Tongue, Cheek & Lip Ties
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What are cheek, lip or tongue ties?
If you lift your upper lip, you will probably see a flap of tissue (frenulum) connecting your lip to your upper gums. There’s a similar flap of tissue under your tongue. Many people also have a noticeable flap connecting their checks to their gums.
Since most of us have these flaps, it goes without saying that most of the time they do not cause problems. Simply seeing one in your newborn or child does NOT mean they need to be cut or lasered. Their function should be evaluated to decide if they need to be addressed.
These ties are often blamed for causing breastfeeding and speech problems, and even gross and fine motor delays. There is NO evidence to support developmental delays due to tongue, lip or cheek ties.
Many parents are being told their baby’s frenulum should be clipped:
Many mothers feel the benefit of an improved latch with less pain after a tight tongue tie is released. This procedure is relatively low risk and has potentially great benefits to support breastfeeding. But it is not recommended to do a procedure to clip the tie when the tongue functions normally – the frenulum attachment does not seem to be related to the breastfeeding problem. Some physicians and dentists are known to clip every frenulum they see. This is not good practice, but it can be hard for parents to know if a procedure is really indicated or if the clinician simply can get paid to do a procedure. As you’ll see below, even the experts have trouble agreeing as to when procedures should be done sometimes.
There are some firm recommendations against certain tie releases though (to be discussed below). There is no evidence to support lip or cheek releases. These are often done with a laser in a dental office without the pediatrician’s knowledge.
PLEASE talk to your pediatrician prior to any elective procedure. We can help assess the need and discuss risks and benefits.
Consensus statement from ENTs:
In April 2020 a panel of otolaryngologists (ENTs = ear nose and throat specialists) published a consensus statement about the treatment of ties.
There were several issues that the panel of experts were not able to agree upon because there is limited data, but they were able to make recommendations on when to release ties – and when it’s best to leave them alone.
Definitions to help understand the statement:
- ankyloglossia – tongue tie
- frenulum – a piece of tissue that helps to anchor a mobile body part
- buccal – cheek
- labial – lip
- frenotomy or frenulotomy – clipping of the frenulum (the tissue that ties)
- frenectomy – removal of the frenulum (often confused with frenotomy)
- frenuloplasty – an incision of the frenulum with a rearrangement of the tissue
- interincisor diastema – wide space between top teeth
The definition of tongue tie (ankyloglossia) that was agreed upon in this panel is a “condition of limited tongue mobility caused by a restrictive lingual frenulum.”
They were not able to come to a consensus regarding the definition of anterior versus posterior tongue ties due to lack of consistent data.
The panel was also unable to come to an agreement on the best rating scale for ankyloglossia. Some of the systems are based solely on the look and attachment location of the frenulum, but others assess functionality. (As mentioned above, I am in the camp that believes functionality matters most.)
How common is tongue tie?
The panel found a wide range of incidence of tongue tie, from 2.8% to 10.7% of the population. The number of infants diagnosed with tongue tie is rising in recent years. This does not mean that it is becoming more common, only that it is being diagnosed more.
They found that in some communities infants are over diagnosed with tongue tie and undergo unnecessary procedures.
Several factors were proposed that may contribute to more children being diagnosed in recent years. This list includes:
- An increased focus on the benefits of breastfeeding.
- An increased awareness that ankyloglossia can negatively affect breastfeeding.
- The number of lactation consultants who identify infants with possible ankyloglossia has increased.
- Social media posts and websites related to tongue-tie.
- An increase in the number of medical practitioners, particularly dentists, who treat ankyloglossia.
What about sleep apnea?
It has been suggested that tongue tie can lead to an altered jaw shape over time and contribute to sleep apnea if not corrected.
The consensus statement offers the argument that if the tie holds the tongue towards the front of the mouth, it is less likely to fall back during sleep and obstruct the airway. The tie might actually help to prevent apnea and serve a benefit if not released.
They do not recommend frenotomy to prevent sleep apnea.
What about future speech issues?
The panel found that in infants with little or no tongue mobility restriction, frenotomy does not prevent future feeding or speech disorders.
They do not recommend frenotomy to prevent future speech issues.
How is breastfeeding best supported?
There are many factors that impact breastfeeding and it is obvious that addressing only one potential issue is not going to improve breastfeeding rates.
