A tongue frenulum is the extra piece of skin that goes from underneath the tongue to the floor of the mouth. Sometimes it is attached all the way to the tip of the tongue and sometimes only the portion just in front of the base of the tongue. The latter can be a normal finding in up to 50% of us. The tongue frenulums may be very thin and look like a membrane, others are thicker and look similar to the rest of the floor of the mouth. A tongue frenulum becomes a tongue tie when it affects the function of the tongue. About half of the babies with a tongue tie have someone else in the family who also has a tongue tie.

A lip tie is when the lip frenulum restricts the movement of the upper lip and thus impacts normal function. There is a lot of controversy about lip tie and the published research is very limited in this area. A lip tie can also cause a gap between the upper central incisors, decay of these teeth and/or difficulty cleaning the upper teeth. However, an upper lip frenulum is nearly universal, with over 90% of babies having them. They will also change in appearance for most babies over early childhood.

All Tongue Tie or Lip Tie divisions at the National Tongue Tie Centre are completed using a CO₂ laser. Having performed tongue tie divisions with scissors for 9 years before switching, initially to a diode laser and then on to a CO₂ laser, the advantages of the CO₂ laser are greater precision of the surgery as it is possible to visualise and release the tie to the appropriate fascial layer, no bleeding for nearly all patients and less inflammation and pain following the procedure.

• Sore or damaged nipples
• Severe pain on latch
• Nipple distortion (lipstick-shaped) or blanching
• Lack of milk
• Mastitis, often occurring more than once

Speech
There is no way of predicting which babies who have a tongue tie will have speech problems. Some children with speech problems can have difficulty with understanding and processing language rather than the mechanical problem which tongue tie can cause. The effect of a tongue tie could be a lisp, difficulty with certain sounds, reduced speed or volume of speech. Some children have difficulty with the intelligibility of speech as they move from words to sentences or when trying to talk quickly.
Dental Hygiene
We see more dental decay in people who have a tongue tie. For some it can be difficult to reach to the back of the mouth with the tongue to remove pieces of food from between the teeth, thus interfering with mouth hygiene. Mouth breathing is also a risk factor for dental decay.
Other Aspects To Consider
Some people believe that it is important for children to be able to poke their tongues out and lick ice-creams! Once children reach their teenage years they may become self-conscious over the appearance of a tie.

Local anaesthetic gel is applied to numb the skin and one to two minutes are given for this to take effect. The surgery typically takes 20 to 30 seconds. Your baby is then unwrapped and brought back to you, for a cuddle or a feed – whichever they prefer. You will have the comfort and privacy of your own room post-procedure. Once they have fed and we have gone through the aftercare you will be discharged home.

Some babies will cry during the procedure as they will feel the tension through the tie when lifting their tongue/lip or they dislike being swaddled.

There is little to no bleeding with a CO₂ laser division. If there is an aberrant blood vessel this can cause bleeding which might require the placement of a suture to control the bleeding, the risk of this is about 1 in a thousand.

The greatest complication is reattachment or sub-optimal healing which is why we have an aftercare program in place. 

To achieve the best result from a tongue tie release we need to follow an aftercare programme. In order to optimise the healing of the surgical site, as well as change how your baby sucks, we need to teach an optimal resting posture of the tongue and teach you some massage to ensure we don’t have any reattachment of the released tissues. A member of our team will go through all this with you, including some bodywork exercises, so that you are confident in the care you are providing at home over the coming weeks.

How the wound heals affects how and if reattachment becomes an issue.

The diamond can heal in one of two ways:

• Primary intention healing
• Secondary intention healing/Re-epithelialisation

The idea is that the diamond area remains open and new skin grows over this area (re-epithelialisation). This means that there is no tethering present between the floor of the mouth and the undersurface of the tongue. What you will see is that the diamond gradually gets smaller over one to two weeks and it remains flat back at the base of the tongue. This type of healing is possible because a wound in the mouth remains moist and thus skin cells are able to migrate over the wound surface.

If the diamond heals by primary intention healing, i.e. the edges join straight back together, then there may be no improvement in feeding as the tie has healed back. This can happen as quickly as only three or four days after the surgery.

If the surgical site heals gradually from the back edge of the diamond, as the top and bottom halves become attached together again, this can also bring back the restriction. This can take 1-2 weeks. The difference in appearance is that the diamond gradually comes forwards and closes the gap between the base of the tongue and the salivary glands.

