Lingual Frenuloplasty with Myofunctional Therapy: Improving Outcomes for the Treatment of Ankyloglossia (Tongue-Tie) with Refined Techniques and Endpoints

Abstract

Purpose: Ankyloglossia (tongue-tie) can lead to oromyofascial dysfunction which affects breathing, swallowing, speech, and posture. This study presents the evolution and outcomes of a refined lingual frenuloplasty protocol that integrates individualized myofunctional therapy to address compensatory patterns. Methods: A prospective cohort of 445 patients (≥4 years) was treated between 2021 and 2023 using a fascia-preserving CO₂ laser protocol with structured pre- and postoperative myofunctional therapy. Patients were stratified as pediatric (<12 years) or adolescent/adult (≥12 years). Key refinements included fascia-sparing dissection, reduced suture tension with cyanoacrylate adhesive, defined functional endpoints, structured myofunctional therapy, and standardized wound-healing strategies. Results: Among 379 patients (85% response) with >2 months follow-up, the 2025 protocol achieved an 86% satisfaction rate and significantly fewer complications compared with 2019 (pain 3.7% vs. 15.8%; bleeding 1% vs. 13%; revision 2.1% vs. 6.6%). Deeper genioglossus dissection increased swelling risk (OR = 4.0, p < 0.0001) but did not affect satisfaction. Conclusions: The refined 2025 protocol represents an outcome-tracked advancement in ankyloglossia management. By emphasizing fascia preservation, functional diagnostics, and integrated myofunctional therapy, the approach improves safety, efficacy, and patient-centered outcomes.

1. Introduction

Ankyloglossia (tongue-tie) is a condition of limited tongue mobility due to restrictive tissues connecting the tongue to the floor of the mouth. [1] Orofacial myofunctional disorders (OMDs) encompass various dysfunctions related to the muscles and functions of the face and mouth, impacting breathing, swallowing, speech, orthodontic issues, grinding, neck tension, jaw pain, and postural stability [2,3,4]. Orofacial myofunctional therapy (OMT or myofunctional therapy, as it is referenced in this paper) includes awareness, individualized exercises, neuromuscular repatterning, and retraining aimed at addressing the root causes of dysfunctional compensations and maladaptive habits [4,5,6,7]. Ankyloglossia is frequently observed in patients with orofacial dysfunction [8,9].

Lingual frenuloplasty, a surgical procedure to release restrictive lingual tissue, can facilitate improved tongue mobility and function [10,11,12]. However, the clinical effectiveness of frenuloplasty has been debated, particularly regarding its impact on speech and developmental outcomes [13,14,15]. These uncertainties highlight the multifactorial nature of OMDs and the importance of treatment approaches that go beyond anatomical correction including addressing learned behaviors and compensatory mechanisms (see Figure S1). Meanwhile, other studies indicate that frenuloplasty can lead to improvements in speech articulation and tongue mobility, supporting its use in clinical practice for children with speech difficulties attributed to tongue-tie [16,17,18]. These studies underscore the need to address not just the mechanical limitations of tongue-tie but also the broader myofunctional, postural, and compensatory mechanisms [11].

In addition to its impact on feeding, speech, and oral hygiene, ankyloglossia can interfere with the normal development and integration of primitive reflexes. Studies have shown that retained primitive reflexes, such as the rooting and sucking reflexes, can be indicative of neurobehavioral reflex disorders and delayed cortical maturation, further emphasizing the importance of addressing tongue-tie early in development [19,20]. A broader understanding of contributing factors, such as nasal obstruction, limited tongue space, fascial restriction, mouth breathing, retained reflexes, and sensorimotor discoordination, is essential for identifying patients likely to benefit from a combined surgical and therapeutic approach [19,20,21].

Prior investigations have demonstrated that lingual frenuloplasty, when integrated with structured myofunctional therapy, improves both safety and efficacy compared to surgical intervention alone [10,22]. Recent refinements in this combined approach have prioritized fascia preservation, functional diagnostics, and reproducibility of outcomes across providers and settings.

This paper outlines the evolution of a lingual frenuloplasty protocol combined with myofunctional therapy. Initially developed in 2017 with a primarily anatomic focus, the protocol has matured through 2025 into a standardized, minimally invasive model that prioritizes functional mobility endpoints, fascia-sparing dissection, and interdisciplinary care. This prospective descriptive cohort analysis was designed to transparently document patient outcomes within a high-volume clinical setting. Rather than isolating variables, this study aims to contribute pragmatic data that reflect clinical implementation and ongoing protocol refinement. The findings are intended to support dissemination of best practices, guide interdisciplinary care, and promote future research in the evolving management of ankyloglossia.

This paper builds upon previously published work from 2019 that described outcomes using a scissors-and-suture approach. The present study documents the evolution of that protocol into a reproducible, functionally defined, fascia-preserving model using CO₂ laser-assisted release, objective assessments, and structured perioperative therapy. Key methodological refinements and outcomes to support wider adoption and further validation are outlined.

2. Materials and Methods

2.1. Study Design

This prospective descriptive cohort study involved 445 patients who presented for treatment of ankyloglossia by a single surgeon (SZ) between January 2021 and December 2023 with a minimum follow-up of 2 months post-op. All subjects were screened for appropriate patient selection and completed pre- and post-operative myofunctional therapy according to the protocol detailed in Supplementary Material Figure S2. Therapy was delivered by licensed professionals (SLPs, RDHs) with training in established, evidence-based orofacial myofunctional therapy programs. Myofunctional therapy sessions were held weekly or biweekly, each lasting 45–60 min. Pre-operative goals included nasal breathing, jaw-lingual dissociation, jaw stabilization, and improved tongue posture, strength, and mobility, all while working to reduce and repattern any compensatory movements. Post-operative sessions focused on scar remodeling, palatal suction restoration, neuromuscular retraining, and compensation elimination. Tongue mobility was tracked using metrics such as Tongue Range of Motion Ration (TRMR) and Floor of Mouth (FOM) Hold Maneuver, taking into consideration normative values (Figure S3) but also the compensations previously mentioned in Figure S1 that may mask severity of restrictions or reflect post-surgical tissue contraction. Therapy assessment and structure were standardized across all locations to support patient adherence. Only patients who completed both pre- and post-operative evaluations under this protocol were included in the outcome analysis.

