Child and Adult Revisions

How do tethered oral tissues effect more than just nursing and bottle feeding infants?

Tongue and lip ties can negatively effect many aspects of the oral cavity, that in turn have systemic results seen within the body as a whole.

Airway Development

The lower jaw or mandible is typically slightly recessed or set back in an infant. This occurs because the infants chin is positioned closely to the chest in the already confined uterus. Once the child enters the world, the chin will slowly start to grow in a downward and forward direction with proper guidance from the tongue. The main growth center for the mandible is located at the Temporal Mandibular Joint or the TMJ. The facial muscles and tongue will exert a force that act on the maxilla and mandible. When these forces are in balance, growth and development will proceed normally and in balance. When facial muscle exert a force that is not balanced by the tongue it may restrict the growth of the jaw. When the jaw growth is restricted the tongue is displaced to the posterior portion or back of the oral cavity and can impinge the airway. As air passes through the nose, back to the nasopharynx and into the oropharynx the tongue may obstruct this path. If this is the case, the body will either switch to mouth breathing which will allow the tongue to then be positioned forward and down and out of the airway. This mode of mouth breathing can lead to irritated tonsils, a dry mouth and in turn a lower pH of the mouth and higher incident of caries.

The tongue will grow to fill in the mandible area when facial growth and development occurs properly. The tongue exerts lateral, vertical and horizontal force within the oral cavity to help expand the entire mouth into an ideal "U" shape. The widening of the jaw and maxilla allows for a wider arch that will better accommodate the developing dentition. If the tongue does not exert the outward force to balance the facial muscles the dental arch can form a "V" shape. Of course this can lead to an aesthetic issue and protruded teeth, but the airway and overall systemic effects are more impactful.

The prolonged use of a pacifier or thumb/finger habit and the intensity in which they are sucked can negatively impact the shape of the maxilla and mandible. The palate will narrow and become higher and can cause the front portion of the maxilla to move forward and become more pronounced, increasing the likelihood for trauma because the lips can not protect the teeth.

SIDS, of sudden infant death syndrome, in breastfed children is dramatically decreased as well. The progesterone in breastmilk along with proper usage of the oral and facial structures will help develop and maintain a patent airway of the infant and improve the musculature tone and position of the tongue helps decrease the risk for SIDS.

Mouth Breathing

Mouth breathing, especially during the night, can have a negative impact on your teeth and oral cavity overall. When we use the mouth to breath at night the oral cavity will dry out and the protective properties of saliva disappear.

Saliva helps clear food from the mouth, remineralize the teeth to help strengthen them, provide enzymes to help the breakdown of food and buffer the oral cavity.

The normal pH level in the mouth is 7.7, which is a balance between an acidic and basic environment. Individuals with problems breathing through the nose when asleep can have a pH drop to a pH of 6.6 and even lower. Once the pH reaches 5.5, the enamel will start to breakdown and cause demineralization within the tooth. Prolonged exposure to an oral environment of this nature can lead to tooth decay.

Sleep Disordered Breathing (SDB) and Obstructive Sleep Apena (OSA)

Sleep disordered breathing (SDB) and obstructive sleep apnea (OSA) can occur at any age and have major short and long term impacts on school and work performance and overall health and well being. Individuals who have been diagnosed or are symptomatic for these issues often have changes in not only behavior, but also physical appearance.

These individuals may exhibit and open mouth posture, sclera or the white area showing under eye, a flat profile with no prominent cheek bones, slower body growth, crooked and crowded teeth that may stem from poor tongue positioning and posture. As the individual sleeps, the lower set or poorly postured tongue will fall back into the airway and obstruct of block the flow of oxygen to the lung and in turn the rest of the brain and body. This lack of oxygen is extremely tough on the brain and causes the brain to work overtime at night, when it should be resting.

The brain needs more oxygen at night to help the prefrontal cortex function and clear the brain of free radicals produced during the day. Individuals with SDB or OSA will have a brain that remains awake and alert and not in a state of rest. Poor breathing leads to poor oxygen uptake and delivery to the brain. When the brain is alerted of lower oxygen level and higher levels of carbon dioxide, the brain will stimulate the body and force it to breathe. The maintenance of oxygen levels will always supercede the brains resting state. These children may fall asleep with little to no problem, but the depth and quality of sleep is compromised.

