Frequently asked questions

Everyone has fraena – that fold of skin on the underside of the tongue
or the skin that joins the lip to the adjacent gum. Traditionally the term “tongue tie” was known and taught to be a frenum that came all the way to the tip of the tongue. However, it has become increasingly apparent both in clinical and research settings, it is not just appearance that determines diagnosis. We are interested in movement, function and the workings of the body in order to determine a diagnosis.

In the case of the tongue and lip, where a frenum becomes inhibitive to the normal functions of the mouth and face, it is then restrictive in comparison to a frenum that does not impact the full functions of the mouth and face. The term restriction or tether are more commonly used by those who are experienced with providing accurate diagnoses and treatments because these terms are a more accurate way of describing the clinical issues with function in mind – not appearance alone.

Tongue and lip ties are the result of a failure of cell death (apoptosis) along the midline of the head and neck at 12 weeks in-utero. The exact reason for this failure of apoptosis is the subject of research at present with various hypotheses currently being explored. Whatever the reason, a failure of apoptosis on the midline almost always affects both the lip and tongue. This does not mean that both will always need treatment. It is our experience that for breastfeeding infants, the lip nearly always contributes to the presenting symptoms. For older children, due to the descending bone with the eruption of the upper teeth and the mouth no longer needing to function for breastfeeding, an upper lip will be assessed based on other clinical signs and symptoms.

While it is impossible to say for certain whether a tongue or lip tie in a child will lead to specific orofacial issues in later life, tongue ties have been linked to a number of potential issues across the lifespan.

For some time, studies have shown the effects of a “descended tongue posture” and “tongue thrusts” on the development of the jaws, positioning of the teeth and certain breathing dysfunctions (please contact us for details of these publications)

Given the importance of breastfeeding in strengthening the tongue and other mouth and face muscles and the important role of the tongue in encouraging correct tongue posture (where we place our tongue at rest), the inability or ineffectiveness of many tongue tied infants to breastfeed adequately may led to poor tongue positioning. Even after breastfeeding has ceased, the establishment of tongue posture and the patterns of tongue movement may be limited by a tongue restriction.

An example of poor tongue posture is where it sits at the bottom of the mouth, rather than resting on the mid-front part of the hard palate (behind the upper teeth). This positioning along with the pressures placed on the particularly malleable hard tissue of the mouth and face in early childhood caused by incorrect tongue positioning or absence of suitable tongue pressure during breastfeeding can cause many tongue tied infants to develop a high arched or “bubble” palate and ultimately a narrow jaw. This may in turn result in obstruction within the nasal airways and may lead to mouth breathing .

Habitual mouth breathing in turn, alters the development of the mandible (lower jaw) resulting in a chin/jaw that sits relatively recessed in comparison to its optimum position (retrognathia) and an over bite. A narrow jaw has limited space for the eruption of adult sized teeth and may result in dental crowding, resulting in malocclusion (poor bite) which can lead to poor oral hygiene, uneven tooth wear and pain in the temporomandibular joint (where the lower jaw hinges with the skull). These issues often require treatment such as braces. Given the important role nasal breathing plays in humidifying and decontaminating air, persistent mouth breathing may also result in frequent infection of the throat and tonsils and the upper respiratory tract.

Recent experience indicates the pressures created in the muscles of the mouth, head and neck caused by tethered oral tissue and poor tongue posture may also be a cause of poor posture and cervical (neck) and thoracic (upper back) pain.

It is important to re-iterate that a tongue restriction may not necessarily lead to all of these issues. It merely may influence the tongue’s ability to fully affect the development of the mouth and face and depending on many other variables, will contribute in part in affecting the growth and development of the face. Also, treatment of a tongue restriction does not guarantee the elimination of all these issues – it is the removal of a postulated contributor to future issues.

Sometimes, a health professional may only highlight a lip tie because a tongue tie, especially a posterior tie, can be difficult to identify without undertaking a full oral examination
(utilising the correct palpation techniqu). In other cases, a health professional may hold the belief that a tongue tie is only an issue if it presents on the anterior (front) underside of the tongue.

