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Tongue Ties, Lip Ties & Cheek Ties are also known as tethered oral tissues (TOTS). Ties are caused by a frenum which is a fibrous tissue that connects and holds other tissues in place. Sometimes a frenum might be short, thick, or tight, and might extend too far down along the tongue, gum, palate, or cheeks to result in a tongue tie, lip tie or cheek tie. When a frenum is positioned in a way to interfere with the normal function, or constricts the movement of the tongue, lips, or cheeks, it can be corrected by a surgery called a frenectomy.
Our treatment philosophy is symptom-driven. We will only perform a frenectomy if there is an impediment to function.
Tongue tie is caused by a lingual frenulum (the membrane under the tongue) that is either too short or too thick. For a newborn, a tongue tie can make breastfeeding difficult for the infant and painful for the mother because the lip’s or tongue’s limited movement prevents the infant from properly latching on.
Mother’s Symptoms of the Infant’s Tongue Tie:
- Painful nursing
- Poor or shallow latch
- Extended feedings (takes more than 30 minutes per feeding)
- Lipstick shaped nipples
- Cracked, creased, flattened, or distorted nipples
- Poor breast drainage
- History of nipple thrush
- Plugged ducts, or sense of engorgement
Infant’s Symptoms of Tongue Tie
- Poor latch on breast or bottle
- Falls asleep while feeding
- Slides off the nipple when feeding
- Cries often / fussy feeder
- Reflux, spitting up
- Clicking sounds
- Poor weight gain
- Chomping on the nipples
- Frequent feedings
- Frustration when feeding
- More than 20 minutes per feeding
- Mouth doesn’t open wide
- Milk blister on the upper lip
Symptoms in toddlers, children and adults
- Difficulty eating solid foods (comes across as a fussy eater)
- Speech difficulties
- High vaulted palate
- Orthodontic constriction
- Gum recession
- Sleep apnea
- Mouth breathing
- Possible link of ADD/ADHD due to airway obstruction
- Posture problems
- Headaches/neck and shoulder aches
- Difficulties in kissing
Type I Tongue tie extending to tip of the tongue
Example of a posterior tongue tie “Popping up” with retraction of the tongue
Babies with lip ties often have difficulty flanging their lips properly to feed and don’t make a good seal at the breast when latching. This can cause them to take in excess air during breastfeeding which often makes these babies gassy and fussy. If left untreated, it can eventually impair the child’s proper tooth alignment or increase the risk of tooth decay.
Thick Lip tie extending to edge of bony ridge. Note the indentation of the gum where the lip tie inserts.
Symptoms of Lip Ties
- Leakage of milk around the mouth when feeding
- Spitting Up
- Poor flanging of lip
- Poor seal around nipple
Moderate lip tie - note the fiber is not as thick and no indentation of bone compared to other picture.
Cheek ties connect the cheek to the bony ridge on the upper jaw. When the tissue impedes normal function of the cheek to generate suction, or effecting the seal around the nipple we may release the cheek ties.
What is a Laser Frenectomy?
Laser frenectomy is the use of a laser beam to detach the frenulum from the lips, tongue and/or cheeks. This may be done with a simple topical anesthetic, or local injection. Sedation is not necessary and the procedure is completed in less than 5-6 minutes.
The benefits of using a laser for the frenectomy are, less bleeding, less scarring, less postoperative pain, shorter healing time, less risk of reattachment, and fewer functional complications.
Healing and Recovery
The mouth heals very quickly and bleeding after a frenectomy is usually minimal. Afterwards it is important to stretch and massage the tongue at least 3 times a day for 3 weeks to prevent the tongue from reattaching as it heals. We discourage the usage of a pacifier.
Most babies experience only minimal discomfort after the procedure, and breast-feeding provides natural pain relief. If, however, your baby seems uncomfortable, Chamilia (teething section of pharmacy) can be given to help with discomfort. Chilled breast milk may be applied to the surgical site.
