Pre & Post Frenectomy Care
The PhysioPartners Renaissance CranioFacial Group is one of the few clinics providing pre and post frenectomy care. Sequencing of treatment can promote the best outcome.
What is Ankyloglossia?
Ankyloglossia, also known as tongue-tie or TOTs (Tethered Oral Tissues), is a congenital oral anomaly that may inhibit the mobility and proper function of the tongue. This is caused by an unusually thick, tight, or short lingual frenulum, a membrane that connects the underside of the tongue to the floor of the mouth.
When Would Someone Be Aware of a Tongue-Tie Issue as an Infant?
Infants are sometimes identified as being tongue-tied when they are not able to nurse properly. If an infant is tongue tied, the restriction of the tongue will result in superficial latch which can cause the mother to develop painful nipples and tender breasts. If they consult with a lactation consultant, many will assess the infant while nursing and identify tongue-tie. If the mother bottle feeds early in the infant’s life, the tongue-tie may never be detected, but the infant may also have difficulty bottle feeding. Many mothers blame themselves when their infant does not nurse well, but baby’s latch must be adequate and the connective tissues of the mouth need to be flexible around the lips and tongue to have the proper latch. If the tongue is tight and tethered to the floor of the mouth, the baby will not be able to position their tongue in the correct resting posture and promoting dysfunctional swallow, reflux, colic, mouth breathing and more.
When Would Someone Be Aware of a Tongue-Tie Issue as an Adult?
Adults may have never been screened for a tongue-tie issue as a baby, particularly if they grew up in a period when most mothers did not nurse their infants.
Tongue-tie is infrequently assessed in adults, but many patients live with the symptoms of tongue-tie, such as: snoring and sleep apnea, chronic fatigue and mouth breathing, dark circles under the eyes, clenching and facial tension, neck tension and headaches, reflux and IBS (Irritable Bowel Syndrome).
Who Can Examine and Diagnose Tongue-Tie?
Lactation consultants are frequently knowledgeable about infant tongue-tie issues. Some pediatricians, pediatric dentists, and ENTs are aware of tongue-tie as an underdiagnosed issue, but may not recommend intervention unless severe. There are different types of tongue-ties, including the posterior tongue-tie which can only visible by creating traction with two gloved index fingers on either side of the frenulum at the undersurface of the tongue while stretching the tongue and connective tissues to the palate.
Some adult ties may be identified by an airway dentist who as they are more aware of the function of the tongue and a limited throat airway space, but not all airway dentists are familiar with Myofunctional Therapy. The limits of each discipline in understanding the complex interactions of the function of the tongue and its effect on the size and shape of the palate, the head and neck posture, and tongue-to-palate position while nose breathing. As physical therapists, we understand the interplay between the function of the tongue, the importance of the proper posturing of the tongue, and the ability for the tongue to rest comfortably up on the palate. We understand that the proper oral posture (tongue up, teeth gently and lightly meeting with lips together but completely relaxed) will support the soft tissue architecture of the throat airway space and promote proper swallow habits.
Why Should Ankyloglossia Be Considered in the Treatment of Obstructive Sleep Apnea (OSA)?
Mouth breathing has been linked to sleep apnea in the medical literature. Mouth breathing at any age, including infancy, can promote the conditions that can lead to Obstructive Sleep Apnea, or OSA.
Infants: Signs of OSA in infants include mouth-breathing, snoring, dark circles under the eyes, nasal congestion, poor sleep patterns, irritability when awake, sleeping with the neck hyperextended and arms over the head, and has been associated with increased risk of Sudden Infant Death.
Children: Children with mouth-breathing patterns at night and who sleep with their heads hyperextended should be evaluated as they may be sleeping this way to help open the throat airway. If the tongue is tied down as the child sleeps, the tongue will be positioned low in the mouth, instead of resting up on the palate and he or she will mouth-breathe. The soft palate will note be supported by the tongue, which can lead to it obstructing the airway. Signs of OSA in children include mouth breathing, snoring, dark circles under the eyes, nasal congestion, poor sleep patterns, audible breathing, irritability when awake, sleeping with the neck hyperextended.
If you detect an issue with mouth-breathing in your child, schedule an evaluation with the physical therapists of PhysioPartners Renaissance CranioFacial Group. Mouth-breathing can also promote swelling in the lymphatic tissues of the throat, such as tonsils or adenoids, further limiting nose breathing and requiring opening of the mouth to compensate.
