Infant Revisions

Lip frenulum’s (maxillary frenulum) are located between the upper jaw and the inside of the upper lip.  These lip frenulum’s can be broken down into 4 categories, but the most important aspect, in regard to breastfeeding, is how the frenulum impacts the ability for the lip to flange and function.  The frenulum can vary in thickness, length and connection point from the lip and upper jaw. 

When assessing an infant to determine if a lip frenulum is negatively impacting nursing a simple exam to assess the range and ease of lip motion can be performed.  The infant’s upper lip should roll out and up towards the tip of the nose with little resistance and minimal to no blanching of the frenulum in the area of where it connects to the maxilla.  If the lip functions well, it will roll back and the tip of the lip will be able to contact or come into very close contact with the nose tip.  During nursing the infant must breathe through their nose and the lip does not even need to flange back as far as the tip of the nose.

One of the most common questions about lip frenulum’s revolves around a space or gap between the front teeth and the frenulum.  Spacing in infant and children’s teeth is extremely beneficial and ideal.  These baby teeth that are spread out and have spaces are easier to clean and the space between the baby teeth will be later occupied by the much wider adult teeth.  Genetics play a large part in spacing between the front two teeth and is referred to as a diastema.  If the child’s parent or grandparent has a prominent space between the two front teeth or the gap was corrected through braces or cosmetic dentistry, the infant will likely have a diastema as well later on in life.  Revising or fixing the frenulum as an infant will NOT resolve the genetic cause of this diastema

How does the lip frenulum effect the teeth and hygiene?

Lip frenulums can present as thicker, shorter and extend over the maxilla and onto the hard palate.  At times this specific presentation can lead to great challenges for the parent to brush the upper teeth and can possibly impact the aesthetics or smile of the child.   If the lip is difficult to reflect back to access the teeth so they can be brushed, the risk for plaque buildup can be increased.  Lip ties do NOT cause dental decay, but the longer plaque sits on those teeth and the more carbohydrates the bacteria in the plaque have access to, it can lead to demineralization (white chalky lines on teeth) and dental caries or a cavity.  Proper hygiene and diet are extremely important at a young age to help minimize or avoid these problems.  Starting to brush once the first tooth erupts is a good practice and seeing a pediatric dentist at or around the 1st birthday is another great way to help monitor and avoid preventable dental issues.

Are lip and/or tongue ties adversely affecting your nursing relationship with your baby?

Nursing is not supposed to hurt! One of the most common, and fixable issues, causing pain during breastfeeding are tongue and lip ties. The issues below often make mothers give up on breastfeeding or struggle through it... but there is help. A simple 5 minute procedure, called laser revision surgery, can eliminate most of the symptoms!

Mother’s symptoms

_____ Creased, Cracked or blanching of nipples
_____ Painful latching of infant onto the breast
_____ Gumming or chewing of the nipples
_____ Bleeding, cracked or cut nipples
_____ Infant unable to achieve a successful, tight latch
_____ Poor or incomplete breast drainage
_____ Infected nipples or breasts
_____ Abraded nipples
_____ Plugged Ducts
_____ Mastitis
_____ Nipple Thrush
_____ Feelings of depression
_____ Oversupply of breastmilk

Infant’s Symptoms

______Waking up congested
______Difficulty in achieving a good latch
______Falls to sleep while attempting to nurse
______Slides off the breast when attempting to latch
______ Reflux (Aerophagia clicking, swallowing air during nursing)
______Poor weight gain
______Short sleep episodes (feeding every 1-2 hours)
______ Apnea- snoring, heavy noisy breathing
______Unable to keep a pacifier in the infant’s mouth
______Waking up congested in the morning
_____ Only sleeping when held upright position, in car seat
_____ Gagging when attempting to introduce solid foods
______ Milk leaking out sides of mouth during feedings

What should breastfeeding be like for your baby?

