Frenum surgery: tongue-tie and lip-tie

What a frenum is

A frenum, also called a frenulum, is a fold of the lining of the mouth, often with a band of fibrous tissue inside, that links a part that moves to a part that stays still. Three matter most for frenum surgery:

• the lingual frenum, under the tongue, joining it to the floor of the mouth;
• the upper labial frenum, inside the upper lip, joining it to the gum above the two front teeth;
• the lower labial frenum, inside the lower lip, joining it to the gum below the lower front teeth.

Everyone has these folds, and they vary a great deal in size, thickness and where they attach. An upper lip frenum is normal in babies.

Tongue-tie

Tongue-tie, or ankyloglossia, is present from birth. The frenum under the tongue is short, thick or tight, and sometimes runs close to the tip, so the tongue cannot lift or stretch forward as far as usual. The diagnosis rests on how the tongue moves, not only on how the frenum looks: a frenum that does not restrict the tongue is not a tongue-tie.

Many tongue-ties cause no problems. In older children and adults, a tight frenum may make it hard to lick the lips, to clear food from the teeth or to keep them clean. It can be linked with a gap between the lower front teeth, and some people find it embarrassing. Tongue-tie does not typically affect speech. When speech is the worry, a speech and language therapist assesses it before surgery is considered.

In babies, tongue-tie can make breastfeeding difficult. Feeding support and a careful assessment come first. When division is needed, NICE advises that it is done only by registered healthcare professionals who are properly trained, and in young babies it is usually done without an anaesthetic. The rest of this page is about older children and adults; for babies and young children, see children's teeth.

The frenum inside the lips

The upper lip frenum sometimes attaches low, close to the gum between the two front teeth, and its fibres can pass between them towards the palate. A gap between the upper front teeth is common while the permanent teeth are coming through, and it often narrows once the canines erupt. Neither a visible frenum nor a gap is, on its own, a reason for surgery. Releasing the frenum in a young child does not prevent a gap later.

When a gap is closed with a brace, the orthodontist and the dentist agree the timing of any frenum surgery. It is usually done during orthodontic treatment, once the front teeth are aligned and the gap is closing, rather than before it, because scar tissue from an early operation can make the gap harder to close. A retainer is still needed afterwards to hold the teeth together.

A lip frenum may also matter when it is thick and attached very low, so that it gets in the way of brushing, is caught by the toothbrush, or ties the lip down. At the lower front teeth, a frenum attached close to the edge of the gum can pull on it as the lip moves and make the area hard to clean, which can contribute to the gum shrinking back. In people who wear dentures, a prominent frenum can get in the way of the denture's edge and affect how well it sits.

When it usually does not need treatment

• a frenum that is easy to see but does not limit movement or cause a problem;
• a tongue that moves normally, where surgery would only be meant to prevent speech or feeding problems in the future;
• a gap between the upper front teeth in a child whose permanent teeth are still coming through.

How a frenuloplasty releases and repositions the frenum

Several names are used, sometimes loosely. A frenotomy is a simple cut through the frenum, the usual procedure in babies. A frenuloplasty releases the frenum and rearranges the tissue, for example by closing a horizontal cut as a vertical line, or with a Z-shaped pair of flaps, so that it heals longer and looser. A frenectomy removes the frenum.

1. Assessment. The dentist or surgeon looks at how the tongue or lip moves, where the frenum is attached and what problem it is causing. For a gap between the front teeth, the orthodontist is involved; for speech, a speech and language therapist.

2. Anaesthetic. Adults usually have a local anaesthetic. For a child, the choice depends on age and on the extent of the surgery, and after the early months of life a general anaesthetic is usually needed.

3. Release. A small cut is made through the tight band so that the tongue or lip is released. Some of the fibrous tissue may be removed.

4. Repositioning and closing. The edges are brought together along a new line, usually with stitches that dissolve.

5. Afterwards. After a local anaesthetic the mouth stays numb for a while, and nothing should be eaten or drunk until feeling returns. The area is then sore for a time, much like a mouth ulcer. The dentist or surgeon gives written aftercare advice and explains what to expect.

Risks

Soreness like a mouth ulcer is common afterwards. Less often:

• the wound bleeds or becomes infected;
• scar tissue forms and tightens the area again;
• rarely, after surgery under the tongue, the nearby openings of the salivary glands are injured;
• the release does not solve the problem it was meant to, because that problem had another cause.

Frenum surgery changes how far the tongue or lip can move. Whether that helps depends on whether the frenum was really the cause of the problem, which is why the assessment comes first.

Whatever is decided, careful brushing along the gum at the front teeth protects it: see cleaning your teeth.