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Licensed Midwife, Homebirth Midwifery and Holistic Women's Health

 A Class II maxillary frenum attachment, or lip tie.

A Class II maxillary frenum attachment, or lip tie.

A new mother is five days postpartum.  Her milk has come in,  but the baby just cannot seem to latch well.  She wants to nurse but is fussy at the breast.  She is hungry because she hasn’t had a really good feeds yet.  Mom is exhausted and frustrated.  After a few more days, everyone is overwhelmed and no one knows how to help the nursing go any better.  Mom takes baby in to the pediatrician/midwife/nurse-practitioner…

The trouble is, most care providers are only familiar with the classic tongue-tie.  Lip-ties and posterior tongue-ties are similar structural obstacles to nursing that are typically overlooked by most of us midwives, pediatricians, even lactation consultants because we simply aren’t aware of them;  We were never taught to look for them.

Unlike my son who nursed voraciously (and hourly), my daughter had a loose and lazy latch, and only nursed for short spurts as a newborn.  I checked under her tongue to see if she was tongue-tied, and she wasn’t.  She did eventually learn to latch well enough to get enough milk to feel satisfied and gain weight — albeit slowly.  Looking back on those first six months, I was so sleep deprived and busy trying to stay connected to my three year-old that it hadn’t occurred to me that she might have some other structural or oral-motor problem contributing to her poor latch.

My familiarity with lip-ties and posterior tongue-ties came only after the subject was introduced in my allergy support group.  Through our own research,  many of us figured out we had babies and kids with these pronounced lip-ties who couldn’t latch or feed well,  had major tooth decay on the upper front teeth or had speech challenges.

Lip-ties occur when the upper lip is tightly attached to the gums or between the teeth.  The diagnosis of lip-tie is relatively new and we do not know how prevalent they are. A recent Greek study revealed a rate of nearly 50% for class 3 and 4 lip-ties among school children.  The incidence of tongue-tie is estimated between 4-12%  although that may be a low estimate considering the difficulty in diagnosing posterior ties.  It is not clear why tongue and lip ties are so prevalent. Some literature lumps them in with a handful of other midline defects which are associated with low folate levels (that’s a story for another post) but their origin appears to be largely unknown.

I’d like to share with you what I’ve learned, as well as some of our stories, to help mothers and midwives be on the lookout for any of these structural problems when you have a baby who is struggling to latch or gain weight. (This post is intended only as a primer.  I have included resources below for learning more).

Signs and Symptoms of lip and tongue ties:

Infants:
poor/weak latch, cannot stay latched; cannot empty the breast;  gums the breast/nipple; clicking while nursing or feeding; nurses for long periods; gassy, “colicy,” or reflux; back arching; always hungry/up all night nursing; poor weight gain; “failure to thrive;”  can’t use a pacifier; tooth decay on the upper front teeth (in cases of lip ties).

Children:
challenges chewing or swallowing; speech delays or difficulty with certain sounds; gap between the two front teeth; tooth decay on the upper front teeth (in cases of lip ties).

Nursing Moms:
flat, creased, misshapen or white nipples after nursing; nipple pain, discomfort with nursing;  cracked/bleeding nipples; plugged ducts/mastitis/full breasts that don’t empty.

Lip Ties

Upper lip-ties occur when the small flap of tissue connecting the upper lip to the gums, called the maxillary or labial frenum (or frenulum), is so short and tight that it restricts movement of the upper lip.  It may make it impossible to fully flange the upper lip upward toward the nose, or it may blanch white as it is extended.  Most people have a minimal maxillary frenum attachment that can be felt by running your tongue back and forth along the upper gum line.  Severe lip-ties can extend all the way down between the front teeth, forcing them apart and creating a gap.  The following photos illustrate the degrees of attachment classified by Dr. Lawrence A. Kotloff, a pediatric dentist and expert on lip-ties and their repair.  Class 1 (not shown) is a normal attachment where no significant skin can felt or seen along the upper gum line back and forth.

 

Class III frenum attachments insert just at or between the front teeth, often creating a telltale gape between the teeth.

Class III frenum attachments insert just at or between the front teeth, often creating a telltale gape between the teeth.

 

Class IV lip tie

Class IV lip ties extend down between the two front teeth and wrap underneath to the palate.

 

Lip-ties can impede a baby’s ability to latch onto the breast well by  1) restricting the upper lip from flanging out (like the bottom lip flanges out),  2) by causing it to tuck inward or  3) by preventing a tight seal from being formed around the areaola, leading to clicky, noisy nursing and swallowing air.  Some babies with lip-ties have no trouble nursing, no tooth decay issues, and no speech problems.  Tight lip-ties will often stretch and tear on their own during the course of normal childhood tumbles and falls.  After I discovered my daughter’s lip-tie I thoroughly checked out my son’s mouth and saw that his tie was more pronounced than hers but appeared to have naturally torn on its own.