The latching of your infant may take a few tries, but once established should only require subtle adjustments. The mouth should open wide and accept the nipple and areola with a wide opening. The tongue will grasp, stabilize and draw the nipple into the mouth and create a vacuum, which will elongated the nipple to the back of the infant’s mouth. Once the milk starts to flow, the tongue will continue the wave-like motion to maintain the vacuum and depth of latch. The infant will make a suck or two and then an audible swallow should be heard as the milk is swallowed. The sounds of “gulping” and “clicking” can signify a poor vacuum is in place and the child is swallowing more air then milk. There should be no blisters on the baby's lips - these “nursing blisters” are a sign that your baby is struggling to suck and swallow properly. The infant’s hands should be open and relax and eye contact maintained with the mother. Frustration, fatigue and quickly falling asleep at the breast are behaviors that are not common with an efficient and effective nursing infant. After feeds, the baby should be fairly easy to burp and be satiated and happy. The nipple should be rounded and not have any flattened edges. The baby must have the ability to have a properly functioning tongue and oral motor coordination to efficiently breastfeed.

Clicking, gulping and gasping for air may be present in a baby who is gaining weight appropriately. This usually happens when the mother has a very active letdown. Adequate weight gain alone in the early newborn weeks is insufficient evidence that breastfeeding is going well, as suck dysfunction may not cause weight gain issues at all, or may result in poor weight gain in the late newborn phase, after 2 to 3 months of age, despite good early growth.

Do ties still matter if we bottle feed?

Absolutely. While different, the mechanics of nursing and bottle feeding are also similar and ties will also effect a baby’s latch on the bottle nipple. 

Why does my child make a clicking or gulping sound when nursing or bottle feeding?

The tongue is needed to make a primary seal and the lips help make a secondary seal when nursing. The inability of the tongue to groove and elevate around the nipple and the upper lip to properly flange out does not allow for the baby to make a good seal at the breast. When the upper lip is curled in and remains curled in, this can allow for milk to leak out of the sides of the mouth or for air to be ingested and swallowed by the baby. You may notice small, darker triangles in the corners of the mouth if the lip is not fully flanged. Even after a revision, the upper lip still may need to manually displaced until prior compensatory habits are unlearned and the facial muscule works less at the breast.

The tongue also plays a part in the maintenance of a seal because it pulls the nipple into the mouth and enables the baby to latch. The tongue needs to extend, groove and cup around the nipple to pull it into the mouth. If a tongue has limited ability to extend and elevate or cup around a nipple, or the finger when examined, this may also contribute to milk leakage and excessive air intake.

The clicking sound that is heard when the infant nurses can be a result of poor elevation of the tongue or a stronger letdown. As the tongue elevates to draw the nipple into the mouth and form a vacuum, the baby needs to maintain a wide open mouth and allow for the tongue to elevate. If the tongue is unable to maintain the elevation, each suck will make a click sound and this occurs as the tongue drops and breaks the vacuum. The infant will gulp air and swallow this when the system is not closed. This clicking and gulping can lead to ingested air and if not properly managed, lead to gassiness, excessive burping and even symptoms of reflux. This is referred to as Aerophagia Induced Reflux (A.I.R.).

Why is my baby having excessive gas, hiccups, fussiness or reflux?

Mild degrees of reflux, hiccups, gas and spit up are all normal for a newborn or infant. These issues may be due to gastrointestinal issues, normal variations in muscle development and tone of the GI system, food sensitivities associated with the mother’s diet or from excess air intake during bottle and/or breastfeeding. If excess air is ingested, it must exit the body either as gas or burping. If the air is burped up, it can bring up stomach acid and cause discomfort and mimic reflux. The excess air can also distend the stomach and cause fussiness and irritation with the child, too. The child’s stomach may be distended or appear fuller when filled with excessive air after a feeding and mimic colic-like symptoms. We refer to this phenomenon of reflux that is caused by excessive air intake during nursing or bottle feeding as Aerophagia Induced Reflux (A.I.R.).

An excessive amount of or very frequent hiccups can be the result of excess air intake while feeding, too. The air intake will distend the stomach and it pushes on the diaphragm, which is the muscle used to fill and empty the lungs. When the stomach places pressure on the diaphragm, its rhythmic cycle can be broken and lead to hiccups, especially after feeding.

What is the white coating on the center of my baby’s tongue?

