The process or correcting tongue and lip ties dates back to the 18th century when midwives would commonly perform a frenectomy, cutting the frenulum, with their sharp fingernail. This practice become common place among doctors of the time as well as a recommendation for infants with feeding difficulty, though the surgical tool was upgraded to a sharp piece of wood or knife. 

Fast-forward to the 21st century and while the practice as seen many necessary changes, the procedure is still conducted regularly. The most common reason a frenectomy is performed is to improve and prolong breastfeeding in infants. 

What is a Tongue & Lip Tie?

Tongue and lip ties are both associated with unusually short or tight frenulum, the small band of connective tissue that connects anatomical structures to one another. They are most commonly identified in infants due to poor feeding.

In the case of a tongue tie, also known as ankyloglossia (AG), the tongue is restricted by the lingual frenulum a rigid tissue on the underside of the tongue that connects the rest of the tongue to the base of the mouth. This restriction keeps the tongue from performing its optimal range of motion (functioning and moving fully) which can lead to speech and eating issues. 

A lip tie is something else, it is associated with the labial frenulum found between the upper inner lip and gum line, it is too tight and keeps the top lip tethered, potentially inhibiting the full Range Of Motion (ROM) of the suckling reflex of the whole mouth potentially creating feeding issues. Tongue and lip ties often occur in tandem, but it is not a given that they will both be present. 

Why Do Ties Need Correcting?

Caregivers of children with tongue or lip ties will often seek medical advice out of fear or concern for the infant or child’s overall development. A shortened frenulum can lead to difficulty speaking, sticking out the tongue, poor oral hygiene, difficulty swallowing and breathing, struggle to self regulate, and feeding disruptions as mentioned previously. 

Later in life speech difficulties related to a tongue or lip tie can interfere with the child’s ability to make certain sounds like “d,” “l,” “r,” “s,” “t,” th,” and “z.” This may not sound like a concerning issue on the surface, but speech difficulties can cause excess financial burden on families caused by corrective therapies. Speech interference can also lead to poor social development and withdrawal among children who are mocked for their speech difficulty or find it hard to be understood clearly.  

Poor oral hygiene is an often overlooked risk for tongue and lip ties that have not been corrected. This is common among older children and adults as existing lip ties, in particular, make it difficult to completely sweep debris from the teeth left from food and beverages. This ultimately increases the likelihood of tooth decay, gum disease, inflammation, and misshapen teeth. Tongue ties have been observed leading to gaps between the bottom front teeth.  

Other oral activities can become more difficult for children and adults with tongue or lip ties that have not been corrected. For instance, some musical instruments are more complicated to play if the lips or tongue are restricted in any manner. 

Breast-feeding like likely the most common reason that caregivers will seek medical advice related to a tongue or lip tie. Nursing mothers agree that it is more difficult for their infant to achieve an adequate latch to the breast if their tongue and lip are restricted. 

If the tight frenulum is not detected after birth through a routine check mothers will generally discover them quickly due to painful or unsuccessful feeding. Nursing infants who are not gaining weight properly will also be checked for tongue or lip ties that could be causing inadequate nursing and ultimately a lack of nutrition and calories causing a failure to thrive. 

Breast-feeding necessitates that the baby keeps the tongue over the lower gum while nursing, specifically performing the sucking motion. If the infant is unable to move their tongue correctly it can lead to a chewing motion rather than sucking, which makes nursing unsuccessful for the child and painful for the mother.  

Diagnosis 

Tongue and lips ties may go unnoticed, especially for children who are not nursing. However, there are some important symptoms that can point to a potential tongue or lip tie in infants that should not go overlooked. Some common symptoms include colic, reflux, slow weight gain, stiffness or arching of the back, gassiness, clicking noises while nursing, and torticollis. 

These can be some of the first indicators that a child should be evaluated for a tongue or lip tie diagnosis. Nursing moms can experience signs of tongue or lip ties as well, such as plugged ducts, engorgement, mastitis, and pain during and after nursing. 

