- 1 What is a tongue/lip tie?
- 2 Signs & Symptoms of tongue/lip ties in adults & children
- 3 Addressing established dysfunction (caused by compensations)
- 4 Supportive Therapies
- 5 Laser surgery (Frenectomy)
- 6 Visiting Enhance Dentistry – what to expect
- 7 Medication and Pain relief
- 8 Active Wound Management (AWM) Stretches
- 9 Further care
What is a tongue/lip tie?
Tongue-tie, professionally known as ‘Ankyloglossia’, is a congenital condition in which the lingual (tongue) and/or labial (lip) frenum (sometimes called frenulum) is too tight, causing restrictions in movement of these parts. This in turn can cause significant difficulty with key functions of this area of the mouth including speech, swallowing, eating and breathing.
In providing some preliminary information about tongue tie, it is important to note that each person is unique and hence tongue/lip tie issues can present differently for everyone. Some common symptoms that may point to a child or adult having a tongue/lip tie are included in the Symptoms and Identification section below.
Tongue ties are formed at about 12 weeks gestation due to a failure of programmed cell death (known as apoptosis) along the midline of the embryo. As a result, a child or adult with a tongue tie may have experienced some degree of symptoms related to oral restrictions their entire life, whether or not they or their mothers were aware of them at the time. The human body is excellent at adapting and coping with suboptimal conditions. In infancy a range of compensations may be used to cope with the effects of a tongue or lip tie, including switching to bottle and formula feeding, using a pacifier or even feeding passively where the mother’s supply is abundant.
However compensations have consequences. The infant who bottle feeds may learn to control the flow of milk by thrusting their tongue forward. This habit then leads to a tongue thrust or reverse swallow – the effect of such a dysfunctional swallow is a constant force on the teeth, moving them around like an orthodontic device. Often, with a tongue thrust swallow, a child will have an anterior open bite (where the front teeth don’t close over each other, leaving a gap) or another form of malocclusion (misaligned teeth).
The consequences of these compensations continue throughout childhood into adulthood. In normal function, the tongue rests in the roof of the mouth, providing a countervailing force on the inside surface of the jaw to balance the pressure of the lips and cheeks on the outside of the jaw. A restricted tongue is unable to maintain its place in the roof of the mouth (or only the anterior portion can be elevated) and so remains in a descended tongue posture. The consequence is often a high arched palate and restricted nasal airways. The frequently blocked nose that results encourages mouth breathing which studies have shown is associated with a range of poor health outcomes.
While most people are familiar with the terms lip or tongue tie (indeed tongue tie is referred to in the Bible), we find it more accurate to refer to use the term “oral restriction” which considers any frena in the mouth which are restrictive. This term also recognises that just because a frenum is present, does not automatically mean there is a restriction that requires treatment. Instead we assess function as well as performing a manual and visual examination to determine whether a restriction exists.
Signs & Symptoms of tongue/lip ties in adults & children
The following signs and symptoms are commonly found in children and adults with oral restrictions. Many of these signs and symptoms result from compensating for oral restrictions over many years as well as the effects of oral restrictions on the growth of the mouth, jaws and face.
Not all people with oral restrictions will have all of these signs and symptoms, however if an oral restriction is present, they are likely to have some. It is also true that some of these signs and symptoms may have other causes and a thorough consultation and examination is required to determine the likely causes of any symptoms a patient may be experiencing.
- A history of difficulty breastfeeding as an infant
- Speech challenges especially with the sounds: S T L R Ch Sh Th F Z
- Strong gag reflex
- Clenching or grinding teeth
- Difficulty nose breathing
- Recurrent ear, nose or throat infections
- History of bed wetting
- Extended pacifier/dummy use
- Thumb sucking, hair chewing or eyelash pulling
- Tiredness after speaking for extended periods
- Challenges with brushing upper front teeth
- History of decayed posterior teeth
- Frequent bad breath
- Crowded teeth
- Dislike of certain textures of food
- Difficulty swallowing food or tablets
- Difficulty clearing mouth of food
- Slow eater
- Digestive problems such as reflux or constipation
- Sleep Apnoea
- Noisy breathing and/or snoring
- Neck, back or head pain
- TMJ pain or jaw clicking
Addressing established dysfunction (caused by compensations)
Where intervention to comprehensively treat oral restrictions is undertaken early – ideally as early as soon after birth as reasonably possible – and treatment is coupled with the establishment of competent, rather than compensatory, breastfeeding which in turn is extended beyond 6 months of age, it is unlikely that symptoms of oral restrictions will occur in later life.