Please speak with your pediatrician if you are unsure about what dose of medication to give, and remember that medication dosages should always be based on the baby's weight.
You may notice some dark streaks of blood in your baby’s diaper during the 24hrs after the procedure. This is from the small amount of blood that your baby may swallow during the procedure, and it is not a cause for concern. If you are noticing blood in your baby’s diaper and it persists for more than 24hrs after the procedure, or you are concerned, then contact your doctor.
The tissue changes color as it heals. It will transform from being initially red, to yellow,, white, and eventually pink as it completely heals.
Your baby’s mouth heals quickly, and stretching exercises are very important after the procedure to make sure the area that was released doesn’t heal back together. Exercises should always be done when your baby is calm and alert, not tired or hungry. If your baby is resisting the exercises, then stop and try again later.
Lift your baby’s tongue using fingers or a tongue depressor while gently pushing back at the same time so that you can see the diamond shaped area where the cut was made, and hold it for 3 seconds. There may be a small amount of blood as the area stretches but this is normal. Do the stretching exercise 3 times a day for 3 weeks after the procedure.
Breastfeeding is the most effective exercise for encouraging effective sucking. For breastfeeding babies under the age of 3 months, sucking issues related to tongue-tie often resolve spontaneously after the tongue-tie is released, with no other intervention needed. If breastfeeding has not greatly improved by about day 5 after the procedure, there are other exercises that can be done to help encourage your baby to use his/her tongue effectively. These exercises should be tailored to your baby’s specific needs with the help of an International Board Certified Lactation Consultant (IBCLC).
The use of a pacifier is strongly discouraged after the procedure as it may increase the likelihood of reattachment.
Post-Op Frenectomy Excercises
Tongue Tie FAQs:
Q: My other healthcare provider did not notice the tongue tie, but some of the other health care providers did. What’s the real story?
A: The knowledge about tongue ties varies greatly from provider to provider. The technique of the examination is critical in diagnosing subtle types of ties such as posterior ties.
The correct positioning technique for a tongue tie evaluation is to have the parent facing the doctor knee to knee, with the head of the baby in the doctor’s lap. This allows the doctor to visually and palpably examine the baby.
If the tongue is not reflected back using two fingers, it is almost impossible to diagnose a posterior tongue tie. A thorough examination, and the symptoms will be key to help discern the presence of a tie.
Q: Why are you recommending bodywork (Chiropractic, Occupational Therapy, Physical Therapy, Cranio-Sacral Therapy) before the release procedure?
A: The bodywork relaxes the tissue, and primes the tissue prior to the release. It is important to follow up with the body worker and lactation consultant after the release procedure.
Q: Do I have to see the lactation consultant after the procedure?
A: We strongly believe in teamwork to get the optimal outcome for the baby. Each healthcare provider brings different expertise to the care. Lactation consultants are very knowledgeable about the changes brought about after the release procedure, and will help to guide the parents and baby through the sometimes stressful process.
Q: How long will the procedure take?
A: Typically 4-6 minutes for release of tongue and lip.
Q: How should we prepare for the appointment?
A: Do not feed the baby 1 hour before the appointment. Bring a swaddle blanket or a velcro swaddle with you. Complete the registration and health history questionnaire before arriving at the office.
Q: Can I be in the room during the procedure?
A: We strongly recommend the parents not be in the room, as it is an emotionally upsetting experience to see the baby crying. Please be assured we will do everything to keep your baby comfortable. Local anesthetic is usually administered in the appropriate dosage to keep the baby comfortable during the procedure. Crying is inevitable, babies don’t like our fingers in their mouths.... Who does?
Q: How many of these do you do?
A: We perform several hundred frenectomies per year.
Q: Are tongue ties a fad?
A: Tongue ties are known to have been treated since the ancient Greek civilization. More women are breastfeeding, therefore dealing with the discomfort associated with tongue ties. As our knowledge about tongue ties increases, and the resulting complications such as airway, jaw development, swallowing - the recommendation to treat is more frequent.