The Difference Between a Lip Tie and a Normal Labial Frenulum

by Bobby Ghaheri


The vast majority of those who read the posts on this site show an interest because of problems with breastfeeding. I have pointed out many of those symptoms before: pain, poor weight gain, poor latch mechanics, reflux and so forth. As our awareness about tongue tie and lip tie increases, more moms will be sharing their stories. We often underestimate the power of sharing a Facebook status, liking a Facebook page, or tweeting out information.

Sometimes, parents will come across information on social media that piques their interest, even if they aren't experiencing a specific problem with breastfeeding. One of the more common ways that manifests itself is when they see a picture of a lip tie. I wrote previously about how upper lip ties (ULT) can affect breastfeeding. Pictures of thick or tight lip ties seem to pop up everywhere. Not uncommonly, parents will see these pictures and then take a peek under their own children's lips. Some are surprised to find what they think is a lip tie. Some will come to see me for treatment; others will email me for advice. Hopefully, this post will clarify some misunderstanding to avoid unnecessary concerns for those parents.

Those of us who frequently diagnose and treat ULT use a classification system to describe where the frenulum attaches. Class 1 lip ties are quite rare (it indicates little to no visible attachment). To date, I've seen more than 1500 babies and have yet to see a class 1 tie. A class 2 ULT will insert somewhere on the gumline (gingiva) above the edge of the gumline. A class 3 ULT will insert at the edge of the gumline, adjacent to a structure called the anterior papilla. Finally, a class 4 ULT will wrap around to the hard palate.

Class 2 Frenulum (no restriction noted - good flanging)

Class 2 Frenulum (no restriction noted - good flanging)

Class 3 Lip Tie (Central restriction noted)

Class 3 Lip Tie (Central restriction noted)

Class 4 Lip Tie (Central restriction noted, bone notching is present)

Class 4 Lip Tie (Central restriction noted, bone notching is present)

This classification system just describes anatomy. It does not determine severity, like a cancer staging classification does. A class 4 ULT isn't "worse" than a class 3 ULT - what matters is the degree of restriction.  This degree of restriction can be determined by feeling the lip and trying to elevate it, mimicking the flanging motion needed on the breast. Alternatively, an IBCLC (international board certified lactation consultant) can evaluate what the lip is doing on the breast.

The most important thing to recognize, therefore, is that the classification used to describe the attachment of the labial frenulum to the gum can describe normal labial frenula as well. Many times, I will get an email asking for opinions on a baby's "class 3 lip tie" in situations where neither the baby nor the mom experiences breastfeeding problems. So in this instance, the baby has a class 3 frenulum.

This video demonstrates how a normal frenulum can have a class 3 attachment but demonstrates no restriction - the baby sleeps through the examination

To illustrate the distinction, we will examine an important study out of Sweden from 1994 by Flinck et al. This study examined 1021 newborns were studied over 8 months to record normal oral findings. Keep in mind that these babies weren't having particular problems - they were just being observed. Of those 1021 babies, only 68 (or 6.7%) had "buccal" insertions of the frenulum (this would indicate a class 1 or 2 attachment). 782 (76.7%) had class 3 attachments and 170 (16.7%) had class 4 attachments.

Keeping this in mind, I maintain that the location of the frenulum's attachment to the gumline CANNOT be a deciding factor on whether or not a frenulum is tied. If that were the case, the Flinck study would justify treatment in 93% of babies, and we know that number can't be right.

If restriction is noted, and the restriction is from the frenulum itself, then treatment is warranted. But in what other situations would treatment be plausible if breastfeeding weren't problematic? The two most common instances are dental decay and a central gap in the teeth (diastema). 

The most important paper regarding the labial frenulum and premature dental decay comes from Dr. Larry Kotlow. In this study, he associates the presence of a prominent maxillary labial frenulum to premature dental decay of the two teeth on either side of the frenulum (the central and lateral maxillary incisors). The most likely mechanism of this premature decay is that a prominent frenulum can allow for pocketing of debris that cannot be cleared away, giving bacteria a reservoir of material to use. In my experience, the frenula that have a "hooding" appearance (like an awning over a patio) are the ones at highest risk. Because the majority of kids have class 3 or 4 frenula, but the majority of kids don't get this premature dental decay, I don't treat preemptively. I think that's bad medicine. But once decay is seen, treatment should be rendered.