They reviewed several large studies that looked at breastfeeding rates with and without frenotomy when breastfeeding support was given. Frenotomy rates decreased without sacrificing successful breastfeeding when effective support was given.
In other words: many of the frenotomies were not necessary.
What is necessary is supporting breastfeeding:
For those infants with breastfeeding challenges, the most commonly associated symptoms of ankyloglossia include nipple pain with nursing, irritation of the nipple skin, and shallow/poor latch. Other considerations should include prematurity, abnormal facial structure, neurologic or cardiac disorders and upper airway obstruction leading to difficulty feeding. Working with a lactation consultant is essential to see if breastfeeding support without a procedure can address the issues.
Maternal factors that should be considered include discomfort during the first few weeks of breastfeeding, maternal nipple anatomy, poor positioning or support at breast, maternal milk supply and breast infection
Planning the frenotomy:
An optimal time at which to do a frenotomy was not found. It should be done only after time to evaluate and assist breastfeeding techniques has been completed. Ideally the release should be done in the first month of life if an infant has a tongue tie that restricts tongue movement and affects breastfeeding.
Discussion of risks and benefits
Complications of frenotomy should be discussed prior to having parents consent to the procedure. These complications may include:
- airway obstruction
- injury to salivary structures
- oral aversion (resisting eating)
- no improvement with breastfeeding
Non-surgical options to frenotomy should be offered. These include:
- working with a lactation consultant
- working with a speech-language specialist
There was no preference of type of frenotomy, such as laser vs clip with scissors. Both seem to be well tolerated but the laser is typically more expensive.
There is no indication for either topical or injectable anesthetic for infant frenotomies.
Oral sucrose (sugar) is often used for painful procedures in infants and can be used for frenotomies. Breastmilk may be used instead. Optimal timing of sucrose (or breastmilk) is unknown. (I personally prefer to have the infant breastfeed immediately after the procedure and most babies don’t show signs of pain or distress during the procedure, with or without sucrose.)
There is no preference to where frenotomies should occur (clinic vs operating room). A clinic is much less expensive than an operating room.
Most of the literature on tongue ties focuses on infants, but in older children there are concerns for speech problems, dental issues, mechanical limitations (inability to lick an ice cream cone or French kiss), and social implications (insecurity due to the look of their tongue).
The consensus group concluded that ankyloglossia does not typically affect speech despite common beliefs. Since there is no method to predict which children with ankyloglossia will require treatment, the consensus group agreed that consultation with a speech pathologist should be done prior to frenotomy for speech concerns.
If there are dental, mechanical or social concerns, there is no maximum age at which a frenotomy should be performed.
There is no ideal type of procedure that is preferred in older children, though they are more likely to require anesthesia compared to infants.
There is no reason to release cheek ties to help with breastfeeding. The consensus of the panel was to recommend against releasing buccal ties.
Why is it done? I suspect because it is a procedure that pays well.
Why isn’t it recommended? The buccal frenulum helps to attach the cheek to the gums. Studies show that the breastfeeding latch can be assisted if there is support added to the cheek – it increases the suction during feeding. Releasing the attachment would do the opposite of what you need.
Don’t have your baby’s cheek ties “repaired” – it may do more harm than good.
There is little evidence that lip ties contribute significantly to infant feeding problems and the consensus statement suggests that lip ties are over diagnosed and treated in some communities.
A common concern among parents is that the lip tie will cause a wide space between teeth (interincisor diastema). This has not been shown to be a definitive correlation. In fact, studies show that as teeth come in, scarring from a lip tie release may actually worsen the positioning of the teeth.
It is not recommended to perform a lip tie release to prevent future tooth spacing issues and there is no firm evidence that it helps breastfeeding.
Tongue tie can lead to breastfeeding issues, but proper assessment should be completed prior to deciding if it should be released or not. While frenotomies have overall low risk, they are not risk free, so non-surgical options should be considered in addition to surgical release. Frenotomies should not be done to prevent future speech issues.
Lip ties are not generally associated with breastfeeding problems. If they are suspected, working with a lactation consultant to improve latch should be done prior to consideration of a release. Frenotomy of the lip tie might increase scarring and future dental problems.
Cheek ties should not be released. Release of these ties might worsen breastfeeding technique.