Data were collected prospectively under a standardized clinical protocol. Age-appropriate measurements of tongue mobility, using assessments including TRMR-TIP (Tongue tip to Incisive Papilla), TRMR-LPS (Lingual Palatal Suction) (Figure S4), bite-block levels (Figure S5), and FOM Hold Maneuver (Figure S6) were assessed before and after the release procedure. The depth of the release (mucosa, fascia, genioglossus muscle) was recorded (Figure S7). Outcome measures included tongue mobility, patient satisfaction, and complication rates. While clinical tools such as TRMR and FOM Hold Maneuver were used for mobility assessments, evaluations of bleeding, pain, and tissue tightness relied on clinical judgment and patient reporting. During in-clinic, telephone, and/or Zoom follow-up interviews, patients were assessed using a standardized set of questions addressing postoperative symptoms such as bleeding, pain, tissue tightness, and overall satisfaction. Responses were collected using binary (yes/no) questions, and symptom severity was categorized as NONE, MILD, MODERATE, or SEVERE based on predefined clinical criteria. The 2019 cohort utilized a 5-point Likert scale for patient satisfaction, whereas the updated protocol adopted a simplified 4-point scale to enhance clarity and consistency in self-reporting.

To align with clinical protocols and developmental dentition, patients were categorized into three age-based groups according to maturity of dentition which correlates to bite block grading levels used in tongue mobility assessments:

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* Young Pediatric (3–5 years) *: Early primary dentition, Bite Block Level 1 (13 mm) in TIP.

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* Pediatric (5–11 years) *: Late primary or mixed dentition, Bite Block Level 2 (21.5–23 mm) in TIP.

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* Adolescent/Adult (≥12 years) *: Permanent dentition, Bite Block Level 3 (28 mm) in TIP.

This stratification reflects both chronological and developmental criteria and was used to guide analysis of assessment tool applicability, treatment response, and clinical outcomes. Tongue mobility and surgical outcomes were subsequently analyzed in aggregate and, where appropriate, separately for each age group to identify any clinically significant trends. Not all tools were applicable across all groups.

Prospective data collection occurred as part of routine clinical care and was documented in a HIPAA secure spreadsheet for research analysis. All patients provided written informed consent acknowledging that their anonymized data could be used for quality improvement and research purposes. The study was approved by an independent ethics board, Solutions IRB (Protocol #0327, Approved 2 April 2025), which initially authorized the project as a Quality Improvement initiative and subsequently as a formal research protocol. This approval explicitly permits prospective data collection and future publication. The study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2013.

2.2. Inclusion and Exclusion Criteria

Inclusion Criteria: Patients were eligible if they were 4 years of age or older, diagnosed with ankyloglossia, and demonstrated full adherence to the pre/post-op myofunctional therapy timelines as outlined in the Clinical Protocol Visual Companion Guide.

Exclusion Criteria: Patients were excluded for syndromic craniofacial anomalies, neurological or developmental disorders, unresolved myofunctional compensations at the time of surgery, and functionally inadequate tongue space. In this context, functionally inadequate tongue space also described as restricted intraoral volume refers to insufficient structural capacity to support optimal tongue posture and airway function. This determination was made using a multimodal approach that integrated clinical screening, functional evaluation, and imaging.

The FAirEST 6 + 4 Screening Tool (Figure S8) was used to identify key clinical indicators such as narrow palate, tongue scalloping, and overflow during lingual-palatal suction. These findings were then operationally confirmed using validated CBCT parameters, including intermolar width, palatal depth, and pharyngeal airway space, with reference to normative ranges [21]. FAirEST 6 and FAirESt 6+4 help identify other considerations which may cause implications of limited results with a functional frenuloplasty alone. It is used to screen and inform patients whether or not they only need to address their tongue-tie with lingual frenuloplasty and myofunctional therapy or more commonly, lead to the conversation about other issues to address alongside tongue-tie such as nasal obstruction, large tonsil, narrow palate and limited tongue space.

CBCT interpretation followed a standardized imaging protocol, with head posture controlled using the nasion–basion–C3 (NBC3) angle as described by Coppelson et al. (2023), which has been shown to improve reliability in airway and intraoral volume assessment [23]. Patients were excluded only if both the clinical FAirEST 6+4 indicators and CBCT measurements met criteria for insufficient structural capacity.

2.3. Measurements of Tongue Mobility and Assessment of Ankyloglossia

Tongue Range of Motion Ratio (TRMR):

Maximum interincisal mouth opening with the tongue tip at the incisive papilla (TIP) and tongue body in lingual-palatal suction (LPS) are each divided by the comfortable mouth opening (CMO). See Reference [21] for more details and Figure S4.

Bite Block Levels:

Measurements of tongue elevation can be influenced by compensatory activation of jaw, neck, and facial musculature. To help stabilize mandibular position and reduce extrinsic muscle activity during tongue range of motion, a disposable bite block (EZ Prop) was placed between the central incisors. Patients were instructed to elevate the tongue tip (TIP) to the incisive papilla and mid-tongue (LPS) by suctioning to the highest achievable points during each elevation while lightly holding onto the bite block with the teeth.

Bite block levels were defined as Level 1 (13 mm), Level 2 (21.5–23 mm), and Level 3 (28 mm), corresponding to age-based expectations for dentition stage and anterior/mid-tongue elevation. These levels also approximated 50–60% of comfortable mouth opening (CMO) for anterior mobility and 30–40% for mid-tongue mobility. Clinical observations demonstrated correlations between bite block level, TRMR grading, and normative TRMR values for anterior and mid-tongue mobility [21] (Figures S4 and S5).

Although electromyographic validation has not yet been performed, bite blocks were selected based on internal observational data from 10 trained orofacial myofunctional therapists assessing over 600 patients. In this internal quality-improvement analysis, the bite block method demonstrated the highest inter-rater agreement among available clinical techniques for controlling visible compensations during tongue mobility testing. While inherently subjective, as is much of clinical myofunctional therapy in the absence of objective EMG measures, this approach currently represents the most consistent method available in our setting for reducing confounding accessory muscle recruitment. See Figure S5.

2.4. Floor of Mouth (FOM) Hold Maneuver for Assessment of Mid-Tongue Restriction (“Posterior Tongue-Tie”)

The assessment of posterior tongue-tie, now more accurately referred to as mid-tongue restriction, is often a challenging and confusing topic. Posterior tongue-tie is defined as limitations affecting the middle body of the tongue, rather than the anterior free portion.

The FOM Hold Maneuver is a clinical technique used to evaluate tongue mobility while minimizing compensatory activity from jaw, neck, and floor-of-mouth musculature. With a gloved finger, the practitioner applies gentle pressure to the sublingual caruncles at the mandibular alveolar ridge (see Figure S6), stabilizing the floor of the mouth and isolating intrinsic lingual effort.

This restriction can be best visualized using the FOM Hold Maneuver, stabilizing the floor of the mouth at its natural resting position below the mandibular alveolar ridge, and the anterior portion of the tongue in order to isolate mid-tongue mobility. This stabilization allows the clinician to focus on intrinsic tongue movement without confounding upward displacement of the floor of the mouth.