However, where oral restrictions remain throughout childhood into adulthood, substantial compensations may develop and ultimately produce symptoms as outlined above. Just like if a person develops a limp due to an injury to their foot, in due course as a result of the compensations they make, problems begin to appear in other parts of the body such as the back, knee and hip of the good leg. Over time, compensations for suboptimal function can cause as much harm to the good functioning of the body as the original problem itself.
The longer these problems continue, the greater the cascading consequences of the compensations. This means that treating oral restrictions in an older child or adult will also have to address the consequences of the compensations and is therefore more than just a quick surgery to deal with the restriction itself.
When oral restrictions are identified in children, we are able to harness the growth process to overcome dysfunctional compensations or facial growth issues that might be causing malocclusion (crooked teeth or poor bite) with the Myobrace system.
If a malocclusion has not yet developed, Myofunctional Therapy is often sufficient to overcome problematic oral habits such as thumb sucking or hair chewing. Myofunctional Therapy retrains the muscles of the tongue, mouth and face to function optimally and overcome dysfunctional compensations.
Where an oral restriction is identified in a child or adult, we will recommend the patient commences a “prehabilitation” program of myofunctional therapy. These mouth and face exercises strengthen the muscles of the mouth and face in preparation for the surgical release of the restriction. After 3 to 4 weekly sessions of myofunctional therapy, the patient will be ready for the laser release of their oral restrictions. After the release rehabilitation is undertaken with another 4-5 weekly myofunctional therapy sessions.
In our practice we have also found Myofunctional Therapy to be effective at overcoming problematic oral habits such as thumb sucking or hair chewing. Current thinking is that both habits may occur due to the tongue not resting correctly in the roof of the mouth. The loss of palatine stimulation normally provided by the tongue is then replaced by the thumb or fingers or by chewing on the hair.
Myofunctional Therapy uses a range of methods and exercises to encourage the tongue to rest in the roof of the mouth, the lips to seal and breathing to occur through the nose. Our experience is that once this occurs, dysfunctional oral habits tend to cease.
Tongue up, lips closed, breathe through the nose
Myobrace is a system that extends the work of myofunctional therapy and applies it to enabling the face and jaws to grow optimally. When the jaw grows optimally, there is rarely a requirement for mechanical straightening of teeth later through orthodontics.
Due to issues associated with an open mouth posture associated with mouth breathing, which may result from a restricted tongue, children with oral restrictions may develop a malocclusion (misalignment of the jaws and teeth) that will eventually require braces to overcome, however it is possible to change the growth path a child is on and restore optimum function with interventions such as Myobrace and oral restriction surgery.
Having treated many thousands of cases, our experience is that the pre-habilitation and rehabilitation of the muscles of the mouth and face is critical to providing the best possible outcomes. The tongue itself connects to 18 muscles and muscle groups in the head neck, upper chest and upper back meaning a restriction tongue can lead to significant postural problems. In particular where a descended tongue has caused airways issues, it is common to see a forward head posture and mouth breathing in order to open the airway. As the heavy head comes forward, the body’s centre of gravity is out resulting in a compensating flip forward of the hips, a locking in of the knees and an inward roll of the feet1.
These descending compensations result in a range of postural issues that are best treated by a manual therapist such as a chiropractor, osteopath or physiotherapist experienced in cranial sacral therapy and the effects of oral restrictions.
1 – Scoppa,F. Glosso-postural syndrome, Annali di Stomatolgia 2005 (A journal of Odontostomatologic Sciences; LIV (1):27-34
Given how much of our speech is determined by the way we position and move our tongue, a restricted tongue will often lead to speech related issues. One of the pioneers of the treatment of oral restrictions was speech pathologist Carmen Fernando who recognised the importance of a free tongue in correctly forming the sounds that make up speech. Her work is published at tonguetie.net.
Once a restricted tongue is released with laser surgery, patients with speech challenges are encouraged to work with a speech pathologist who is knowledgeable in the effects of oral restrictions
Breathing dysfunction, such as mouth breathing, often occurs when the tongue is restricted due to the descended tongue posture that results from a tongue restriction. Other dysfunctional habits such as thumb or finger sucking, hair chewing, pacifier use or even bottle feeding can further encourage a descended tongue posture and an open mouth leading to mouth breathing.