The much more common question I get is about a central diastema or gap in the front teeth. Some parents are very worried about gap formation - they have brought otherwise asymptomatic babies to me before teeth have even come in, asking for revision. More commonly the gap is noticed once the front teeth come in. I still don't like to release those frenula at that stage - the gap can be temporary. As more teeth come in, the incisors can rotate forward, and the gap can be obliterated without the need for any intervention. My preference is to wait until all the teeth are in before deciding on a revision. Obviously, there are some exceptions - the severely thick frenulum or the ULT that is pulling on the gumline hard enough to cause notching of the border of the gumline will always have a gap, and treatment is reasonable. Other instances where treatment is helpful is when the child is experiencing pain from repeated minor trauma - this can occur during eating or brushing teeth.  Regardless, it's important to understand that both a lip tie and an untied normal frenulum can cause a gap between the teeth. It's often more about the presence of tissue that can cause the gap, even if that tissue isn't under tension. Finally, it's important for parents to understand that releasing a frenulum that's causing a gap may not result in closure of that gap. Dental spacing is much more complex than the simple presence or absence of a low frenulum. If parents want a frenulum released to "prevent the need for braces", I advise them that there's no guarantee in the result because of the variable causes of abnormal spacing.

A normal frenulum can act as a space holder between teeth and cause a gap, like elevator doors that close on you. The mere presence of tissue (like the guy in the red shirt) can hold the teeth apart. A lip tie, which can also have abnormal bulk, has added tension to keep the teeth apart, just like someone using active force to keep elevator doors open. Both a nornal frenulum and a tie can cause a gap in those teeth.

A normal frenulum can act as a space holder between teeth and cause a gap, like elevator doors that close on you. The mere presence of tissue (like the guy in the red shirt) can hold the teeth apart. A lip tie, which can also have abnormal bulk, has added tension to keep the teeth apart, just like someone using active force to keep elevator doors open. Both a nornal frenulum and a tie can cause a gap in those teeth.

While some may argue that this is an issue of semantics, I feel that it's an important distinction to make. When parents realize that what their child has is considered normal, it makes non-treatment a much less stressful choice. My goal is to make sure that we are releasing the appropriate frenula for the appropriate reasons.                                                                                                                     


Tongue Tie and Lip Tie FAQ

by Bobby Ghaheri


This post was originally published on my Facebook page (www.facebook.com/DrGhaheriMD) but I've had requests to post it here as well for ease of reference. I hope to quickly answer some of the common questions surrounding tongue tie and lip tie here. 

1) Can a tongue tied baby stick her tongue out past her lips?

Absolutely. Just because the tongue has normal motion in one direction doesn't mean that the tongue has normal motion in ALL directions. The most important movement for the tongue during breastfeeding is UP and not OUT, so the normal outward movement of the tongue is as relevant as normal shoulder movement for the purposes of breastfeeding.

2) Can laser revision cause scar tissue?
Yes. Any wound can have scar tissue. The precision of laser and the lack of collateral damage because of focused energy is thought to minimize that scar tissue. Regardless of the technique used, however, if the entire tongue tie is released (including the posterior portion), then there is a higher chance of scar tissue because the wound is deeper and the opposing edges of the release site are closer together, increasing the chances of scarring.

3) Are stretches necessary to prevent reattachment?
Stretches are necessary to prevent reattachment for the lip and a released posterior tongue tie. If someone just releases the anterior component, then I don't really think that stretches matter. The opposing raw edges of the wounds in a lip tie or posterior tongue tie are too close, and will stick together to some degree without stretching. 

4) Do I need to have a thick lip tie cut in the OR in case it bleeds?
No. It's all about preparation. When I did scissor treatment, I just injected a small amount of numbing medicine that contained adrenalin. After 10 minutes, there's minimal bleeding, and the release can be done easily in the office.

5) Do stitches prevent reattachment?
If the release is done absolutely perfectly and the stitches are placed precisely, then theoretically reattachment would be difficult. That being said, my experience is that placing stitches requires general anesthesia, and the provider using stitches generally doesn't have an understanding of posterior tongue tie, so while it doesn't reattach, it's often inadequately released.

6) How often does a tongue tie accompany a lip tie?
In my experience, >90% of cases

7) Is there always a posterior tie behind an anterior?
Yes. The real restriction of a tongue tie is typically at the posterior component (for the motion necessary during breastfeeding).

8) My baby's tie has been cut. Why is her tongue still heart shaped?
The band that had tethered the tongue to the floor of the mouth travels from within the substance of the tongue down to the floor of the mouth. Cutting that band somewhere in the middle doesn't remove the portion of the band inside the tongue. That can still change the shape of the tongue but typically doesn't affect function.

9) Can a tongue tie cause speech problems?
Absolutely. The most common letters affected are R, S, L, Z, D, CH, TH, and SH but other sounds are also difficult. While some kids can make these sounds in isolation, stringing the sounds together during speech can be very difficult. Recent studies have shown some improvement in speech function following a frenotomy, although most studies don't show obvious benefit. I feel that speech can be improved in specific cases where restriction is prominent and the child has had speech therapy and improvement hasn't been noted. As more studies are done, I think we will see an improvement in objective speech measures with the procedure, but not every patient will benefit.

