Knowledge of tongue and lip ties has become more and more mainstream these days. We are seeing the impact these have on breastfeeding, oral development, and speech. More practitioners are learning how to diagnose and treat these conditions. This article will be a very brief explanation of what tongue ties and lip ties are, how they can impact you or your child’s health, and how to treat these conditions.
First, lets look at what tongue and lip ties are. A tongue tie is when the frenulum, or band of connective tissue that connects the tongue to the bottom of the mouth, causes restriction in the motion of the tongue. A lip tie is when the frenulum that connects the upper lip to the gums causes a restriction in the motion of the lip or causes structural change to the gums. There are also buccal ties that can occur too. These are less common but they form along the upper gum more towards the back teeth on either side. These connect the upper gum to the inner cheek. These tend to not cause the same amount of issues as the tongue and lip ties.
There are different grades to identify the type of lip and tongue tie. So lets start with the tongue tie classifications. There are four types of tongue ties and they are distinguished by where the tongue tie attaches to the tongue. They are not indicative of severity of the tie (type 4 is not worse than type 1). These numbers are based on Dr. Kotlow’s classification system for tongue ties. Pictures of these can be found at here.
- A Type 4 tongue tie is when the frenulum under the tongue attaches all the way to the tip of the tongue.
- A Type 3 tongue tie is when the frenulum attaches at the midline of the tongue.
- A Type 2 tongue tie is when the frenulum attaches to the tongue at a point posterior (behind) to the midline of the tongue.
- A Type 1 tongue tie is when only the posterior tissue is restrictive. This may not be observable without palpation of the tissue and may be hidden under the mucosal tissue beneath the tongue.
Now for the lip tie classification. Again, there are four classes of lip ties and they are distinct for the anatomical variations not based on severity.
- A Class 1 lip tie has no significant attachment to the gum line.
- A Class 2 lip tie attaches exclusively to the gingival (gum) tissue.
- A Class 3 lip tie attaches just in front of the anterior papilla (the edge of the gum tissue).
- A Class 4 lip tie attaches posterior to the papilla onto the hard palate.
So now that we know what we are looking at, lets look at why this occurs. During development the body grows as cells multiply and create different tissues. As these tissues grow and shape themselves, cells are produced and some cells are degraded, a process called apoptosis. This process requires different enzymes to have methyl groups (a carbon atom with three hydrogen atoms attached) attached to them so that the enzyme can be functional and do its job of degrading unnecessary tissue. This process runs smoothly for those with no methylation problems. However, more and more people today are expressing genetic anomalies such as MTHFR that disrupt the methylation process and make it harder for a person to add methyl groups to molecules to make them functional. So as a result more babies are being born with midline defects such as a lip and tongue tie. If you have an issue with methylating the best thing to do is start taking a Vitamin B complex that has methylated B vitamins (It should say folate as 5-methylfolate and Vitamin B12 as 5-methylcobalamine). You also want to eliminate any other supplement that has unmethylated B vitamins (these would say folate or folic acid and Vitamin B12). You also want to cut out any processed foods that are fortified with Folic Acid. Many breads and grain products will be fortified with an unmethylated form of Folic Acid.
Lip and tongue ties can be difficult to diagnose, but there are some common symptoms that occur when a lip or tongue tie is present. Babies can have difficulty nursing. This can manifest as a painful latch or pain while suckling, clicking, choking or gaging while nursing especially upon milk letdown, inability to transfer milk affectively (this leads to more frequent nursing), shallow latch, or all together an inability to latch. Babies may also have digestive symptoms such as reflux, gassiness, spitting up, or colic. As the mother you may experience pain while nursing, creased or flat nipples after nursing, dryness or cracks on the nipple due to too much friction while nursing, clogged milk ducts, mastitis, or low milk supply. While these are not symptoms exclusive to lip and tongue ties, they are very common symptoms that should influence you toward getting evaluated by a professional.