The white coating on the center of the tongue is most likely residual milk left on the tongue and in rare cases, it could be thrush. The “milk tongue” is typically only found on the center portion of the tongue and not the perimeter of the tongue. This can occur because the tongue cannot fully elevate against the roof of the mouth and “self-cleanse” against the higher palate. The perimeter, or outer border of the tongue, will be the normal pinkish color, because the upper and lower jaws make contact with the tongue perimeter. The presence of a milk tongue is one reason to suspect or further investigate a potential tongue tie, which is not allowing for ideal movement and elevation of the tongue.

In cases of thrush, the white coating typically can be wiped off and the tissue under the coating is very red and sore. White patches in other areas of the mouth, typically the cheeks, can be another sign of thrush. Thrush can affect the mother and child, and if properly diagnosed, both individuals should be treated with appropriate anti-fungal medicines. Mothers may experience a burning sensation after nursing and can be confused with thrush, but may actually be vasospasms. These vasospasms are a result of trauma to the nipple’s blood and nerve supply because the infant is causing damage to the nipple end. With improvement in the depth of the latch and function, the vasospasms should subside soon after revision. When the tip of the nipple is able to be drawn to the back of the infant’s mouth, the pain and discomfort will typically subside.

My baby has a very strong suck, but breastfeeding is painful and the infant is not gaining well?

Some babies will have a very strong suck when a finger is placed within the mouth to examine the tongue function and palate shape. The tongue may elevate enough and the mouth may partially close to form a vacuum. These infants may be overcompensating by using facial muscles to suck and form a vacuum. The suck or negative pressure they produce is like sucking through a straw and will ineffectively transfer milk from the mother, but feel like a strong vacuum or suck. The tongue is essential incompletely and ineffectively draining milk from the breast and if the tongues function is compromised, so will efficient and effective transfer. The baby still may “transfer” milk, but this may occur more due to the mother’s oversupply, milk ejection reflux and overactive letdown. If a mother has an oversupply or overactive letdown, the baby just needs to subtly stimulate and swallow as the milk goes into the mouth. These mothers will rarely feel empty when they are finished nursing because the thicker, higher fat content milk requires more effort to empty from the breast. In certain cases, the thicker milk, or hindmilk, that is not removed from the breast will cause the milk ducts to clog. If these clogged ducts are not cleared in a timely manner, they can progress into mastitis, which can be very painful and in cases require antibiotic treatment or surgical drainage. This will obviously cause problems with the milk supply and feeding of the infant. Should this imbalance in milk occur between fore and hind milk, the stools of the infants may appear greenish, frothy and not the typical yellow-seedy appearance. Variations in stools can occur for other reasons as well like maternal dietary intake, food sensitivities and formula.

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 stretches and exercises before hand and have the medications (if you desire), so you can focus on your child following the procedure.

Tylenol - You do not need to give any medication prior to the procedure. Dosage: Using the dropper in the manufacturer's packaging. This can be given every 6-8 hours after the procedure. The concentration of Tylenol should be the 160mg/5mL dosage. Some places may sell a concentrated form at 80mg/0.8mL - this is not the one I want you to use.

6-11 pounds - 1.25mL

12-17 pounds - 2.5mL

18-23 pounds - 3.75mL

24-35 pounds - 5mL

For children 6 months of age or older, you may use ibuprofen instead (or with Tylenol). Please follow the dosing instructions on the package.

You may use whatever works for your family. This includes homeopathic remedies like arnica or Rescue Remedy, or nothing at all.  

Practice Post Op Stretches in Post Revision

This will accustom your baby to being in his/her mouth and prepare you, if you have any questions on performing them. 

Sucking Exercises - It's important to remember that you need to show your child that not everything that you are going to do to the mouth is associated with pain. Additionally, babies can have disorganized or weak sucking patterns that can benefit from exercises. Starting these exercises from the moment you make your appointment can speed up your recovery after the procedure. The following exercises are simple and can be done to improve suck quality. Aim for 4x/day leading up to the day of your procedure.

1. 1. Slowly rub the lower gumline from side to side and your baby's tongue will follow your finger. This will help strengthen the lateral movements of the tongue.
   2. Let your child suck on your finger and do a tug-of-war, slowly trying to pull your finger out while they try to suck it back in. This strengthens the tongue itself. This can also be done with a pacifier.
   3. Let your child suck your finger and apply gentle pressure to the palate. Once the baby starts to suck on your finger, just press down with the back of your nail into the tongue. This usually interrupts the sucking motion while the baby pushes back against you. Listen for a seal break and then put your finger back up into the palate to re-stimulate sucking. Repeat as tolerated.

