Frenectomy

A normal tongue function is important for multiple reasons. Amongst many other benefits, a normal tongue allows the baby to latch adequately and breastfeed efficiently, it promotes normal speech development, it makes it possible to self-cleanse the mouth during feeding, it allow adequate swallowing patterns and it makes fun little things like eating ice cream, kissing or sticking your tongue out to catch snowflakes possible.

Ankyloglossia is the restriction of tongue movement as a result of fusion or adherence of the tongue to the floor of the mouth. A tongue tie is therefore caused by a frenum abnormally short or attached too close to the tip of the tongue. THIS CONDITION CAN BE CORRECTED BY SIMPLE EXCISION, either with scissors/ scalpel or with soft tissue laser like what is offered at Milltown Dental.

Tongue ties are normally straight forward to diagnose and fairly easy to treat: the tongue is heart shaped when the baby cries; there is an obviously tight frenulum underneath that runs from the floor of the mouth to different area close to the tip of the tongue (depending on severity). This “obvious” tongue tie is what most doctor or dentist is able to recognize.

However there is also what we call “posterior tongue tie” which is a lot more difficult to diagnose and recognize if the clinician is not trained and familiar with the condition. The frenulum looks like it’s inexistent so the first instinct is to believe that tongue tie cannot be the issue for the breastfeeding difficulties. The tongue looks squared off with the floor of the mouth webbing/tenting the tongue. The edges of the tongue will form a cup when crying as it is unable to elevate. The tongue cannot move side to side but instead twists side to side. The tongue struggles to extend out of the mouth while it’s open but is absolutely incapable of “sticking out” when wide open, which is the ideal position for breastfeeding.

Mothers who try to breastfeed their tongue-tied baby suffer tremendously, both mentally and physically. Not only does she have to re-latch the baby multiple times during a feed and deal with feedings that last sometimes hours, she also experiences damaged nipples, cracks, bruises, pain during feeds. Her risks of breast infection increases and her milk supply can greatly reduce at fast pace due to the lack of stimulation from an inefficient latch. It is, overall, a very debilitating exhausting experience that has nothing to do with the beauty of the breastfeeding bond promised in all the books.

The babies may be losing weight, get sleepy during feeds (as they work much harder than other babies to stay latched), and become extremely gassy and irritable making the parents experience even more frustrating. Some babies end up with blisters on their lips from “trying so hard to stay latched”. Babies tend to feed a lot more often because their inefficiency results in less intake of milk so hunger kicks in faster. This increases the mother’s frustration and exhaustion.
 

WHAT IS THE FRENECTOMY?

It consists of releasing the frenulum under the tongue to allow for better range of motion


WHY HAVE THE TONGUE TIE RELEASED?
 
  • To make breastfeeding successful
  • To make the pain of breastfeeding go away, regain healthy nipples and breasts
  • To stimulate milk production by adequate stimulation
  • To correct the drama surrounding the breastfeeding issue, give parents their sanity back and finally achieve satisfactory bonding between a mother and her baby (huge psychological relief for parents resulting in better moods, better sleep, better relationship between mother and father, less risks of post-partum depression, etc)
  • To ensure adequate feeding and growth of the baby (baby will thrive, sleep and develop better)
  • To avoid serious long term issues with palatal development, tooth spacing, dental caries, speech impairments, social stigma

ARE THERE ANY ADDITIONAL BENEFITS TO TREATING A TONGUE TIE?
Absolutely and here is a list:
  • It can help prevent speech issues
  • It will allow the development of a normal swallowing patter (as opposed to a pathological tongue thrust) and this will in return avoid any malformation of the oral cavity and displacement of teeth that would then require major orthodontic treatment and expenses in the future
  • It will allow the tongue to self-cleanse the mouth thus lowering the risks of gums disease and decay
  • It will allow for licking ice cream cones, kissing a future life partner, sticking the tongue out for fun, and feeling self-confident as some children get bullied for their inability to move their tongue properly, etc.
  • It will help reduce the risks of choking (if the tongue cannot move adequately, it fails at manipulating and controlling the bolus of food) and reduce the risks of developing an atypically strong gag reflex consequent to a throat becoming defensive and protective.
  • There is ample research now also being done on the relationship that tongue ties may have with spinal issues, temporo-mandibular joint problems, snoring and apnea, etc
So yes, there is a lot more to a frenum that what meets the eyes and yes, it’s still totally worth it even if your nursing experience ends up failing…