During the maneuver, the examiner observes for depression, dimpling, or cupping at the dorsal mid-tongue (DDT), as well as palpable tension. These findings are consistent with structural restriction in the mid-tongue region. A positive result is indicated when there is visible depression and reduced elevation of the tongue in the absence of floor-of-mouth compensation.

It is important to note, however, that reduced mid-tongue mobility may sometimes be due to factors other than an anatomical restriction. Weakness of the tongue, strain, or compensatory recruitment of surrounding musculature can mimic restriction. For this reason, the FOM Hold Maneuver also includes observations of compensatory activity and muscular weakness to help distinguish structural restriction from functional limitations.

These assessments were developed through an iterative process involving multiple rounds of testing and refinement, with internal validation used to progressively improve inter-rater reliability and internal validity.

2.5. Surgical Treatment Protocol

2.5.1. Preparation

All patients underwent an oral rinse with antiseptic solution before surgery. Procedures were performed under local anesthesia. Topical anesthetic in the form of 2% viscous lidocaine (Akorn, Lake Forrest, IL, USA) and/or lidocaine and prilocaine cream (USP 2.5%/2.5%) (Alembic, Vadodara, India) was applied to the mucosa of the lingual frenulum. Injection of ~0.5 mL to 2 mL of 4% prilocaine (Citanest plain, Dentsply, York, PA, USA), 2% lidocaine HCL with 1:100,000 epinephrine, and/or 0.5% Marcaine with 1:200,000 epinephrine (Cook-Waite, Novocol, ON, Canada) was applied submucosally via 30-gauge needle to the fascial layer of the lingual frenulum tissue taking care to avoid any underlying blood vessels, salivary gland, or nerve structures.

The presence of concurrent buccal or labial tethering was addressed at the discretion of the surgeon but was excluded from this outcome analysis. Data and outcomes presented herein reflect only cases of isolated lingual frenulum release.

2.5.2. Release Technique

The procedure began by pushing back on the ventral surface of the tongue at the floor of the mouth with a small square (2 × 2) of gauze to identify the site of maximal tension of the lingual frenulum near the sublingual caruncles. The tension band was first visualized then palpated and clamped with fine hemostats at a site 2–4 mm above the sublingual caruncles. All cases included in this analysis were performed using the refined protocol, which utilized a CO₂ laser (10,600 nm) (LightScalpel LLC, Bothell, WA, USA) for tissue release at the appropriate settings described in Figure S9. This wavelength enables clean, layer-by-layer dissection of mucosa, fascia, and genioglossus with high precision and minimal collateral thermal damage, especially critical in the anatomically dense floor-of-mouth region. The laser’s simultaneous cutting and coagulative properties minimize intraoperative bleeding and reduce the need for suction or electrocautery. Additionally, laser sealing of lymphatics and nerve endings may facilitate improved patient comfort and faster healing [24,25]. The pulsed delivery of the CO₂ laser allows for tailored endpoint control to ensure effective and functionally guided releases. Release of the tissue along the tracks of the clamp from the hemostat was performed with small curved surgical scissors (JedMed, St. Louis, Missouri, USA) and/or CO₂ laser (Lightscalpel) at the appropriate settings. The release procedure continued through continued palpation and observation to identify further tension bands contributing to limited tongue mobility. The endpoint of the release was identified when there was adequate mobility and elevation of the anterior tongue tip and mid-body, consistent with functional tongue anatomy (Figure S10), according to the assessment protocols detailed above (Grade 1–2 TRMR TIP/LPS without compensations as assessed with bite-block and FOM Hold Maneuver). Care was taken to minimize dissection of deep fascia surrounding the genioglossus muscle as well as limiting the release of muscle fibers themselves to the minimal amount necessary to achieve the defined endpoints of tongue mobility.

Laser dissection was supplemented, as needed, with curved surgical scissors (JedMed) along the track defined by the hemostat clamp. Palpation and dynamic testing were employed throughout the procedure to identify and release additional fascial restrictions. The endpoint of the release was defined as functional elevation and mobility of the anterior and mid-tongue, specifically, achievement of Grade 1–2 TRMR-TIP and TRMR-LPS scores (Figure S4) without compensatory recruitment, as confirmed using bite-block (Figure S5) and FOM Hold Maneuver assessments (Figure S6). Care was taken to preserve the surrounding deep fascia and minimize the release of the genioglossus muscle beyond the minimal extent required to achieve the functional endpoint.

2.5.3. Hemostasis

Hemostasis was achieved using the CO₂ laser prior to closure. In cases of persistent bleeding, cyanoacrylate adhesive dressing (Periacryl 90 high-viscosity, violet; GluStitch Inc., Delta, BC, Canada) (Figure S11) was selectively applied to the deep fascia or vascular sites that failed to respond to initial laser coagulation.

2.5.4. Wound Closure

Closure was performed with 4-0 chromic sutures placed 2–6 mm apart in an interrupted fashion. A figure-of-eight suture was typically placed at the base of the wound near the sublingual caruncles. Additional simple interrupted sutures were used along the incision length, and a loosely applied horizontal mattress suture was positioned across the mucosa of the sublingual caruncles. Minimal redundant mucosa at the wound apex was excised with care to preserve tissue integrity. In select cases, cyanoacrylate tissue adhesive(GluStitch Inc., Delta, BC, Canada) was applied between sutures for added tension support.

2.5.5. Postoperative Care

Patients were instructed to rinse with warm salt water and/or diluted alcohol-based mouthwash three times daily for 7–10 days after the procedure. Pain control regimen included ibuprofen (Genexa Inc., Los Angeles, CA, USA) and/or acetaminophen (Tylenol, Johnson & Johnson, Fort Washington, PA, USA). Some patients elected to use homeopathic (such as arnica) or holistic remedies (turmeric, ginger, cannabidiol oil) for analgesia instead of the other more routine allopathic medications. Ice therapy was recommended in the form of an icepack on the submental area for 10–20 min repeated every 2 h for the first day while awake. The use of narcotic pain medication was not found to be as common or necessary in comparison to the prior protocol. Absorbable sutures typically dissolve within 3–10 days, and cyanoacrylate tissue adhesive if used, should be left undisturbed or gently massaged off with mineral oil after one week. Gentle tongue activities like speaking and singing were recommended initially, with post-operative therapy sessions resuming within a week. Patients were also advised to consider bodywork therapies as recommended by their healthcare provider. For more detailed post-operative care instructions, see Figure S12.

