AUSTRALIAN COLLABORATION FOR INFANT ORAL RESEARCH (ACIOR)

ACIOR Position Statement 1 (4 October 2017) :
Upper lip-tie, buccal ties, and the role of frenotomy in infants

Morphology

What are the maxillary labial and buccal frena?

The word frenum derives from the Latin frēnum, meaning ‘bridle’. Frēnulum is the diminutive of frēnum, meaning ‘little bridle’. The terms frenum and frenulum may be used interchangeably when discussing intra-oral connective tissue. In this statement, we use the term frenum.

A frenum is a small fold of tissue that secures or restricts the motion of a mobile organ, functioning anatomically as a protective connective tissue anchor, or tether, or tie. Frena are found in various parts of the body.

In the mouth, frena tether the lips to the gum, and the tongue to the floor of the mouth. These include the maxillary labial frenum and the laterally positioned buccal frena.

The midline maxillary frenum is made up of loose connective tissue, dense collagen, elastic fibres and epithelium. Sometimes it also contains muscle fibres, but these are usually few and located outside of the frenum proper. ¹ ⁻ ²

The buccal frena are small connective tissue folds between the buccal mucosa and the gums, located lateral to the maxillary frenum, typically between the canines and premolars. This Position Statement does address frena abnormalities associated with genetic orofacial syndromes, which require specialised treatment.

What is the functional relevance of the maxillary labial and buccal frena?

The wide range of maxillary labial and buccal frena morphologies do not tether or tie the lip in a way that impacts on function.  ³ ⁻ ⁵ The infant’s upper lip does not need to flange for effective breastfeeding. The upper lip participates in a neutral position in the seal created by the lower half of the face when the breastfeeding infant’s face buries symmetrically into the breast. The upper lip is not actively involved in effective milk transfer in breastfeeding, and is not visible when optimal intra-oral breast tissue volume and positional stability of the infant during breastfeeding are achieved.  ³ ⁻ ⁵

How should maxillary labial frena be classified?

Since the diverse range of maxillary labial morphologies do not impact upon function, there is no reason to classify variants as ‘upper lip ties’. The Kotlow scale and other systems for classification of the maxillary labial frena (see Appendix), including the Stanford classification, are of anatomic interest, but lack clinical relevance. ⁶ ⁻ ⁷

How should buccal frena be classified?

Since buccal frena do not impact upon function, there is no reason to classify variants as ‘buccal ties’.

Why is this topic of concern?

Currently, health professionals diagnose variants of maxillary labial and buccal frena as abnormal in infants with breastfeeding problems or unsettled behaviour, and refer to dentists or other providers for ablation or incision with either laser or scissors frenotomy. Parents are advised to follow-up with wound stretching exercises multiple times a day for two or more weeks. Parents may also be advised to undertake a course of myofunctional or craniosacral therapy, which requires stretching and massage of the infant’s oral connective tissues and muscles a variable number of times a day.

There is no evidence to suggest that frenotomy of variants of maxillary labial and buccal frena helps with breastfeeding problems or protects against hygiene difficulties and anterior incisor decay in later childhood, despite claims. ⁶ ⁻ ⁸ ⁻ ⁹

Although providers of oral surgery claim that pre-post surveys and chart reviews demonstrate the efficacy of the diagnosis and surgical treatment of upper lip-tie, ¹⁰ ⁻ ¹⁵ these represent only Level IV evidence in the NH&MRC hierarchy and do not prove causal links.16 Providers of frenotomy have also argued that infants with an upper lip-tie or tongue-tie swallow more air when breastfeeding, causing stomach distention, crying behaviours, and reflux. However, studies that support this claim are methodologically weak, demonstrating interpretive bias. ¹⁶ ⁻ ¹⁷

What are the risks of maxillary labial and buccal frenotomy?

In the absence of relevant studies, we draw on expert clinical experience and anecdotal reports to list risks in order of clinical significance.

1. Haemorrhage if scissors frenotomy (mitigated by use of laser) ¹⁸
2. Unnecessary pain and distress
3. Wound infection ¹⁹
4. Oral aversion resulting in worsened feeding problems in infant with pre-existing breastfeeding or feeding problems
5. Underlying feeding/breastfeeding problems remain unidentified and unmanaged
6. Worsened diastema of upper incisors in later childhood due to scarring

What is appropriate, evidence-based management of maxillary labial and buccal frena?

We recommend no intervention, as maxillary labial and buccal frena are normal anatomic variants and do not ‘tie down the upper lip’ to impact on breastfeeding or feeding function. Unnecessary anxiety is created for parents when a normal anatomic variant is labelled as a ‘tie’.

The presence of what may appear to be a prominent midline maxillary frenum in infancy is not predictive of spacing between permanent maxillary central incisors. If a significant diastema emerges in later childhood, intervention may be appropriate at that time.

ACIOR Position Statement 1 Summary:
Upper lip-ties, buccal ties, and the role of frenotomy in infants

1. In infants, maxillary labial and buccal frena:
a) demonstrate a wide range of normal anatomic variation
b) do not impact upon function, including in breastfeeding
c) are not appropriately labelled as ‘upper lip ties’ or ‘buccal ties’.

2. There is no role for frenotomy of maxillary labial or buccal frena in normal infants.
3. In the absence of benefit, frenotomy for maxillary labial and buccal frena poses unacceptable risk.