Lip-ties can be revised surgically or by laser.  Laser revision is preferable for a few reasons.  It can be performed in the office, does not require anesthesia, is over in about a minute, does not require sutures, and babies are immediately able to nurse following the procedure.  Unfortunately pediatric dentists specializing in laser repair are few and far between, and most dentists and physicians only have experience with surgical repairs (which are more traumatic to the tissues and require suture and usually anesthesia).  I’ve listed a few pediatric specialists below.  The procedure is termed interchangeably in the literature: frenectomy, frenotomy, and frenulotomy.

In evaluating whether or not an infant or child would benefit from a maxillary frenulum (lip-tie) revision, Dr. Kotlow considers the following questions:

1. Is the frenum creating a diastema (gap) between the maxillary central Incisors?

2Will revision of the frenum prevent an orthodontic problem such as a gap or diastema from developing or remaining in when all the permanent teeth erupt into the mouth?

3. Does the frenum interfere with normal lip position? Does this effect eating [latching, or breastfeeding]? Does the lip get stuck between the front teeth?

4. Does the frenum make oral hygiene care difficult?  Is there bleeding?  Does the frenum contribute to caries formation or post treatment home care?

5. Has the frenum area been subject to repeated trauma?  [Has the frenulum already torn on its own?]

excerpted from http://www.kiddsteeth.com/articles/Maxillary%20Frenectomy2006adobenews.pdf

 

Tongue-ties

Tongue tie classification by Dr. Kotlow DDSA tongue is “tied” when the lingual frenum (the stretch of tissue that attaches the tongue to the floor of the mouth) is short and tight, restricting the movement of the tongue.  The tongue may not be able to extend out past the lower lip and usually the tip of the tongue cannot touch the roof of the mouth when the mouth is wide open.  Tongue-ties may cause many of the same problems as lip-ties: poor latch or feeding, challenges with speech and forming certain sounds, digestive troubles, etc.

There are different types of tongue-ties. the ‘classic’ or anterior tongue-tie is one most familiar to practitioners.  It is easily seen when the tongue is lifted and it can be felt with a finger swept underneath the tongue.  It has been referred to as feeling a speed bump, fence or ridge in the bottom of the mouth.  Classification of tongue-tie severity can be found on Dr. Kotlow’s site.  Another type, the ‘posterior tongue-tie’ (or PTT) is also called a ‘hidden’ tongue-tie because it is not easily seen or felt.  Posterior tongue ties attach towards the back of the mouth and under the mucosa, out of sight.  While the classic is perceived to be the more common type, one children’s hospital reports that more than half of the revisions they perform are on posterior ties.

A heart-shaped tongue tip is a common feature of tongue-ties.

Most infant and child healthcare providers are not trained to diagnose posterior tongue-ties.  Some may be aware of them, but only know to assess one sign — how far the tongue extends beyond the lips, which alone is not a sufficient for a diagnosis.  This is why, if you suspect a tongue-tie in your child, it is so important to take them to someone who really knows the ins and outs of detecting these ties. In the absence of a wise lactation consultant, a knowledgeable pediatric dentist may be best person to evaluate your baby for tongue and lip-ties, and then do the repair if necessary (resources below).

Tongue-ties can be easily be revised by a quick snip of the frenulum.  This procedure is referred to interchangeably in the literature as frenectomy, frenotomy and frenultomy.  Historically, snips were  performed after birth by the midwife or attendant.  Nowadays snipping at birth is uncommon;  Birth providers lack the skills and/or necessary tools (and may also fear excess bleeding/VKDB or infection).  Tongue-ties can be snipped at any time and often do not require anesthesia, although toddlers may be more difficult to repair on account of the wiggle/fear factor.

For babies, breastfeeding in positions where baby is on top or with the head hyper-extended, e.g. the ‘biological nurturing’ style may help them to latch better than in cradle or football holds.  Here is a helpful step-by-step guide to evaluating your baby for anterior and posterior tongue tie and a short video demonstrating one way to check for posterior tongue tie.

Mother’s Stories:

Mama Leigh and Rostick
When Rostik was born, he was fine, but over the next few days he got more and more agitated, and was resisting latching on. Then on the third day he had ZERO in his diapers. (Good thing I was keeping a record). So there we were around 8pm, with him screaming nonstop, and I said “I must be doing something wrong.” I had gotten a recommendation for a postpartum doula, so I called her. She said she thought he was tongue-tied and gave us the number for Dr. Coryllos. In the meantime she showed me how to hand express but there was almost nothing since I hadn’t had any stimulation from Rostick. My father drove around looking for somewhere to buy formula that was open in the middle of the night, and we cup-fed him. Every hour round the clock he woke up wanting to guzzle down a ton of formula. First thing in the morning we rented a pump to try to bring my milk in and to give him whatever I could get out so he would have less formula.