2.5.6. Follow-Up

Patients were seen for follow-up at 1–2 weeks and again at >2 months post-operatively to assess for any complications or problems with wound healing using the Lingual Frenulum Wound Healing Assessment Scale (WHIMS—Figure S13). Postoperative outcomes were assessed at two distinct follow-up intervals. Short-term outcomes, including reports of pain, swelling, and other complications, were recorded during the initial follow-up visit within 1–2 weeks after surgery. Long-term outcomes, including patient satisfaction and perceived treatment benefits, were evaluated at follow-up interviews conducted two or more months postoperatively. In addition to these assessments, patients were also seen by the orofacial myofunctional therapist at 3 days post-op, followed by weekly and biweekly intervals for the first 2 months, and ongoing thereafter as needed depending on the specific goals of care. Sutures typically fell out within 2–10 days, and patients were instructed to perform manual tongue stretches beginning around the third day postoperatively. Expected healing stages and timelines are summarized in (Figure S14). If healing was satisfactory at the 2-month follow-up, reassessment of function determined individualized treatment planning to continue care with their Orofacial Myofunctional Therapist as needed. If concerns remained, such as persistent tension, limited mobility, or reduced WHIMS scores, triamcinolone acetonide (Kenalog-10, Bristol-Myers Squibb Company, Princeton, NJ, USA) injection (Figure S11) was considered between 2 and 6 months postoperatively. If symptoms persisted beyond 6 months despite conservative measures, revision surgery was offered. Overall patient satisfaction and outcome success were based on subjective reports and objective OMT assessments.

2.5.7. Statistical Analysis

All statistical analyses were conducted using JMP Pro 16.0 (SAS Institute Inc., Cary, NC, USA). Continuous variables are reported as mean ± standard deviation (SD), and categorical variables are, with a two-tailed p-value of <0.01 considered statistically significant. To compare reported frequencies and percentages with standard error (SE), univariate comparisons were performed using independent t-tests for continuous variables and Pearson’s Chi-square tests for categorical variables complication rates between the 2019 and 2025 surgical protocols, Pearson’s Chi-square analyses were applied to 2 × 2 contingency tables for each complication moderate and severe pain, moderate and severe bleeding, numbness, salivary gland issues, and need for second-stage revision with odds ratios (OR), 95% confidence intervals (CI), and p-values calculated.

3. Results

3.1. Demographic Characteristics

As listed in

Table 1. Demographic Characteristics of Patients.

	# Reported
Total Patients	445
Response Rate	379 (85.1%)
Age (mean ± SD)	25.2 ± 15.9 years
Age Range	4 to 81 years
Age Distribution
4 to 5	11 (2.5%)
6 to 11	99 (22.2%)
12 to 81	335 (75.3%)
Gender Distribution
Female	248 (55.7%)
Male	197 (44.3%)
Primary Presenting Symptoms	Total n = 379	Ages 4–5 n = 7	Ages 6–11 n = 87	Ages 12–17 n = 62	Ages 18–40 n = 156	Ages 41+ n = 67
Oral dysfunction	225 (59.4%)	4 (57.7%)	44 (50.6%)	35 (55.6%)	90 (57.3%)	52 (76.5%)
Open mouth posture	216 (57.0%)	4 (57.7%)	56 (64.4%)	45 (71.4%)	86 (54.8%)	25 (36.8%)
Neck and shoulder tension	182 (48.0%)	0	0	4 (6.3%)	129 (82.2%)	49 (72.1%)
Bruxism	174 (45.9%)	3 (42.9%)	31 (35.6%)	12 (19.0%)	93 (59.2%)	35 (51.5%)
Headaches	119 (31.4%)	0	4 (4.6%)	4 (6.3%)	83 (52.9%)	28 (41.2%)
Temporomandibular joint dysfunction	106 (28.0%)	0	2 (2.3%)	1 (1.6%)	79 (50.3%)	24 (35.3%)
Speech issues	95 (25.1%)	3 (42.9%)	44 (50.6%)	23 (36.5%)	18 (11.5%)	7 (10.3%)

, a total of 445 patients were treated, with 379 (85.1% who completed both pre- and postoperative forms that included symptom reporting) included in the analysis, with a mean age of 25.2 ± 15.9 years (range: 4 to 81 years). The cohort was 55.7% female, with 43.6% pediatric patients. Of the 445 patients included, 110 were in the pediatric group (<12 years) and 335 in the adolescent/adult group (≥12 years) which are further broken down in Table 1 to preschool years (3–5), middle school years (6–11) teen years (12–17) young adults (18–40) and middle age/older adults (41+). This stratification may provide a more clinically meaningful framework across the lifespan, helping clinicians identify which symptoms are prevalent at specific psychosocial stages guiding age-appropriate diagnostic and treatment priorities. Presenting symptoms associated with restricted tongue mobility included oral dysfunction (59.4%; e.g., tongue thrust, low tongue posture, swallowing dysfunction) [3], open-mouth posture (57.0%), neck and shoulder tension (48.0%), bruxism (45.9%), headaches (31.4%), and temporomandibular joint symptoms (28.0%). Pediatric patients presented more frequently with speech and feeding issues, whereas adult patients more often reported TMJ, clenching, and postural complaints. Adolescence marks a transition where functional problems exist, but pain-related symptoms begin to emerge. Relevant analyses were separated by pediatric, adolescent, and adult groups. The findings are presented in Table 1, Table 2, Table 3, Table 4, Table 5 and Table 6 and demonstrate that key outcomes, complication rates, satisfaction, and functional mobility were largely consistent across groups, with some differences noted in symptom profiles.

3.2. Assessment of Tongue Mobility

Among the 445 patients, 183 exhibited moderate to severe tongue mobility restriction (Grade 3: n = 155; Grade 4: n = 28) as assessed by TRMR and FOM Hold Maneuver to control compensatory recruitment of extrinsic structures such as the jaw, floor of the mouth, and neck muscles (Table 2). Among them, 75.5% were found to have DDT suggestive of a mid-tongue restriction, and 95.1% were found to have a change in range of motion using the FOM Hold Maneuver, suggestive of compensatory recruitment. Immediately after the release procedure, all patients demonstrated normal levels of tongue mobility and resolution of DDT except for 19 patients (4.5%) who exhibited partial resolution of compensation associated with tongue weakness.

Table 2. Assessment of Tongue Mobility.

	# Observed/Assessed
Number of patients with compensated mobility (TRMR and FOM Hold Maneuver)	262/445 (58.9%)
Number of patients with moderate to severe restriction of tongue mobility	183/445 (41.1%)
Grade 3	155/445 (34.8%)
Grade 4	28/445 (6.3%)
Assessment of Compensated Mobility
Change in Range of Motion (FOM Hold Maneuver)	423/445 (95.1%)
Normal levels of tongue mobility and resolution of DDT post-release	174/183 (95.1%)
Persistently compensated mobility post-release associated with tongue weakness, instability, or fasciculation/Improved but Persistently Compensated Mobility	19/445 (4.3%)
Depression on dorsal surface of the tongue (DDT) indicative of Mid-Tongue Restriction (“posterior tongue-tie”)	198/262 (75.5%)

Table 2. Assessment of Tongue Mobility.

