for Tongue Ties and Restrictions
Are you confused by what you have learned about tongue ties?
If so, you are not alone.
Our hope is that the information on this website might offer you a new perspective and a safe place for you to learn and grow in your understanding while exploring new horizons of treatment options based on principles and not opinions.
This page offers insight into the journey of many healthcare professionals, concerned parents and disillusioned patients on the journey of learning “something more” about the mysterious tongue.
Why is it often incredibly frustrating to find a simple answer and one treatment that is effective for a such a common condition?
Ankyloglossia, also known as tongue-tie, is a congenital oral anomaly that may decrease the mobility of the tongue tip and is caused by an unusually short, thick lingual frenulum, a membrane connecting the underside of the tongue to the floor of the mouth. Ankyloglossia varies in degree of severity from mild cases characterized by mucous membrane bands to complete ankyloglossia whereby the tongue is tethered to the floor of the mouth.
It is the 2nd strongest muscle in the body.
Has has 3 neurological inputs (general sensory, taste, motor).
It is powered by 5 cranial nerves.
It is surrounded by the pretty white teeth that drive the millions of dollars that influence the dental and orthodontic industries
Yet is has the interesting and powerful position of holding the title of “no man’s land”
with many legal and interdisciplinary considerations
Let's face it. (*pun intended*)
Medicine and dentistry are a combination of an art and a science.
They are called "practices" for a reason.
Knowledge is an evolution of understanding. The benefit of research on human subjects is limited based on the simple fact that no two people are the same and should not be compared as if everyone will react the same to a technique or medication.
Surgical tongue tie releases are performed by:
Tongue tie procedures are commonly performed:
*When using lasers to release soft tissue, suction and additional ventilation is recommended and critically important to remove the plume of vaporized tissue and aerosols from the surgical room
Many surgical release providers will learn their skill set during their training for the laser that they decide to purchase and will feel more comfortable with a particular age group or patient population.
Where's the "research"?
Despite the obvious value of scientifically based research, there are inherent limitations to the value of basing every clinical decision based on what has been deemed to be true by the research community. Much of the research funded by laser companies have certain goals of this research which should be considered when considering the methods and findings of the research project.
Many clinicians have been around long enough to distrust industry funded "research for a reason" and are on the front lines doing their best to help their patients. They can't wait 20 years for someone else's the research to prove the most recent publications right or wrong. They need to help their patients right now.
Researching the research methods
"Clinical equipoise, also known as the principle of equipoise, provides the ethical basis for medical research that involves assigning patients to different treatment arms of a clinical trial. The term was first used by Benjamin Freedman in 1987. In short, clinical equipoise means that there is genuine uncertainty in the expert medical community over whether a treatment will be beneficial." https://en.wikipedia.org/wiki/Clinical_equipoise
Enter the Evidence Based Clinician
Evidence based providers do what they can with their training, technology and skills to help their patients to the best of their ability. " Evidence based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients."
"The posterior frenulum did not interfere with sucking and swallowing during breastfeeding; therefore, surgery was not recommended for any of the subjects in this sample."
High concentration of type I collagen was detected in all types of lingual frenulum. Due to the fact that type I collagen is resistant to traction, stretching exercises
may not be helpful to elongate the lingual frenulum.
Therefore, lingual frenectomy may be considered the appropriate procedure to release the tongue in order to provide better oral functions
The FOM tissue composition suggests that, in at least some individuals, the FOM fascia may have a greater degree of distensibility than fascia found in other areas of the body, challenging the dogma that all lingual frenulums are nondistensible. However, our study suggests there is significant individual variability in the proportions and distribution of fibers (Type III collagen and elastin) that would influence the fascia’s properties of distensibility. We raise the possibility that this variability in tissue composition may impact an individual’s range of tongue mobility and biomechanics and may be one reason why individuals with similar frenulum morphology may have variability in whether they experience functional limitation of tongue mobility.
Consistent with the recently described adult and neonatal lingual frenulum anatomy [3, 4], we have confirmed that lingual nerve branches are located superficially on the ventral tongue surface, immediately beneath the fascial layer. This emphasizes the vulnerability of these nerve branches during frenotomy surgery, particularly when using any surgical tool that creates thermal energy that can be transmitted into the underlying tissues. Direct neural connections have been shown between lingual nerve (sensory) branches and hypoglossal nerve (motor) branches [12, 13], creating a direct link for sensation to stimulate intrinsic muscles to alter dorsal tongue contour. Dorsal tongue contouring around the nipple has been shown to be critical for creating the intraoral vacuum required for milk extraction during breastfeeding . Therefore, if temporary or permanent impairment of sensation to the anterior tongue occurred in a neonate at the time of frenotomy, it would be likely to significantly impair their ability to breastfeed.