In fact, all tongue ties have a posterior element, whether or not there is an anterior component. Another way to explain this is that every tongue restriction has an anchor under the skin (submucosal). In many cases posterior tongue ties do not prevent the protrusion (sticking out) of the tongue and so cannot be readily identified visually. The accurate identification of a posterior tongue tie, especially a sub-mucosal tie, requires manual palpation by a health professional experienced in the correct examination technique. In addition to this manual examination, issues with elevation that indicate a tongue tie can best be identified by a good understanding of the functional issues being experienced by the child and mother in the case of breastfeeding or issues with eating, speaking and breathing in other cases.

In some rare cases, a health professional may express an opinion that posterior ties do not exist, however there are numerous articles in reputable scientific journals as to the presentation and effect of posterior tongue ties and the effective treatment of them with laser. Please feel free to contact us if you would like access to these articles.

It is impossible to make any diagnosis for surgery without taking a full history, carrying out a thorough physical and manual examination conducted by a practitioner with experience treating tongue and lip ties.

A good understanding of the functional issues potentially relating to tongue and/or lip ties is essential and is the reason for the extensive history of symptoms we compile prior to conducting the physical examination. A visual examination is insufficient to determine whether a tongue tie exists, as it is common for a posterior, sub-mucosal tie to be difficult to identify with a visual examination alone. Rather, palpation of the area under the tongue is required by an experienced and appropriately trained practitioner. At Enhance we make use of magnification loupes and a head lamp as well as a specific examination technique to determine whether a posterior tie is present.

We receive referrals from lactation consultants, other dentists, doctors, chiropractors, speech therapists and other health professionals. Where they have identified the tongue restriction as a source of symptoms, we would still carry out a through examination. Only after this thorough history is taken and physical examination will our dentists advise whether surgery is a recommended path to consider as an option to improve/ resolve signs and symptoms

Laser use in all aspects of surgery has benefits that lead to improved outcomes for patients when compared with traditional methods. It is not uncommon to hear claims that the surgical tool is not relevant, but rather it is the skill of the surgeon that matters. While a skilled surgeon is a fundamental aspect of optimal surgical outcomes, the suggestion that all surgical tools are the same is simply not correct and is not supported by clinical evidence. Clinical evidence strongly supports the advantages of laser surgery over traditional methods that use blades (scissors or scalpel) and the observations from this research can be applied to frenectomies.

There are many different types of lasers and each works a little differently. Lasers can perform procedures traditionally carried out by conventional tools like scalpels, scissors, cryosurgical and electrosurgical units. In the hands of an appropriately trained, licenced and skilled operator, the benefits of laser treatment far exceed treatment using traditional tools. A laser ablates tissue, it does not cut, but rather the water in the tissue cells absorbs the laser energy turning it into steam and vaporising the tissue. This has the added benefit of coagulation, sealing the blood vessels resulting in significantly less bleeding and trauma. Tissues (and cells) that are cut by scissors also experience crushing injuries to which the body responds by producing sticky healing tissue designed to reattach the wounded tissue, increasing the risk of reattachment.

In addition, due to the process of ablation, lasers have an antibacterial effect on the surgery area, therefore minimising the risk of infection, swelling and pain. Their very precise effective operating area means they are safer to use in the mouth of an alert child as the area of ablation is only in a very small focal range, beyond which tissue ablation will not occur. So if a child moves during the procedure, there is little risk of injury. Certain lasers also have an analgesic effect and hence there is reduced post-operative pain. These factors, combined with the experience of our team, allow children of all ages to be treated without having to be exposed to the risks associated with procedures performed under general anaesthetic.

For laser surgery, we do not need to use artery forceps to crush the blood vessels in order to control bleeding. Lasers seal blood vessels thus resulting in less bleeding compared to other methods, meaning there is no need for sutures and there usually is little to no bleeding.

Not all lasers are the same and each device has its various dental and medical applications. At Enhance, we use one of two different types of laser for frenectomies, depending on the needs of the specific case. For infants and children, we believe the procedure needs to be as quick as possible and provide minimal penetration and heat to the tissue beyond the top layer of the skin. This is why for this age-group, we use a Waterlase iPlus 2.0*, which is an Er,Cr:YSGG laser.