What to Expect

In general, the procedure is very quick and well-tolerated by children. We take every measure to ensure that pain and stress during the procedure is minimized.

1. General anesthesia is not utilized in the office and is almost never needed to perform the procedure.
2. Due to laser safety regulations, parents are not allowed in the treatment room during the procedure. I will carry your baby to and from the room, and the approximate time away from you is about 3 minutes. The actual time of lasering is 5-15 seconds.
3. Crying and fussing are common during and after the procedure. While the laser creates minimal pain, your baby will be mad they were swaddled and had their mouth opened by strangers. In addition, they will be frustrated that their tongue and lip feel and work differently. 
4. We encourage you to breastfeed, bottle-feed, or soothe your baby in any manner you'd like following the procedure. You may stay as long as necessary.

Post Surgical Care of the Upper Lip and Tongue. Our bodies are excellent healers, and the two pieces of separated tissue will reattach unless you successfully keep this from occurring.

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!

This is the hardest part of the procedure for parents; but also the most important. Your baby is likely to scream and cry in your face and make you feel like a terrible person, but you are not hurting them. They simply do not want you in their mouth. You are not making the wound any worse than I did...you are not going to rip off their lip or tongue.

You are going to hold the stretch of each revised area for 3 seconds, 3 times a day, for 2 weeks. After 2 weeks, you will have a follow up visit, and we will evaluate the sites.

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. The exercises demonstrated below are best done with the baby placed in your lap (or lying on a bed) with the feet going away from you.

Partner Stretches

One-Person Stretches

Problems doing the stretches? You are not alone. Reach out to Dr. Billiot or one of the other members of the post revision support group. 

Ithaca

Shanna Jesch IBCLC, 607-257-4073
Abby Persoleo, pre/ post-natal chiropractor, 607-272-0006
Elaine Surowick, LMT, CranioSacral Therapy, 607-592-0760
Rebecca Costello, IBCLC, 607-269-7757, intheflowlactation.com

Elmira

Jennifer Whitt- IBCLC, 607-732-1515
Jackie Shubuck- IBCLC, 607-735-5717
Crystal Gullo-Buzetti, pre/post natal chiropractor, 607-731-8155
Alicia Mahaney- speech and swallowing therapist, Arnot 607-733-6541 x2814

Dansville

Katherine Whitman IBCLC, 585-204-0260

Corning

Ashley Costa- LLC, 607-857-1408
Theresa Miller- MS CCC-SLP, speech and swallowing therapist, 607-329-3222

Hammondsport

Heather Mastro, IBCLC, 607-383-0187, fingerlakeslactation.com 

Buffalo/Aurora

Mary Miller IBCLC, 716-780-2662
Michelle Pietrantone- pre/post natal chiropractor, 716-655-1421

Virtual Myofacial Therapist

Carmen Woodland, OMT, 720-587-9985

The following articles and papers are broken down by subject matter and can help expand and clarify some of the information presented in this website.  This is only a select group of articles and many more exist.

Laser Revision and Improvement of Breastfeeding, Feeding and Speech

Breastfeeding Improvement Following Tongue-Tie and Lip-Tie Release: A Prospective Cohort Study

Impact of frenulectomy procedure on breastfeeding

Speech and Feeding Improvements in Children After Posterior Tongue-Tie Release: A Case Series

Laser Revision and Improvement of Reflux/Colic

Infant Gastroesophageal Reflux (GER): Benign Infant Acid Reflux or just Plain Aerophagia?

Aerophagia Induced Reflux in Infants with Ankyglossia and Short Maxillary Labial Frenum (tongue and lip ties)

Infant Health

Face and neck muscle usage during breastfeeding

Failure to thrive and ankyloglossia: Case Report

Development of suck and swallow mechanism post-partum

Growth and Development

Skeletal and dental impact of ankyloglossia

Early tongue mobility helps speech develop

Airway Development / Obstructive Sleep Apnea

Tongue tie and it's impact on OSA in children

The impact of mouth breathing on the body

Lip Tie Revision Healing Sequence

Tongue Tie Revision Healing Sequence