The tongue influences and interacts with the body system. Its dysfunction leads to different local and systemic pathologies. During the assessment of the tongue, other associations that may influence its physiological behavior, such as the lower limb, the TMJ, the neck, the respiratory, and the pelvic diaphragm, and the muscles of the thoracic outlet, should not be neglected. Considering its anatomical and physiological connections, during manual evaluation, will help the operators increase the importance of the tongue assessment, the rehabilitation organization, and consequently, the therapeutic results
Functional release providers value working with licensed and skilled providers to support tongue function, neurologic integration, whole body connectivity, airway, functional oral volume and orthodontic concerns.
They often recommend therapies to prepare the patient for the surgical intervention, recommend optimal timing for the surgical release and promote therapies to support the patient during their post surgical recovery.
Visual release providers who perform surgical releases based on visual observation of tissue insertion (eg class 1-4 tongue tie classifications). They prefer to treat only what they can visualize despite the presence of additional factors that influence the outcomes of their procedures.
The easiest to understand and most obvious tongue tie is easily observed by parents and patients by looking under the tongue. Many Facebook posts ask about tongue ties using only a camera phone.
This diagnostic tool is limited and has been dismissed as an accurate assessment of physiologic impact through several studies. Here is a reference to one of those studies:
Defining the anatomy of the neonatal lingual frenulum Nikki Mills a, b, Natalie Keough c , Donna T Geddes d , Seth M Pransky e , S Ali Mirjalili b
The impact of the combination of mucosa and superficial structures visible between the sublingual caruncle and tip of the tongue is usually understood by the providers focused on providing releases of what can been seen and felt during the surgical procedure. The appearance of the tissue under the surface of the mucosal lining of the mouth which is often different than things appear on the surface and can be felt and visualized as long as the surgical instrument allows careful dissection of the tissue layers. If the tool or technique utilized to perform the procedure is aggressive, these important subtleties are often missed and unnecessary tissue removal and scarring can be an unfortunate side-effect.
More enlightened release providers appreciate the impact of the cranial nerve integration and influence of the shape of the oral environment as they understand the functional aspects of tongue restrictions and their releases.
The interdisciplinary and comprehensive patient care approach is often embraced by the minority of all release providers, The global integration of the whole body fascial and neurologic system that support whole body function requires a high level of training, dedication and experience by the release provider and excellent communication with their colleagues, co-therapists and referring providers.
Many of these dedicated providers refuse to perform a surgical release without the cooperation and feedback from their professional teams.
The interdisciplinary surgical release provider often has colleagues with whom they share common values as well as a streamlined and efficient referral and communication process. These providers have received additional training and often include:
The Titanic was not sunk by part of the iceberg that could be easily seen.
The additional layers of restrictive tissues under the tongue that are being referred to as the "posterior tongue tie" are often deeper, more broad, follow no distinct pattern and are much less obvious than the popular and visible "anterior tongue tie".
If not addressed during the surgical intervention, these tissues remain and often result in less than optimal results of tongue release procedures.
According to one of the thought leaders in the tongue tie community:
"A posterior tongue tie is the presence of abnormal collagen fibers in a submucosal location surrounded by abnormally tight mucous membranes under the front of the tongue" - Bobby Ghaheri, MD
But what if there is even more to consider?
What if the submucosal fibers implicated in the posterior tongue tie involve the fascial system of the tongue...and therefore the entire body?
How about the impact of the reflexive system (especially the startle reflex known as the Moro Reflex) on the fascia?
Why would anyone think that treating the lower jaw, neck and hyoid bones wasn't just as important as treating the tongue muscle itself?
What if the nerves that make the tongue work aren't actually working well?
And what about how the brain interprets all of this?
The term release is used when referring to the first time that a tongue tie is surgically treated.
Also known as a surgical operation (n): a medical procedure involving an incision with instruments; performed to repair damage or arrest disease in a living body
The term revision is used when referring to a surgical intervention that is intended to address the undesirable effects of a previous surgery.
Also known as revision surgery
: surgery performed to replace or compensate for a failed implant (as in a hip replacement) or to correct undesirable sequelae (as scars or scar tissue) of previous surgery
Let's compare a light bulb with tongue function.
1. If the power isn’t on (from proper neurologic signalling from the brain), the light (tongue) will not work efficiently.