HOW IS THIS DONE?
There are 2 ways: scalpel/scissor OR Laser
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Scalpel
Advantages Disadvantages
 
  • Procedure is very fast
  • Often covered by OHIP (if done in hospital by physician for example)
 
  • Extremely painful (Dr Julie’s mother and brother had it done as adults and they shared their experience with her)
  • May need time to heal if lesion is important and bleeding occurred
  • Possible infection
  • May require sutures
  • Usually bleeds a lot.  Controlled easily and nothing dangerous but quite stressful for the parents to watch.
  • Need for pain medication
  • Unpredictable.  You “guess” where you start and end
  • Elevated risks of relapse
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Laser
Advantages Disadvantages

  • A lot less pain (some babies actually sleep through the procedure and Dr Julie being also a speech pathologist treats young children and cooperation is amazing)
  • Very rare bleeding (which laser would cauterize or saliva control)
  • No infection
  • No needle required, no sutures
  • Totally predictable: the dentist knows exactly where to start and when the frenum is fully release.  The very obvious diamond shape opening is a dead giveaway of successful release
  • None or very minimal post-op pain as the laser seals the nerve endings.  Medication is not usually needed but as babies cannot give feedback, we still advise low dose of Tylenol for a few days “just in case”.
  • No recovery time, immediate successful feeding is not unusual!
 
  • May not be covered by insurance
  • May take longer than scalpel (a few seconds more…)
  • If topical anesthetic was used, baby can be fussy or unable to feed for about 30 minutes after the procedure.
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MILLTOWN DENTAL OFFERS LASER FRENECTOMY: HOW DOES IT WORK?

A soft tissue laser does NOT cut…it is more a “vaporization” of tissue that occurs.  Imagine a grape turning into a raisin for example.  Or if you have dead skin around your nails, you can easily peel it off without any pain or bleeding.  The laser has a similar effect on the skin cells.
When you apply the laser on the frenum, it literally “splits” by itself after a few back and forth movement on the tissue, almost like opening a zipper.

Because it is not a cut, even if your child moves during the procedure, there are no risks: we need to “work” on the tissue a little bit with the light to see some result occur as the energy needs to build-up first the same way the popcorn in your microwave will not pop right away but after a few seconds.  Therefore, a quick contact between the laser tip and the skin, like what would happen if the baby moved quickly or if we slipped accidentally, will have absolutely no effect on the tissue.  This is why we do not need to restrain the child very much but simply gently hold the hands down.  There is not blanket wrapping, no “pinning down” and the baby is somewhat free to move the head: we simply follow her movements and remove ourselves from the mouth if she moves too much, and gently bring her back to center to finish the work.  It is always a very gentle procedure, done with respect to the parents and the child’s own rhythm, during which you hold your baby as opposed to seeing her being taken away from you.


WHY CHOOSE LASER OVER SCISSORS?
 
