Lip and Tongue Tie – Is it controversial?

Lip and tongue tie are being diagnosed and treated for breastfeeding issues more and more commonly all over the world. In Australia for example, an increase of 420% in the procedure rate has been reported.

Critics of the treatment believe that the increased number of procedures is due to overtreatment by the providers of the procedure and that this is driven by greed or financial gain. These critics have also described these treatments as a “fad”. However, we have no doubt that if it was a fad, the trend would have long subsided as referring practitioners would have stopped recommending patients for a procedure.

We believe that this dramatic increase in numbers is due to the success of the treatment which has led to a consumer-driven demand by parents to have their babies mouths checked, a stronger desire for mothers to maintain their breastfeeding experience, the increased availability for training courses for health professionals and the readily accessible information which is available on the internet and in particular social media.

Literally hundreds of papers have been written in medical and dental journals about lip and tongue tie. Many books have also been written. Well designed research such as double-blind cross over studies and randomized control studies re difficult to organize and often have ethical issues. Therefore, well-planned studies may never come to fruition. We all agree that more research is needed. The same situation holds true for many, if not most, surgical procedures in medicine and dentistry. Nevertheless, just because more research is needed, doesn’t mean that the procedure shouldn’t be done.

The Problematic Frenum

The frenum is a small fold of skin and connective tissue that prevents an organ or muscle mass in the body from moving too far. It is a normal part of the body and while most people do not require any surgical intervention of the frena, some do.

If a frenum is too large or deep it can sometimes restrict or obstruct normal function of the body part to which it is attached, for example, the tongue or lips.

There are five frena in the mouth. The most problematic frenum is found in the midline under the tongue. This is known as a lingual frenum. When this frenum prevents correct tongue function, it is commonly known as tongue-tie or ankyloglossia.

There are two frena found in the midline under the upper and lower lips. They connect the lip to the gums below the two front teeth and these are known as maxillary labial frenum and mandibular labial frenum respectively.

The two other frena are found on the inside of our cheeks connecting to our gums, these are known as buccal frenula.

When is a procedure recommended?

A lingual frenectomy is the removal of the lingual frenum and is commonly performed to treat tongue-tie or ankyloglossia. A frenotomy is the term used when the frenum is snipped and the bulk of the tissue is still present. A frenuloplasty involves a similar procedure but the frenulum is cut, usually with a “Z” incision and then sutured. These procedures are performed for patients of all ages from neonates to adults. The most common reasons for recommending a lingual frenectomy include difficulty with breastfeeding, speech development or tongue functions such as licking, eating or swallowing.

A labial frenectomy is the removal of the lip frenum. It is performed for a variety of reasons, including breastfeeding problems, the prevention of gum recession where the frenum is too high on the gums, orthodontic reasons, where a large frenum causes a space to develop between the two front teeth (as an adjunct to orthodontic treatment) and to improve the fit of a denture where the frenum interferes with the function of the denture.

Laser, scissors or scalpel?

All of the tongue tie procedures can be performed using a laser, scalpel or scissors. The tool which is used is not the main determinant for surgical success but rather it is the experience of the surgeon which is one of the main factors. Many surgeons and laser companies promote their own technique or tool but whether it’s a diode, CO2 or Erbium laser a successful outcome can be achieved. My personal preference is to use the diode laser rather than other lasers because there is no water spray which can be a potential aspiration risk issue and there is no aerosol, so it is the safest laser to use under COVID-9 protocols. In addition, the diode laser cauterizes the mucosa beautifully so unlike other lasers, there is no bleeding in most cases. This gives the surgeon a much better field of view. The procedure is very quick, taking only a minute or two at most.

The majority of patients do not require any local anaesthetic, but a topical anaesthetic cream or a local anaesthetic injection is given in some situations.

How is a tie diagnosed?

Firstly, an assessment is made of the function of the tethered oral tissues to determine if there is a restriction in the range of movement of the related muscles.

An assessment is then made of the structure of the frenulum and whether a release will improve the function.

Finally the related signs and symptoms are correlated to the structural and functional assessment to determine if treatment is likely to improve these signs and symptoms.

