WHAT IS A TIE?
The medical term for the condition known as tongue tie is ankyloglossia. It results when the frenulum (the band of tissue that connects the bottom of the tongue to the floor of the mouth) is too short or tight, causing the movement of the tongue to be restricted. Tongue tie is congenital (present at birth) and hereditary (often more that one family member has the condition). It occurs relatively often: between 4-10% of babies are born with tight frenulums (source).
Without treatment, infants must learn to compensate for any restrictions - sometimes, the tie causes no problems with feeding or speech development; for others, function is severely impaired throughout life. A lot depends on the degree of the tongue tie: if the points of attachment are on the very tip of the tongue and the top ridge of the bottom gum, feeding and speech are more likely to be affected than if the frenulum is attached further back.
A lip tie occurs when the frenulum that attaches the upper and/or lower lip to the gums on the upper jaw bone. Sometimes the frenulum can wrap all the way around the gums and attach on the palate. The degree of attachment does not always correlate with decreased function - the need for treatment is based solely on symptoms, not thickness of the frenulum or where it attaches.
A severe tie may cause a notch to form on the upper gum line. This is due to the tension from the frenum pulling on the bone. In a battle between muscle and bone, muscle will always win - in this case, the muscle is causing the jaw bone to pull upwards, which can affect the child's erupting teeth.
The term "Tethered Oral Tissues" (TOTs) refers to all types of ties - lingual (tongue), labial (lip), and buccal (cheek).
TIES & BREASTFEEDING
One of the biggest challenges facing a baby with ties is breastfeeding, as well as bottle feeding. There are several studies on the subject of breastfeeding and ties, and as a result, there is also a wide range of opinions on the subject. Some practitioners believe that babies adapt or the frenum stretches, while others believe the only way to resolve the issue is with surgical treatment to release the lip and/or tongue to allow its full range of movement.
Understanding breastfeeding mechanics helps to explain why ties may interfere with successful breastfeeding. A normal suckle begins with a flanging of the lips to create a seal around the areolar tissue of the breast - much like a suction cup on a piece of glass. If the lips cannot flange out (because of a tight labial frenulum), a good seal cannot be created and a poor latch-on could be the result. When there is a poor seal on the breast, the baby often loses suction (a "click" sound can usually be heard), and air is drawn into the mouth with each suck. This results in the baby swallowing air, which can lead to gassiness, fussiness, flatulence, hiccuping, a distended belly, reflux, and colic.
As the baby latches on, the breast (nipple and areola) gets drawn into the mouth and the nipple extends to the junction of the hard and soft palate. The tongue extends forward past the lower gums to a position where the tip of the tongue can begin the suckle by compressing the breast tissue. Compression of this area, aided by the mother's let-down process, begins the flow of milk through the breast. The middle of the tongue elevates to the palate, and then drops, creating a buildup of negative pressure in the baby's mouth, which draws milk from the breast. In normal breastfeeding in a baby without a tie, there is minimal compression of the nipple or compensations from the lips and jaws.
When a baby is tongue tied, one of two things may happen. Either the baby's tongue blocks the nipple from fully entering the mouth (thrusting it towards the front of the mouth), or the nipple fully enters the mouth but the baby clamps down and bites the base of the nipple. In the first scenario, the tongue is not able to move upward and can only move forward - these babies often have trouble holding a pacifier in their mouths, as well. In the second scenario, the nipple is properly positioned, but the baby's inability to move the tongue results in compensation by the gums and lips.
A lip tie prevents the upper lip (and sometimes the lower lip) from being able to create a seal on the breast. The baby often compensates for this poor seal by clamping down on the breast to try to stay latched. The lip often rubs on the breast, creating friction that is both painful for the mother and results in lip calluses/blisters for the baby. The mother's nipple often looks blanched or compressed when the baby unlatches. Often, the damage to the mother's nipple may result in breast infection (e.g. mastitis) and clogged ducts.
There is no guarantee that revising a lip or tongue tie will magically solve all your breastfeeding problems. There is also a chance that there is a separate underlying issue that is affecting breastfeeding, and revising a tie will not help correct the nursing problems. However, if it appears as though a lip or tongue tie is negatively affecting breastfeeding, then releasing the tie will help give you and your baby a better chance at a healthy breastfeeding relationship. It is important to note that an IBCLC is a crucial part of breastfeeding, and all nursing mothers should follow up with their IBCLC after treatment to help train her baby how to nurse with their newfound lip and tongue mobility.
TIES IN OLDER CHILDREN
Tongue ties can lead to a wide range of dental issues. The inability of the tongue to create a seal on the palate leads to a narrow upper jaw and dental crowding. The tie may pull on the jaw bone, resulting in teeth shifting out of position. it may prevent the teeth from closing together, causing a large gap between the front teeth.
Removing restrictions of the tongue and lips can allow the teeth to erupt in a more ideal alignment, which may help reduce the need for future orthodontic treatment.
When the tongue is unable to move freely, a child may have difficulty producing certain speech sounds. The most common letters affected are R, S, L, Z, D, CH, TH, and SH, but other sounds are also difficult. Furthermore, stringing multiple sounds together may also present a challenge.
There is no guarantee that a tongue tie will automatically create speech problems, just as there is no guarantee that a frenectomy will solve existing problems. There are, however, recent studies that show speech improvements after frenectomy.
In order to properly diagnose your child, a thorough examination is necessary. In some cases, there may be underlying issues in addition to the lip and tongue that may be restricting movement and limiting function.
Dr. Aaronson will perform a comprehensive evaluation of the child's head and neck and, whenever possible, will speak with the child's IBCLC, bodyworker, or any other practitioner who may help provide insight that can aid in proper diagnosis.
She will look closely at the tongue, lips, cheeks, and determine whether there are any restrictions that might be impacting function. If ties are diagnosed, she will then discuss treatment options and post-operative care.
If treatment is indicated, parents have the option to have their child treated the same day, or, if they prefer, they may schedule treatment for another day.
The treatment of choice for tethered oral tissues is called a frenectomy (or frenotomy), which is a minor surgical procedure that releases the tension on the frenum, allowing the tongue and lips to move freely.
While some providers use a scalpel or scissors, Dr. Aaronson uses a CO2 laser to quickly and nearly painlessly release the tethered tissue. The benefit of a laser is that it reduces postoperative swelling and bleeding by sealing off the lymphatic and blood vessels. Studies have also shown that patients treated with a CO2 laser have significantly less postoperative pain, both on day 1 and day 7, as compared to scalpel surgery, and patients who were treated with a laser require less pain medication after treatment than those who were treated with a scalpel. (Patel, et al., 2015)
A frenectomy takes less than a minute to complete. Anesthesia is generally not used in infants, unless parents request it. For older babies, kids, and adults, a topical anesthetic gel is be given to help reduce discomfort during the procedure, followed by local anesthesia (via injection into the frenum tissue) to ensure a painless procedure.
After treatment is complete, we encourage parents to feed their baby, either from the breast or bottle. The majority of breastfeeding mothers immediately notice an improvement in their baby's latch and the amount of pain in the breast and nipple. It is strongly recommended that all breastfeeding mothers follow up with their IBCLC as soon as possible after treatment to help the baby learn to effectively breastfeed with their newfound tongue and lip mobility.
DR. AARONSON'S HOURS
New Generation Dental Center
1 Washington Street, Suite 306
Wellesley, MA 02481
Tuesday: 8:00 am - 1:00 pm
Wednesday: 8:00 am - 6:00 pm
Thursday: 8:00 am - 1:00 pm
The office is open Monday through Thursday from 8:00 am until 6:00 pm