Upper Lip Tie, Fall Guy...

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Or the "maxillary labial frenum" if you want to be technically correct.

Before I get started I want to stress now that some babies absolutely do have a restrictive  upper labial frenum.  Some babies and children need it releasing to have appropriate function.  This blog isn't intended to try and deny a problem exists, but we have gone beyond that to the point it seems every baby has lip tie, tongue tie or both!

Recently "I think my baby has upper lip tie and it's causing feeding problems", is the most common phone call I receive. Whilst I've often blogged about tongue tie, I've avoided lips until now. I wanted to research, discuss with those treating, and experience working with parents who have decided to get treatment, and those that didn't.

To be fair I can see why it seems the obvious answer.  Mum experiences feeding problems, pushes back the top lip, sees a frenulum and bingo - it's clearly the cause.  If things were only so simple...

So let's start at the beginning.

What is a lip tie?

Firstly we need to recognise that the adult and infant mouth are different.

I think many people are looking for adult dentition in a baby's mouth.  In adults the frenum is typically high up the gumline, well away from teeth.  This is because for the vast majority of people, the frenum regresses during the early years of life:

"In little children, the maxillary labial frenum is often attached between the two central teeth. In most cases, this attachment migrates away from the teeth as the child approaches the age of 8 or 9.

Children generally have a large space between their central incisors during the "ugly duckling" years, but by the time the adult canine teeth are fully erupted, between the ages of 11 and 12, the space should close." (1)

and

"The attachment of the frenum to the gingiva moves progressively upwards and thins out as the alveolar process enlarges and maxillary incisors and canines erupt" (2)

and

"Labial frenal attachments are thin folds of mucous membrane with enclosed muscle fibers originating from orbicularis oris muscle of upper lip that attach at the lips to the alveolar mucosa and underlying periosteum. It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration." (3)

and

"For most children, the medial erupting path of the maxillary lateral incisors and maxillary canines, as described by Broadbent 3, results in normal closure of this space. For some individuals, however, the diastema does not close spontaneously" (4)

 So what are we expecting to see when we push back the lip of a baby?

 Those who are members of our Facebook Group will know I have shared this study a lot over the last few years, as we absolutely need to establish what is normal, to identify what isn't...

"Oral examinations were performed of 1021 newborn Swedish children
The upper labial frenum was attached to the crest of the alveolar ridge in 76.7% of the children, palatally in 16.7% and buccally in 6.7%." (1)

Which means, should you go and push the lips of many babies back, over 3/4 will have a frenum attaching on the gum-line, with another chunk going through to the palate. This clearly highlights it is the physiological norm for a baby.

This means that for a baby, the frenum attaching close to, or on the gum or palate - does not confirm a lip tie. Let's say that twice.  Seeing your baby's frenum attached to the gum or palate, does not automatically mean they have a lip tie.

It simply means they have an upper frenum, which the vast majority of people do. In fact absence of an
upper frenum can indicate it is worth ruling out other genetic abnormalities.(3)

I decided to ask for photos online, from parents who had not experienced problems.  So babies who had always breastfed wonderfully since birth, gained weight well, slept well day and night, no reflux, colic or wind ie the definition of a typical "easy baby" that Gina Ford and co would be proud of - can you please flip their lip and take a picture?

Here are the first six I received, the rest were no different:

So photographs aren't a reliable way of assessing the function of the lip. What else?

Lip Tie Myths:

• If baby's lip does not flange when feeding, stays straight or even curls inwards - it suggests lip tie.

A baby transfers milk effectively by making a seal with the lips and tongue.  This seal allows them to create a negative pressure, as the tongue lifts and drops.   If a baby has tongue tie, the tongue may not be reliably playing its part in this process, and so in my experience the baby will very often attempt to compensate by gripping extra hard with their lips.

If they didn't/can't compensate enough they can constantly slip off the breast.  I have seen babies do this who have no upper frenum as it has already been removed.  You can often spot babies doing this as the mum tends to hold her breast, baby's head and sit holding the two together. 

Furthermore if a baby is reliant on the grip from their lips, they will frequently be so tight mum is unable to flick the lip to a more comfortable position, or if they can it may gradually pull back under.

Post feed both lips can look blanched, swollen or "shiny" from the pressure.  Baby can also develop a red stripe above the top lip and below the bottom (this tends to happen more when using a bottle)

Photo courtesy of theleakyboob.com

There is also a misunderstanding in the "non breastfeeding world" as to what the top lip actually should be doing during feeding.  