Adults: Adults diagnosed with OSA should be screened for tongue-tie. As the tongue rests lower in the mouth, with or without mouth-breathing, the soft palate lowers and decreases the throat airway space. The throat airway space, tongue position, tongue function and length of the lingual frenulum should be evaluated to see if a tongue-tie is contributing to the soft palate collapse that is limiting the airway. Signs of OSA in adults can be mouth-breathing, snoring, dark circles under the eyes, nasal congestion, poor sleep patterns, irritability when awake, sleeping with the neck hyperextended with their mouths open, chronic fatigue, loud breathing, long pauses of breath holds when sleeping.
What Tests Can Measure the Airway?
3-D Cone-Beam Standard X-ray can be used to evaluate the airway architecture (deviated nasal septum or narrowing of the throat, tongue position, and swelling of the tonsils and adenoids) and requires less radiation exposure, allowing children as young as 4 years old to be evaluated.
Your Infant May Have Tongue-Tie If:
- Breaks latch seal, clicking or smacking sounds, gassy, reflux, vomiting, colic
- Shallow latch, not able to latch or unsustained latch (sliding off nipple), clamping
- Chewing or gumming while latching
- Unsatisfied nursing episodes, fights latching
- Prolonged feeding episodes
- Unable to hold pacifier
- Failure to thrive, poor weight gain
- Signs of congestion, mouth breathing, abnormal breathing, sleep apnea
- Falls asleep on the breast
What May a Mother Experience with a Tongue-Tied Infant During Nursing?
- Cracked, blistered, bruised nipples
- Bleeding nipples
- Blanched or creased nipples after feeding (flattened)
- Severe pain upon latching infant
- Plugged ducts and mastitis
- Engorged or unemptied breasts
- Nipple thrush
- Infected nipples
- Exhaustion or even depression
- Premature weaning
How Can I Check My Infant for Tongue-Tie?
Run your finger under the tongue to identify a "guitar string", which may indicate that the tongue attachment is problematic.
If there is a smooth, uninterrupted pass under the tongue, the infant likely will be able to have a successful latch. If there is a significant interference during the sweep under the tongue, seek evaluation of the tongue-tie.
What is Aerophagia?
Aerophagia is excessive swallowing of air, which may result in abdominal distention, belching, vomiting and excessive gas. The infant’s tummy will be swollen and full of air.
What is Colic?
Colic is an exhausting, unrelenting, all-consuming condition that causes an otherwise healthy infant to cry inconsolably, typically occurring between 2-16 weeks of age. The physical therapists of PhysioPartners Renaissance CranioFacial Group have had success in reducing colic utilizing functional manual medicine treatment to the cranium and fascia of the body.
What Symptoms May an Infant Experience as He or She Grows?
- Choking, vomiting, or gagging on foods
- Persistence of dribbling
- Inability to chew age-appropriate solid foods
- Delayed development of speech
- Loss of self-confidence because they feel different
- Dental problems with a high narrow palate, decay, narrow jaws, recessed jaw
- Improper swallowing habits
- Breathing problems, mouth breathing habit, snoring sleep apnea
What is Lip-Tie?
The piece of tissue behind your upper lip is called the frenulum. When these membranes are too thick or too stiff, they can keep the upper lip from moving freely, know as lip-tie. Lip-tie has not been studied as much as tongue-tie, but treatments for lip-ties and tongue-ties are very similar. Lip-tie occurs when the frenum connecting the upper or lower tip is too short or too tight. The frenums that connect the upper and lower lips to the gums are called labial frenulums. When they are tight or short, they can cause difficulty moving the lips, speaking and eating.
How Does Lip-Tie Affect an Infant as He or She Grows?
Nursing may be affected by a lip-tie and cause difficulty with latching properly. Dr. Ghaheri, an ENT and leader in the field of tongue- and lip-tie, believes that a lip-tie can promote a gap between the two front teeth. If the lip-tie is so severe that there’s notching at the gum line, a lip-tie release may help prevent gapped teeth. If the lip-tie is less severe, the gap may be temporary, closing as other teeth come in and shift the teeth.
What is a Buccal Tie?
