluate at the appointment

The evaluation at Bites takes about 30 minutes and combines several elements:

Anatomical exam of the tongue:

• Ability to lift against the palate.
• Lateral movement.
• Shape of the tongue when extended and when lifted.
• Where the frenulum attaches (tip, body, or base).
• Characteristics of the frenulum (thin, fibrous, wide, with a muscular component).

Watching the baby feed: whenever possible, I observe a feed directly. The mother breastfeeds or bottle-feeds, depending on the case, and I watch how the baby seals, how the tongue moves, what happens with the nipple or teat. We also look at the baby's overall posture, neck, and limbs. If we have doubts, we refer to a physical therapist or osteopath, since this can also affect breastfeeding.

A conversation with the mother:

• The breastfeeding story from day one.
• Current professional support (midwife, lactation consultant, pediatrician).
• The baby's weight curve.
• What the family is already considering.

I always refer to a speech therapist specialized in breastfeeding or a lactation consultant for a complementary evaluation. When doubt persists, a frenectomy is not a decision made in a single appointment.

When surgery IS indicated

I indicate a frenectomy when all of the following are true at the same time:

1. There is a clear, persistent functional limitation (at least 2-3 of the signs listed above that haven't improved with non-surgical management).
2. The anatomical exam confirms the frenulum as the likely cause (not just an incidental finding).
3. The family understands what changes and what doesn't with the surgery. A frenectomy doesn't guarantee breastfeeding improves immediately: the baby may need to relearn how to use the tongue, always with speech therapy support.

When those three criteria are met, the procedure improves function in the vast majority of cases. I do it with a diode laser, in the dental chair, as an outpatient procedure, and the mother can nurse the baby immediately afterward. You can see more about laser frenectomy in Vitacura: the procedure, what it includes, and how to book.

When I DON'T operate

I don't indicate a frenectomy when:

• The reason is aesthetic ("the tongue looks odd").
• The baby is gaining weight well, the mother has no pain, and functional limitation has been ruled out. Even if the frenulum looks short or questionable.
• Another cause of the feeding problem is more likely and the tongue looks fine (positioning, technique, low milk supply).
• There's no support team for after the surgery. A frenectomy without lactation and speech therapy support may not translate into functional improvement.

Those "no"s matter as much as the "yes"es. Over-treatment in ankyloglossia is a real problem.

If a speech therapist or lactation consultant already referred you

The referral is a good first step. It doesn't automatically mean your baby needs surgery. The evaluation at Bites is there to confirm (or rule out) the indication using functional criteria. If we decide to operate, we do it at the same appointment when feasible.

Before booking, it's worth reviewing when a frenectomy is actually necessary in babies. If several functional signs sound familiar, the appointment makes much more sense.