Synergy Dental Solutions 1000 Eleven South Suite 3F Columbia, IL 62236 US
Fit 2 B Tied
Functional
Integrative
Therapies
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.
What is a tongue tie?
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.
Tongue Twisters
Why is it that the tongue is so important yet so misunderstood?
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
What are the differences in release providers
The 1 thing that 2 doctors will agree on is the the 3rd should have done things differently.
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:
- ENT's
- Pediatricians
- General dentists with additional training
- Periodontists
- Oral surgeons
Tongue tie procedures are commonly performed:
- In dental and medical offices under minimal or no anesthetic
- In surgical centers under sedation or general anesthetic
*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."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789163/
The difference in philosophies
Functional Release
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
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.
Layers of tissue and levels of understanding
Level 1: What you see is what you get.
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
Level 2: Looking a little deeper...
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.
Level 3: It's more than just a tongue...
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.
Level 4: The few. The proud. The interdisciplinary provider teams.
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.
FIT: Functional Integrative Therapists
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:
- Dentists and orthodontists trained in orofacial myology
- Lactation consultants (including and especially Certified Lactation Consultants)
- Speech and language pathologists trained in infant feeding function
- Physical Therapists and Occupational Therapists trained in infant feeding function
- Osteopathic Physicians, Medical Doctors, Registered Nurses and Nurse Practitioners
- Chiropractors trained in pediatrics
- Craniosacral Therapists
- Airway minded pediatricians and ENT's
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So... what is a posterior tongue tie?
What you see is not always what you get.
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?
Release vs revision: setting things straight
Release
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
Revision
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
Principles of physiology
Principles: And then there was light.
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.
forgetting the basics in the name of convenience
One step forward...two steps back
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:
- overheated and damaged tissue becomes a part of the new surface
- the epimysium is injured and fascia grows into the scar causing a restriction…which is the opposite of the goal of a procedure intended to remove restriction to movement.
Going too far?
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. "
Such a big debate for such a small muscle.
Cutters are gonna cut and haters are gonna hate.
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?
To stretch or not to stretch...that is the question.
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.
Should we introduce a simple solution to a complex patient?
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:
- Cranial nerve dysfunction
- Unresolved birth trauma
- Cervical compression and rotations
- Aerophagia/gassiness
- Unintegrated and retained primitive reflex patterning
- Low-tone babies (Autonomic nervous system dysregulation)
- High tone babies (Autonomic nervous system dysregulation)
- Torticollis
- Cranial molding and craniosynostosis
- Cleft lip and palate
- Non-integrated suck swallow breathe reflex patterning
- Insufficient buccal fat pad development
- High palatal vault development
- Maternal challenges with dysregulation
- Maternal breastfeeding challenges (nipple size, over or under supply, nipple soreness, lack of professional support for efficient nursing, etc)
- Insufficient functional oral volume (mouth is too small)
- Mandibular recruitment (abnormal and hyperactive muscles pulling the lower jaw back and mouth open)
- Underdeveloped/insufficient airway/mouth breathing
- Enlarged tonsil and/or adenoid tissue
- Presence or oral habits
- And many more
Who should we believe? It's all so confusing.
Good question.
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.
Adults are simply children with complex unresolved issues.
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.
Let knowledge be your superpower and keep the FUN in function!
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!
FIT: Functional Integrative Therapies to complement Surgery
Lactation Consulting
SLP-based feeding therapies and Orofacial Myology
SLP-based feeding therapies and Orofacial Myology
SLP-based feeding therapies and Orofacial Myology
SLP-based feeding therapies and Orofacial Myology
SLP-based feeding therapies and Orofacial Myology
Chiropractic Care
Chiropractic Care
Chiropractic Care
Physical Therapy
Chiropractic Care
Chiropractic Care
FIT: Functional Integrative Therapies to COmplment Surgery
Craniosacral Therapy
Cranial, neurological and airway-minded physicians, pediatricians and ENT's
Nurses and Nurse Practitioners Specializing in Infant Function
Nurses and Nurse Practitioners Specializing in Infant Function
Cranial, neurological and airway-minded physicians, pediatricians and ENT's
Nurses and Nurse Practitioners Specializing in Infant Function
Cranial, neurological and airway-minded physicians, pediatricians and ENT's
Cranial, neurological and airway-minded physicians, pediatricians and ENT's
Cranial, neurological and airway-minded physicians, pediatricians and ENT's
What are the differences between the surgical tools used
Thumbnail
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.
Scissors
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
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.
https://www.researchgate.net/publication/268277419_Electro_surgery_in_dentistry_Report_of_cases
CO2 Lasers - LightScalpel and Solea
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/
ErYag Lasers - Fotona LightWalker
Waterlase/Biolase
NdYag 1064 - Fotona LightWalker and XLase/XPulse - "Hot tip" surgical tool
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
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NdYag 1064 - Fotona Lightwalker and XLase/XPulse - Therapy handpieces
The FDA approved therapy handpieces (coming soon) can be utilized to deliver healing doses of non ionizing light using high level laser energy through both non-touch techniques and those that touch the skin without disrupting the surface. https://oralasetherapy.com/ and www.babylase.com
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Resources and References
Types of lasers and what your practice needs: laser dentistry made easy and profitable
Apr 1st, 2007 by Donald J. Colluzzi, DDS, FACD