The least commonly known type of tethering is the buccal tie, lateral frenula, or buccal frenula. The term “buccal ties” is most commonly used by feeding specialists and lactation consultants and are restrictions or taut fibers that are abnormally attached from the gums to the inside of the cheeks. Some doctors will release these ties as well during frenectomy.
Who Benefits from Lingual or Labial Frenectomy?
Adults and Children: If you have been diagnosed with a tongue-tie, releasing the lingual frenulum may allow a better resting position of the tongue to the palate. The tongue functions optimally when it is able to rest effortlessly up on the palate without any downward pull due to a tight lingual frenulum. The position of the tongue when initiating a swallow helps support the airway and throat. Tongue training with a physical therapist (postural training and myofunctional therapy) before the procedure will help you learn to position the tongue properly, strengthen and stretch before release. After frenectomy, tongue training with a physical therapist (myofunctional therapy) promotes optimal function of the tongue, restores optimal breathing pattern with the tongue resting on the palate, and includes head and neck manual therapy to optimize your posture.
Infants: Infants with tongue-tie having difficulty latching, sucking and swallowing would benefit from these procedures. If mom has painful nipples and breasts when nursing, mom will benefit from having the procedures performed on her infant. Infants are recommended to have at least 3 sessions of physical therapist care before frenectomy and possibly 2-3 more sessions more after the procedure, depending on the infant, and decrease the likelihood that the frenectomy will need to be repeated.
Time is of the essence for those infants that cannot nurse well and need to gain weight, but have failure to thrive. Our physical therapists will teach parents the intra-oral techniques to release the lips, back of the tongue, and undersurface of the tongue to help the baby stretch prior to the procedure, ideally at least one week before the procedure.
What Other Symptoms May Associated with Tongue-Tie?
Each person is different, but tongue-tie and the associated breathing problems can contribute to:
- Tension in the face
- Clenching at night or during the day
- Neck pain
- A lisp
- Speech delay
- TMD or TMJ
- Mouth breathing
- Sleep apnea
- Not able to latch properly while nursing
- Recessed jaw and narrowed jaws
- Long narrow face
- Cold hands and feet
- Chronic fatigue
- Overbreathing, fast breathing pattern
- Dark circles under the eyes
How should one be prepared to have a lingual or labial frenectomy?
Infants: We recommend that the parents bring their infant to the office at least a week before the procedure is scheduled to learn the intra-oral techniques to help aid the healing process after the procedure. Specialized physical therapist care can also help with improving mobility of the infant's soft tissues as well, and we will address any issues related to the cervical spine, torticollis or a tendency to favor one side.
After the procedure is performed, the parents will support the healing with the previously trained intra-oral techniques, and in-office treatment twice a week for two weeks will allow the incision site to be monitored and treated to heal vertically with soft tissue treatment to the lip and tongue, decreasing the likelihood of it reattaching to the floor of the mouth. Treatment in the day or two after the procedure will help ensure that you are performing your exercises properly and that the incision site is healing well.
Manual stretching of the soft tissues of the lip and tongue should be performed at least 3 to 6 times per day as tolerated to decrease the likelihood of reattachment of the healing tissues.
What if my infant has plagiocephaly or torticollis along with the tongue-tie and or lip-tie?
During the evaluation, we will also evaluate for plagiocephaly (flattened head) and/or torticollis (twisted neck), which can be treated post-frenectomy with osteopathic functional manual medicine during and after the post-frenectomy phase of treatment as needed. Learn more about Cranial Manual Therapy here. Collaboration with a lactation consultant to ensure the infant is breastfeeding effectively is also important after the procedure.
How Should One Prepare for Lingual or Labial Frenectomy?
Children and Adults:
Any child or adult undergoing frenectomy should initiate tongue training or myofunctional therapy for at least 4 weeks prior to the procedure to minimize the risk of reattachment at the frenectomy site. Training the tongue to position on the palate and stretching the tight connective tissue around the lips and tongue promote a more successful procedure.
After the procedure, continued training the tongue to function properly in its new range of motion and promoting proper oral posture of the tongue will promote proper swallowing and breathing habits. While the tongue-tie may be released, the tongue does not know how to functional optimally with this new flexibility and increased range of motion. Continue tongue training until you have successfully attained the proper head and neck posture, good “oral” posture (tongue to palate, teeth gently meeting and lips together but completely relaxed), proper relaxed initiation of swallowing position and function, and functional nose breathing, which may be one to six months post frenectomy procedure.
