There are two important concepts to understand about oral wounds:
- Any open oral wound likes to contract towards the center of that wound as it is healing (hence the need to keep it dilated open).
- If you have two raw surfaces in the mouth in close proximity, they will reattach.
I feel that post-procedure stretches are key to getting an optimal result. These stretches are NOT meant to be forceful or prolonged. It's best to be quick and precise with your movements. I feel that getting an affordable LED headlight (like a camping headlight) allows you to get the best results.
You may use Tylenol, Ibuprofen (if 6 months of age or older), arnica, Rescue Remedy or other measures to help with pain control. Previously, we recommended the use of Hyland's Teething Gel or Orajel Naturals. As of October 2016, the FDA has requested that these gels no longer be used. A suitable replacement is an organic coconut oil, which can be safely used in the mouth following the procedure.
The main risk of a frenotomy is that the mouth heals so quickly that it may prematurely reattach at either the tongue site or the lip site, causing a new limitation in mobility and the persistence or return of symptoms. The exercises demonstrated below are best done with the baby placed in your lap (or lying on a bed) with the feet going away from you.
How to approach your child when doing stretches:
A small amount of spotting or bleeding is common after the procedure, especially in the first few days. Because a laser is being used, bleeding is minimized. Wash your hands well prior to your stretches (gloves aren't necessary). Apply a small amount of the teething gel to your finger prior to your stretches.
TIMING: DO ONE STRETCH ON THE EVENING OF SURGERY. THEN, SKIP AHEAD TO THE NEXT MORNING (KEEP IN MIND THAT THIS IS THE ONLY TIME THAT YOU SHOULD SKIP THE OVERNIGHT STRETCH). My recommendation is that stretches be done 6x/day for the first 3 weeks, and then spending the 4th week quickly tapering from 6 to 5 to 4 to 3 to 2 to 1 per day before quitting completely at the end of the 4th week. I find it's easiest for parents to do 5 of the stretches during their waking hours and one of those stretches in the middle of the night, taking care to not go more than 6 hours between stretches. diaper changes are a good time to do the exercises.
The Upper Lip is the easier of the 2 sites to stretch. If you must stretch both sites, I recommend that you start with the lip. Typically, babies don't like either of the stretches and may cry, so starting with the lip allows you to get under the tongue easier once the baby starts to cry. For the upper lip, simply place your finger under the lip and move it up as high as it will go (until it bumps into resistance). Then gently sweep from side to side for 1-2 seconds. Remember, the main goal of this procedure is to insert your finger between the raw, opposing surfaces of the lip and the gum so they can't stick together.
The Tongue should be your next area to stretch. Insert both index fingers into the mouth (insert one in the mouth and go towards the cheek to stretch out the mouth, making room for your other index finger). Then use both index fingers to dive under the tongue and pick it up, towards the roof of baby's mouth. The tongue needs three separate stretching motions:
- Once you are under the tongue, try to pick the tongue up as high as it will go (towards the roof of the baby's mouth). Hold it there for 1-2 seconds and then relax. The goal is to completely unfold the diamond so that it's almost flat in orientation (remember, the fold of the diamond across the middle is the first place it will reattach). The key to the success of this stretch is that your fingers are placed deep enough prior to lifting the tongue up. Picture how a forklift works: If you don't get the forklift tynes completely under the pallet, lifting the pallet up will cause it to tip backwards. If you get the tynes completely under the pallet, you can lift the pallet straight up. I recommend pushing your index fingers together to prevent them from separating, push towards the diamond and then make sure the tongue goes up and not backwards. If your fingers separate and go on either side of the diamond, your lifting pressure will be directed at the sides of the tongue and not at the diamond itself.
- With one finger propping up the tongue, place your other finger in the middle of the diamond and turn your finger sideways and use a lifting motion from front to back to try and keep the diamond as deep as possible. Use a lifting motion when you sweep through the diamond, trying to separate the horizontal fold across that diamond. Make sure your finger starts within the diamond when doing this stretch.
- Massage on either side of the diamond (outside the diamond) to loosen up the musculature of the remainder of the floor of mouth. You can use more pressure when doing these stretches because you aren't in the wound at this point.
This is an example of an improper stretch. Do you see how the fingers are away from the diamond? As these fingers lift up the tongue, too much of that force is directed at the sides of the tongue, and the middle portion is still pinned down. This will lead to reattachment.
Focus on getting your index fingers mentally glued together - this forces you to stay in the middle, right on top of the diamond. As you push into the diamond and then lift the tongue up, the top half of the diamond will ideally come away from the bottom half of the diamond. It is attention to separating the fold across the diamond that results in a successful post-operative stretching regimen.
It's important to remember that you need to show your child that not everything that you are going to do to the mouth is associated with pain. Additionally, babies can have disorganized or weak sucking patterns that can benefit from exercises. The following exercises are simple and can be done to improve suck quality. I would start these on the 3rd day following the procedure, and spend 30-45 seconds on each exercise prior to the wound stretches (no need to do these sucking exercises during your nighttime stretch).
- Slowly rub the lower gumline from side to side and your baby's tongue will follow your finger. This will help strengthen the lateral movements of the tongue.
- Let your child suck on your finger and do a tug-of-war, slowly trying to pull your finger out while they try to suck it back in. This strengthens the tongue itself. This can also be done with a pacifier.
- Let your child suck your finger and apply gentle pressure to the palate, and then roll your finger over and gently press down on the tongue and stroke the middle of the tongue. Alternatively, once the baby starts to suck on your finger, just press down with the back of your nail into the tongue. This usually interrupts the sucking motion while the baby pushes back against you.
- With one index finger inside the baby's cheek, use your thumb outside the cheek to massage the cheeks on either side to help lessen the tension.
Starting several days after the procedure, the wound(s) will look white and/or yellow and will look very similar to pus.
This is a completely normal inflammatory response. Do not let your child's regular doctor, lactation consultant, friend who thinks they're an expert, or anyone else make the determination for you. If you think an infection exists, give our office a call.
It is essential that you follow-up with your lactation consultant after the procedure to ensure optimal results.
Call our office for any of the following:
- Uncontrolled bleeding
- Refusal to nurse or take a bottle
- Fever > 101.5