* Waterlase iPlus 2.0 is our laser of choice for frenectomies on infants as we believe it has significant advantages over other methods of performing surgery to correct a tongue or lip tie. The Waterlase iPlus 2.0, provides concentrated light energy and water spray to remove tissue, layer by layer, coagulating as it removes tissue. This laser does not cut or burn tissue, but rather works to vaporise the water contained in the tissue cells resulting in their removal. This laser has the particular benefit of shallow penetration, meaning only the targeted area receives the laser energy. This is particularly helpful in an alert child patient.

Lasers are used in a number of dental practices as they have a wide range of applications in dental treatment. However their use is heavily regulated, especially in Queensland, requiring specialist training. Three separate licences are required – one for acquisition, another for possession and another for laser use. The premises where lasers are used must undergo certification as suitable for use and users must comply with stringent regulatory requirements.

In addition, most lasers are very expensive to acquire and in many dental practices will be the most valuable piece of equipment. For many other health practitioners, the extra training, regulatory compliance and substantial cost is difficult to justify for a procedure they may perform infrequently. However, for practices where lasers are an integral part of providing a broad range of dental or surgical treatment, an investment in a quality laser of $100,000 is justified to achieve better outcomes.

Infant frenectomies

At Enhance, your appointment begins with a member of our team taking a thorough history of the challenges being experienced. In the case of a breastfeeding infant, that history will include gaining an understanding of the symptoms of both mother and child, as each are vital in understanding the functional issues at play. Even with older children, an understanding of historical breastfeeding challenges are highly useful to gain an insight into the nature of function prior to the child potentially learning compensatory mechanisms. After the history has been gathered and passed to one of our treating dentists, she or he will perform a physical examination in the mouth using magnification loupes and a head lamp, examining under the top lip and palpating under the tongue to determine whether a tongue and/or lip restriction exists and the nature and categorisation of each. This processes may include a suck test and other assessment tools to identify the presence, nature and location of ties.

If additional time has been scheduled for treatment, and the treating dentist recommends laser surgery, the procedure will be explained to parents who are then asked for their consent for the procedure before treatment is carried out. At every stage, there is ample opportunity provided to ask any questions and seek clarification about any aspect of the treatment and what you may expect (so please ensure that after reading the fact sheet, you write any questions you have to bring with you).

For treatment, our little patient is taken to our treatment room, gently but securely swaddled (infant cases) and the laser release of the tongue and/or lip ties is performed. Throughout the procedure, the infant has a dedicated midwife focused on soothing and comforting them, while the dentist and dental assistant focus on performing the surgery. Immediately after the surgery, the infant is provided with skin to skin care and taken to the parents’ room. In the case of a breastfeeding infant, the baby will usually be assisted to nurse immediately. This has the benefit of ensuring the treated area is immediately bathed in sterile, soothing breast milk. The child is comforted following the procedure and the treating dentist and midwife are able to observe the functional aspects of the mouth and the midwife is able to determine the functional depth and quality of the latch achieved. Where an infant is bottle fed, we arrange with parents to ensure a bottle is ready post-surgery to allow for a feed and cuddle.

Following this, families are provided with as much time as they need to finish feeding and prepare for departure.

For non-breastfed toddlers and older children, the procedures are very similar, however the aftercare associated with obtaining a latch will be unnecessary and often these families are able to finish their appointment more quickly post-surgery if they wish.

Consistent with the approach endorsed by the Australian Dental Association, the application of anaesthetic will depend on the age of the patient and nature of the procedure. Due to potential complications associated with injectable anaesthetic, these are not used in very young children. In addition, the effect of anaesthetic prevents effective breastfeeding immediately after the procedure which is important for healing, for settling and comforting the child post-surgery, and to enable our team to observe the breastfeeding latch. The laser we use has an analgesic effect following application, however this does not usually remove all discomfort and infants may experience some pain during the brief period of surgery. In slightly older, non-breastfeeding children, a strong topical anaesthetic gel may be applied. For some children, the taste of the anaesthetic is more disconcerting than the feeling of the laser release. Parents who wish to may also give an age appropriate analgesic to their child about an hour before surgery, although preparations containing ibuprofen (like Nurofen or Advil) and aspirin should not be used.

