Jeanne Anne Krizman, DMD
1601 N. Tucson Blvd., Suite #35
Tucson, AZ 85716
520‐326‐0082

Frenotomy is a procedure used to correct a congenital condition when the lingual (tongue) or labial (lip) frenulum is tight resulting in restriction of function. This may potentially result in difficulty of breastfeeding and other concerns such as dental, digestive and speech issues. If your lactation consultant or doctor feels that this procedure is warranted, then the following is what you can expect.

A tight upper lip frenum attachment may compromise full lip flanging and appear as a tight, tense upper lip during nursing. This can result in a shallow latch during breastfeeding. Additionally, the tight upper lip may trap milk, resulting in constant contact of the milk to the front teeth. This can result in decalcification and dental decay can develop when the milk is not cleaned off of these areas. This same issue can occur with bottle‐feeding. If the frenum attaches close to the ridge or into the palate a future diastema (gap between the teeth) can also occur.

A tight lower tongue frenum attachment may restrict the mobility of the tongue and appear as a cupping or heart-shaped tongue when the tongue is elevated. This can result in an inability to get the tongue under the nipple to create a suction to draw out milk. Long term a tongue tie can result in speech problems and/or issues later with transferring food around the mouth for chewing. Approximately 3‐5% of the population presents with this condition.

Some babies can have ties and not be symptomatic. To know if the ties are a problem, we ask two major questions: “Is the baby getting enough to eat?” and “Is nursing comfortable for the mother?”

Symptoms can be as follows:

The procedure is tolerated very well by babies and we try to ensure that discomfort is minimized. A topical numbing gel is placed on the frenulum for frenotomies (an incision of the frenulum attachment) and a very small amount of local anesthetic may be injected for frenectomies (frenulum tissue removal) for infants over 12 months of age.

It is common for babies to cry and/ or act fussy during and after the procedure. Babies typically lose only a small amount of blood, if any at all when a laser is used. You may notice a very dark stool if your baby swallowed any blood and this is normal. Your baby may even experience oozing of blood or brown spit-ups or stools after the procedure if he or she swallows blood after the procedure. Once baby is numb, they are treated in our laser treatment room and immediately returned to you. Please feel free to nurse, bottle‐feed and/ or cuddle your baby, depending on your preference. Note that it is common for babies to drool after the procedure until the numbing dissipates.

The complication after the procedure is that due to the rapid healing capability of the mouth, and the healing site may want to reattach. Therefore, it is highly recommended that you follow the guidelines listed on stretching exercises for your baby. Failure to stretch with the pressure and frequency that Dr. Krizman demonstrates may lead to reattachment at either the tongue site or the lip site, causing a new limitation in mobility and the persistence or return of symptoms.

Wash your hands very well prior to performing the stretches. You may consider coconut oil to aid in the stretches due to its slippery nature and anti‐bacterial properties. 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. You can make these exercises fun if you sing a song or play when stretching. Please ensure the stretches happen as prescribed and that caretakers are proficient at stretching as well. If you are unable to perform stretches or the caretakers are unable to do so, you may want to consider scheduling when proper care is available. Keep in mind that the wound may ooze the first few days but healing happens rapidly in the oral cavity. Keep the tissues open and the wounds will heal for optimal function as long as they are not allowed to close.

DO ONE STRETCH ON THE EVENING OF SURGERY. THEN, SKIP AHEAD TO THE NEXT MORNING. THIS IS THE ONLY TIME THAT YOU SHOULD SKIP THE OVER NIGHT STRETCH.

Stretches should be done 6x/day for the first 3 weeks, and then spending the 4th week quickly tapering from 6 to 5 to 4 to 3 to 2 to 1 per day before quitting completely at the end of the 4th week. Do 5 of the stretches during the day and one of the stretched in the middle of the night. Do not go more than 6 hours between stretches.

Apply a small amount of coconut oil or teeth gel to your finger prior to stretches

UPPER LIP STRETCH: is the easier of the 2 sites to stretch. If you must stretch both sites, I recommend that you start with the lip. Typically, babies don't like either of the stretches and may cry, so starting with the lip allows you to get under the tongue easier once the baby starts to cry. For the upper lip, simply place your finger under the lip and move it up as high as it will go (until it bumps into resistance). Then gently sweep from side to side for 5 times (back & forth = 1 time). Remember, the main goal of this procedure is to insert your finger between the raw, opposing surfaces of the lip and the gum so they can't stick together.