Mama Heidi and Lucas

A nurse pointed out Lucas’ tongue tie after his birth, but nobody mentioned that it might be a problem. I noticed Mike had an almost identical tie and they both have the same cleft chin. Lucas was in and out of the hospital his first 10 days for jaundice, and by the end of the first week nursing was very painful. I called the lactation consultant at the hospital and she gave me tips to increase my supply, but offered no advice on the tie. At his 2 week checkup he was still down quite a bit from his birth weight so I asked the pediatrician if his tongue tie could be the reason for the pain and the slow weight gain. The pedi told me his tie wasn’t severe and wasn’t the cause of either the nipple pain or the slow weight gain, but gave me a can of formula because he needed to gain weight. I didn’t feed him the formula. He nursed for 1.5 hrs, every 3 hrs, around the clock. The pain was intense. At one point in the middle of the night I told Mike to go to the store and buy a can of formula because I was just done. He refused (and I’m glad) and we persevered.At around 5 weeks I asked my sister if this pain was normal. She said no, of course not. I called a new pediatrician and made an appointment for later that week.  At the appointment, Lucas was around 7.5 lbs (his birth weight was 6lbs15oz) and the doctor immediately recognized his tie. We put him on his back on the table and the doctor clamped his frenulum then cut the tie while I held Lucas. This took maybe 30 seconds. I picked Lucas up and immediately nursed him, which stopped the bleeding. I could feel an immediate difference. It still hurt, but his latch was better.We scheduled a follow-up for 2 weeks later to coincide with his 2 month checkup. At that appointment, we found that he’d gained more in that 2 weeks than he had in the previous 4 weeks. The doctor took a look at his tongue and decided to clip just a bit more. Same procedure as before. I was still in a bit of pain – my nipples were very bruised and Lucas had developed a bad habit of nursing with his gums. About a week later – I remember Mike was taping up the windows for Hurricane Rita – I noticed that nursing didn’t hurt anymore. At all.

Mama Heather and Isabel

I’ve always had a lot of pain in the early days of nursing my babies.  It wasn’t until my fourth baby was 2 months old that I finally realized why: they were all tongue-tied.  None had a severe, anterior tie, but all four had significant posterior ties.  My daughter had a variety of nursing issues, including choking, gagging, apnea, and tiring out, at which point she would unlatch and let a mouthful of milk drain out of her mouth.  She had a shallow latch and my nipple would be “lipstick shaped” after every nursing.  Her tongue didn’t elevate when she cried and didn’t pass her lower gum line.  I pursued a variety of options for getting her tongue clipped but found difficulty because it was “only” posterior.  After seeing a doctor one morning who told me, cheerily, that she was, “Just fine!,” I drove an hour to a midwife who could clip it that afternoon.  An hour later, she stuck out her tongue for the first time!  Nursing improved with the dribbling, choking, and apnea ceasing.  Her latch was still fairly shallow and she still has a tendency to cause the “lipstick shape” on my nipples.  An experienced ENT has confirmed that she still has some tie that should be revised.  While we have yet to get a second clip, she is still nursing at 20-months-old and has a wide range of movement for her tongue.  She is highly verbal and can make sounds that her older, tongue-tied brother cannot.  I smile every time she sticks her tongue out!  It’s a reminder that the struggle to get her tongue revised was entirely worth it.