When we mouth breathe, we take in a higher volume of air, without the benefits of filtration, humidification and helpful biochemical processes that take place in the nasal cavity. Given the benefits of nasal breathing, it can be helpful to retrain dysfunctional breathing habits to establish nasal breathing. It may be beneficial to work with a breathing educator, such as a Buteyko practitioner, to establish optimal breathing habits.
Nutrition and gut health
The tongue and mouth are the beginning of the digestive tract, and a tongue that is unable to move optimally may compromise the beginning of the digestive process. In the mouth, food is broken down mechanically through chewing and also through digestive enzymes in saliva that pre-digest food before it reaches the stomach and intestinal tract.
Premature swallowing of food may also impact the peristaltic movement involved right throughout the digestive tract, which when combined with incomplete pre-digestion may result in a range of digestive issues.
Further to this, certain foods may provoke an inflammatory response in the body causing nasal congestion, resulting in mouth breathing whether or not a tongue restriction is present. The advice of an appropriately qualified and experienced nutritionist or naturopath may also be able to assist those who experience persistent nasal congestion.
Laser surgery (Frenectomy)
Lasers have significant advantages over scissors or scalpels as a means to treat soft tissue. In laser terms, the tissue is “ablated”. Light energy is used to remove tissue entirely rather than the cutting that occurs with scissors or scalpels. The advantages of laser surgery include:
- Reduced collateral damage (it is more precise, removing tissue layer by layer)
- It is bactericidal (kills bacteria as it works, dramatically reducing risk of infection)
- Reduced discomfort/pain during and after surgery (some lasers have an analgesic effect)
- Reduced bleeding (coagulates as it goes)
- Reduced swelling and inflammation after treatment
- Allows for better healing through photobiomodulation, where light energy stimulates a healing response at the cellular level.
All methods of surgery for oral restriction require a good knowledge of the condition, its treatment as well as the necessary post-operative care. Use of lasers requires additional training in laser physics, laser safety and laser use for different techniques.
Each type of dental laser works in its own specific way – not all lasers work in the same way. Some, (generally diode lasers) use a hot tip to remove tissue through contact. With diodes, the heat of the tip melts the tissue and cauterises it, meaning tissue is removed completely and any bleeding is stopped quickly. These types of lasers also encourage healing due to their deep penetration into tissue. Diode lasers are cheaper for dentists and other surgeons to acquire and so are more accessible. However, their extreme heat presents certain risks and can be painful where anaesthetic is not used, as is the case for infants and toddlers. These lasers also tend to be much slower than some of the alternatives meaning they are less useful where a fast procedure is required, such as for infants and young children. However, they do provide a number of advantages over scissors or scalpels.
At Enhance, after significant investigation and speaking with laser experts who are dentists and have multiple publications on laser surgery, we have elected to use a Waterlase for frenectomies. The Waterlase (Erbium, Chromium: YSGG) is a non-contact laser. The cells in the tissue absorb the laser energy directly, causing vaporisation and complete removal of the tissue. It also works alongside a cooling stream of air and water, thus minimising the discomfort to the patient. The Waterlase also has an analgesic (pain-relieving) effect and allows for a very quick procedure (often less than a minute per frenectomy in skilled hands) meaning it is very well suited to infants and young children. However, a Waterlase can cost up to thirty times more than an entry level diode laser and so they may be less available in dental surgeries.
For more information on the benefits of laser, please read our article on this subject.
For most children and adults, we will use either a topical or injectable anaesthetic prior to the treatment. While the Waterlase is more comfortable during the procedure, and some patients elect not to have anaesthetic, nevertheless it has been our experience that most patients prefer to avoid the discomfort via anaesthetic.
For very young children, we will make an assessment during the consultation and immediately prior to treatment as to whether anaesthetic is advisable. It has been our experience over many hundreds of cases, that very young children often react very badly to the feeling of numbness becoming far more distressed at the new and unknown feeling than they do to the more familiar feeling of discomfort or pain. Also, there is a very significant risk of substantial damage to the tongue, cheeks and lips from biting where a very young child is numb following treatment. This issue will be discussed with parents during the consultation and prior to treatment.
Please note that any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from an appropriately qualified health practitioner.
Visiting Enhance Dentistry – what to expect
For all children and adult patients visiting Enhance, we start with a consultation. This is a comprehensive and extended examination and includes:
- Gathering information about the patient’s symptoms and challenges (past and present)
- A visual examination to observe whether there is any limitation of movement and position of the frena
- A manual examination to identify and evaluate the presence of any restrictive tissue and form a diagnosis.