It is now common to hear "both lips should flange like a duck".  This actually isn't true, and as lactation consultants many have commented we often see this "duck positioning" when baby is shallow.

When a deep latch is achieved, the top lip typically sits in a neutral position - as can be seen on this animated latch clip here and the photo on the right.

In contrast lets look at the lips of a baby with a shallow attachment:

Catherine Watson Genna, author of the fantastic "Supporting Sucking Skills in Breastfed Infants", agrees and touches on this in her book:

Whilst Catherine often writes about tongue tie, I was interested to hear whether she felt lip ties were a significant cause of breastfeeding issues. She replied:

"I think the upper lip frenulum is infrequently an issue when breastfeeding.  I am concerned that the term "lip tie" causes parents to be overly concerned about this issue and could increase doctors' skepticism of frenotomy."

• Sucking blister on the top lip

So we have a baby gripping hard with its lips, if the tongue is thrusting, rather than undulating (as we frequently see with a tongue tie), it can cause the baby to move back and forth like a piston.  This can often be more easily seen when baby is sucking a finger or bottle, ie it physically moves in and out of their mouth, like Maggie sucking her pacifier in the Simpsons...

Add together tight grip of the lips + moving = friction blister on upper lip/babies slipping off the breast as their own suck pushes them backwards.

• Clicking when feeding

We discussed baby needing to make a seal above.  A tied tongue or shallow attachment can provoke "snap back",  breaking this seal and a loud clicking is often heard. As the tongue moves forward it briefly creates a seal, and as it slides back for the swallow it breaks.  Because it is linked with a shallow attachment, babies without tongue tie can click too.  

• Small gape

It's easy to assume a smaller than typical gape is because the lips are preventing adequate movement, however tongue tie is king of the small gape.

Take a look at this picture:

The gape is wider than it is tall.  If a baby opens their mouth to cry, the tongue naturally lifts which in turn (if tightly anchored to the floor of the mouth), pulls the bottom jaw up = small gape.

Now let's consider feeding.

Baby comes to breast, if he gapes wide and the bottom jaw drops, in the case of tongue tie - so does the tongue.  However baby needs to bring their tongue forward to latch, if not they will need the breast/bottle placing right into their mouth, rather than latching on effectively.  Some babies develop a great "spaghetti style suck" - where the nipple is drawn in with a suck like a child with a long string of spaghetti :)

However if they lift the tongue, it pulls their mouth closed again.

We see many many babies who post tongue tie treatment open with a giant mouth compared to pre division.

Here is a before and after pic:

Again things other than tongue tie are linked with small gape.  A tight or stiff jaw, neck or base of the skull from delivery may also cause baby to be uncomfortable with a wide mouth.

• The lip wont flange when pushed easily.

Now I'm half with this one.

If a baby has had their tongue tie released, isn't stiff or has any other obvious causes for increased oral tension such as say a forceps delivery, very rapid labour or suchlike - that's when we typically reassess the upper lip, if tightness is identified at the initial assessment.  IF mum continues to experience problems.

I don't believe it's often accurate to assess with a tongue tie in place, or within the first few weeks after birth for many babies.

Take a look at this picture:

The oral tension is significant throughout the whole mouth.  Sometimes this can be so significant in my experience it can be hard to even get in the mouth to assess - and the babies are often declared to have tiny mouths with a short tongue.

The bottom lip looks equally as pinched, as do the corners and even the area around the mouth looks tight.  Once the tongue is released a significant number of babies have "pop out lips" ie they suddenly have full, flexible function.

• Toddler teeth

Again, it is common for people to expect to see adult dentition in young children, nice teeth neatly sitting together, without gaps.  

According to orthodontist, Glenn Carty:

"Did you know that Adult front teeth are 2-3 mm wider than baby front teeth? Adult front teeth therefore occupy more space than baby front teeth. 

A young child's smile should appear very different to that of an adult's. The smile should resemble a picket fence. The baby front teeth should be spaced. While this might not look pretty, the extra space is needed for proper alignment of the adult front teeth".

Furthermore, it's well recognised they may have a gap:

"The permanent maxillary central incisors are flared laterally at this time because the unerupted lateral incisors constrain the roots of the centrals. The median diastema, which results from this flaring is normal and often is called the "ugly duckling stage" of the developing dentition. As the permanent maxillary lateral incisors and canines erupt, pressure is exerted medially, causing the space to close and the frenum to atrophy." (4)

"In some cases the series of events just described does not occur." (4)

In the UK it is common to treat an upper frenum around the ages of 10 or 11 if it has not regressed and is impacting on alignment of the upper teeth, a brace may also be used at this time to assist with closure.  And I think this reflects healthcare typically in the UK, and why treating upper lip frenums is much less popular here.  As a tax funded system, we treat something if and when it's a problem.