What tools are used to perform the frenectomy?
Doctors use laser, scissors or a scalpel to perform frenectomy. The tool is not as important as the doctor performing the procedure. Some believe that the laser promotes less bleeding. Parents should seek referral from an experienced lactation consultant, myofunctional therapist, physical therapist or other health care providers who work with patients after frenectomy. Doctors who understand the importance of collaborating with a lactation consultant and myofunctional physical therapist promote addressing the whole body and understand the importance of pre and post frenectomy care in preventing reattachment and promoting optimal outcome.
What is a Functional Frenectomy and How Should One Prepare for It?
Dr. Soroush Zaghi is an ENT in Los Angeles, California trains dentists, oral surgeons, ENTs, and pediatricians to perform a functional frenectomy for children and adults. For this procedure, patients hold their tongue gently sucked up on the palate, repeatedly performing the “Cave” exercise that they learned during their myofunctional therapy training during the release, which allows the doctor to see how far to release.
At least four to six weeks of tongue training/myofunctional therapy, posture and breathing training is recommended prior to this procedure. In some cases, several months of preparatory treatment will
be recommended to ensure that you have achieved proper head and neck posture, correct mouth/tongue resting position, and tongue flexibility prior to the procedure. The post frenectomy protocol is twice per week for the first 2 weeks post procedure and continued training of the tongue for at the very least 6 weeks once per week in clinic or via telehealth appointment to ensure a healthy trained tongue outcome.
What Will the Physical Therapist Care Include Post Frenectomy?
Your physical therapist will promote proper vertical healing of the scar through manual techniques to help lengthen and achieve the tongue-to-palate resting position, monitor and progress your post frenectomy exercises, mobilize the healing scar, and gently stretch the tongue with manual techniques. He or she will also continue to improve your posture and breathing with manual techniques and exercises to the head, neck and spine.
After the initial 2 weeks post frenectomy, your physical therapist will continue myofunctional therapy until you are able to properly position your tongue for a functional swallow, properly chew your food, and create the proper resting position in the mouth with your newly flexible frenulums to help support your airway. Continued tongue training post procedure is recommended once per week for 6-8 weeks.
What Should One Expect After Frenectomy?
Infants: Many infants at day one are able to latch on with a more normal latch and allow mom to feel more comfortable during nursing. Infants will have a small diamond open wound at the undersurface of their tongue that will form white granulated tissue as it is healing. Some infants who still have problems latching may benefit from additional physical therapist care and manual therapy. Our physical therapists will treat the intra-oral structures and fascia to decrease the likelihood that the frenectomy sites will reattach. After 2 weeks, the therapist will teach the parents how to mobilize the scar as the baby continues to heal. After two months, when the site is healed and the scar is flexible, nursing may improve further. We recommend that intra oral techniques continue to be performed by the parent for 2 months post frenectomy.
The first 2 weeks post frenectomy (especially the first 3 days) are very challenging because the parent must perform the intra-oral stretches as the baby is crying and uncomfortable. Parents must be mentally prepared for the crying while performing the intra-oral stretches to ensure that the frenectomy sites don’t reattach.
Children and Adults: The first 24-72 hours post frenectomy are painful and you will want to rest. Homeopathic remedies for pain and swelling or over-the-counter pain medications can reduce discomfort. Tongue exercises must be performed the first day, which is painful. The pain will lessen with time and after two weeks the stitches will dissolve or be removed if stitches were used or if no stitches were used, the incision open site should have filled with white granulated tissues that slowly heals, leaving a healthy flexible scar. Many adults state that they feel lighter in the head and experience less tension and clenching in the face, neck and shoulders after the procedure is performed.
At two months, the undersurface of your tongue and the frenulum is much more flexible and no longer painful. Many do not realize that the released frenulum is still there. As you open and do the cave (suction up of the tongue to the palate while opening your mouth), they will still see a frenulum and the webbing of the connective tissue around the frenulum but it will be more flexible. Many patients progress from being able to put 1 finger width between their teeth while performing the "cave" exercise to being able to put 2 and even 3 finger widths stacked on top of each other inside the mouth during this exercise.
Please call (312) 986-9833 for more information or schedule an onsite or virtual appointment.