	# Observed/Assessed
Number of patients with compensated mobility (TRMR and FOM Hold Maneuver)	262/445 (58.9%)
Number of patients with moderate to severe restriction of tongue mobility	183/445 (41.1%)
Grade 3	155/445 (34.8%)
Grade 4	28/445 (6.3%)
Assessment of Compensated Mobility
Change in Range of Motion (FOM Hold Maneuver)	423/445 (95.1%)
Normal levels of tongue mobility and resolution of DDT post-release	174/183 (95.1%)
Persistently compensated mobility post-release associated with tongue weakness, instability, or fasciculation/Improved but Persistently Compensated Mobility	19/445 (4.3%)
Depression on dorsal surface of the tongue (DDT) indicative of Mid-Tongue Restriction (“posterior tongue-tie”)	198/262 (75.5%)

3.3. Overall Risks and Complications Associated with Lingual Frenuloplasty

There were 379 of the 445 patients (85.1%) for whom data with follow-up of at least 2 weeks was available with an additional mean long-term follow-up time of 83 ± 124 days. Table 3 lists overall risks and complications stratified by age. Pain: 57.0% mild, 25.9% moderate, 3.7% severe. Bleeding: 14.5% mild, 1.1% moderate; only one (0.3%) patient experienced severe or prolonged bleeding. Swelling: 23.2% mild, 11.3% moderate, 2.4% severe. Tightness or contraction: 39.1% mild, 12.1% moderate, 0.3% severe. Most symptoms of tightness or contraction are resolved on their own by 2–6 months post-op. There were 14/379 (3.6%) who were treated with triamcinolone acetonide (10 mg/mL) (Kenalog-10) (see Figure S11) to address hypertrophic scarring and there were 8 subjects (2.1%) who proceeded with a second-stage or revision lingual frenuloplasty. Numbness: 5.3% mild, 0.5% moderate. Zero patients experienced prolonged numbness of the tongue-tip over 2 weeks. Salivary gland: One patient developed an anterior lingual gland cyst that was treated by excision. There were no other long-term complications with any of the other salivary glands or ducts. To evaluate the impact of surgical protocol refinements, complication rates in the 2025 cohort were compared to those reported in the original 2019 protocol.

The updated protocol was associated with significant improvements in postoperative outcomes across multiple measures. Significant reductions were observed in the following:

• Severe pain: decreased from 15.8% to 3.7% (OR 4.89; 95% CI: [2.67–8.98]; p < 0.001).
• Numbness: decreased from 4.9% to 0.5% (OR 9.68; 95% CI: [2.22–42.22]; p = 0.0013).
• Salivary gland issues: decreased from 3.4% to 0.3% (OR 13.50; 95% CI: [1.75–104.37]; p = 0.0063).
• Second-stage revisions: decreased from 6.6% to 2.1% (OR 3.28; 95% CI: [1.45–7.44]; p = 0.0022).

Moderate pain showed a decrease from 29.3% to 25.9% (p = 0.149). Bleeding rates (moderate and severe) were too low in the 2025 cohort for valid statistical comparison but were notably reduced overall, from 14.6% in 2019 to 1.4% in 2025.

These findings support the conclusion that the refined 2025 protocol featuring standardized patient selection, functional surgical endpoints, and structured pre- and postoperative care, was associated with statistically and clinically meaningful reductions in complication rates

Table 3. Overall Risks and Complications.

	Reported Total n = 379	Reported Ages 4–5 n = 7	Reported Ages 6–11 n = 87	Reported Ages 12–17 n = 63	Reported Ages 18–40 n = 156	Reported Ages 41+ n = 67
Pain
Mild	216 (57.0%)	3 (42.9%)	54 (62.1%)	39 (62.9%)	83 (53.2%)	37 (55.2%)
Moderate	98 (25.9%)	1 (14.3%)	16 (18.4%)	17 (27.4%)	45 (28.8%)	19 (28.4%)
Severe	14 (3.7%)	0	3 (3.4%)	1 (1.6%)	8 (5.1%)	2 (3.0%)
Bleeding
Mild	56 (14.8%)	0	6 (6.9%)	13 (21.0%)	26 (16.7%)	11 (16.4%)
Moderate	4 (1.1%)	0	0	1 (1.6%)	2 (1.3%)	1 (1.5%)
Severe	1 (0.3%)	0	0	0	1 (0.6%)	0
Numbness
Mild	24 (6.3%)	0	6 (6.9%)	1 (1.6%)	10 (6.4%)	7 (10.4%)
Moderate	2 (0.5%)	0	0	0	2 (1.3%)	0
Severe	0	0	0	0	0	0
Swelling
Mild	88 (23.2%)	1 (14.3%)	16 (18.4%)	17 (27.4%)	40 (25.6%)	14 (20.9%)
Moderate	43 (11.3%)	0	1 (1.1%)	6 (9.7%)	23 (14.7%)	13 (19.4%)
Severe	9 (2.4%)	0	0	0	8 (5.1%)	1 (1.5%)
Tightness/Contraction
Mild	148 (39.1%)	1 (14.3%)	22 (25.3%)	27 (43.5%)	73 (46.8%)	25 (37.3%)
Moderate	46 (12.1%)	0	4 (4.6%)	3 (4.8%)	26 (16.7%)	13 (19.4%)
Severe	1 (0.3%)	0	0	0	0	1 (1.5%)
Salivary Gland Issues	1 (0.3%)	0	0	0	1 (0.6%)	0
Second Stage/Revision	8 (2.1%)	0	0	0	4 (2.6%)	4 (6.0%)

Table 3. Overall Risks and Complications.