TONGUE STRETCH: Insert both index fingers into the mouth (insert one in the mouth and go towards the cheek to stretch out the mouth, making room for your other index finger). Then use both index fingers to dive under the tongue and pick it up, towards the roof of baby's mouth. Please complete the following stretches for the tongue:

1. Elevation of Tongue: Once you are under the tongue, try to pick the tongue up as high as it will go (towards the roof of the baby's mouth). Hold it there for 1‐2 seconds and then relax. The goal is to completely unfold the diamond so that it's almost flat in orientation (remember, the fold of the diamond across the middle is the first place it will reattach). The key to the success of this stretch is that your fingers are placed deep enough prior to lifting the tongue up. Picture how a forklift works: If you don't get the forklift tynes completely under the pallet, lifting the pallet up will cause it to tip backward. If you get the tynes completely under the pallet, you can lift the pallet straight up. I recommend placing your fingers on either side of the diamond and pushing past the diamond before lifting up on the tongue. To make the stretch effective, make sure the tongue goes up and not backward.
   
   
2. Sweeping the Diamond: With one finger propping up the tongue, place your other finger in the middle of the diamond and turn your finger sideways and use a lifting motion from front to back to try and keep the diamond as deep as possible. Use a lifting motion when you sweep through the diamond, trying to separate the horizontal fold across that diamond. Make sure your finger starts within the diamond when doing this stretch. Once it's done, repeat the motion on either side of the diamond (outside the diamond) to loosen up the musculature of the remainder of the floor of the mouth.

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

1. Slowly rub the lower gumline 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. This can also be done with a pacifier.
   
   
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 will look white and/or yellow and will look very similar to pus.

It is normal and expected for babies to be fussy once the numbing medicine wears off, approximately 4‐5 hours from the time of application. Most babies are fussy for 2 days. Some will be fussy for 5 days, and others are not at fussy at all. Some babies may go on a “feeding strike,” and this may last 5‐6 hours. We understand this is a scary experience, but stay calm for your baby and focus on nurturing them through this time. If they refuse breast and/or bottle, try syringe feeding or finger feeding.

Remember that Arnica is an effective, non‐toxic alternative to Tylenol that can help with pain, swelling, healing and trauma. The tablets can be crushed and ½ tsp of breast milk or water added and drawn in a syringe. Keep the syringe refrigerated and administer in very small amounts every 15 minutes as long as baby is fussy. Once baby is comfortable, discontinue use. If arnica is not relieving the discomfort, consider the appropriate dosage of Tylenol. Warm baths, playing music, skin-to-skin and changing environments often helps to keep a fussy baby happy. Lip swelling is normal after a lip release, so consider small frozen milk chips for comfort. Swelling may last 3‐4 days.

You may use Tylenol or Ibuprofen (if 6 months of age or older) to help with pain control. Additionally, many moms have found that amber necklaces are very effective with pain management.

Remember that this is not a “quick fix” and only a piece of the puzzle. Babies with ties have compensated by over‐developing the wrong muscles and under‐developing the proper muscles. It takes time, patience, and commitment to re‐train with suck training and bodywork. Stay positive and committed to your journey in having a beautiful, successful breast‐feeding relationship.

It is essential that you follow‐up with your lactation consultant after the procedure to ensure optimal results.

The use of Tylenol can be helpful in reducing discomfort. Use the dropper provided in the manufactures packaging.

Tylenol (Acetaminophen) Dosing: (no dyes or additives is ideal) infant bottle‐‐‐‐‐‐‐‐ 160 mg/ 5cc (1cc= 32 mg.)

Dosing is 10 mg. / kg for infants OR 10mg./2.2 lbs.

Conversion Table for 160 mg. / 5cc bottle:

6 lbs. = 2.7 kg = 27 mg. = 0.8 cc
8 lbs. =3.6 kg. =36 mg. = 1.1cc
10 lbs. = 4.5 kg. =45 mg. =1.4 cc
12 lbs. =5.4 kg. =54mg. = 1.7 cc
14 lbs. – 6.3 kg. =63 mg. = 2.0 cc
16 lbs. =7.2 kg. =72 mg. = 2.3 cc
18 lbs. = 8.1 kg. = 81 mg. = 2.5 cc
20 lbs. = 9.0 kg. =90 mg. = 2.8 cc
22 lbs. = 10kg. =100 mg. = 3.0cc

Call our office for any of the following:

Uncontrolled bleeding
Refusal to nurse or bottle‐feed
Fever > 101 F