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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. For infants, the key function of the mouth region is to breastfeed so restrictions involving the motion of tongue and position of lips can have a significant impact on successful breastfeeding.
In providing some preliminary information about tongue tie, it is important to note that each mother/baby dyad is very unique and hence tongue/lip tie issues can present differently for everyone. Some common symptoms that may point to the infant being tongue/lip tied are included in the Symptoms and Identification section.
Some mothers and infants manage to cope with some or all of these issues, either by compensating through postural, positional or other ways. For many, however, it severely impacts on successful breastfeeding, and compensations that may work in the initial phases of breastfeeding become less effective when milk supply is driven by demand rather than by the mother’s hormones. There are lifelong implications for tongue and lip ties beyond breastfeeding, so it is important to establish early competence in the use and position of the tongue. Short term compensations frequently lead to establishment of long-term habits, which manifest in other issues across the lifespan. Merely ‘coping’ is neither favoured nor ideal for long term habits and functions.
Tongue or lip ties present in many different shapes and forms. Most health professionals working with infants and toddlers have received training to be familiar with very physically prominent, classic tongue-ties that end on the tip of the tongue or cause a heart-shaped tongue. However, tongue ties can be deceptively hidden on the underside, at the base of the tongue and cannot be easily visually confirmed. We commonly call this a “sub-mucosal tie” although in many circles it is called a posterior tongue tie. Proper assessment and evaluation from a clinician or health care provider who is experienced with their identification is critical. In fact, in her education courses, Dr Jones suggests that professionals begin to use the terminology “oral restriction” to enable better understanding of the functional implications, rather than just physical presentation of tongue ties.
Some common signs of Infant Tongue/Lip tie include:
As mentioned above, it helps to understand the nature and impact of tongue or lip ties by referring to them as oral restrictions.
Similarly it is helpful to understand the different presentations of tongue restrictions by understanding where they start. In certain circles, tongue restrictions are sometimes referred to as “anterior” or “posterior” ties. These terms refer to the position of the tie in relation to the underside of the tongue and whether the tie extends above the skin. However, this description can lead to confusion and debate about whether a posterior tie is in fact present.
It is important to understand that every tongue restriction begins under the skin of the mouth (called mucosa) so it is most accurate to refer to it as sub-mucosal (under the mucous membrane). Some tongue restrictions have an extension outside of the mucosa toward the middle or toward the tip of the tongue. It’s a bit like the concept of an iceberg where the main component is under the water. In the case of tongue restrictions, there may or may not be a visible portion and the degree of the extension towards the front of the underside of the tongue varies. Regardless of where the anterior portion attaches, it is vitally important to note that the classification, appearance or point of attachment does not indicate the severity or impact of a tongue or lip tie. What determines the severity and impact of an oral restriction is the degree to which it contributes to functional issues and symptoms. It is more a focus on how things work not merely how things look.
As such, it is not correct to refer to a tie as mild or severe on the basis of appearance or classification alone. For example, a type IV (4) or III (3) tie may appear deceptively as a normal functioning tongue, but can in fact result in severe nipple pain and damage. Whereas, a type I (1) attachment that goes all the way to the tip of the tongue, may result in less severe functional issues, despite having a far more obvious presentation.
The bottom line is, if a child or mother are experiencing several of the symptoms listed above consistently, it is prudent to explore for a tongue and/or lip tie and these should be checked by a practitioner experienced in diagnosing and treating ties.
Understanding of ties is still fairly limited for most medical and dental practitioners due to the lack of education on ties in basic and specialist medical and dental degrees. Therefore, it is advisable to check the level of experience and education a practitioner has had in ties when choosing who to visit. There are a number of tongue and lip tie support groups on social media that can assist in identifying suitable practitioners and associated therapies. Not sure where to look? You can find them on our useful resources page.
A frenectomy refers to the surgical removal/ freeing of the fold of mucosa under the tongue or the upper/lower lip (frenum/frenulum). This is often referred to as freeing, releasing or revising a tongue or lip tie.
