Frenectomies

What is a Frenectomy?

A frenectomy frenuloplasty, or frenotomy is a procedure used to correct a congenital condition in which the lingual (tongue) or labial (upper lip) frenulum is too tight, causing restrictions in movement that can cause significant difficulty with breastfeeding, and in some instances, other health problems like dental decay or spacing, speech difficulties and digestive issues. When it affects the lingual frenulum, this condition is commonly called a tongue tie (the medical term is ankyloglossia). Approximately 5% of the population has this condition, so your lactation consultant or doctor may feel that a procedure is warranted to improve symptoms.

How to prepare for the procedure?

The use of Tylenol 30-60 minutes prior to the procedure can help to minimize discomfort. You may also use this dose of Tylenol every 6 hours after the procedure.

Dosage: Using the dropper in the manufacturers packaging:

• 6-11 pounds – 1.25mL (1/4 teaspoon)
• 12-17 pounds – 2.5mL (1/2 teaspoon)
• 18-23 pounds – 3.75mL (3/4 teaspoon)
• 24-35 pounds – 5mL (1 teaspoon)

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.

What to Expect?

1. In general the procedure is very well tolerated by infants and children. We take every measure to ensure that pain and stress during the procedure is minimized.
2. General anesthesia is not used in the office, but if you prefer, it is an option for babies 6 months and older.
3. Parents are allowed in the treatment room during the procedure. One of our assistants will hold the infant on their lap and simply hold your baby’s hands. We do not use straps or a papoose board! The actual procedure time is roughly 10-15 seconds.
4. For babies under the age of 12 months, no topical numbing cream is applied as this will prevent your baby from eating.
5. For children 12 months of age or older, numbing cream is applied.
6. Crying and fussing are common during and after the procedure.
7. You may breastfeed, bottle-feed, or soothe your baby in any manner you’d like following the procedure. Feel free to stay as long as necessary.

Important concepts…

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

I feel that 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.

You may use Tylenol or ibuprofen (if 6 months of age or older). If you like, you can purchase of a non-numbing teething gel like HyIand‘s Teething Gel or Orajel Naturals (not regular Orajel). This gel will be used during your stretching exercises and can help with pain afterwards as well. The main risk of a frenectomy 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. 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.

Stretches:

A small amount of spotting or bleeding is common after the procedure, especially in the first few days. Wash your hands well prior to your stretches (gloves aren’t necessary). Apply a small amount of the teething gel to your finger prior to your stretches if you like. My recommendation is that stretches be done 5-6X/day (ie before you feed them) for the first 3 weeks, and then spending the 4th week quickly tapering from 4 to 3 to 2 to 1 per day before quitting completely at the end of the 4th week.

The wounds created are typically diamond-shaped. This diamond has 3 dimensions – height, width and depth. This is especially important for the tongue wound, which is much deeper than the lip wound. Maintaining these 3 dimensions is the key to successful healing.

The Upper Lip:

• Place finger under upper lip and move it up as high as it will go.
• Gently sweep from side to side.
• Make sure your finger is between the open surface of the lip and gum on the incision.

The Tongue:

• Insert one finger under the tongue (should be placed in the wound)
• Pull the tongue up toward the roof of the baby’s mouth and push slightly back
• Hold the tongue up for 2-3 seconds, let the tongue drop and repeat the stretch one more time
• With a finger lifting the tongue again gently perform a circular massage directly on the wound to promote dilation
• Lastly turn finger to the side and in a rolling motion move the finger sideways over the open wound. Make sure the finger is inside the wound when you begin this stretch then move it back and forth. After this, use the same motion on either side of the wound to assist in loosening the muscles around the incision sight.

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. The following exercises are simple and can be done to improve suck quality.

1. Slowly rub the lower gum line 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.
3. Let your child suck your finger and apply gentle pressure to the palate, and then roll your finger over  and gently press down on the tongue and stroke the middle of the tongue.

Starting several days after the procedure, the wound(s) will look white and/or yellow and will look very similar to pus. This is a completely normal inflammatory response. Do not let your child’s regular doctor, lactation consultant, friend who thinks they’re an expert, or anyone else make the determination for you. If you think an infection exists, give our office a call. It is essential that you follow—up with your lactation consultant after the procedure to ensure optimal results. Call our office for any of the following:

• Uncontrolled bleeding after feeding
• Refusal to nurse or take a bottle
• Fever > 101.5

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