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For centuries, issues that prevent infants from latching properly while nursing have been treated with scissors, scalpels, and even fingernails. However, with the introduction of dental lasers, treatment has become a more viable and effective means of care. Studies have shown that for every day of maternal pain from nursing during the initial three weeks of breastfeeding, there is a 10% to 26% risk of cessation of breastfeeding.1 Therefore, correcting issues such as "tongue-tie," which is more formally referred to as ankyloglossia, and "lip tie" by performing frenectomies can be critical to optimizing the health of affected infants. With proper training and a working relationship with the medical community, dentists can incorporate a surgical program to treat these cases in their practices.
Breastfeeding Issues and Benefits
A common complaint from new mothers is pain experienced during nursing. An infant's muscle architecture requires adequate development during the first few days of life for it to maintain a proper latch. In-utero sonograms often show babies sucking their thumbs. This thumb-sucking may be developmental training of the lip muscles for latch attachment. After delivery, babies who are able to achieve a proper seal for latching can produce incredible suction. For those who experience difficulty latching, the struggle can cause additional pain and discomfort to the mother.
Throughout history, mothers have either adjusted to their babies' excessive forces or found alternative means to nursing. Mothers who struggle under these conditions frequently quit nursing in favor of feeding with a bottle. According to Stevens and colleagues, the first feeding bottles, which were created in France in 1851, were elaborate.2 They had a cork and nipple as well as ivory pins at air inlets to regulate flow. In 1896, a simpler open-ended, boat-shaped feeding bottle was developed in England, became popular, and was sold well into the 1950s.
Although bottle feeding is adequate, breastfeeding has been associated with nutritional and other benefits. How much and what kind of work our muscles do are also critical environmental factors for ongoing development. Breastfeeding is seen as a determining factor for proper craniofacial development because it promotes intense exercise of the orofacial muscles, favorably stimulating the functions of breathing, swallowing, chewing, and speech production.3 Breastfeeding is also helpful in avoiding malocclusion. However, pacifier use, in contrast, can encourage the development of malocclusion. One study found that the prevalence of malocclusion among children who continued sucking habits beyond 48 months was approximately 71%, but among those who ceased sucking before 24 months, it was only14%.4
Anecdotally, mothers of babies with tongue or lip ties often report being told immediately following birth that their baby's tie is not out of the normal range or that the baby will ultimately learn to nurse regardless of the tie. Some have even reported being told that their baby's lip tie will be corrected when the child tears it during a fall or some other event. Unfortunately, some physicians are not adequately trained in the diagnosis and available treatment of these conditions. First-time mothers may not fully understand their discomfort from nursing, but experienced mothers usually know when something is wrong and often promptly seek help. When mothers complain about nursing discomfort following birth, we need to listen to them very carefully. The first week of nursing is a critical time. Self-doubt about the ability to nurse can creep in. The critical period when a mother may abort nursing due to pain is entirely variable. Therefore, the babies of mothers who report serious discomfort from nursing should be examined for the presence of tongue-tie and lip-tie conditions, and surgical intervention should be initiated when indicated. The sooner these mothers find access to ablation, the more likely they will continue nursing. With current surgical corrective techniques, the discomfort from nursing and total dependance on bottle feeding may not be necessary.
Tongue-Tie
Although the classification of frenulum presentations can help in identifying the severity of ankyloglossia, the most important diagnostic tool is listening closely to nursing mothers. There is no well-validated method for establishing a diagnosis of ankyloglossia. Five studies using different diagnostic criteria found that the prevalence of ankyloglossia was 4% to 10%.1
Tongues should advance anteriorly, forming a pointed tip instead of a cupping design. They should also protrude freely without impingement. Complaints of tongue ties are centered around either a lack of suction or the infant simply fatigues and falls asleep before expressing a significant volume. A frenulum revision may be indicated if a nursing mother describes certain symptoms or conditions, including nipple pain during nursing, clicking sounds during nursing, latch failure during nursing, frustratingly long nursing sessions, inadequate infant weight gain, low milk production, excessive infant gas or reflux, and the presence of strawberry milk, split nipples, shredded nipples, or nipple blisters. These are all common complaints. More severe conditions resulting from tongue-tie can include weight loss and possibly jaundice. Too often, a simple nipple shield is prescribed to the mother to assist with these cases, which may soon be discarded in favor of a bottle.
Lip-Tie
When the superior labial frenulum is tethered and believed to be interfering with breastfeeding, it has been described as a "lip-tie." With lip-tie, a fully protruded lip will demonstrate a flattening in the outer lip design. This condition results from a roll of tethered oral tissues, or "TOTs," extending from the anterior third of the lip to the incisive papilla. In an untethered lip, a rounded curve should be observed in the outer portion of the lip when extended. Because an upper lip tie can result in a chewing motion rather than a smooth, suckling one, the condition is often the primary factor when mothers complain of pain during nursing.