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 cutting that occurs with scissors or scalpels. The advantages of laser surgery include:
All methods of surgery for oral restriction require a good knowledge of the condition, it’s treatment as well as the necessary post-operative care. Use of lasers requires additional training in laser physics, laser safety and laser techniques.
Each type of dental laser works in its own specific way – not all lasers work 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 (numbing) effect and allows for a very quick procedure (less than 30 seconds 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.
Enhance Tongue Tie Clinic dentists, Dr Jones and Dr Hanson lecture to international audiences on the comprehensive treatment of tongue and lip tie and while a number of the participants of their courses may start with diode lasers, those serious about treating infants and toddlers move very quickly to the Waterlase with the comfort of the patient in mind.
Finally, it should be noted that treating infants is not merely a quick “snip”. It involves a thorough removal of any tissue inhibitive to proper tongue and lip functioning to allow full motion and optimum positioning of the oral structures during breast (or bottle) feeding. It is our experience that through laser surgery the inhibitive structures can be removed completely to allow optimum outcomes.
For more information on the benefits of laser, please read our article on this subject.
Where another health practitioner has not identified or diagnosed the presence of oral restrictions, or where there are only limited observed symptoms, a consultation in the first instance is suitable. This takes no less than 30 minutes for infants and toddlers under 2 years of age.
If you have contacted Enhance on the recommendation of another parent or through your own search, please read the signs and symptoms that often indicate functional issues due to a tongue tie. Our receptionists will be able to determine the length of your visit based on your concerns and needs. A consultation and examination will take approximately 30 minutes. While the actual laser treatment usually takes less than a minute, if this is required, a further 30 minutes will be planned to allow time for settling and feeding where possible after surgery.
At Enhance Dentistry, our consultation consists of:
If your infant or toddler (under 2 years) has been referred to us after identification or diagnosis of a tongue or lip tie from another health professional, or where the symptoms are significantly indicative of oral restrictions, we are able to allow additional time for the laser treatment to immediately follow your consultation. These visits are generally an hour in duration and include a consultation, examination, laser treatment and a post-operative feed accompanied by our in-house Lactation Consultants. This is not a full lactation consultation – our consultants are here to support our mums with post-surgical lactation only. We recommend you work with an experienced IBCLC pre and post-surgery to gain optimum results.
The treatment is carried out with a high quality, non-contact laser (not scissors or scalpel) called Waterlase. It is a relatively straightforward procedure, not requiring general anaesthesia, sutures or complex oral medications. The surgery itself is usually completed within one or two minutes.
At Enhance, we pioneered a multidisciplinary approach to the treatment of tongue and lip ties that is now replicated around the world. This means that we work alongside other health care providers that work toward better oral function (whilst achieving optimum outcomes) from the frenectomy. Dr Marjan Jones, who treats tongue and lip ties at Enhance, also lectures on the topic to a range of health professionals on the importance of a collaborative team approach. Working with a body worker such as a chiropractor or osteopath as well as an IBCLC is critical to achieve best outcomes.
For those travelling from regional, interstate or overseas areas, we are happy to allocate time for a remote consultation via Skype ahead of you making travel arrangements to Enhance. Once you make an appointment for a Skype consultation we will advise you of the type of information you will need to gather ahead of the consultation.
A booking fee of $100 is taken to secure the appointment time. This booking fee is held in credit until the day of your visit and applied to your account. For Skype consultations we do ask for payment in full, in advance.
The booking fee can be paid using your credit card at the time of arranging your visit. So that we can give adequate notice to others who would like a sooner appointment, we require 2 business days’ notice should you be unable to keep your appointment.
Cancellations within the 2 business day notice period will result in the loss of your booking fee.
