There Are Differences of Opinion and Insufficient Information Among Physicians About Lip Tie Treatment and Diagnosis

Lip Tie Diagnosis and Treatment, Feeding Difficulties and Other Symptoms in Infants

The maxillary labial frenulum, lip tie, treatment and diagnosis of lip tie
Upper lip tie (the maxillary labial frenulum) is a tissue in a ligament structure that is typically found between the inner mucosa of the upper lip and the upper gums, and in some babies can reach the hard palate through the upper incisive teeth. Apart from anatomical classification, in babies whose lip tie structure is stretched and fibrotic, severe restriction in upper lip movements, insufficient mouth sitting on the breast and insufficient vacuuming cause nutritional disorders, diastema in the upper teeth and changes in the jaw structure and the front part of the upper teeth. It may cause bruising or tartar formation. It is inevitable that a distance will arise between the upper incisive teeth in the following period, especially in babies with notching in the midline of the upper gingiva and with lip ties in a thick and elongated structure. Since there is no treatment or approach guidline standardized on lipt tie and tongue tie all over the world, serious approach differences may arise among physicians. In a systematic review of Upper Lip Tie and Breastfeeding: A Systematic Review - PubMed (, it was emphasized that there are differences in approach among physicians regarding lip tie. Some physicians even emphasize that a baby has a lip tie; other physicians may state that there is no lip tie. In this case, families are confused, lip tie treatment is delayed, or unnecessary breast rejection or feeding problems may occur in babies. Turkey 'is an adequate amount of unpublished scientific studies on this subject. Differences in lip tie approach between clinics and physicians are evident. According to the upper lip tie classification system emphasized by Dr. Kotlow, one of the leading physicians in this field, lip tie is classified according to the adhesion of the lip tie to the gingiva, anterior papilla and hard palate. Anatomically, the most severe lip tie is the lip ties (Class IV attachment or Type IV upper lip tie) that adhere to the hard palate or antieror papillae (as seen in the photo).

A baby with a lip tie may have difficulty getting enough milk while breastfeeding

Some babies may have a very short and tight lip tie, or they typically tie lower gums. This can make it difficult for the baby to move the upper lip. In some babies, this impairs nursing ability and malnutrition can turn into a serious problem.

In some babies with lip tie and severe upper lip movement limitation, it may be seen that they cannot do enough "latching" by inserting the breast deeply into the mouth while breastfeeding. Unfortunately, there are physicians who think that this situation can be solved with a simple breastfeeding counseling service or that it may be sufficient to follow the percentile growth marbling of the baby by giving additional formula.

Parents and caregivers may notice that the baby has a more pronounced lip tie or may notice that the baby has difficulty moving the upper lip.

A lip tie anatomy is a difference. This is not a symptom of a disease or serious problem.

Surgical treatment is not required for all babies with lip ties!

When a baby is not having difficulty breastfeeding and breastfeeding is not painful without shrinking breastfeeding, there is no reason to treat lip tie. Follow-up is sufficient for babies who have lip ties and do not have breastfeeding problems. It is ideal to perform lip tie relase surgery at the earliest possible period in babies who are followed up by breastfeeding consultants, who are not fed adequately and who have pronounced milk lip movement limitation.

Unfortunately, some babies who are very tense and have fibrotic lip ties and experience feeding difficulties or breast rejection are fed with formula without treatment. Just like the tongue tie, babies are deprived of breast milk or malnutrition due to diagnosis delay or approach differences. Especially in families with low socioeconomic status, recovery of breastfeeding can be achieved with a simple surgical intervention; it is wrong to use unnecessarily sufficient formula or bottle, to blame the baby or to emphasize it as a structural disorder of the mother's breast.

Tethered Oral Tissues
Regarding the diagnosis and treatment of tongue tie and lip tie in babies, training of physicians, nurses, midwives and auxiliary personnel working in neonatal clinics is very important. It is very important to avoid an unnecessary surgical procedure and to perform the procedure without delay when necessary. In babies whose breast milk is completely depleted and growing, there is no urgent case for discontinuing lip tie. Since it is not necessary to perform an urgent surgical procedure for jaw structure changes and tooth separation, the follow-up of the baby can be planned. You can take a look at Sos 4 TOTS, a resource book written by Dr. Kotlow (SOS 4 TOTS by DDS Lawrence Kotlow (2016-08-02): Lawrence Kotlow, DDS: 9781614683438: Books).

You can click to access the articles and links about lip tie that I have previously published >> Lip Tie

When babies cry, tongue tie, lip tie can be seen!

Above, you can see a video that was played in slow motion and was captured while the baby was crying. Just by looking, you can understand the following:

- tongue tie and tongue structural changes
- upper lip tie
- bump or callous (nursing blister) on the upper lip.
- notching in the gum line (can be seen with the stretched upper lip tie)

If a baby has tongue tie or lip tie, feeding problems, colic pain, reflux and nipple damage in the mother, the baby should be evaluated by a physician who is interested in the subject, and the tongue tie should be examined manually.

Notch (Pitting) in The  Upper Gum Line

In the photo above, there is a very tight upper lip tie and a notch (pitting) in the upper gum line. In this case, it is likely that the first deciduous teeth (upper incisive teeth) will come out separately from each other (diastema).

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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