Patients with a challenge with getting the signal for the muscle to work properly from the brain to the tongue might have a tongue that "looks normal" yet functions poorly. If the patient does not have a balanced autonomic nervous system and a reflexive system that is working for them, their tongue might not be working well for them either. There are several reflexes that should be evaluated in the context of a surgical release including Moro, Rooting, Babkin and others depending on the presentation the patient.
2. If the light bulb is burned out (muscle fatigue), the light (tongue) will not work efficiently
Patients who have been using the wrong muscles to do the right thing (swallowing) often develop profound muscle fatigue and soreness. This discomfort and fatigue can result in poor tongue function.
3. If the circuit breaker is flipped (birth or surgical trauma), the light (tongue) will not work efficiently
Patients who suffer compression to their necks during labor and delivery may have damage to the nerves that support proper feeding. Trauma can also cause a "power surge and flip the breaker" in the analogy with cranial nerve function. Gentle therapies to stimulate the cranial nerves and decompress the neck are very helpful in improving tongue function.
4. If the dimmer switch is on (structural mucosal restriction/visual ankyloglossia), the light (tongue) will not work efficiently.
Much like a dog on a short leash, the tongue with a tight structural restriction will not be able to move freely. This can cause the muscles that are supposed to move the tongue for an efficient swallow to stay weak and ineffective while the muscles that elevate the floor of the mouth to get sore and hyperactive.
Any of these factors can prevent ideal tongue function.
These are only a few of the reasons to consider when evaluating tongue function.
Most experts agree that acceptable clinical outcomes have less to do with the tool used by the surgeon and more to to with the skill of the surgeon. The tongue is a delicate and complex organ.
Surgeons who respect that complexity are to be admired.
Surgeons who do not understand that complexity should be questioned,
Surgical tools that allow the surgeon to carefully dissect the delicate layers of tissue while being careful not to perform additional damage through aggressive techniques are preferable.
Once the tissue is removed, the surgeon cannot put it back. There is no backspace button. Maximal benefits with minimal damage produce the most optimal results.
It's all connected. Period.
Anyone who tries to tell you that the impact of a tongue release procedure is limited only to the tissues that are being treated is either naïve or undereducated.
Choose your provider wisely based on their understanding of the many complexities of tongue function and the implications of their treatments.
Doctors are taught during their basic training in anatomy and physiology that if different layers of tissue are cut or damaged, they need to be repaired separately so that they can heal through the most efficient methods of healing. These wounds will heal more slowly with more scar tissue formation if reinjured during the healing process.
This also applies to the tissues under the tongue.
When high heat procedures are used to "heat seal" the different layers of mucosa, connective tissue, fascia and muscle together, optimal healing can be negatively affected through lack of tissue glide.
But that's not the most important aspect of over-aggressive tongue tie releases.
Healing happens when new tissue from the different tissue layers released during surgery repopulate the surgical site and create a new surface. Scarring happens when:
Research indicates that if the surgeon injures the delicate layer of tissue that surrounds the muscle fibers (called the epimysium), there can be scar formation that can reduce tissue mobility and ideal function.
In other words, a surgical incision that goes beyond the layers of tissue that are blamed for the restriction with the goal of improving tongue function...and they injure the epimysium...they can end up CAUSING the tongue to LOSE function through SCARRING
The following is a study that documents the potential damage caused by over-aggressive surgical releases:
The histochemical structure of the deep fascia and its structural response to surgery
J Hand Surg Br. 2001 Apr;26(2):89-97.
McCombe D1, Brown T, Slavin J, Morrison WA.
"This structure was also evaluated after it had been raised as a fascial flap and in another site after the underlying muscle surface had been disrupted.... The post-surgical specimens demonstrated preservation of the structure of the interface between fascia and muscle, including the retention of the hyaluronic acid lining, if the epimysium was intact.
However, if the epimysium was disrupted, the structure of the interface was obliterated. "
Some providers are simply going to focus on their surgical skills and not their role as a healer. Regretfully, some people will try to provide a simple solution to a complex problem and place doubt on those who try to educate their patients on an integrated approach. Patients love to hear that there is a cheap, easy solution (which is of course completely covered by insurance) and providers are able to make more income by giving the insistent patient/parent what they want when they want it.
Parents who want a quick and easy "snip or clip" will gravitate to the surgeons who do same day, quick releases. Parents who choose this option will often justify their decision by saying that the outcome for the procedures was great......even if they might be not so great. These less than optimal results of stand alone surgical interventions often result in severe oral aversions, feeding difficulties, cranial nerve dysfunction and retained primitive reflex patterning into adulthood.