Laser treatment, especially with the Waterlase, compared to traditional methods of surgery is minimally invasive and much less painful. Your infant/toddler will likely object by crying as we have to hold them still during the procedure for safety and precision of treatment. While the treated area will not be painful immediately after the surgery (due to the analgesic effect of the Waterlase), the treated area will likely be tender after a few hours. As such, you may wish to pre-medicate with your chosen pain-relief (no Nurofen or other forms of ibuprofen, as they may promote bleeding) about an hour ahead of the procedure. When you make an appointment we will email you further information on pain relief in your “welcome” email.
To allow the tongue and lip to fully function after treatment in breast or bottle feeding, we do not anaesthetise infants and toddlers. This also allows us to observe how the mouth functions after the treatment (breastfeeding, bottle feeding or drinking). Numb tissue may not behave normally as the infant will not be able to fully feel its position.
In some cases, in consultation with parents, we may decide to anaesthetise toddlers with a topical anaesthetic gel. The risks of a toddler biting their tongue if it is numb has to be weighed up with the very short period of discomfort that may stem from the procedure. It is also common for toddlers to be more distressed by the strange feeling of numbness than from the treatment itself.
Our little patients will experience varying degrees of discomfort 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 infant and mother as well as other factors. Following treatment, we provide a suitably relaxed environment where we encourage plenty of skin to skin contact to enable optimum breastfeeding or to provide a comforting cuddle while bottle feeding. The same can be emulated at home – relaxed comfortable environment, lots of close skin to skin contact, taking relaxed baths together to provide natural pain relief. This is especially important for infants under 4 weeks of age where usual pain relief medication is not recommended.
For those older than 4 weeks of age, parents may decide to use their chosen pain-relief according to the advice of their health practitioner and to administer it about an hour prior for a more comfortable feed.
Every family will have their views as to the type of pain relief they wish to use on their children. Some families prefer natural pain relievers dispensed by their homeopath or naturopath (eg. Arnica mixed with other substances) while others choose generic pain relief medication (such as Paracetemol – do not use Ibuprofen on the day of surgery or for two to three days after surgery). Always choose these according to the advice of your health practitioner and based on what you feel is best for your baby.
We have found that we are more efficient and effective in treating our patient (your precious little one) when parents are not in the surgery during treatment. We are able to give them our full attention, observe their response during treatment and respond to their needs. This means they are able to return to parents as soon as possible (usually in less than a couple of minutes). Our treatment room is staffed with experienced and calm professionals, creating a predictable and positive environment. In particular, where a child will be breastfed following surgery, it is vital that mum is as calm as possible to allow for milk let-down and to encourage the infant to settle quickly post release. We have found the post-operative period is significantly more difficult if mum is highly anxious or distressed.
While it is uncommon for family members to be present in a surgical setting (and we recommend against it for the reasons above) we leave the final decision to be present for surgery with you.
We understand that coping with feeding challenges in a tongue/lip-tied infant can be an emotional and physical roller-coaster for families. As such, we share this information so that all families receive the care they need. We have found a few key elements result in better outcomes for patients and they are included in this section.
Having gone through a surgical procedure, you can expect that your infant or toddler will likely be tired, irritable, or very unsettled for the remainder of the day. In some instances, the infant may be inconsolable. Where your child will not settle, or take milk, the first step is to get in contact with your IBCLC (International Board Certified Lactation Consultant). While you wait for contact with her, try to remain calm yourself, provide skin to skin contact, and attempt to feed your child. These challenges may continue for a few days after surgery depending on the healing process and on the individual circumstances of the child.
Please note that a small amount of oozing is normal in the few days following surgery and a little blood goes a long way amidst saliva. Generally, a small amount of blood is not a concern, especially where it stops quickly (for example where bleeding occurs after a stretch but stops quickly). If you are concerned, please contact us at the practice on 07 3217 6688 during business hours. You will also be provided with a direct contact, after-hours mobile number for your surgeon in your post-operative documents.