Most tongue and lip ties will be diagnosed by a healthcare provider, often the child’s pediatrician, through a routine physical examination of the mouth. Other providers commonly referred to for potential tongue and lip tie diagnoses include lactation consultants, ear nose and throat (ENT) doctors, and pediatric chiropractors. The practitioner will generally use a screening tool to score the tongue’s appearance and mobility. 

The accuracy of diagnosis and efficacy of treatments, especially those done surgically, have been the subject of debate among pediatric healthcare providers in recent years. The incidence of true tongue and lip ties have also come into question. 

The definition of tongue and lip ties have been has broadened to include two classifications: anterior and posterior. Anterior include two types, Type 1 and Type 2. While posterior includes Type 3 and Type 4. Some professionals believe the expansion of tongue ties into two categories has led to an overdiagnosis of the condition and an increase in unnecessary surgical interventions. 

As of 2017 diagnosis of Tongue Tie has been reported at a range between 4% and 11% among the infant population diagnosed within the hospital setting. Diagnosis among children over the age of 6 is lower, around 3%. A 2020 review of studies concluded the numbers are higher now at 8% prevalence of tongue tie being 7% in males and 4% in females. 

Of all studies conducted and statistics taken it is clear that tongue and lip ties are a congenital anomaly and without adequate intervention, surgical or non-surgical, serious life threatening repercussions can occur for baby and nursing mothers. 

Treatment 

The proper treatment of tongue and lip ties are another area of controversy among healthcare providers administering care within this area of health and development. Some providers are more aggressive in their approach requiring correction of the abnormal frenulum prior to discharge. Other healthcare providers take a more conservative approach and recommend waiting and seeing if the issue will correct itself. 

The loosening of the lingual frenulum has been observed in some patients and in others  tight frenulums have not led to common problems being reported. Children who have not had their tongue or lip ties corrected, surgically or otherwise, may require breastfeeding consultations with lactation consultants or speech therapy with a speech-language pathologist later in childhood. 

Surgical Treatment 

Surgical treatment for an abnormal frenulum, a frenectomy or frenuloplasty, can be conducted with surgical tools or laser. Most surgical treatments are simple and can be performed in minutes with or without anesthesia. These surgical treatments typically take place as an outpatient procedure either at a doctor’s office, dental office, or hospital setting. 

Frenectomy 

During a frenectomy the practitioner performing the surgery will examine the frenulum of and using sterile scissors will snip the frenulum. The procedure is relatively painless due to very few nerve endings being present in the frenulum. Bleeding may occur but is usually just a few drops. Once the procedure is over the infant should be able to immediately nurse effectively. 

Frenuloplasty 

The frenuloplasty is a less common approach to surgical intervention in this area, but is sometimes necessary for frenulum’s that are too thick for the more common frenectomy. This approach is more extensive and requires general anesthesia and surgical tools. The wound requires more attention after being snipped and will likely be closed by suturing the cut. 

Laser

Lasers are being used more often to loosen the tight frenulum of the tongue or lip tie. As one would imagine, this is a far less extensive method than either of the previously described. This approach is simply called a laser frenectomy and is associated with less pain and lower rates of infection than a traditional frenectomy. A surgical frenectomy utilizing scissors or other tools may require local anesthetic at the sight. Lasers are said to be painless and do not require a local anesthetic, potentially lowering the cost and discomfort of the procedure from start to finish. Lasers also provide the practitioner a level of accuracy and precision that the other methods may not. This approach is used most often by dentists. 

Post-Surgery Care 

After proper diagnosis and correction of a true tongue or lip tie caregivers should then turn their attention to researching the best post-treatment options for the child in their care. Corrective surgery should not be the final stage in ensuring it has been successful. 