Of course, the providers and parents might not realize the limitations of their understanding until the unwelcomed compensations set in.
Then again, the baby might have a full recovery with a successful outcome in the absence of other complications. Sometimes it all works out.....but sometimes it doesn't.
Do you want to find out the hard way that you or your baby was more complex than a simple snip could fix?
Many release providers will instruct the parents (or patient) to actively and repeatedly rip the wound open to prevent healing of the surgical site with the goal of preventing reattachment. This creates incredible discomfort not only for the baby, but the entire family especially when the patient is an infant.
Other providers will advocate for effective feeding and gentle stretches of the muscle and fascia surrounding the surgical site to facilitate improved function and healing. They will tell the parent to avoid the discomfort of re-injuring the wound and to create a gentle, loving healing environment for the child as they learn new patterns of swallowing and tongue movements.
Here are some fun facts of physiology:
If the surgeon appropriately removed the tissue causing the restriction, the remaining tissue should be encouraged to quickly heal in the environment of improved function.
In the case of a baby, this is through successful nursing and/or feeding.
In the case of an older child or adult, this is through the pre-surgical exercises that were instructed and supervised by a licensed therapist who composed a comprehensive pre and post surgical plan for the rehabilitation of the patient to promote ideal function.
Any provider who advises their patient to do anything to delay successful wound healing and/or avoid any Functional Integrative Therapies might be using a moral decoy to try to justify the limitations of their own practices and belief systems.
And how do we know who is a complex patient?
Here is a short list of complexities in treatment sequencing with tongue tie release surgeries:
Keep asking questions and looking for answers. Find professionals that you trust in your local area who are licensed and experienced in situations like yours.
Please be careful in taking the advice from Facebook groups. Even though some of the members are well intentioned, they are not your doctor and cannot diagnose anything with a picture taken with your phone. (especially if a surgical release is "complete")
Do not rush to treatment and find acceptable alternatives to infant feeding until you feel comfortable with the decision to choose a surgical intervention.
Delaying treatment often results in further complexities through the development of compensation patterns that must be "unlearned" before a more functional pattern is to be established after a surgical release or revision. This is why skilled care is necessary before and after the release to ensure the most optimal outcomes of treatment.
We learn best through play so make sure that the pre-surgical learning phase and the post-surgical recovery period is full of gentle support and playful exercises, especially for children. The creation of oral aversions may have a negative impact on you or your child for a lifetime and having fun will minimize the negative effects of the procedure. Remember, the mouth and tongue are linked to emotion. Let's make it a good one!
Okay... no one uses this tool anymore but it was a primary method of saving babies from malnutrition and death before surgical interventions were possible. Midwives, grandmothers and family members of mothers in ancient civilizations used this technique to treat the tongue tied baby if nursing was unsuccessful because of a visible tongue tie.
Surgical steel has the advantage of operator control of their tool with a technique guided by sight and feel. The disadvantage comes with the likelihood of bleeding at the surgical site.
Electrosurgery is an application of electrically generated heat energy to tissue to alter it for therapeutic purposes. Even though electrosurgery has advantages, its use
in dentistry is declining due to lack of knowledge during earlier days, production of heat by unit, chances of gingival recession and introduction of lasers. Electrosurgery has the drawback of odor during procedure and collateral heat damage (unless properly managed) It is fairly inexpensive for the provider and patients generally report uneventful healing.
The carbon dioxide laser (CO2 laser) was one of the earliest gas lasers to be developed. Despite being one of the most primitive technologies, it is one of the most used laser wavelengths in modern dentistry much in part to the popularity of the LightScalpel company. Some CO2 lasers are used exclusively to treat soft tissue while others can treat both hard and soft tissue. It has the benefits of popularity and efficiency, but the drawback of potential aggressive tissue damage created by less experienced providers due to the lack of tactile feedback for the surgeon.
For more information on the LightScalpel laser, please visit their site using the following link: https://www.lightscalpel.com/education/surgical-co2-laser-tissue-interaction/
For information on the Solea Laser, please use the following link:http://www.convergentdental.com/solea/
This wavelength using the Fotona technology can be utilized as a cutting tool for soft tissue using a light touch using a small diameter fiber and surgical dissecting technique
Types of lasers and what your practice needs: laser dentistry made easy and profitable
Apr 1st, 2007 by Donald J. Colluzzi, DDS, FACD