10) Can a lip tie cause speech problems?
Generally, I say no. In some severe cases, if the lip tie is causing the child some discomfort with mouth opening (because of tension), they may alter their oral anatomy to minimize pain, which could impact speech.

11) Do lip ties cause tooth decay?
Yes. The most affected are the 2 teeth on either side of the upper lip tie (the incisors). Cavities on the teeth in the back (molars) typically happen in the setting of tongue tie (can't sweep the tongue back there to clean). Dr Kotlow has a great article describing the impact of a lip tie on cavities, and if you want to print it off and give it to your dentist or doctor, go to:
http://www.kiddsteeth.com/articles/The_Influence_of_the_Maxillary_Frenum_on_the_Development_and_Pattern_of_Dental_Caries_on_Anterior_Teeth_in_Breastfeeding_Infants_Prevention,_Diagnosis_and_Treatment010%5B1%5D.pdf 

12) I have no difficulties with breastfeeding but it looks like my baby has a lip tie. What should I do?
Enjoy your normal breastfeeding relationship :)

 


Tongue Tie Interview!

by Bobby Ghaheri


I recently had the opportunity to speak with Veronica Jacobson, CLC, regarding tongue tie and the impact on breastfeeding. We discussed the following:

  • Why is there more awareness of the issue now versus 5 or 10 years ago?
  • What is the biggest hurdle to getting HCPs to understand tongue and lip ties and the health effects?
  • Why do posterior tongue ties need to be taken more seriously as something that needs fixed?
  • What kind of research is currently being done on the subject?
  • What's your advice to parents who are having a tough time getting a pediatrician or other HCP to take their concerns about a possible tongue or lip tie?

Here's a link to the video


The Evidence Supports Treating Tongue Tie for Breastfeeding Problems

by Bobby Ghaheri


This post aims to address the common argument that there is no published evidence supporting the treatment of tongue tie when breastfeeding is problematic. It's directed at the doctors, lactation consultants, speech pathologists, and family members of mother/baby dyads who, for whatever reason, think that the release of a tongue tie is completely unwarranted. Often, the adamant negative response mothers get is so strong that they are scared to pursue treatment. This is especially true when the negativity comes from a doctor or lactation consultant, who mom may feel are "experts" in the field and whose opinion carries weight.

Unlike other medical conditions with a perceived significant societal impact, studies looking at TT and breastfeeding don't include large numbers of babies. You will not find a multi-center, double blind, randomized controlled trial (RCT) that looks at the efficacy of the procedure. But that does not discount the available body of literature, and we will examine the best studies to demonstrate the safety, efficacy and importance of tongue tie release when breastfeeding isn't going well. Keeping in mind that the majority of the studies were likely only treating anterior tongue tie (ignoring the posterior tie that is always behind the anterior ties), it's impressive to see how much these moms and babies benefit. Additionally, there are currently no studies that show that frenotomy does NOT help breastfeeding symptoms - they universally show improvement, regardless of study design.

Steehler and colleagues (2012) retrospectively collected data on 367 babies seen in a 5 year period of time who had breastfeeding problems related to tongue tie. 302 of them underwent a procedure but only 91 agreed to participate in the study. 80% of those participating felt that the procedure helped their baby breastfeed. 83% of the babies were able to initiate or resume breastfeeding. This study is limited by its retrospective nature and the very young mean age of the babies (18 days old), which makes extrapolation of the results to older children difficult. That being said, the study demonstrates a high level of satisfaction and safety. This study does look at posterior tongue tie, making it one of the only ones to demonstrate that even those babies can be safely treated in the office.

Berry, Griffiths, and Westcott analyzed 57 babies who were referred for tongue tie who were having problems breastfeeding. The groups were divided into a treatment and non-treatment group to create a double blind, randomized study. The babies were taken away, treated (or not treated) and then returned to mom. Pre and post-treatment evaluations were performed and those in the non-treatment group were treated after the data were collected. 78% of the treatment group noted improvement; interestingly, 47% of the non-treatment group also reported improvement, showing the bias involved. 1 day after the procedure, the cumulative improvement was 90%. At 3 months, 92% reported continued improvement. The double-blind RCT design of this study is admirable, but it truly only blinds the results for the improvement noted on the day of the procedure. In reality, the vast majority of babies treated don't improve immediately, especially in the setting of posterior TT.  This study does not look at posterior TT, nor does it truly control for bias beyond the day of the procedure.