	Reported Total n = 379	Reported Ages 4–5 n = 7	Reported Ages 6–11 n = 87	Reported Ages 12–17 n = 63	Reported Ages 18–40 n = 156	Reported Ages 41+ n = 67
Pain
Mild	216 (57.0%)	3 (42.9%)	54 (62.1%)	39 (62.9%)	83 (53.2%)	37 (55.2%)
Moderate	98 (25.9%)	1 (14.3%)	16 (18.4%)	17 (27.4%)	45 (28.8%)	19 (28.4%)
Severe	14 (3.7%)	0	3 (3.4%)	1 (1.6%)	8 (5.1%)	2 (3.0%)
Bleeding
Mild	56 (14.8%)	0	6 (6.9%)	13 (21.0%)	26 (16.7%)	11 (16.4%)
Moderate	4 (1.1%)	0	0	1 (1.6%)	2 (1.3%)	1 (1.5%)
Severe	1 (0.3%)	0	0	0	1 (0.6%)	0
Numbness
Mild	24 (6.3%)	0	6 (6.9%)	1 (1.6%)	10 (6.4%)	7 (10.4%)
Moderate	2 (0.5%)	0	0	0	2 (1.3%)	0
Severe	0	0	0	0	0	0
Swelling
Mild	88 (23.2%)	1 (14.3%)	16 (18.4%)	17 (27.4%)	40 (25.6%)	14 (20.9%)
Moderate	43 (11.3%)	0	1 (1.1%)	6 (9.7%)	23 (14.7%)	13 (19.4%)
Severe	9 (2.4%)	0	0	0	8 (5.1%)	1 (1.5%)
Tightness/Contraction
Mild	148 (39.1%)	1 (14.3%)	22 (25.3%)	27 (43.5%)	73 (46.8%)	25 (37.3%)
Moderate	46 (12.1%)	0	4 (4.6%)	3 (4.8%)	26 (16.7%)	13 (19.4%)
Severe	1 (0.3%)	0	0	0	0	1 (1.5%)
Salivary Gland Issues	1 (0.3%)	0	0	0	1 (0.6%)	0
Second Stage/Revision	8 (2.1%)	0	0	0	4 (2.6%)	4 (6.0%)

3.4. Depth of Release

All cases included some element of mucosa and fascia dissection (Table 4). In 52.3% of cases, it was found necessary to release the genioglossus muscle to achieve the surgical goals. Cases involving release of the genioglossus muscle were associated with significantly higher reports of moderate to severe postoperative swelling compared to cases limited to mucosa and fascia only. Specifically, moderate to severe swelling occurred in 21% of patients when the muscle was released, versus just 6% when it was not. Mucosa and Fascia Only: 94% (170/181) none/mild, 6% (11/181) moderate, 0% severe; Mucosa, Fascia, and Genioglossus Muscle: 79% (157/198) none/mild, 16.1% (32/198) moderate, 4.5% (9/198) severe. The odds ratio for moderate to severe swelling was 4.0-fold higher for cases involving the genioglossus muscle (95% Confidence Interval 1.99–8.08, Pearson Chi Square 16.9, p < 0.0001). There were no statistically significant differences in any of the other risks or complications by depth of release. Based on our experience, however, increasing depth does increase the complexity of the case including the possibility of bleeding and pain; this was offset with good hemostatic techniques and deep injection of Marcaine into the muscle to offset potential pain.

Table 4. Depth of Release and Associated Complications.

	# Cases
Depth of Release	445
Mucosa only	0
Cases with mucosa and fascia dissection	212 (47.7%)
Release of genioglossus muscle required	233 (52.3%)
Swelling: Mucosa and Fascia Only	181
None/Mild	170 (93.9%)
Moderate	11 (6.1%)
Severe	0
Swelling: Mucosa, Fascia, and Genioglossus Muscle	198
None/Mild	157 (79.3%)
Moderate	32 (16.1%)
Severe	9 (4.5%)

Table 4. Depth of Release and Associated Complications.

	# Cases
Depth of Release	445
Mucosa only	0
Cases with mucosa and fascia dissection	212 (47.7%)
Release of genioglossus muscle required	233 (52.3%)
Swelling: Mucosa and Fascia Only	181
None/Mild	170 (93.9%)
Moderate	11 (6.1%)
Severe	0
Swelling: Mucosa, Fascia, and Genioglossus Muscle	198
None/Mild	157 (79.3%)
Moderate	32 (16.1%)
Severe	9 (4.5%)

3.5. Patient-Reported Satisfaction Rates

The overall patient-reported satisfaction rate was 86% (320/372; 86% ± 1.8% SE) (Table 5). Due to the small number of children aged 4–5, they were combined with ages 6–12 for the table. Although outcomes were largely consistent across age cohorts, it is noteworthy that the youngest patients (ages 4–6) demonstrated the highest satisfaction rates. This may reflect a combination of early intervention benefits and parental reporting, but the finding should be considered preliminary given the small sample size. There were 12.1% (45/372; 12.1% ± 1.7% SE) who reported feeling “neutral” regarding their experience with no issues but no perceived benefit but only 1.3% who were “somewhat dissatisfied” (5/372; 1.3% ± 0.6% SE) or “very dissatisfied” (2/372; 0.5% ± 0.4% SE). The major complaints regarding dissatisfaction were associated with contraction, persistent tightness, or reattachment (e.g., failure to adequately improve tongue mobility to the degree of patients’ expectations or desire). One patient experienced worsening of sleep, grinding symptoms, and biting of the tongue; another patient described a subjective sense of fascia destabilization along with postural discomfort, re-emergence of tongue thrusting, and lateral tongue biting. Of the 7 dissatisfied patients, 5 had borderline structural findings on initial evaluation but elected to proceed with surgery despite being counseled on potential limitations related to tongue space.

Table 5. Patient Reported Satisfaction Rates.

	# Reported Total n (% ± SE)	# Reported Ages 4–12 n (% ± SE)	# Reported Ages 13–17 n (% ± SE)	# Reported Ages 18–40 n (% ± SE)	# Reported Ages 41+ n (% ± SE)
Number of Patients	372	108	50	152	62
Overall satisfaction rate	320 (86.0% ± 1.8%)	93 (86.1% ± 3.3%)	45 (90% ± 4.2%)	134 (88.2% ± 2.6%)	48 (77.4% ± 5.3%)
Neutral	45 (12.1% ± 1.7%)	14 (13% ± 3.2%)	5 (10% ± 4.2%)	15 (9.9% ± 2.4%)	11 (17.7% ± 4.9%)
Somewhat dissatisfied	5 (1.3% ± 0.6%)	1 (0.9% ± 0.9%)	0	2 (1.3% ± 0.9%)	2 (3.2% ± 2.2%)
Very dissatisfied	2 (0.5% ± 0.4%)	0	0	1 (0.7% ± 0.7%)	1 (1.6% ± 1.6%)

Table 5. Patient Reported Satisfaction Rates.