Once it is determined that your baby has a lip or tongue tie there are a few options to help resolve the issue. Non invasive solutions include bodywork, myofascial therapy, chiropractic care, and craniosacral therapy. These focus on releasing the tight connective tissue, improving structural alignment, and increasing cranial and dural motion. This can be helpful in cases where the ties are not as severe and there are more mild symptoms. However, a more invasive treatment may be necessary. There are two different frenectomy procedures that are available that involve cutting the frenulum. One involves using scissors to cut the tissue. This procedure is typically done when there is an obvious anterior component to the tongue tie. Typically this procedure does not cut far enough back to eliminate any posterior components of the tongue tie. However, you may find a good pediatric dentist who will do a thourough procedure to release both anterior and posterior components. The other frenectomy procedure involves a cutting laser. A pediatric dentist trained in lip and tongue tie revision will use the laser to remove the excess tissue allowing for immediate increase in motion of the tongue and/or lip. After care requires stretches every few hours to prevent reattachment. Once the laser revision is performed it is ideal to have bodywork, craniosacral therapy or chiropractic care to help release and unwind any underlying restrictions that still remain. The ties are like the tip of the iceberg, there can be a lot of underlying restriction and tightness that is not obvious, but can continue to affect function. Results after the laser revision can vary quite a bit. Some mothers notice an immediate improvement and can feel like the revision completely corrected all the problems. However, there are times when there seems to be little to no immediate improvement. This is when bodywork and chiropractic care is especially necessary. The underlying tightness needs to be released in order to notice improvement and is necessary when attempting suck retraining exercises. If there are still restrictions within the cranium, jaw, neck, upper back and throat, then nursing and suck retraining exercises are going to be hindered. Suck retraining exercises can be given to you by your lactation consultant (the lactation consultants we used are referenced at the bottom of the article).
So what can happen if you decide to leave the tongue or lip tie alone and not pursue any revision or fascial therapy? There are many possibilities. One being that there may not be any obvious issues, adaptations, or symptoms later in life. However, with the abnormal structure present of a lip and/or tongue tie there will be adaptations necessary, obvious or not, and there is a likelihood that other symptoms would arise. Some common symptoms are speech difficulties, gapping in the teeth, early or worsened tooth decay, narrow maxillary and mandible (jaw) development causing sinus problems or TMJ issues, headaches, neck/upper back/shoulder pain and tightness, reflux, digestive issues, torticollis, plagiocephaly and possibly others. Speech issues can be an obvious sign if the child was not diagnosed with a tie earlier. Most children will have trouble with R, S, L, Z, D, N, T, Y, K, -NG, CH, TH, SH, and –dge although other sounds may be difficult as well. Having a tongue tie can lead to mouth breathing which can contribute to asthma, allergies, sleep apnea, snoring, and enlarged tonsils/adenoids. Ear infections may be more prominent in someone with a tongue tie because the back of the tongue can not elevate enough to equalize the pressure in the Eustachian tubes. This can lead to fluid build up that can not drain properly, allowing for an environment for the growth of a bacteria or virus. When children get older the swallow mechanics are altered due to the tongue tie and can affect drinking from a straw or how the child is able to swallow foods.
If you choose to have the lip and tongue ties revised with the cutting laser or scissors, there are several things to be aware of and to include in the care of your child. As mentioned earlier, there are varied degrees of improvement in symptoms with the frenectomy. Stretches for the tongue and lip should be shown to you at the time of the frenectomy and are typically done every few hours for the first 1-2 weeks and continued at a less frequent rate until the tissue is fully healed (about 1 month). Suck retraining exercises may be necessary to help strengthen the muscles necessary for a good latch and proper suckle. Bodywork, Craniosacral Therapy, and/or chiropractic care is very important regardless of the degree of tie and regardless of the type of symptoms you see. Very commonly, those with lip and tongue ties also have a tight dural tube. The dural tube is the connective tissue that surrounds the nervous system, the brain and spinal cord down to the sacrum. Unwinding the tightness in the dura and throughout the body will help your child feel more at ease and comfortable. Tummy time is another important addition to care after a frenectomy. Tongue and lip ties affect cranial nerve function, restrict normal range of motion and can diminish the baby’s ability to develop proper head control. Along with removing restrictions by utilizing chiropractic care and bodywork, having your baby build the muscles responsible for head control and movement helps to strengthen cranial nerve function and encourage a proper development. Children and adults over the age of 2 may benefit from orofacial myofunctional therapy. An orofacial myofunctional therapist works to help strengthen the tongue and other facial muscles to help correct breathing, chewing and swallowing issues that may still be present after a lip or tongue tie revision.
It is improtant to remember that not every child is the same and there are so many variables that can impact the decision of how to care for your child's lip and/or tongue tie. Not every tongue tie will need a frenectomy. Some children can reestablish proper function just through chiropractic care and bodywork. Other children may need a frenectomy to be able to reestablish proper function. Tongue ties and lip ties can be a complex and sometimes overwhelming issue to navigate. However, with the right team of care providers on your side it can become a lot more manageable; and you can rest assured you are doing everything you can to help you and your baby thrive together. Below are a few trusted providers that we have used and referred others to.
Holistic Dentist (Lip & Tongue Tie Preferred Provider)
Dr. Preetha Thomas, DMD, Enclave Dental - www.enclavedental.com
Mellanie Sheppard, IBCLC, RLC (and associates) - For Babies' Sake - www.forbabiessake.com