Exercises, stretches, and cranial adjustments post-surgery can help make certain the issue will not return and the surgery leaves no lasting negative side effects. It is common to be sent home with post-op care instructions that include stretches or exercises. A trained chiropractor can offer guided and accurate support and care to supporting and surrounding soft tissues and cranial bones during this time. 

Craniosacral Therapy can offer support and often diminish the healing time as well as help ensure the areas surrounding the frenulum are aligned and functioning properly. Through stretches, retraining exercises, and craniosacral therapy the post frenctomy practitioner can assist with successful recovery and prevention of soft tissue hardening and proper alignment.

Utilizing a hands-on manual therapy pedeatrically trained practitioner may seem unusual, but an expereinced chiropractor is concerned with keeping the entire body in alignment including the neck, head and face. Considering that the entire body is connected through the fascial system, a restriction in one area can lead to tension or limited range of motion in surrounding areas and throughout the body. If healing does not occur symmetrically uneven reattachment can occur and ultimately lead to a misaligned vertebra in the neck. 

Benefits

Infants post frenectomy under the care of a Craniosacral Therapist experience quicker recovery, improved mood, better sleep, weight gain, enhanced immune function, and overall better quality of life. Parents also experience benefits in having guided and hands on care in their child’s recovery. 

The benefits of correcting a tongue or lip tie range from physical to psychosocial improvements. As mentioned previously, the most common issue with a tongue or lip tie is poor feeding. An infant that is unable to feed properly will experience weight loss, colic, fussiness, poor sleep, irritability, and a host of negative emotional and physical impacts. 

Infants and children who undergo lip and tongue tie revisions will encounter adequate weight gain, better nutrition, and an overall better relationship with their caregivers. They will have a better interaction with the world around them as they are better able to experience life without pain, hunger, or poor sleep.  

Children who have had their tongue or lip ties revised as toddlers or elementary age will find they are better able to communicate. This can lead to improved social relationships, willingness to interact with others, and overall increase in confidence and ability. 

Risks

With any surgery there exists the potential for risks. There is risk both during and after the procedure. Post-surgery it is possible for the frenulum to reattach leading to the same issues and difficulties. 

Risks that are common to most surgeries as well include poor reaction to anesthesia, infection, bleeding, pain, and swelling. Those that are more concerned with a frenectomy include nerve damage in the mouth or tongue and reattachment of the frenulum. 

The most common concern around having a frenectomy is aftercare, specifically the likelihood of reattachment. There is just a 4% chance of reattachment from standard frenectomy procedures. Frenectomies performed by lasers are said to completely prevent reattachment. 

Parental Feedback 

The perception from patients and caregivers alike is that having a frenectomy performed is beneficial and achieved their overall goals. Many caregivers report hearing and seeing improvements in a child or adult’s speech and behavior post frenectomy. 

One review of studies found that caregivers reported improved breastfeeding, better feeding outcomes, less nipple pain, adequate weight gain, and speech improvements. The most common harm reported in these studies was minimal bleeding with one case requiring reoperation. 

A study by Face Mouth & Jaw Surgery (FMJS) journal reported 89% of participants found their pre-operative issues were resolved which included feeding difficulties within 4 weeks after surgery. Within just one week 75% of those individuals saw improvements in 1 week. Of the 100 responses to the survey they were able to indicate a high level of satisfaction at 98.2%.  

Conclusion

Whether a parent, caregiver, or adult is considering a tongue or lip tie reversal it is not a decision to make lightly. It is becoming a more common procedure, but this does not necessarily mean that it is what is best for every individual at all times. Each person and caregiver must take their unique circumstances into consideration like their support system, the potential for aftercare, and their ability to provide potential care or therapy if they opt to not have the tongue or lip tie treated. 

Each person must weigh the risk and benefits of going forth with the procedure or not. At minimum, there should be a plan in place for post-operative care and exercises. Craniosacral Therapy from a skilled Chiropractor is one of the most effective means to ensure adequate aftercare and reduced risk of reattachment.