  • Painfree or very slight discomfort: some babies sleep through the procedure!  At Milltown Dental, we have gathered the feedback of a few adults and teenagers before starting the procedures on babies but despite the consensus that there was no pain involved, we still use topical anesthetic “just in case” since babies cannot give feedback and they usually get aggravated simply by the fingers in the mouth or light restrain.  Dr Julie has 2 young children at home, who both have received the frenectomy, and she is very sensitive about how little patients are treated in her office so she takes no chance at all.  There WILL be NO pain during procedure.
  • After the procedure, children and adults who can express themselves report “tension”, “feeling like food is stuck under the tongue”.  Children like to “pock” at the treated area and report no pain doing so but consistently say that “this is bothering me” pointing at the scab that will form where we worked.  The new frenum area covers up with granulation tissue (wet scab) and this can feel thick or annoying in the mouth.  Children/babies usually adapt to it after a few days but it’s not unusual to have a fussy child for a few days following the procedure.  We do recommend low dose Tylenol for Infant or Advil for Infant for a few day to ensure pain control IF there was any as we have no way to know with a baby.  It is fully optional and up to the parents but Dr Julie Boudreault supports the use of medication and can help you figure out the appropriate dosage for your child.
  • No bleeding or minimal amount: any bleeding is easily and quickly controlled as it would be cauterized “on the spot” with the laser and left for saliva to control within a minute or two.  
  • No infection or very slight risks: a laser has the great property of sterilizing at touch and again if there is no bacterial infiltration as the blood vessels are sealed on the spot, there is less risk for infection.  
  • The healing is very quick: a laser stimulates bio regeneration and healing
  • Since the result is beautiful tissue (no wound, no bleeding lesion), chances of relapse, adhesions and scar tissue is greatly reduced compared to scalpel/scissor approach.  However, as healing tissue is excited to connect to other healing tissue, we still insist that exercises/stretches be done thoroughly every 3-5 hours.  Babies heal so much quicker than adults!  Therefore, the exercises need to be done a lot more often to avoid reattachment and relapse.  The exercises are done until the wound is fully healed and back to a natural pink color. Posterior tongue ties are more at risk of relapse simply due to the nature of where the frenum was and the severity of the condition.  
  • Almost always covered by the dental insurance plan
  • Parents can stay in the room and hold the baby as there is absolutely no “disgusting or bleedy” thing to see.  Plus nothing is more reassuring a child than the proximity of their parents…


HOW MUCH DOES A LASER FRENECTOMY COST?

The fees vary from case to case.  No tongue tie is the same and fees vary with severity of the ankylosis and the difficulty level of the procedure.  Please call our office to enquire or refer the patient for an assessment.  We recommend to address tongue ties quickly as breastfeeding success is a time sensitive matter but we would gladly send predeterminations to the client’s insurance company if requested.

IS THERE ANY DOWNTIME?

No.  We actually advise the mother to try breastfeeding immediately after the procedure is done as her breast milk contains amazing healing properties and the simple act of breastfeeding will reassure and soothe the baby.  That is only possible if no local anesthesia was used.  If topical gel was used, the nursing can resume after about 40 minutes and we advise to have the child fed before the procedure. Just like drinking water is difficult for the adult who just received dental treatment after being “frozen”, the baby will also struggle with her mouth’s proprioception for up to 40 minutes after the procedure, making breastfeeding a bit of a challenge.  It will be easy for you to know when your baby is back to normal as we will also apply some topical gel in your inner lip as a reference (cool trick right?)

WHAT HAPPENS AFTER THE FRENECTOMY?

It is important to understand that frenectomies are rarely a “miracle cure”.  Yes, some infants feed successfully immediately after but more often than not, some “physiotherapy” is needed afterwards and that is what your lactation clinician provides.  This the same way a patient who receives new legs will most likely need to get used to them and have to re-learn how to walk before he can run.  As we change the parameters of your baby’s mouth, she will need a few days to adapt and figure out the new range of motion.  You would get exactly the same clumsiness and frustration from someone trying high heels for the first time but chances are, with a bit of practice and perseverance, that person will eventually own that new strut. Posterior tongue ties may require even more practice before seeing the benefits of the frenectomy.  The efforts and exercises to break the bad compensation habits may last up to 8 weeks in certain cases before success is achieved so be strong, perseverant and don’t give up!  

There are also rare cases that unfortunately don’t improve after the frenectomy…  This is usually affecting babies over 3 months old, those who received bottles, those who now enjoy solid foods or those who are a little more stubborn and resistant to change.  It’s basically the same as trying to change a 9 year old’s golf swing versus trying to change that of your grand-father.  Chances are the longer you have been doing something wrong, the harder it will be to change it!  So the earlier the treatment the higher the chances of success!! It will also happen if you are not diligent with the stretches afterwards and end up in relapse.   

Basically, right after the procedure, if you have accepted the numbing gel, the baby may either sleep or fuss a bit.  She may also be very worked-up and aggravated by the anesthesia and struggle with saliva control which results in drooling and even “wet breath” due to mucus accumulation in the throat.  This will be coughed or swallowed as sensation comes back and we usually invite you to stay in the office so we can support you with that 30 minute of struggle.  Once your baby gets feeling back in the mouth, she is ready to resume nursing as usual but it’s now time to work on the technique.  The baby may be rejecting the breast at first, appear frustrated and fussy.  That is because we changed the parameters of her mouth and not only does she feel sensitive, she also doesn’t understand how the tongue is moving anymore.  It usually settles after a few days but again, have your lactation clinician support you with this transition and emotional journey.