	# Reported Total n (% ± SE)	# Reported Ages 4–12 n (% ± SE)	# Reported Ages 13–17 n (% ± SE)	# Reported Ages 18–40 n (% ± SE)	# Reported Ages 41+ n (% ± SE)
Number of Patients	372	108	50	152	62
Overall satisfaction rate	320 (86.0% ± 1.8%)	93 (86.1% ± 3.3%)	45 (90% ± 4.2%)	134 (88.2% ± 2.6%)	48 (77.4% ± 5.3%)
Neutral	45 (12.1% ± 1.7%)	14 (13% ± 3.2%)	5 (10% ± 4.2%)	15 (9.9% ± 2.4%)	11 (17.7% ± 4.9%)
Somewhat dissatisfied	5 (1.3% ± 0.6%)	1 (0.9% ± 0.9%)	0	2 (1.3% ± 0.9%)	2 (3.2% ± 2.2%)
Very dissatisfied	2 (0.5% ± 0.4%)	0	0	1 (0.7% ± 0.7%)	1 (1.6% ± 1.6%)

3.6. Management of Persistent Symptoms

Patients with inadequately treated symptoms and/or worsened postoperative dysfunction were treated with a combination of the following avenues: (1) topical application of serrapeptase and/or injections of triamcinolone (see Figure S11) to reduce scarring followed by revision frenuloplasty if indicated; (2) physical therapy and bodywork modalities including deep tissue laser therapy, (3) referral for evaluation and treatment of limited tongue space by a qualified dentist, orthodontist, and/or maxillofacial surgeon, (4) further myofunctional, speech, and/or swallow therapy.

Key Findings

This prospective descriptive cohort study of 445 patients builds upon our previously published 2019 series of 348 patients treated with a scissors-and-suture technique (Table 6) [10]. The refined, standardized protocol for lingual frenuloplasty combined with myofunctional therapy demonstrated enhanced safety, reproducibility, and clinical outcomes in a high-volume, real-world clinical setting.

Key advancements included:

• Standardized pre- and postoperative myofunctional therapy protocol with readiness assessments.
• Use of functional mobility endpoints (TRMR and FOM Hold Maneuver) for improved diagnosis and surgical planning.
• Transition to CO₂ laser-assisted, fascia-sparing dissection for improved surgical precision, healing, and reduced complications.
• Use of cyanoacrylate adhesives and optimized suturing for enhanced wound stability.

Table 6. Comparative Look at 2019 Study vs. 2025 Study.

	Patient Reported Findings at 2 Weeks		Patient Reported Findings at 2 Weeks
Overall Risks and Complications: 2019 Protocol	# Reported: 2019	% Reported: 2019	# Reported 2025	% Reported: 2025
Pain
Moderate	102/348	29.3%	98/379	25.9%
Severe	55/348	15.8%	14/379	3.7%
Bleeding
Moderate	8/348	2.3%	4/379	1.1%
Severe	7/348	2.0%	1/379	0.3%
Numbness	17/348	4.9%	2/379	0.5%
Salivary Gland Issues	12/348	3.4%	1/379	0.3%
Second Stage/Revision	23/348	6.6%	8/379	2.1%

Table 6. Comparative Look at 2019 Study vs. 2025 Study.

	Patient Reported Findings at 2 Weeks		Patient Reported Findings at 2 Weeks
Overall Risks and Complications: 2019 Protocol	# Reported: 2019	% Reported: 2019	# Reported 2025	% Reported: 2025
Pain
Moderate	102/348	29.3%	98/379	25.9%
Severe	55/348	15.8%	14/379	3.7%
Bleeding
Moderate	8/348	2.3%	4/379	1.1%
Severe	7/348	2.0%	1/379	0.3%
Numbness	17/348	4.9%	2/379	0.5%
Salivary Gland Issues	12/348	3.4%	1/379	0.3%
Second Stage/Revision	23/348	6.6%	8/379	2.1%

4. Discussion

The present findings reflect a systematic evolution in the management of ankyloglossia, transitioning from an anatomy-focused surgical technique to a functionally integrated, outcome-based protocol. In comparison to the 2019 cohort, refinements in patient selection, surgical approach, and standardized preoperative and postoperative care were associated with notable reductions in complication rates. Although this study cannot determine which components led to the improvements, the consistent application of the full protocol yielded positive outcomes across multiple domains. Under the updated 2025 protocol, severe pain decreased from 15.8% to 3.7%, moderate bleeding from 13% to 1.1%, numbness from 5% to 0.5%, salivary gland issues from 3.4% to 0.3%, and the need for second-stage revision from 6.6% to 2.1% (Table 6). These reductions in complication rates, especially in pain, bleeding, and need for revision, represent important clinical findings and warrant further study to validate in other settings. These improvements were achieved without compromising patient satisfaction, which remained high at 86%.

Age-stratified analyses revealed that outcomes were largely consistent across pediatric, adolescent, and adult cohorts, with satisfaction rates remaining high in all groups (≥86%). Our findings highlight age-specific patterns in presenting symptoms. Pediatric patients (ages 4–11) most often presented with functional and speech-related concerns such as oral dysfunction, open mouth posture, and speech issues, with few pain complaints. Adolescents (12–17) showed a transitional profile, maintaining functional difficulties while beginning to report bruxism and headaches. In adults, particularly those ages 18–40, pain and tension symptoms (neck/shoulder tension, TMJ dysfunction, headaches, bruxism) became predominant, while functional/speech issues decreased. Older adults (41+) demonstrated persistence of functional impairment and tension, although headache prevalence declined. These patterns suggest that treatment planning should be age-informed: pediatric care may emphasize functional rehabilitation and speech support, while adult care may prioritize tension, TMJ stabilization, and pain management.

The incorporation of clearly defined functional endpoints and consistent therapeutic protocols appears to enhance clinical outcomes while promoting safety, precision, and reproducibility. In our experience, the structured clinical protocol enabled consistent application of therapy milestones, surgical endpoints, and follow-up procedures across a diverse patient population.

Ankyloglossia is increasingly recognized as a multifactorial condition with consequences extending well beyond speech and feeding. Restricted tongue mobility impairs palatal tongue posture, contributing to open-mouth posture, altered craniofacial development, dental malocclusion, clenching and bruxism, cervical strain, and sleep-disordered breathing [26,27,28,29]. In vocally demanding populations, such as singers and professional speakers, ankyloglossia may also contribute to muscle tension dysphonia (MTD), resulting in vocal fatigue, range limitations, and increased laryngeal tension [30]. Addressing these complex functional impairments requires more than anatomical correction alone. The combined approach of lingual frenuloplasty with targeted myofunctional therapy seeks to address both mechanical tethering and associated dysfunctions and behaviors, thereby enhancing overall function, health, and quality of life [7,10,11,12,31,32]. By freeing the tongue to achieve a fuller range of motion, frenuloplasty directly addresses the mechanical limitations imposed by ankyloglossia. Myofunctional therapy enhances the outcomes of lingual frenuloplasty by using targeted stretches and neuromuscular exercises to maintain postoperative range of motion, promote optimal wound healing, and prevent reattachment.