Mama Cori and Cady, Sadie, Maya

I emailed Dr. Kotlow to ask for a referral to someone local who could help me determine whether my girls had significant frenulums that would benefit from a revision.  He replied the next morning (a Sunday!) indicating there was no one here in Florida.  I emailed him photos of their mouths which he reviewed and responded with a ‘yes’ or a ‘maybe’ to each one. He was especially convinced when I mentioned that Maya, one of the ‘maybes’ for lingual tie, also had digestive and speech problems. He said to call his office on Monday to schedule appointments if we wanted to come up. The following thursday we left home at 4:00 AM and landed in Albany at noon.  A short cab ride later we were at Dr. Kotlow’s office. Each of the older girls had Novocaine, laughing gas, and Tylenol with their frenectomies. Cady, my 4 month old, had no medication whatsoever due to a corn allergy but was swaddled during the surgery. Since her repair a few days ago, Cady has been nursing more aggressively, less frequently, and hardly spitting up at all.  She is also vocalizing quite a bit more and seems to be enjoying her free moving tongue!  We are hoping to prevent further problems that can arise when these ties are overlooked, such as those experienced by her older sisters. Sadie was 7 at time of her repair. She was a colicky baby and in hindsight I believe her severe lip tie prevented her from sucking on a bottle or pacifier properly and caused her to wean over a year earlier than my other children. She now has a 3-4 mm gap between her two front teeth. We were told by a former dentist that she would need braces to bring them together. Since her repair, the extra tissue between her front teeth is now gone and her teeth are expected to move together naturally. She will still need orthodontic care for palate expansion, but we hope to avoid braces. Maya was 9 at the time of her repair. By age 2 she had severe dental decay and needed caps put on her teeth. The remaining nubs of her front teeth rotted away and she had an adorable, but unfortunate, toothless grin for years until the adult teeth grew in. Around age 2 we also noticed she was having speech problems and had her evaluated by a speech pathologist.  Deficits, yes, but for her age it was OK. Finally, in third grade, her teacher referred her to speech therapy again and this time they agreed she had a problem.  She worked hard but didn’t get very noticeable results. Since her frenectomy, her speech is nearly perfect.  Within seconds of the surgery it was better!  Speech therapy had taught her how to speak, but the surgery allowed her tongue to cooperate finally.  She also reports that eating is much easier now (we had lamb steak the other night and I didn’t hear one complaint out of her).  She has not had any reflux since surgery. In all, the 3 girls’ laser surgeries cost $1450 out-of-pocket, and I understand some insurance will cover it.  That’s pennies compared to all the dental work (past and future) it could prevent, the pain and suffering from poor digestion, the social cost of a speech impairment, and the risks associated with early weaning.

More Reading

Tongue Tie – a good general site with detailed information on types of revision
Articles from Lawrence A. Kotlow, D.D.S., P.C. on tongue-ties, lip-ties, and frenectomy
Brian Palmer’s extensive frenulum presentation with case histories (adults and children) More tongue-tie photos
Top 10 Tongue-tie Myths
The kindest Cut? The Emotional Impact of the Tongue-Tie Maze
Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial

Providers offering surgical and laser frenectomies (If you have a good reference to add, please let me know)
National Databank of Providers
Florida – Denise Punger MD
Missouri – Amy Grawey MDJames Maxwell MD
New York – Lawrence Kotlow DDS
Ohio –  Dr. Notestein 
Utah – Branton Richter DDS
Virginia – Ashburn Children’s Denstisty

Comments

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  1. October 7, 2012

    This is an important Tongue-Tie PDF:

    Tongue and Lip Ties: http://www.kiddsteeth.com/nursingbookaugfc2011.pdf

  2. October 7, 2012

    There is also a private tongue-tie/lip-tie support group on Facebook (which anyone can request to join) that has an entire, global list of trusted Drs for corrections. I believe Dr. Kotlow helps run it, along with a few other MDs, DDs.

  3. January 4, 2013

    Michelle…not sure if I am already a member of this FB group (I am in one TT/Lt group) but I have been searching for a recc for someone to evaluate in the Duluth area, MN (also close to WI). There isn’t anyone listed anywhere near there! Any ideas? Thanks!

  4. Natalie #
    June 28, 2013

    Just had my sons ptt and lip tie laser revision done in Dayton, Oh. Dr. Notestein had been trying to teach the procedure to other professionals in the Midwest and says many just don’t want to do them! He’s just as frustrated as parents. He is GREAT!

    • erin ellis #
      July 12, 2013

      Thank you Natalie for sharing this resource!

  5. Claire #
    July 5, 2013

    “Some literature lumps them in with a handful of other midline defects which are associated with low folate levels (that’s a story for another post)”

    My daughter was misdiagnosed by many health care providers & I didn’t discover her ptt/ult until we were deep into low milk supply issues. After 2 miscarriages, I was diagnosed with MTHFR. Have you heard of tt/ult being more common in babies whose mothers have the mutation?

    • erin ellis #
      July 12, 2013

      Claire, yes, physiologically it makes sense that low folate/MTHFR and lip and tongue ties are connected, just as MTHFR is connected to more severe midline defects. There aren’t any large studies on tongue and lip ties and MTHFR that I am aware of — heck the docs are just beginning to recognize the these structural challenges! I only have anecdotal experience with my particular population, which is comprised of folks that have known issues, like TTs, many of whom have dug into their own healing paths and discovered relevant mutations and nutrient deficiencies etc.

  6. Amy #
    August 15, 2013

    I do not know if this is why my daughter didn’t gain weight quickly or not. She has the one that looks like the III picture. Part of her weight issues might have been genetics, part milk supply, maybe this tied into it. I noticed it, but not until her teeth came in and we started brushing them. We often snag her tie and cause it to bleed. Drs never did notice it.

  7. March 2, 2014

    My update: We drove down to SLC for our second attempt at frenectomies. Dr. Richter was great, my 6 year old was very comfortable with his nitrus oxide :) His maxillary revision took about 20 minutes as it was pretty severe. My three year old however refused to open her mouth or sit in the big chair so we’l have to try again with her in a year or so.

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