Kotlow described the problematic frenulum as one that interfered with the infant's ability to flange the upper lip around the nipple and achieve a successful latch.5 To assist in diagnosis, he classified the labial frenulum based on its appearance and location of insertion on the gingiva, producing four grades. Kotlow Grade 1 labial frenula exhibit minimal alveolar mucosa and minimal attachment. In Kotlow Grade 2, the labial frenulum attaches primarily into gingival tissue at the junction point of the free and attached gingival margins. In Kotlow Grade 3, the labial frenulum inserts just in front of the anterior papilla between the central incisors. And in Kotlow Grade 4, the labial frenulum attaches into the anterior papilla and extends into the hard palate.5 Although the literature has demonstrated benefit from frenotomy in patients with tongue-tie and patients with concurrent tongue tie and lip-tie, to date, there has been no high-level evidence to show benefit from frenotomy in patients with isolated lip-tie.6
Laser Frenectomy
Regarding traditional surgical approaches, the lip is far too vascular to reduce with a scalpel or scissors; therefore, it receives minimal attention. Conversely, lasers cauterize as they ablate, which results in a rapidly healing wound. With a laser, there is greater control of the surgical site and less risk when compared with traditional surgical approaches. Because there is little to no bleeding, laser surgery facilitates a continuous ability to identify anatomical landmarks at the surgical site. Dentists who are adequately trained in laser techniques can safely accomplish ablations in minutes. However, a complete and thorough understanding of infant oral anatomy and laser performance is paramount for these procedures. Each case needs to be evaluated regarding the amount of tissue that needs to be reduced as well as the ability to provide control of the patient and the surgical site. In addition, the laser settings and tip sizes selected should be specific to each case.
To perform laser frenectomy on an infant, have the mother sit and firmly hold the baby on her chest while an assistant provides evacuation. A swaddle can be of great assistance in maintaining a stationary child. Infant wraps and restraints can be beneficial as well. Therefore, having these available is highly recommended. Utilizing a high-volume evacuator attachment with slotted sides can help to ensure that excess water is efficiently removed during these surgeries (Figure 1). Have an assistant cover the child's eyes with a soft towel while holding the head as calmly as possible. For lingual frenectomies, retraction of the tongue is achieved with a grooved director with polished edges, which facilitates visual identification of the frenulum, lingual veins, saliva ducts, and salivary tubules (Figure 2).
Surgical techniques using laser technology will vary depending on the laser that is used, the wavelength that is used, and the anatomy of the tissue being treated. Er,Cr:YSGG and Er:YAG lasers are often selected for frenectomies because the oral soft tissues contain a high percentage of water, and research has shown that the erbium wavelengths have the highest absorption of water of any laser wavelengths.7 Research has also shown that the use of water cooling during laser surgery can reduce the total area of laser-induced thermal damage and prevent tissue carbonization.8 According to the results of a study by Kawamura and colleagues,9 histologically, the coagulated and thermally affected layer produced by an Er:YAG laser was extremely minimal (ie, 38 µm in thickness) and free from epithelial collapse. When compared with other devices, Er:YAG and Er,Cr:YSGG lasers resulted in less compositional surface change. In addition, the findings indicated that the use of water spray further minimized thermal influence.
Lasers can provide a highly effective means of treating tethered oral tissues. However, without water cooling, slight charring can occur. Slow and steady motions across the target tissue facilitate rapid ablation with minimal bleeding. Lingual frenulum ablation should permit the tongue to raise and freely extend forward without cupping or curling at the tip (Figure 3 and Figure 4). In many cases, the tongue will almost immediately increase its extension as the tie is released. Regarding the labial frenulum, releases should permit the upper lip to protrude forward adequately enough to develop a proper seal and a more stable latch around a nipple or pacifier (Figure 5 through Figure 7).
Once the procedure is complete, mothers and patients should be taken to a quiet, private room to relax. Laser corrective sites demonstrate minimal bleeding and swelling, which allows for immediate postoperative nursing. Preferably, infants will be ready to nurse or bottle feed immediately after the procedure. This gives mothers an opportunity to evaluate the effectiveness of the surgery and receive instructions regarding postoperative care. Advise mothers to train their babies' upper lips out and over the nipple. Mothers should do this routinely until their babies develop the ability to do this on their own. In addition, provide mothers with gloves to be used during lip and tongue stretching of wound sites, instructions on wound care, and plenty of reassurance. The author also offers brochures with information about breastfeeding benefits as well as the office phone number and the clinician's cell phone number as part of a take-home packet. Preoperative and postoperative photographs, a report from the mother on the latch distress experienced before surgery, and a brief statement regarding the postsurgical results should be sent to the attending pediatrician, and any lactation consultants currently working with the family should be included in the correspondence.
Conclusion
Dentistry and medicine are entering a new era of care for postpartum infants. As regional healthcare providers become increasingly aware of the results that these surgeries provide, referral bases continue to grow. Too many mothers complain of pain felt during nursing before being released from the hospital. The babies of these mothers could be effectively treated for improved latch profiles before their discharge. Greater awareness and training among all healthcare providers will be fundamental to improving access.
Further research regarding the effectiveness of laser frenectomy for tethered oral tissues in nursing infants to improve their latch profile is needed. One area that requires further study pertains to the weight gain of affected premature babies who receive treatment when compared with that of those who do not receive treatment. Babies who have issues and are treated reportedly gain weight quickly; however, this observation needs verification.
Queries regarding this course may be submitted to authorqueries@broadcastmed.com
About the Author
John Blaich, DMD
Private Practice
Poplar Bluff, Missouri
References
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6. Freeman CG, Ohlstein JF, Rossi NA, et al. Labial frenotomy for symptomatic isolated upper lip tie. Cureus. 2022;14(12):e32755.
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