The tissue of an open wound following 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
During healing of a frenectomy site, we wish to encourage healing by secondary intention which is where healing factors migrate from the outer edge of the wound to the centre. Thereby minimising the 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.
Breastfeeding is a very helpful function of the mouth that assists to minimise the rapid closure of wound borders (reattachment) post-surgery. However, the mechanism of breastfeeding alone does not provide adequate stretching (especially in sub-mucosal tongue ties) to prevent the outer edges of the wound from healing together rapidly to reform the restriction (also known as reattachment).
Therefore, even in breastfeeding infants, gentle (but thorough and firm) and regularly repeated pressure on the wound is strongly recommended to prevent primary intention healing and reattachment. We have found these stretches to be instrumental in minimising the reattachment of the frenum to its former position. The process can be very challenging for parents and baby – stretching of a wound can be very uncomfortable and the child will likely cry and will dislike the stretches (you are pressing on or beside a surgical area). However, it is vital to keep in mind that the stretches are to promote optimum healing with minimal reattachment. You will be given post-operative instructions at your appointment and shown in our AWM stretches video. The stretches are a three second motion for each treated area ensuring the process is quick but thorough. You can then embrace, feed and comfort your baby as soon as it is done. Making the stretch part of a game makes it easier to do. We encourage parents to remember that they are doing the stretches FOR their child, not TO them.
Some infants/toddlers are provided with additional exercises by their body worker or lactation consultant to address certain muscle tone or habit issues. It is important to note that AWM stretches are different from those that may be given to you from your lactation consultant or body worker and must be performed regardless of other exercises you may have been given. Please see the AWM stretches video to ensure you are performing the stretches correctly or call to ask after our next stretch clinic if feeling unsure.
The amount of time taken to see a change in function can be highly variable, from virtually instantaneous to a few months. This variability depends on the child, their age and the severity of dysfunction before treatment. In addition to the above, many infants require assistance to learn the new mechanism of latching on and mothers may need to learn how to help the infant to latch on properly. This is where the assistance of an IBCLC (International Board Certified Lactation Consultant) is crucial. An IBCLC who understands the possible dysfunctions related to oral restrictions will be able to accompany the dyad (whether breastfeeding or not) in the period before and/or after the frenectomy. Also, certain muscle tightness or irregularities may need to be treated through manual therapy (osteopath or chiropractor) and this too, will need variable time depending on the needs of the patient.
The importance of the support of an IBCLC and body worker post-surgery cannot be overstated. This multidisciplinary support is critical to minimising the chance of reattachment and overcoming established dysfunction.
Recent research shows that the health of our digestive system has a great bearing on the functioning of our body systems. Including our immune response and ability to heal. We recommend that in cases where the mother or baby have taken antibiotics or experience digestive challenges (bloating, gas, diarrhea, reflux, constipation) or where there are ongoing infections or thrush, that taking probiotics be considered. These may be taken by both mother and baby. When taken by the mother alone, it will optimize her milk’s content for the benefit of the baby. When the mother’s gut health is healed, the baby’s gut health is optimised. We suggest a practitioner brand of probiotics for stronger potency and broad spectrum (with a content established to enter into breastmilk). We currently stock the following three formulations.
Probiotics are sold at our practice at below RRP and are subject to change. We have no affiliation with this company and stock their products due to the variety available. These products may also be available from your health food store. For more information, visit Bioceuticals.
Ultrabiotic Pregnancy (and lactation)
While there is a steadily growing body of practitioners and health care providers who are becoming familiar with lip and tongue ties, it is important to note that not all feeding challenges are created by a tongue or lip tie, nor can releasing the restriction necessarily idealise the feeding situation in every case. Sometimes there is immediate improvement after the procedure and sometimes it is a gradual process as the tongue gains better tone and function once it is moving in new ways.
The source of a breastfeeding challenge may be multi-layered and multi-factorial. Therefore the treatment of breastfeeding issues often requires a multi-disciplinary approach needing the collaboration of several providers, depending on the specific situation of the infant. The surgical release of oral restrictions is only one step in the process of optimising breastfeeding outcomes.