If you are not sure about a particular situation, a screening tool such as the Dobrich Frenotomy Decision Tool for Breastfeeding Dyads can be very helpful.

Why is a referral required?

Many providers require a referral from a relevant health care worker for several reasons in many different situations.

For example a baby with feeding difficulties should be assessed by a lactation consultant first to ensure that the problematic symptoms are related to ties and not another issue. We prefer the lactation consultant does a thorough assessment of feeding and uses an assessment tool such as the Dobrich assessment tool. (We can send this to a referrer)

A child with speech issues should be assessed by a speech pathologist first to determine if conventional speech therapy can resolve the issue. The speech pathologist should include a report of the outcome of the speech articulation testing with the referral.

Chiropractors and osteopaths also should make a pre-operative assessment of their patients to evaluate the likelihood that a frenectomy procedure will be beneficial.

For patients, parents, and caregivers, there is peace of mind knowing that a knowledgeable health care worker has evaluated the patient to some degree and feels that the patient may benefit from the procedure.

The referring health care worker should then be involved in the aftercare of the patient if the frenectomy procedure is performed.

Recovering From Your Frenectomy

Healing of a lasered tongue tie can take 10-14 days and during that time most practitioners recommend doing open wound management or stretches to lessen the likelihood of the frenulum growing back. This is often called reattachment.

Frequently Asked Questions

Why wasn’t my baby’s tongue and lip tie diagnosed in hospital when the child was born?

Doctors including paediatricians are not well taught about ties during their undergraduate or post-graduate training as it is not part of the Australian medical curriculum. Similarly, nurses and midwives have very limited exposure to training and to the wealth of information that is available. These health professionals who wish to learn more about ties need to access courses and training in their own time. As a result the level of knowledge in hospitals is inconsistent.

I was told my baby has a slight tongue tie but there are no issues and he’s putting on weight. Should it be treated?

Approximately 10-11% of babies are born with a tongue-tie. There are many variations in the morphology and tightness of tongue-ties. Hence, many of these babies can breastfeed with some compensations and no symptoms. However, issues can occur later in life such as an inability to eat some solid foods, speech issues, or dental growth and development issues. Currently there are no reliable predictors of functional issues related to tongue-tie.

As a general rule in medicine and dentistry we don’t treat something unless there are issues. However, there are exceptions to this. Some people prefer to wait until symptoms arise. Others prefer to have a tongue-tie treated earlier to maximize the potential of dental growth and development and avoid other issues.

Avoiding sedation or general anaesthetic later in childhood is another consideration.

There is no definite correct answer in all cases.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.

Always seek the guidance of your doctor or other qualified health professional with any questions you may have regarding your health or a medical condition. Never disregard the advice of a medical professional, or delay in seeking it because of something you have read on this Website.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of The Paediatric Nurse. Any content provided by our bloggers or authors are of their opinion, and are not intended to malign any religion, ethnic group, club, organization, company, individual or anyone or anything.

Author - Dr Jeffrey M Kestenberg – General Dentist

Dr Jeffrey Kestenberg graduated from the University of Melbourne in 1980 and completed his Master’s Degree in prosthodontics in 1982. In 1983 he was awarded a fellowship of the Royal Australasian College of Dental Surgeons.

He has a keen interest in micro-dentistry, minimally invasive dentistry, and laser dentistry. In recognition of his efforts, Jeff was awarded a Fellowship of the World Congress of Minimally Invasive Dentistry. He also has an interest in the dental treatment of tongue-tie and /or lip tie, snoring, and obstructive sleep apnoea.

Jeff has been at Coburg Dental Group since 1981 and is a consultant in Prosthodontics at Monash Medical Centre where he treats cancer patients after mouth surgery to reconstruct their teeth.

He has also been a clinical teacher and examiner for final year students at the University of Melbourne and is an examiner for the Royal Australasian College of Dental Surgeons. Furthermore he is a Panel member for the Dental Board of Australia / Australian Health Practitioner Regulation Agency and has mentored and audited dentists for those organizations.

He has also lectured locally, interstate, and overseas to undergraduate and graduate dentists on laser dentistry, prosthodontics, and obstructive sleep apnoea.

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