There is certainly some discomfort associated with any surgery in the oral environment, regardless of the tool. Our laser procedure is customised to provide the best outcomes for each patient depending on their age:

ADULTS YOUTH AND MOST CHILDREN

For adults, youth and most children, the procedure is painless as it is performed under local anaesthetic. Either of the two main lasers will be used in this procedure.

TODDLERS AND SOME CHILDREN

Toddlers may have the application of a strong topical anaesthetic gel. This depends on whether the child is breastfeeding, and the degree of cooperation we are able to receive on the day. Some young children are more distressed by the taste and feel of the topical anaesthetic than they are by the treatment itself.

INFANTS

For our infants, in accordance with guidelines of the Australian Dental Association, infant frenectomies are not carried out with local anaesthetic. See below Section on Local Anaesthetics for rationale of this protocol. The procedure for infants is carried out within 3-5 minutes and they are returned to their parents promptly.

Pain is very subjective and patients report a variety of pain levels following a frenectomy. For a procedure that is carried out thoroughly (beyond just the membrane of the tie), some pain can be anticipated. To ensure realistic expectations, we anticipate that like the days following any surgery, after a frenectomy there will naturally be some associated discomfort or pain, mainly during eating. Standard analgesics may be of comfort in the days following surgery.

A frenectomy is a relatively non-invasive procedure, but it is still surgical in nature. We have a very efficient yet caring treatment protocol that ensures that our little ones are reunited with their families as soon as possible. By keeping the number of people in the surgery to a minimum we are able to be most efficient, focus on our patient, have a predictable surgical setting, and provide care in a less emotionally charged environment. We have witnessed, first hand, that a parent’s response to watching their child go through a surgical procedure can be unpredictable and quite distressing for parents. This is especially true for mothers who will be breastfeeding immediately after the procedure. It is for these reasons that we encourage parents to remain outside of the surgery during the procedure. However, should you wish for a parent to be present during the surgical procedure, please discuss this with the dentist during your consultation so that suitable arrangements can be made (eg laser safety glasses).

In the case of infants and toddlers, if you have been booked in for a consultation and treatment appointment, the consultation component will take 30 minutes, the treatment phase takes about 5 minutes and the post-operative phase takes up to 25 minutes, but depends largely on how much time you need to take. For most of our patients, the appointment will be complete in about an hour.

We have a well-planned protocol to ensure that our infant and toddler patients will have the shortest surgery time possible and to enable them to breast or bottle feed straight away. The surgical aspect of the visit generally takes 3-5 minutes.

For older children (generally 4+ years old,) we allocate more time as we need to step them through the procedure including the topical and local anaesthetic. This may take up to half an hour, although the surgery component may take only minutes.

For adults, around half an hour is allocated although the surgery may take only minutes

The type of additional support required is a function of the nature of the challenges being experienced and the age of the patient. Regardless of age, we recommend patients receive manual therapy (chiropractic/osteopathy) in the 24 hours prior to treatment and in the 48 hours subsequent to treatment. Manual therapy from an experienced and appropriately qualified practitioner, increases the suppleness and flexibility of the muscles of the mouth, head and neck, significantly increasing accessibility in the mouth, contributing to positive surgical outcomes. In addition, manual therapy is valuable in teaching new muscle habits and establishing new neural pathways.

In the case of infants undergoing treatment due to problems with breastfeeding, we strongly encourage ongoing lactation support from an appropriately qualified lactation consultant. This is important in helping mother and baby overcome any compensations or habits developed while the tethered oral tissue was still in place.

The consultation and surgery at Enhance is considered a dental procedure and so is currently not covered by Medicare. It may be covered under extras cover with private health insurance. The rebate amount will vary depending on your insurer and level of cover. The codes used are 015 for the consultation and 391 for each frenectomy required.

There are minimal restrictions on travel or other activity after surgery, however carers should bear in mind that our active wound management protocol requires stretches to be performed every 6 hours for up to 4 weeks post-treatment so travel plans will need to be considered carefully to ensure this regime can be maintained. In general it is best to take things easy in the first couple of days post-surgery and we advise against swimming or other medical procedures (such as immunisations) for seven days after the procedure.