My understanding of US medicine is that it more heavily focusses on potential prevention.  Lip attachment appears to be removed at times because they might cause a problem later, or they might be causing a problem now, and the parents travelled across 8 states for four days to get here, and as we understand it we don't "need" an upper frenum, so lets remove them just in case; it's only a frenum!  And I'm sure there are both pros and cons to this approach too.

I also collected photographs from people kind enough to share of untreated upper lips and the normal regression that occurs:

The baby in the bottom image, is the sibling of the child on the right

Despite treatment 2 1/2 years ago for the child on the right, the gap remains and looks remarkably similar to his sibling's pictured bottom left.

This isn't surprising.  To give you a potted history of the information I've gleaned about upper ties and diastema, and then a link to where you can read the full caboodle if you fancy.

In 1907 it was first suggested that a thick labial frenum was the cause of diastema.  By the middle 1900s, the it was believed to be correlation rather than a cause.  They found gaps without frenums, frenums without gaps, and several studies found no associations between the size of the gap and the frenum.  They also discovered that in some cases, the bone had not formed correctly - and that in such cases an abnormal frenulum was the result.  Ie potentialy the gap caused or correlated with an abnormal frenum rather than the reverse.

"A V-shaped bony cleft develops between two central incisors, and an "abnormal" frenum attachment usually results.16.  Transseptal fibers fail to proliferate across the midline cleft, and the space may never close.1 ' 18"" (4)

In short during conception, a tiny cleft forms in the bone, holding the teeth apart.

They even studied the effect of frenectomy on diastemas, and found "that although closure progressed more rapidly in the frenectomized group than in the unoperated group, there was no difference in the final results after 10 years. These results intimate that frena may exert passive resisting mesial pressure, but are not an important etiologic factor in midline diastemas.22" (4)

Thus we absolutely cannot say that ties cause gaps, or treating a tie will resolve or prevent one.

The next question logically therefore is does potential early closure of a gap affect placement of other teeth, and if so in a negative or positive way? 

This image on the left was sent to me by a dentist who got it third hand, so I'm not sure who it belongs to in terms of crediting/using here, there was no copyright notice displayed - therefore if it's yours please get in touch!  (I have tried reverse image searches etc to no avail)

You can see the gap quickly closes post revision.

The UK dentists I've spoken to all seem unsure and say they would rather wait until clear and obvious reasons for immediate intervention.  But then very few here regularly perform frenectomies on babies, and so have little experience.

Presumably the American dentists treating upper frenums don't notice an increase in problems?  But I haven't seen any written material addressing this, if you have please share :)

The issue of decay to infant teeth also arises in the case of a tight frenulum, which again seems to split dentists (even those who treat).  As one pointed out, if you know there's a frenum, simply wipe up each side instead of over the top as it's stray food particles than cause the problem - so make sure you remove them.  Others don't feel that is sufficient to prevent problems.  Reducing bottle use can also reduce the impact of milk plus food together, which is a known risk in terms of decay; brushing teeth after the last feed if using formula is also advised.

Any other risks?
Without studies, how can we know?  An ENT here in the UK who would treat upper frenum with a "half snip" only if the tongue tie didn't improve things, and only if a midwife or lactation consultant confirmed they believed it to be the cause (I speak past tense as he's now emigrated), used to ask parents to sign a document stating that there may be potential unforseen consequences, without research we cannot be sure.

He also theorised a risk of removing the upper frenum, may be that without the "anchor", the lip would then lift too high exposing gum.  I was assured by two different providers this absolutely wasn't the case, and in fact the opposite was true - a tight frenum pulled the lip.

As soon as I published this blog today, someone got in touch to say this is exactly what both she and her dentist felt happened to her, and she sent me the photo you can see on the left hand side.  Her upper frenum which extended onto the palate was removed at 10 years of age due to a huge gap.  As you can see this closed, but she states that whilst she does have long gums, her lip didn't lift to reveal them to this degree before surgery.  She has promised to dig me out some childhood pictures, and so I will update then.

I also believe there are increased risks to treating both areas at the same time.  For a baby with tongue tie, compensating with the lips as discussed, to make both the tongue and lip sore can be a step too far. Remember they have likely already found feeding difficult for sometimes months.