In 2011, Buryk and colleagues published in Pediatrics a randomized trial studying the same topic. They looked at 58 babies who were randomized to a treatment arm vs a sham treatment arm. The babies in the sham treatment arm were offered treatment at or before 2 weeks following the initial visit. Whereas the Berry study's sham group was offered treatment that day, this study allowed for babies to wait well beyond what I feel is reasonable. Despite that ethical problem, however, the study shows improvement in the frenotomy group when compared to control, using objective measures to grade the latch and the presence of nipple pain. 

Hogan and colleagues (2005) looked at the association between TT and breastfeeding problems in a different way. They identified 201 babies with TT and determined that only 88 of them were having breastfeeding problems. This study emphasizes my contention that not all babies who have tongue tie need treatment. Those that are asymptomatic should be followed rather than empirically treated. Of the 88 in the study having problems, 57 were included in the study. 28 babies were included in the treatment group, and 96% had improvement in breastfeeding. The 29 controls were subsequently offered treatment after intensive non-surgical treatment was offered, and 28 of the 29 requested frenotomy. 96% of those babies also showed improvement in breastfeeding. 

Arguably the most important study that furthered our understanding of breastfeeding mechanics came from Dr Geddes and colleagues in 2008. Recently, Dr. Elad's paper emerged to further characterize how babies actually nurse. Geddes' paper looked at 24 babies and analyzed their breastfeeding using ultrasound, identifying appropriate nipple position, what happens to the nipple pre- and post-frenotomy, and most importantly, what the babies' tongues do when they nurse. It redefined our understanding of this motion, changing it from a previous theory where we thought babies stripped the breast to nurse to the current understanding of the generation of a vacuum in the mouth that draws the milk out via negative pressure. If doctors and lactation consultants fail to understand the implications of this paper, they will categorically fail to understand why frenotomy is helpful in the setting of tongue tie. This paper showed how objective latch scoring, maternal pain scores, milk intake and milk-transfer rate almost universally improved in babies who underwent frenotomy.

Earlier this year (2014), Dr Ochi, a pediatric ENT in San Diego, conducted a small study showing improvement in 20 babies who underwent frenotomy for breastfeeding problems. He also showed the importance of using a breastfeeding quality of life survey to measure maternal satisfaction following the procedure.

Finally, the best examination of the improvement babies can experience following frenotomy comes from Dr. O'Callahan in his 2013 study. He looked at 300 babies who underwent frenotomy (along with lip tie revision in 37% of those babies) for breastfeeding issues. More than 1/2 of them responded to survey follow-up, making it a large patient sample studying this topic. For moms reporting nipple pain, 64% reported improvement within 1 week. Unfortunately, long term follow-up wasn't done, so the remaining moms and babies couldn't be studied further. Importantly, no moms experienced worsening pain. About 1/2 of the moms reporting latching difficulties reported improvement at the 1 week follow-up. The likely explanation for why more babies didn't improve in both arenas is that follow-up beyond 1 week wasn't performed, and it is well-understood that a subset of babies (especially older children) need a longer period of time to relearn appropriate sucking patterns. I feel that the most important part of this paper is the fact that only 16% of babies who presented with breastfeeding problems had an anterior TT (class 1 or 2). 84% had a posterior TT (class 3 or 4), which we already know is the type of TT that is most often missed or misunderstood by doctors and lactation consultants. If only babies with an obvious anterior TT are the ones that doctors are willing to treat, they would be missing 5 out of 6 potential babies who would benefit from treatment.

As time goes on, more data will emerge. But in my opinion, there is already a sufficient body of evidence to demonstrate that frenotomy is a very safe and effective treatment for babies with ankyloglossia who are having difficulty with breastfeeding. If we demand large RCT's for every disease process, we would never make any progress. In this sense, we must walk before we can run, and in this instance, I feel that we're jogging in the right direction.


References

Steehler, MW, et al. A retrospective review of frenotomy in neonates and infants with feeding difficulties. International Journal of Pediatric Otorhinolaryngology 76 (2012) 1236–1240

Berry, J, et al. A Double-Blind, Randomized, Controlled Trial of Tongue-Tie Division and Its Immediate Effect on Breastfeeding. BREASTFEEDING MEDICINE Volume 7, Number 3, 2012

Buryk, M, et al. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial. Pediatrics 2011;128;280

Hogan, M et al. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J. Paediatr. Child Health (2005) 41, 246–250

Geddes, DT, et al. Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound. Pediatrics 2008;122;e188

Elad, D, et al. Biomechanics of milk extraction during breast-feeding. PNAS. 2014 Apr 8;111(14):5230-5

Ochi JW. Treating Tongue-Tie - Assessing the Relationship Between Frenotomy and Breastfeeding Symptoms. 2014 United States Lactation Consultant Association Clinical Lactation 2014, 5(1), http://dx.doi.org/10.1891/2158-0782.5.1.20

O'Callahan, C, et al. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology 77 (2013) 827–832