This lack of quality and sustained sleep can severely impact the performance these children have in school and adults at work or while driving. Studies have shown that poorly performing and inattentive students at times are labelled as have ADD or ADHD because of their behaviors in school. The major issue in many of these children was they were in fact not ADD or ADHD, but quality sleep deprived and were suffering from sleep disordered breathing at night and waking up and having to focus and function at school.
Review the article here.

These patients with obstructed airways may have multiple environmental allergies, a higher arched palate, a deviated septum, enlarged turbinates in the nose, a lower set tongue with a resting position behind the lower teeth and lower muscle tone in the face.

This is not an absolute either…..not all mouth breathers are ADD/ADHD and not all true ADD/ADHD are mouth breathers. Kids still need a lot of sleep when they are young and still developing and must have the opportunity to have the recommended amount of sleep. These children will display hyperactivity, impulsive behavior and poor focus. These can then lead to anxiety and depression when untreated and not addressed.

In adults OSA leads to higher blood pressure, day-time sleepiness or sluggishness which is unhealthy for the individual, but may pose a risk for others if the individual is driving and poorly rested. Weight management, redundant neck tissue and other medical conditions can predispose indivduals to OSA, but with proper tongue resting position, facial muscle tone and a healthy airway, the individual can rest better. This theory is mimicked by the use of breathing machine at night forces the individual to breathe through the nose and if they try to mouth breath, the positive pressure air generated by the machine will forcefully stop air intake via the mouth.

How to prepare for the procedure

The best way to prepare for the procedure is to practice the post op exercises before your visit and have a few appointments with a body work specialist (chiropractor, physical therapist, or craniosacral therapist). 

Gentle body work such as chiropractic or craniosacral therapy is an important part of the process of treating the lip and tongue tie. It is recommended to begin treatment prior to the laser release and then again after the release. The type of bodywork matters less than the skill of the practitioner. It's VERY important to find someone who is qualified and experienced working with patients who have undergone tongue and lip tie releases. This pre- and post operative body work helps the body release the adaptations that have formed over a lifetime of being restricted. 

Children having speech difficulties due to a tongue tie, should work closely with a speech therapist prior and after the release. 

It is also recommended to have softer foods available for the first few days post op and OTC pain medication such as Tylenol and Ibuprofen.  

Understanding oral wounds

1. An open oral wound likes to contract towards the center of that wound as it is healing (hence the need to keep it open).
2. If you have two raw surfaces in the mouth in close proximity, they will reattach.

The main risk of a revision 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. 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.

1. Upper Lip: Place your thumb and index fingers on either side of the surgical release, until they almost touch and elevate the lip. You need to see the entire inside of the lip and entire surgical site to be successful in preventing healing tissue to repair itself back together. This is done 3-4 times a day, 3 times for 3 seconds for 2 weeks
   
   
2. Tongue: Your goal is to keep the underside of the tongue from maintaining contact with the floor and thus preventing the tissue from fusing back together. You need to peel the tongue away from the floor of the mouth. This is accompanied by gently pushing the tongue up and back until you can see the diamond of the surgical site. This is done 3 times, at least 3 times a day, for 2 weeks. At your 2 week post op check, we will make sure no reattachment has occurred and give you a better timeline of how much longer you have to do stretches based on how the site is healing. Alternative method for children: coat the inside of a shot glass with chocolate syrup, or honey and try to lick it clean.
   
   
3. If you allow the area to grow back together, you need to “pop” open the site or return for relasering. If you are able to reopen the site, it will most likely bleed as healing will bring new blood vessels; you will need to do the stretching exercises for an additional 2 weeks.

Healing surgical sites will turn white and yellowish. It looks, for lack of a better word, gross. This is normal and is not any type of infection. Infection of these surgical sites is almost nonexistent.

Please call the office 607-272-2033, with any questions or concerns, Mon-Thurs 7:30am-3pm.

If you have read all my information and still have unanswered questions, please email me lizbilliot.dds@gmail.com or text me between the hours of 8am-9:30pm. 203-233-6979. Feel free to send me a text or email with a healing photo 1 week after the procedure. I would love to reassure you that everything looks good!