The human body is composed of many working parts that are integrally connected. No cell, no body part or organ is affected in isolation. The functioning of one body part will affect other parts of that working system and the ripple effect continues.
While our laser treatment releases the chief restriction and allows a proper latch, breastfeeding utilizes other superficial and deep muscles beyond the tongue and the lip. Further, a tongue that is restricted in its movement will have collateral influence on all of the attachments of the muscles of the tongue. The paired tongue muscles (right and left) attach into the lower jaw (mandible), the lower base of the skull (styloid process), a bone at the base of the throat (hyoid bone) and the palate (palatine aponeurosis). An anchored tongue means that these areas are also affected and often dysfunctional.
We have found that where tension, restrictions and limitation in these other structures are addressed alongside the frenum release, the results of success are enhanced. It has been our observation that patients who receive manual therapy from a suitably experienced chiropractor or osteopath (who works with infants and knows the influence of lip/tongue ties, works with attachment areas of the tongue muscles), present with significantly greater mobility of the tongue, providing better access for surgery and greater potential for rapid improvement of function post-surgery.
Body work may involve palpating various muscles or the soft bones of the face, head or neck to help with stabilisation of the soft tissue in conjunction with laser surgery. It can release the pressure and tension that results from the limited tongue and/or lip movement that occurs due to a tight frenum. It also has a flow on effect on the areas of the body that cranial nerves supply such as the Vagus nerve which affects intestinal movement as well as other organs.
The number of manual therapy visits depends on the patient’s needs. We have observed that where there has been at least two sessions of manual therapy (with one directly before the surgery), the tissues are more pliable and the procedure is more successful. We suggest at a minimum, one visit 24-48 hours ahead of frenectomy and another 24-48 hours after the frenectomy. This allows the supportive tissues to become more agile and support the new found freedom of the tissue. In most cases, more visits are required to ensure maximum and sustained improvement in tongue function. Ask your provider as to what suits your case. Manual therapy is particularly helpful if your little one suffers from reflux, “colic”, wind or vomiting or shows a preference to feed on one breast over another.
For more information on manual therapy, see our article or visit http://www.ankyloglossiabodyworkers.com.
Most infant patients arrive for a frenectomy after having already seen a lactation consultant whom they will visit shortly after the surgery. The infant who has difficulty breastfeeding will benefit from the supportive care of a lactation consultant after surgery. This is especially true where an infant requires suck training to overcome established dysfunction.
While it is possible for almost anyone working with breastfeeding mums to refer to themselves as a Lactation Consultant, we strongly recommend working with an International Board Certified Lactation Consultant (IBCLC). IBCLC’s go through an extensive training program and must regularly sit challenging exams to maintain their certification; they also adhere to a rigorous code of professional conduct.
Over the many years and thousands of cases we have seen treating oral restrictions, we have developed a network of professionals in a range of fields experienced with the diagnosis, treatment and after care of tongue and lip ties. In order to assist patients and their families to access supportive therapies we have compiled a list of practitioners who we feel confident will provide appropriate pre and post-operative care. In addition, several of these practitioners have attended a continuing professional education Foundation Course offered by the Tongue Tie Institute meaning their learning and approach is highly aligned with the Enhance treatment protocol. We have indicated which practitioners have completed the TTI Foundation Course.
Supportive Therapies Practitioner List
We should stress that Enhance has no business or financial relationship with these practitioners, but we have a high level of confidence in their competence as we have found that their care ensures optimum outcomes. Enhance employees are only paid for their work at our surgery and no further financial relationship exists.
Please also review our Frequently Asked Questions section as this provides answers to many of the more general questions we receive and will enable the time in the consultation to be focused on your child’s specific issues.
We have compiled an extensive list of scholarly articles on the research regarding the effects and treatment of oral restrictions and related conditions.