Most parents decline medication for their newborn but we still recommend a small dose of Infant Tylenol or Advil after the procedure, especially in posterior cases.  We always follow-up with the parents the next day.  

IS THERE A NEED FOR RETOUCH?

Retouches are more frequent with the scissor/scalpel approach.   An open wound can “reattach” to the other side of that same open wound.  Since the laser closes/cauterizes and sterilizes the tissue where it touched it, chances of reattachment are more unusual but they do occur in cases where the parents were not thorough or too gentle with the prescribed exercises.

If there is a need for retouch, we always offer the first one at no charge.  Further treatment will have fees attached to it.

ARE THERE ANY RISKS OF DOING THE FRENECTOMY?

With scalpel/scissor yes.  It’s a cutting instrument.  

With laser, not really… You can have a fussy baby who doesn’t like the taste of the topical gel and the feeling of being numb; you can have a baby who is a bit upset with the gentle restrain and the fingers in their mouth for a few seconds; you may have a baby that is fussy for a few day because things changed on her and she is not used to it and the exercises may be hard for you to do because it’s often and you may not like to see your child upset.  Other than that, you may find the journey a bit taxing because changing the bad habits can be hard and it’s rarely an immediate success.  The biggest risk is to have relapse and that will happen either because the parents were way too gentle or negligent with the stretches OR sometimes because of nature!  

There is basically no risk to paralyze or stay frozen or cut an important blood vessel or nerve: first because those important landmarks are not in the vicinity we carefully select to work around and second because it’s laser and therefore very predictable and easy to control.

WHAT ABOUT THE LIP TIE?

It is not rare to see a tongue tie associated with a lip tie.  They are both midline defects and usually come together almost like flat feet come together.  

The lip, when too tightly attached to the gums, may prevent a good latch and some of the signs include:
  • Lip blister
  • Blanching of the lip during nursing (gets tight and white as the circulation is reduced)
  • Curling of the lip inwards during feeds
  • Pursing of the lips and ending up at the tip of the nipple, sucking like a straw
  • Constant re-latching and frustration
  • Clicking sounds and/or losing the latch when you flange the lip out.
  • Notch on the gum ridge where the teeth will eventually erupt due to the frenum pulling it upwards.
  • Leaking of milk on the side of the mouth

The first step for adequate breastfeeding is to achieve a nice wide sealed latch.  If the lip is preventing this, then there is really no point trying to get to step #2.  

Reducing the lip frenum will allow for the lip to flange out nicely and effortlessly, providing the necessary seal the baby needs to then get the tongue going to extract milk from the breast.  If the child has to work hard and use the lip muscles to stay attached to the breast, the nursing may fail, the child will fatigue and fall asleep quickly, the blisters will form and the mother may even be in pain.

There are no risks to doing a frenectomy of the lip other than mild discomfort afterwards and a feeling of thickness for a few weeks until it’s all healed.  You also have to stretch it to avoid relapse.

Other benefits include:
  • Avoiding a double lip (the inside lip sticking out like “meat” when you smile).  Look up double lip on the internet to have a visual of this.  Overall nicer smile esthetics…
  • Prevent trauma as a tight frenum can easily rip when a child falls
  • Better oral hygiene and avoiding the food from trapping on each side
  • Helps prevent a space between the teeth later on.  Not guaranteed but definitely a much better chance of avoiding this unwanted space that will require orthodontics to correct.

At Milltown dental, we like to stay conservative so we will only treat a lip tie when it is obviously contributing to the breastfeeding issues or would clearly lead to future issues.  As most frenum tend to assume a normal position with growth, we do not touch it if the parents are only concerned about the potential other risks.  We recommend to wait and see if any of those problems actually develop later on and treat it then as it can be done at any point in time.

HOW DO I MAKE AN APPOINTMENT?

If you have any question, concern or if you would like to book a consultation with Dr Julie Boudreault, please contact our office at 905-878-8528 and we will more than happy to assist you and support you to the very best of our abilities.

We look forward to meeting you and even more to meet your precious bundle of joy!