- A thorough discussion to provide information and answer any questions about the condition, its treatment and expected outcomes.
- Recommendations on a path forward which may include myofunctional therapy, Myobrace and/or laser frenectomy.
After booking an appointment at Enhance, patients receive an email detailing the sorts of pre-appointment information that will assist in coming to a diagnosis during your consultation. This may include photographs of mouth posture when sleeping and recording sleep to determine whether and to what degree the patient snores.
Long distance patients (Skype is an option)
For those travelling from regional, interstate or overseas areas, we are happy to allocate time for a remote consultation via Skype ahead of making travel arrangements to Enhance. Once an appointment for a Skype consultation is booked, we will advise the type of information needed to be gathered ahead of the consultation.
Booking Fee and Cancellations
A booking fee of $50 is taken to secure the appointment time, which is credited toward the fee at the end of the appointment. It is not an additional fee.
The booking fee is paid via credit card over the phone at the time you are making the appointment. As our schedule is planned to allow the best possible care of our patients, we require two business days’ notice should you be unable to keep your appointment so that we can give adequate notice to others who would like that time. Cancellations within the two business day notice period will result in the loss of your booking fee.
Medication and Pain relief
Ahead of treatment
Laser treatment, especially with the Waterlase, compared to traditional methods of surgery is minimally invasive and much less painful than many other methods. Where anaesthetic will be used for children and adults, it is not normally necessary to take pain relief medication ahead of treatment.
Patients will experience varying degrees of discomfort or pain for the first 1-3 days following the procedure. This can depend on the nature of surgery required to gain a full release, the temperament and state of health of the adult or child as well as other factors.
Following treatment, it is advisable to avoid foods with a high level of acidity such as tomatoes or citrus. During this time, patients may find it necessary to take pain killers such as paracetamol. While the risk of post-operative bleeding in the days after surgery is low, it is nevertheless important to avoid medications such as asprin or ibuprofen and even anti-inflammatory foods and supplements such as fish oil and turmeric.
It has been our experience that the need for pain relief subsides after the first couple of days and while there may be some discomfort in the subsequent days, especially during eating and when performing active wound management stretches, it subsides quickly.
Active Wound Management (AWM) Stretches
The tissue of an open wound following injury or surgery will attempt to return as close as possible to its original character, with the outer edges of tissue normally migrating tightly together. Sometimes the skin/mucosa is pulled even tighter in the healing process (similar to how a cut on your arm might heal). This type of healing is known as healing by primary intention.
In healing a frenectomy site, we wish to encourage healing by secondary intention where healing factors migrate from the outer edge of the wound to the centre thereby minimising tightness. If we are to avoid the process of healing by primary intention (and the associated tightness), and instead encourage healing by secondary intention, certain steps need to be taken. Accordingly, it is important that a thorough post-operative care protocol is followed to prevent healing that results in a return of restricted tissue, but rather maintains the freedom of movement provided by the initial surgery.
Exercises provided by a customised myofunctional therapy program are very helpful in building muscle tone in the tongue once greater range of movement has been established, however further assistance is needed to prevent reattachment of the treatment site.
Active wound management stretches are performed three times per day (upon waking, around lunch time and prior to sleeping). Please note this frequency should not be confused with that used for infants and toddlers which requires an overnight stretch in addition. If any variance to this frequency is required, you will be advised during your appointment.
The stretches aim in particular to prevent the diamond of the wound closing horizontally and so the stretch involves stretching the upper point of the diamond of the wound and the bottom point away from each other. This stretch is demonstrated during the appointment. Especially in the first week after treatment, this stretch is quite painful, but pain will subside quickly after completion. For children, it may be advisable to have some sort of reward in place for performing the stretch.
Depending on a patient’s age at time of treatment, varying compensations or consequences may have developed due to the restricted oral tissue. Issues such as problems with oral hygiene caused by an inability to clean food from back teeth or from the cheek surface of teeth may have resulted in dental decay.
Where mouth breathing has resulted from a descended tongue posture, they may be a developing malocclusion (misalignment of the teeth) and in teenagers and adults the malocclusion may be quite significant.
In recognition of this and as part of our comprehensive approach to dental care, we have established a protocol for addressing the oral health needs of patients affected by oral restrictions. Examination appointments are available with our team of highly skilled and well-trained dentists and oral health therapists who can assist you or your child on a path to better oral health including general dental treatment such as restorations and crowns, myofunctional and regular orthodontics. Please ask our front office team if you would like to schedule an examination appointment