How this then affects feeding can occur in one of the following three ways:

• The first is that as the diamond heals forwards, the restriction comes back, and the symptoms gradually return.
• The second is that the diamond reattaches but with better height to the ‘band’ so there is some improvement in feeding initially but as wound contraction occurs under the influence of myofibroblasts, typically 3 to 5 weeks after division, this brings back restriction and then the feeding problems recur.
• The third is that the diamond heals as in the second example but it is sufficient in height, thus facilitating normal tongue function, and hence the feeding symptoms resolve.

The purpose of diamond care is to keep the upper and lower halves of the diamond separate so that they cannot reattach to one another and this facilitates the ideal healing process of re-epithelialisation to be achieved.

Eating

• Extreme picky eating/ Development of food aversions
• Pushing food forward out of the mouth
• Difficulty with textures and lumps
• Choking/Gagging
• Difficulty licking ice-cream

Speech

• Lisp or difficulty articulating certain sounds
• Reduced speed, volume or clarity of speech

Dental

• Increased dental decay
• Rotation or overcrowding of teeth
• Gum recession
• Teeth grinding (Bruxism)

Joints and posture

• Jaw joint problems (TMJ)
• Postural issues – head forward posture, neck pain

Social

• Self-conscious about appearance
• Unable to french kiss

Sleep / Breathing

• Open mouth posture/mouth breathing
• Sleep-disordered breathing – Concentration/attention issues
• Sleep apnoea
• Restlessness
• Snoring

Yes, but we use midazolam so we achieve a state of conscious sedation. This means they are breathing for themselves and maintaining their own airway but they will have no awareness what happens (dissociative and amnesic). In much the same way as when adults have endoscopy tests.

We insert a cannula to get IV access either at the ankle or back of the hand. Midazolam is given via this. If we cannot get IV access the midazolam can be given intranasally. The intranasal has a slower onset and can give a similar sensation to swimming pool water going up your nose.

Eating

• Difficulty in moving a bolus of food to the back of the mouth
• Difficulty swallowing tablets
• Pushing food forward out of the mouth
• Difficulty with textures and lumps
• Choking/Gagging
• Difficulty licking ice-cream

Speech

• Lisp or difficulty articulating certain sounds
• Reduced speed or volume of speech

Dental

• Increased dental decay
• Rotation or overcrowding of teeth
• Gum recession
• Teeth grinding (Bruxism)

Joints and posture

• Jaw joint problems (TMJ)
• Postural issues – head forward posture, neck pain

Social

• Self-conscious about appearance
• Unable to french kiss

Sleep / Breathing

• Open mouth posture/mouth breathing
• Sleep-disordered breathing – Concentration/attention issues
• Sleep apnoea
• Restlessness
• Snoring
• Wake up tired despite being asleep for a normal or long duration.

Yes. For adults who are very nervous then we can use Nitrous Oxide (also known as laughing gas/gas and air/Entonox).

No. A local anaesthetic (lignocaine/lidocaine) will be used to numb the area under your tongue. If you opt for sedation then Nitrous Oxide (laughing gas) also has a pain relief effect.

You may experience a little soreness at the division site and may also have muscle soreness of your tongue following the procedure as you will be able to move your tongue very differently. You will be prescribed appropriate pain relief (Paracetamol and Ibuprofen).

Only if you are having sedation. In this case, the fasting times are as below:

• Morning surgery – late supper the night before (up until midnight)
• Afternoon surgery – light breakfast at 6 am
• Sips of water are allowed up until the procedure.

You may feel numb for a little while following the procedure but then they will be able to eat normally. You may find eating salty or acidic foods sore for a few days.

Most people can return to work after 1 or 2 days.

There are a few appointments involved:

• An initial consultation which includes taking a history and examination
• The oromyofunctional therapy would usually be online both before and after surgery
• The procedure appointment/surgery day
• A 4-5 week discharge appointment
• Extra physiotherapy may be needed which you may be able to obtain locally or is available at our clinic, just call 085 202 2244
• For some adults, we may recommend palate expansion prior to release.

You are welcome to bring another adult with you for the consultation and on the day of the procedure. Please do not bring any children with you so you can focus on the information that we are giving to you during the assessment or procedure.

If you are having sedation, someone to drive you home.

For adults because the diamond is sutured (stitched) back together there is no woundcare to do in the first week. However, there is published research in older children and adults that doing oromyofunctional therapy before and after division has a positive impact on outcomes and this is why we advocate this.

The possibility of infection of the surgical site is very low, with a chance of about 1 in 10,000. You may see some redness around the site. If you have concerns about the appearance of the surgical site then please contact us.