In addition to preserving mobility, myofunctional therapy retrains proper tongue function and reduces compensatory patterns. Long-term success is further supported by careful patient selection, appropriately timed surgical release, and integration with adjunctive therapies such as palatal expansion, red light therapy, and bodywork modalities such as physical therapy, craniosacral therapy, manual fascial release, and other integrative techniques [33]. Although these adjunctive therapies were not directly evaluated in this study, their widespread clinical use underscores the need for further research into their potential role in optimizing long-term functional outcomes.

Major refinements to the protocol over time, have included: (1) adoption of a standardized pre- and postoperative therapy protocol with readiness assessments and defined functional mobility endpoints; (2) use of CO₂ laser-assisted, fascia-sparing dissection for precise release with minimal collateral trauma; (3) application of cyanoacrylate adhesives and refined suturing techniques to optimize wound stability and healing; and (4) incorporation of the FOM Hold Maneuver to improve diagnostic precision. These refinements contributed to improved patient outcomes, including reduced reports of postoperative pain, bleeding, numbness, and the need for revision procedures.

The FOM Hold Maneuver, used in conjunction with TRMR assessments, enhances diagnostic accuracy by identifying DDT, an objective marker of mechanical restriction. This allows clinicians to distinguish true restrictions, best addressed with surgical release, from compensated patterns, which may resolve with therapy alone. This layered approach helps prevent unnecessary interventions and strengthens diagnostic precision.

The CO₂ laser technique enhanced surgical precision by enabling controlled, layer-by-layer dissection with preservation of fascia and muscle when indicated, thereby reducing complications and promoting faster healing trajectories. Deeper dissection involving the genioglossus muscle was associated with transient swelling but did not increase the risk of major complications.

Importantly, diagnosis of tongue-tie should rest on demonstrable functional limitation, not merely on anatomical appearance or secondary signs such as high-arched palate or mouth breathing. Multiple etiologies, including nasal obstruction, adenoidal hypertrophy, and poor orofacial tone can contribute to low tongue posture. When restriction is suspected but not clearly visualized, tongue-tie should be a diagnosis of exclusion after failed conservative therapy. This approach helps mitigate overdiagnosis and reinforces clinical integrity.

A key strength of this study is its pragmatic design: outcomes were prospectively captured from a high-volume, authentic clinical setting using a reproducible, standardized protocol. The pragmatic aspect allows the results to be considered in light of real-world settings, acknowledging the limitations inherent in clinical variability and non-controlled conditions. These findings support the safety, feasibility, and efficacy of this combined surgical–therapeutic approach and provide a strong foundation for further interdisciplinary training and controlled trials.

Future research should continue to refine surgical endpoints, further isolate the effects of individual protocol components, and explore novel adjunctive modalities such as 800–1064 nm wavelength laser therapy (e.g., red light therapy, cold laser, Oralase) for their potential to enhance healing, reduce inflammation, alleviate pain, and improve neuromuscular outcomes.

Limitations

Despite the advancements and comprehensive approach of the current study, several limitations should be noted. Although this study is prospective, which helps reduce some biases inherent in retrospective studies, it lacks a control group, which limits the ability to draw definitive conclusions about the efficacy of the interventions compared to alternative treatments or no treatment at all.

The follow-up period in this study was also relatively short, extending just over two months for most patients. However, this timeframe is relevant to the stages of wound healing during which contraction occurs and generally is completed and the maturation process has begun [34,35]. While many patients continued with orofacial myofunctional therapy beyond the formal follow-up window (2 weeks standardized objective (WHIMS) and subjective reporting with some additional reports at >2 months), no structured long-term tracking of functional outcomes was conducted. Future studies with extended follow-up are warranted to assess the durability of therapeutic gains in breathing, chewing, swallowing, oral rest posture, speech, and quality of life.

While patient-reported outcomes are valuable for capturing patient satisfaction and perceived benefits, they remain subjective and prone to recall bias or patient expectations. Objective measures are crucial in future research to complement these findings, ensuring a more comprehensive understanding of the intervention’s true efficacy. Additionally, variations in surgical techniques (e.g., use of scissors vs. CO₂ laser) could have impacted the outcomes observed in this study. While this study emphasizes the importance of a holistic and multidisciplinary approach to treating ankyloglossia, further exploration is needed to determine the specific contributions of each component, such as nasal breathing rehabilitation, myofunctional therapy, physical therapy and additional body work modalities, and lingual frenuloplasty toward the overall outcomes.

Lastly, assessment tools such as TRMR and CBCT have been primarily validated in older children and adults. However, these tools remain useful in younger pediatric populations when interpreted with appropriate clinical judgment. These measures may demonstrate greater variability among children due to normal developmental differences, cooperation levels, and results should therefore be interpreted within that clinical context. Small subgroup sample sizes may also limit power for certain age-based comparisons. Additionally, the lack of inter-rater reliability measures and the absence of standardized outcome validation tools limit generalizability. Future research should prioritize the development and testing of all assessment tools and protocol components for reliability and validity across age groups and clinical settings.

5. Conclusions

This prospective descriptive cohort study demonstrates that a refined, standardized protocol for lingual frenuloplasty combined with myofunctional therapy can be safely and effectively implemented in a high-volume, real-world setting. The evolution of this protocol from an anatomy-based surgical model to a functionally integrated, outcome-driven protocol reflects significant advancements in surgical precision, functional assessment, perioperative care, and interdisciplinary management of ankyloglossia.

By addressing both structural restrictions and neuromuscular compensations, this combined treatment approach yields reproducible, durable functional outcomes with fewer complications and high patient satisfaction. Although presenting symptoms varied by age, with younger patients more frequently affected by speech and feeding issues and adults more often reporting TMJ and postural complaints, treatment outcomes were uniformly favorable. High satisfaction and low complication rates across all age cohorts suggest that the refined lingual frenuloplasty protocol is both safe and effective throughout the developmental spectrum. The integration of validated assessment tools (TRMR, FOM Hold Maneuver), fascia-sparing surgical techniques, and optimized wound management has further enhanced diagnostic precision, surgical planning, and clinical outcomes. This work highlights the efficacy of a multidisciplinary protocol that integrates surgical release, myofunctional therapy, and adjunctive modalities to achieve durable improvements in tongue function and orofacial health.

To support reproducibility and broader clinical adoption, all protocol components, including assessment tools, surgical best practices, and structured therapy frameworks, have been consolidated into a Clinical Protocol Visual Companion Guide (Supplementary Material), developed to facilitate training, protocol fidelity, and future validation efforts.

This refined protocol provides an evidence-based, replicable model for interdisciplinary teams seeking to advance outcomes in the management of ankyloglossia and related orofacial myofunctional disorders.