Anatomic Distribution of the Morphologic Variation of the Upper Lip Frenulum Among Healthy Newborns | Child Development | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Original Investigation
August 22, 2019

Anatomic Distribution of the Morphologic Variation of the Upper Lip Frenulum Among Healthy Newborns

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Otolaryngol Head Neck Surg. 2019;145(10):931-938. doi:10.1001/jamaoto.2019.2302
Key Points

Question  What is the anatomic distribution of the maxillary labial frenulum among newborns, and which anatomic measurements could be useful to create a classification system to advance research investigating this structure?

Findings  This cross-sectional study of 150 healthy newborns found that the maxillary labial frenulum had numerous morphologic components with varying distributions. Several components having means and SDs with broad distributions were helpful in differentiating degrees of lip tethering, including alveolar edge to frenulum gingival attachment; frenulum length of stretch; frenulum gingival attachment thickness; frenulum labial attachment thickness; and the percentage of free lip to total lip length.

Meaning  This new understanding of the anatomy of the maxillary labial frenulum may be useful in future studies investigating the maxillary labial frenulum and neonatal breastfeeding difficulty.


Importance  The maxillary labial frenulum and its potential contribution to breastfeeding difficulty may substantially affect public health. However, objective studies of the frenulum are limited.

Objective  To measure the variations in length, thickness, and attachments of the maxillary labial frenulum in healthy newborns and to identify which anatomic measurements could be used in further research investigating the maxillary labial frenulum.

Design, Setting, and Participants  This prospective cross-sectional study conducted measurements on images of maxillary labial frenula captured by digital photography from 150 healthy newborns admitted to the newborn nursery at a tertiary care children’s hospital in Maryland between September 1, 2017, and April 1, 2018.

Main Outcomes and Measures  The primary outcome was the measurement of numerous frenulum morphologic components.

Results  Of 150 newborns enrolled, 77 were female, the mean (SD) gestational age was 38.60 (1.72) weeks, and the mean (SD) birth weight was 3180 (570) g. The means and SDs of the morphologic components of the frenulum with the broadest distributions, which were most helpful in differentiating degrees of lip tethering, included the following: alveolar edge to frenulum gingival attachment, 1.53 (0.85) mm; frenulum length on stretch, 5.19 (1.68) mm; frenulum gingival attachment thickness, 0.84 (0.36) mm; frenulum labial attachment thickness, 2.83 (1.33) mm; and the percentage of free lip to total lip length, 87.38% (7.67%). Gingival attachment mean (SD) thickness differed between late-preterm (0.69 [0.24] mm) and term (0.88 [0.37] mm) infants (Cohen d, −0.52; 95% CI, −0.94 to −0.10).

Conclusions and Relevance  To our knowledge, this cross-sectional study was the first to objectively measure the numerous morphologic components of the upper lip anatomy in healthy newborns. Variations in maxillary labial frenulum morphology were identified, and some combination of the stated measurements may be used to create a more robust classification system to advance quality research in the association of lip-tie with breastfeeding difficulty.