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Tongue and Lip Ties

Tethered Oral Tissues (TOTs) Explained

What are TOTs?

Tethered oral tissues (TOTs) refer to restrictive tissues in the mouth that can affect how you use your mouth. The medical term for a tongue tie is ankyloglossia. Just because there is a piece of tissue (frenulum) under the tongue, lips, or around the cheeks doesn’t necessarily mean a person is “tied.” A tie occurs when this tissue restricts function and impacts how the body works.

TOTs can interfere with breastfeeding or chest feeding, bottle feeding, chewing, swallowing, speech, sleep, breathing, and even body movement or posture. There are many symptoms associated with TOTs, and not everyone will experience the same symptoms.

Lip Tie

A tight upper lip frenulum can prevent the lip from fully flanging during nursing, leading to a shallow latch. This tightness can also trap milk against the front teeth, increasing the risk of decalcification and dental decay, which can also occur with bottle-feeding. Additionally, if the frenulum attaches near the ridge or palate, it may cause a gap between the teeth. Further, as a child develops with a strong lip tie, it can restrict the growth of the upper jaw or maxilla.

Tongue Tie

A tight lower tongue frenulum can limit tongue mobility, causing the tongue to cup or appear heart-shaped when elevated. This can interfere with creating the necessary suction for effective breastfeeding and, over time, may lead to speech problems or difficulties with chewing and swallowing food and airway restriction. Approximately 3-5% of the population has this condition.

What Is a Frenectomy?

A frenectomy is a procedure designed to correct a congenital condition where the lingual (tongue) or labial (lip) frenulum is too tight, restricting movement and potentially leading to issues mentioned above, such as difficulty breastfeeding, dental problems, digestive concerns, airway restriction, and speech difficulties. If your lactation consultant or doctor recommends this procedure, here’s what you can expect.

Preparing for a Frenectomy

Before performing a frenectomy of any kind, Dr. Amore has specific requirements that must be adhered to. For a breastfeeding baby, she requires an IBCLC (International Board Certified Lactation Report) prior to release. She requires a SLP (Speech and Language Pathologist) report or OMFT (Oral Myofunctional Therapist) report for clearance to release a patient. For infants under 1 year of age, based on proven studies and literature, we require the Vitamin K injection.

For all patients, Dr. Amore strongly encourages significant preparation of the body, meaning working closely with a craniosacral therapist and a myofascial release therapist prior to release. A full commitment to body work and stretches and exercises after release is required as well.

Procedure

Babies generally tolerate the frenectomy procedure very well, and we take steps to minimize any discomfort. A topical numbing gel is applied to the frenulum before the laser/scissors is used to remove the frenulum attachment. In older patients, a small amount of local anesthetic may also be injected. Children and adults will be sutured after with dissolvable suture for primary closure wound healing. It is even common for a myofascial release therapist to be on site for the procedure to help the body release with it.

It’s normal for babies to cry or become fussy during and after the procedure. Typically, babies lose little to no blood. Once your baby is numb, the procedure is done, your baby is immediately returned to you. Afterward, you’re welcome to nurse, bottle-feed, or cuddle your baby, depending on your preference. It’s also common for babies to drool until the numbing wears off.

Dr. Amore recommends using Hyland’s Teething Gel and any natural remedies you prefer, such as Arnica or Rescue Remedy. If your baby swallows a small amount of blood during the procedure, you may notice brown spit-ups or stools afterward.

After the Procedure

One potential complication after the procedure is that the healing site may try to reattach due to the rapid healing ability of the mouth. To prevent this, it's important to follow the oral myology stretching exercises designed by your Oral Myofunctional Therapist specifically for your baby, child or self.

Before performing the stretches, wash your hands thoroughly and ensure your fingernails are short. Lay your baby on your lap or a changing table with their head close to your hips. Dr. Amore recommends using coconut oil infused with Calendula for wound management during stretching.

On the first day, perform the stretches at dinner time, then 6 times a day for the next 3 weeks. After that, reduce to 5 times a day for a week, 4 times a day for a week, and then 3 times a day for a week. Gradually decrease the frequency until you are doing it once daily. We recommend continuing with daily stretches for one year, as research shows that oral wounds can heal over this period. Dr. Amore also advises following up with your lactation consultant within two days and seeing a Cranial Sacral Therapist the day before and the day after.

Commitment to these stretches is crucial, and a frenectomy should not be performed if parents are unable to ensure the required amount of daily stretching. A white or yellow patch around the treated area is normal, indicating the presence of clotting material. Keep the area stretched and mobile until the white is replaced by pink tissue, and continue the exercises for one year. A new frenum will form, but this does not necessarily indicate reattachment unless there is a restriction in function.

Tongue and Lip Ties: Service
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Signs and Symptoms

Symptoms in a Neonate May Include:

  • Poor latch

  • Sliding off the nipple or falling asleep while attempting to latch

  • Colic-like symptoms

  • Reflux symptoms

  • Poor weight gain

  • Continuous feedings

  • Gumming or chewing on the nipple

  • Difficulty taking a pacifier or bottle

  • Creased, cracked, bruised, or blistered nipples

  • Bleeding nipples

  • Incomplete breast drainage

  • Infected nipples or breasts

  • Plugged ducts

  • Mastitis (inflammation of the breast)

  • Nipple thrush

Symptoms from Early Childhood to Adulthood May Include:

  • Speech issues

  • Feeding difficulties (gagging, texture sensitivity, trouble licking an ice cream cone)

  • Difficulty moving food in the mouth or clearing food from the upper back molars

  • Swallowing problems

  • Challenges with kissing

  • Open mouth posture

  • Forward head posture

  • TMJ or TMD

  • Headaches

  • Malocclusion or crowded teeth

  • Snoring or loud breathing during sleep

  • Sleep apnea

  • Mouth breathing

  • Gingivitis

  • Periodontal disease

  • High risk of cavities

  • Allergies or sinusitis

  • ADHD or behavioral issues

  • Bedwetting

  • Dark circles under the eyes

  • Teeth grinding

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