Helen Marshall IBCLC said:

"I am seeing a high incidence of breast refusal. Usually just for 24-48 hours but that is significant to the mother who was exclusively breastfeeding and is now having to bottle or cup etc"

Discussion:

In the UK we tend to like regulations, guidance and studies.  We have that in the form of NICE guidelines for tongue tie treatment, which confirms anaesthesia is not required, and has evaluate the risks benefits involved.  We don't have this for frenectomy, we don't even have any studies confirming if and when it helps feeding.

The other problem appears to be that both upper lips and tongue ties are treated at the same time - so how on earth do we establish which intervention helped?  At suggestion they could potentially study this I was advised it was unethical to do so, as it would mean leaving a baby with a known tongue/lip tie to test the theory.  Can't say I'm entirely convinced by that logic.

Undoubtedly as I said in the introduction to this article, there are times the attachment is restrictive.  I've seen several so thick and tight the lip is unable to function properly - and who wants to spend their life with their top lip stuck down?  But these, in terms of feeding problems, appear to be a small percentage of babies.

What's more, if we're not quite right with the diagnostic criteria, could we potentially miss those that are restrictive?  My son (8) for example has a thin upper frenum, well away from his teeth and with apparently normal "flangability".  However he has for several years intermittently told me it's "too tight", asked if they can "cut it off", struggled to clean a spoon for a long time, and I think has reduced movement when talking.

If you feel up inside his lip when it's relaxed - that's the point at which the frenum feels tight.  (I should add he does have a posterior tongue tie that wasn't diagnosed during infancy)

In short we know some, we are still learning, but there's a lot left to learn.  In my opinion anyone who talks in certainties about lip ties can only be speaking anecdotally, because there are no controlled studies.  Whereas tongue tie and the impact on infant feeding has been explored over decades, we have a hole where the lip tie studies need to be.

Yes it's a relatively minor intervention in the scheme of things, if there are clear issues the preservation of feeding is of course paramount, due to the health implications of early cessation of breastfeeding.  But if we are talking "every baby with a tongue tie has a lip tie" (as some webgroups claim), don't we need guidance?

Does the area need numbing?  What is appropriate pain relief? If you're into complementary medicine, an

acupuncturist once tol me the upper lip frenum is a key point as it apparently sits on a junction of two significant channels. This might mean more to you than me, but there's a little more information here.

It's a minefield for parents at the moment, in an age of trying to seek out answers via the internet, and simply wanting to resolve their baby's issues - they're vulnerable to the next quick fix or magic wand.  I get calls three days after a tongue tie treatment saying "it hasn't worked and should we now treat the upper lip?".  The reality is that there are no instant solutions for many babies, even once the tongue is free - being a muscle it often needs to develop strength to consistently perform well, particularly with posterior ties.  You wouldn't get a cast removed from your leg and expect to run a marathon 24 hours later.  Similarly there is no benefit to patiently waiting weeks if baby has another reason they're not feeding better, such as a supply dip, a stiff neck or reattachment.

This is why working closely with your lactation consultant or breastfeeding counsellor who specialises in tongue tie is key for some.  One look at the internet chatter tells us that removing a piece of skin before pushing parents out the door 10 minutes later simply isn't enough for many.  Babies and their barriers to feeding are more than bits of skin, but that's a blog for another day....

Note:  I got 3/4 of the way through this blog, when Dr Ghaheri posted this great article.  Worth a read as although there is some crossover, it's great to get another perspective.

References:

1.  http://doctorspiller.com/Childrens_Dentistry/Childrens_Dentistry.htm#adult_eruption_schedule

2. Tethered Labial Frenum With Midline Diastema, SANJEEV TULI, MD, DEEPA SUNKARI, MD, DALLAS McKAY, MD, MARIA KELLY, MD, and SONAL TULI, MD, University of Florida, Gainesville

2. Department of Pedodontics, University of Umeå, Sweden.International Journal of Paediatric Dentistry (Impact Factor: 0.92). 07/1994; 4(2):67-73. DOI: 10.1111/j.1365-263X.1994.tb00107.x

3. An overview of frenal attachments, M Priyanka, R Sruthi, T Ramakrishnan, Pamela Emmadi, N Ambalavanan, Department of Periodontology, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India, Year : 2013 | Volume : 17 | Issue : 1 | Page : 12-15

4. The midline diastema: a review of its etiology and treatment Wen-Jeng Huang, DDS Curtis J. Creath, DMD, MS, American Academy of Paediatrics, Pediatric Dentistry - 17:3, 199