1 APRIL 2022 ausdoc . com . au
Therapy Update
Cutting through the tongue tie myths
Paediatrics
Dr Briony Andrew is a GP obstetrician and lactation consultant in Adelaide , SA . She is co-founder of the Adelaide Mums and Babies Clinic , is a neuroprotective developmental care practitioner , and provides a full scope of obstetric as well as routine general practice care .
There is a lot of conjecture surrounding the diagnosis and management of tongue , upper lip and buccal ties , but what does the evidence say ?
PARENTS receive an astounding amount of conflicting advice from well-meaning healthcare professionals when it comes to the question of normal infant oral anatomy . No wonder many parents are left confused and vulnerable . Once the seed of doubt has been planted about an oral ‘ abnormality ’, it is really hard to shake .
Opinions about the diagnosis and management of tongue ties , upper lip ties and buccal ties are fierce and diverse . Similarly , advice on post-release stretching exercises and counselling regarding risks and benefits are often contradictory . Parents do not know who to trust and can be easily swept up in the present enthusiasm for release of oral ties , a practice that has significantly escalated over the last 10 years or so .
Thankfully , two consensus statements on the evidence for oral frenula releases have been published in the last two years . These are valuable resources when discussing the evidence base about oral ties and their management with patients .
The first statement , by the Australian Dental Association , is the ‘ Ankyloglossia and Oral Frena Consensus Statement ’, and the second is the Academy of Breastfeeding Medicine ’ s ‘ Position Statement on Ankyloglossia in Breastfeeding Dyads ’. Both organisations sought multidisciplinary input from clinical experts in this field and summated the current evidence on this topic .
The reality is , there is a lack of both good quality randomised-controlled trials on this topic , and good quality longitudinal data , which proves the need for further clinical trials in this area .
Both consensus statements reached the same conclusions . This article will summarise their take-home points on the management of oral frenula .
‘ Posterior ’ tongue tie
This term should never be used , as it has no anatomical basis . The anatomy of the sublingual frenulum had never been described in
medical literature until 2019 , when Dr Nikki Mills , a New Zealand paediatric ENT surgeon , published her PhD findings on the subject . Clearly , this must be understood before any anatomical variants can be determined to be pathological .
Dr Mills studied both adult and infant cadaver specimens for her thesis . She determined that the sublingual frenulum is formed by a fold of tissue of the floor of the mouth , comprised of oral mucosa and sometimes the floor of mouth fascia and genioglossus muscle , rather than being a distinct entity or a midline structure . She found no anatomical structure that could be accurately described as a posterior tongue tie . Indeed , the deep cuts that would be made into this non-descript location during the release of such a tie are made into the genioglossus muscle , and are intimately related to the lingual nerves , blood vessels and salivary ducts .
Upper lip and buccal ties
Upper lip and buccal frenula are simply
There is no evidence that [ upper lip or buccal frenula ] cause any problem with breastfeeding , speech or solid feeding .
anatomical variants and very rarely require surgical intervention , and specifically not in infants . There is no evidence that either of these anatomical variants cause any problem with breastfeeding , speech or solid feeding . Indeed , ultrasound studies have shown that , during breastfeeding , the upper lip just needs to sit neutral , and not flange as was previously thought . The upper lip frenulum will regress as the baby grows , and will be much less prominent after the adult teeth come in .
There are some cases of quite broad labial frenula being persistent after the adult teeth come in , causing an ongoing diastema between the upper two middle incisors . In some cultures this is revered ; in ours it is generally not . Cosmetically , this can be managed with the release of the upper labial frenulum as a teenager , just prior to orthodontic work . Releases done in infants carry a risk of scarring and can actually worsen the diastema .
Buccal ties ( mucosa from the cheek meeting the gums ) have been hypothesised to cause breastfeeding challenges ,
NEED TO KNOW
Parents need reliable , evidence-based information about feeding and normal infant oral anatomy , and GPs are ideally placed to provide this .
The term ‘ posterior ’ tongue tie should be avoided , as it has no anatomical basis , and release of such purported ‘ lesions ’ risks injury to the genioglossus muscle , lingual nerves , blood vessels and salivary ducts .
Upper and buccal lip ties are simply anatomical variants and rarely warrant surgical intervention , and specifically not in children .
There are limitations to all the diagnostic assessment tools used for ankyloglossia ( tongue tie ).
The only indication to release an anterior sublingual frenulum is for nipple pain in a breastfeeding mother , where the pain is not improved by changes to positioning and attachment , and the baby clearly has a restricting anterior sublingual frenulum that extends to near the tip of the tongue and / or the gingival margins on the floor of the mouth .
Scissor frenotomy is currently the gold standard for releasing an anterior tongue tie .
There is no indication to recommend stretches following anterior tongue tie release .
There is a risk of harm when performing releases of oral frenula . These need to be thoroughly discussed with the parent and should strongly guide considerations around the risk / benefit ratio ( especially considering the lack of evidence for some of these procedures ).
but again there is no evidence that this is the case . Successful breastfeeding involves the baby creating a seal around the mother ’ s breast with its whole face ( not just the lips ). A baseline negative pressure ( or vacuum ) is created inside the baby ’ s oral cavity . When the baby drops its jaw and tongue together ( when suckling ), the vacuum increases , and the milk flows from the breast ( assisted by the mother ’ s letdown reflex ).
Oral anatomical variants in babies can be overcome by filling the baby ’ s mouth with as much breast tissue as possible . This is done via a deep face – breast bury ( see figure 1 ), and the creation of the negative pressure in the mouth will draw still more breast tissue into the mouth with each suckle . The total amount of tongue lift needed to successfully breastfeed is only about 4-6mm . Certainly , the mobility of the inner cheek relative to the gums , and the movement of the upper lip , have no role in breastfeeding .
The recommendations are that these frenula are all anatomical variants and should not be referred to as ties .
First published online on 24 March 2022
Figure 1 . Deep face-breast bury
Diagnostic assessment of tongue tie
The diagnostic assessment tools for ankyloglossia ( tongue tie ) all have limitations . The preferred systems are those that look at both form and function . Even these are imperfect and use the outdated stripping model of breast milk removal that focuses on tongue peristalsis and over-rates the importance of tongue movement . Interrater reliability is poor on the functional items included in these tools , strongly