The lingual frenulum: how does it work and why may surgery be necessary?

The lingual frenulum connects the lower surface of the tongue to the floor of the mouth. If it has grown too short, it restricts the mobility of the tongue, which leads to difficulties in breastfeeding, swallowing and speaking, as well as breathing. As a result, the tongue cannot be raised far enough to drink physiologically, i.e. normally. Thus, testing tongue sticking out is not a sure sign of adequate tongue mobility. The baby slips off while sucking on the breast and also has a hard time taking liquid from a bottle. Symptoms of the child: Clenching of the jaw and gagging when eating. It is therefore advisable to remove this adhesion as early as possible. The membrane connecting the tongue and the base of the tongue is cut or lengthened by means of a short incision.

Before the procedure

At the beginning of a successful operation, there is a detailed discussion and examination of the oral cavity and tongue function with the attending physician. If it is determined that medical advice or intervention is needed, appropriate action will be taken. In addition, the child must be completely healthy at the time of surgery.

What happens during the procedure?

In the classic procedure tongue is first pulled up and held. Then the tongue frenulum can be cut. More commonly, however, frenoloplasty is performed. In this procedure, the doctor cuts the lingual frenulum in a Z or V/Y shape with a scalpel, which results in lengthening. Alternatively, the tongue frenulum and lip frenulum can be separated with scissors. The surgery is performed either under local anesthesia or anesthesia.

The Tongue Ligament Center separates ligaments with an anesthetic gel and/ or local anesthesia with the super-pulsed CO² laser in a few seconds.

How does the procedure affect breathing?

Very positive. The tongue is freed from its backward low position in the floor of the mouth, which restricted the airway. It subsequently settles into its optimal natural position at the top front of the palate, where it attaches itself by adhesion using saliva. The lower jaw comes forward, the lips and mouth close, and healthy nasal breathing begins. The tongue lies in its physiological, i.e. normal, resting position on the palate and shapes it. From a high pointed “Gothic” palate with a narrow jaw, the tongue forms the desired flat palate shape with a normal wide upper jaw. As a result, the permanent teeth have sufficient space and the interocclusal bite can adjust correctly, as the size ratio between the upper and lower jaws leads to a desired regular overbite. Because the roof of the palate is also the floor of the paranasal sinus, the flat Romanesque palate shape also leads to good shaping and ventilation of the paranasal sinuses.

How do I recognize a frenulum that is too short?

The lingual frenulum is not always easy to see, especially when it lies deeper under the tongue. And not every doctor, lactation consultant IBCLC or nurse has enough experience to investigate this accurately. Therefore, it is important to consult a dental office, in advance, a photo can be sent. A tongue tie often causes a heart-shaped tongue with an indentation in the middle. If the baby cries, the tongue sinks to a lower position and may take on a bowl-like shape. White deposits from the center of the tongue are possible. Often a shortened lingual frenulum is genetic and restricts the mobility of the tongue, ineffective breastfeeding and sucking is the result.

Is it possible to stretch the frenulum?

No, not in principle. The tongue tie is made of type I collagen, which is 3% extensible. This means at 1 cm you can stretch the tongue tie by 0.3 mm. Stretches the floor of the mouth, surrounding soft tissue and tongue muscles, which can lead to short-term improvement in borderline cases of symptoms. If the stretching exercises are stopped, the symptoms often return or other symptoms appear as compensation.

Recognize posterior lingual frenulum?

A posterior frenulum is the presence of abnormal collagen fibers hidden beneath the mucosa. Thus, a classic anterior lingual frenulum always has a posterior component behind it. Therefore, any lingual ligament that causes problems with breastfeeding is actually also a posterior lingual ligament; some of these ligaments also have an anterior component. Failure to loosen all abnormal collagen fibers will result in persistent tongue mobility limitations. For diagnosis, the tongue in the forklift handle must be lifted. Only then does the posterior lingual frenulum become visible.

What are the disadvantages of cutting the too short lingual frenulum?

It is though very minimally invasive surgical procedure. A scar may develop. The main disadvantage in infants are active wound management for at least 4 weeks every 4-6 hours even at night. This can be uncomfortable for infants and stressful for parents.

What are the costs of cutting the lingual frenulum?

In Germany, the statutory health insurance does not usually cover separation with laser. Also, not all private insurances cover the costs, as the billing is analogous, since this minimally invasive procedure as it is performed by us is not included in the service catalog.

Does the too short frenulum cause problems in toddlers and schoolchildren?

If the tongue cannot be raised in the direction of the palate, this can cause pronunciation problems and speech becomes unintelligible. Eating solid foods is also made more difficult because the tongue cannot move from left to right and front to back. Swallowing also becomes more difficult. Some children use their hands to eat or have to choke.

The teeth cannot be adequately cleaned, which blocks access to the back of the mouth and the tongue cannot be used to clean itself. In the case of a middle ear infection or when flying, the eustachian tube cannot open freely enough to equalize pressure when swallowing, resulting in ear pain. In the long term, tongue and lip ties limit quality of life and healthy development.

Is it useful to separate the too short frenulum in adults?

Yes, especially if symptoms such as mouth breathing, snoring, throat tightness, coughing irritation, cervical and/or thoracic spine tension, headaches, clenching or grinding of teeth, and migraines are present.

What are the consequences of not having the excessively short lingual frenulum cut?

Although some physicians mistakenly believe that the shortened lingual frenulum grows out over time, systematic studies have shown that this rarely occurs. If not detected early enough and left untreated, not only is breastfeeding made more difficult, but later in life, protracted and complex speech disorders, problems with breastfeeding or eating, dental problems, and respiratory difficulties occur. Therefore, many specialists advise treating the shortened lingual frenulum as early as possible.

Is it because the tongue tie is too short if my baby can’t hold the pacifier?

Yes, that can be a possibility. Please use the pacifier only very specifically like a medicine. As few pacifiers as possible and as many pacifiers as absolutely necessary is the motto. Always stick with the smallest size.