ACIOR Position Statement 1 Summary:
Upper lip-ties, buccal ties, and the role of frenotomy in infants

  1. In infants, maxillary labial and buccal frena:
    a) demonstrate a wide range of normal anatomic variation
    b) do not impact upon function, including in breastfeeding
    c) are not appropriately labelled as ‘upper lip ties’ or ‘buccal ties’.
  2. There is no role for frenotomy of maxillary labial or buccal frena in normal infants.
  3. In the absence of benefit, frenotomy for maxillary labial and buccal frena poses unacceptable risk.

Appendix

Aetiology

Embryologically, the oral frena develop from central cells of the vestibular lamina. The maxillary labial frenum originates from the tectolabial bands, which appear at three months in utero and connect the tubercle of the upper lip with the palatine papilla. As the lateral halves of the alveolar ridge fuse, the bands are divided, forming the palatine papilla palatally and the labial frenum labially. ¹ ⁻ ²⁰ ⁻ ²¹

The position of the maxillary labial frenum shifts apically as the alveolar process develops and moves coronally. ¹ ⁻ ²² Commonly, the maxillary labial frenum inserts at the mucogingival junction but individual variations are marked. 23-25 The relative shape and size of the maxillary labial frenum change with age and variations among individuals are also substantial.24-26 In line with the migration of the maxillary labial frenum with age, the width of any presenting diastema also commonly decreases from infancy to early childhood, but this may vary again when children reach the mixed-dentition stage.27

Classification of maxillary labial frenum

Sewerin(1971) classified the frenum according to morphological variations into “normal, normal with a nodule, normal with appendix, normal with nichum, bifid labial frenum, persistent tectolabial frenum, double frenum and wider frenum”.28

Mirko et al (1974) classified frena by position of insertion and attachment: 23
• Mucosal – frenal fibres attached to mucogingival junction
• Gingival – frenal fibres inserted in attached gingiva
• Papillary – frenal fibres extended into interdental papilla
• Papilla Penetrating – frenal extended to palatine papilla.

Mirko et al reported that mucosally attached frenum were the most common in adults and papillary attached frenum were the least common.23

Classification of maxillary labial frenum alters with development

Boutsi and Tatakis in 2011 utilized Mirko’s classification in their study of different types of
maxillary labial frenum in 226 children, aged 1-18 years, and concluded that “age differed significantly among children with different type of frenum attachment (p=0.0006)”. Older children were more likely to have mucosally attached frenum whereas the youngest children were more likely to have papillary penetrating frenum. They did not find any gender or ethnic differences.24 The findings from Lindsey et al., which examined 1285 English infants, children and adults, and those from Popovich et al. concur with the results of Boutsi and Tatakis, namely that apical migration of the maxillary labial frenum occurs with increasing age in children. 29

Very occasionally, in the case of a frenum which is exceptionally large, or when the frenal attachment fails to migrate sufficiently, a persistent band of tissue is observed at or crossing the alveolar ridge crest and between the central incisors. It is possible that this may be associated with hygiene-related, anatomical and aesthetic concerns in later childhood and adulthood e.g. gingival margin retraction, dental plaque retention, diastema, lip or vestibule restrictions.1, 8, 24
In these rare cases, frenotomy may be of benefit, but this decision is made in later childhood or early adulthood, not in infancy.

*ACIOR members

Dr Pamela Douglas MBBS FRACGP IBCLC PhD
ACIOR Co-ordinator
Medical Director, The Possums Clinic, Highgate Hill, Brisbane, Queensland
Senior Lecturer, Discipline of General Practice, The University of Queensland
Adjunct Associate Professor, Maternity Newborn and Families Research Collaborative MHIQ,
Griffith University

Associate Professor Angus Cameron BDS (Hons), MDSc, FDSRCS, FRACDS, FICD, FADI
Staff Specialist, Paediatric Dentistry, Westmead Hospital
Clinical Associate Professor, Paediatric Dentistry, University of Sydney

Dr Julie Cichero BA BSpThy Hons PhD
Honorary Senior Fellow, School of Pharmacy, The University of Queensland;
Adjunct Professor, School of Clinical Sciences, Queensland University of Technology;
Co-Chair International Dysphagia Diet Standardisation Initiative

Associate Professor Donna Geddes DMU PGDipSc PhD
Head of the Hartmann Human Lactation Research Group, School of Molecular Sciences,
University of Western Australia

Associate Professor Peter Hill BA MBBS BHAdm FAFPHM
Division Head, Health Systems and Policy, School of Public Health, The University of
Queensland

Dr Vishal Kapoor MD FRACP MClinEpi
Senior Staff Specialist in Paediatrics, Lady Cilento Children’s Hospital
Senior Lecturer, School of Medicine, The University of Queensland

Dr Craig A McBride MBBS FRACS
Senior Staff Specialist Paediatric Surgeon, Children’s Health Queensland
Senior Lecturer, School of Medicine, The University of Queensland
Adjunct Research Fellow, Griffith University

Winthrop Professor Marc Tennant BDSc PhD AFCHSE
School of Human Sciences, The University of Western Australia

Dr Annetta Tsang BDSc(Hons) GCClinDent GCEd(HE) MScMed(Pain Mgt) DClinDent(Paed Dent) PhD
Paediatric Dentist

Professor Laurie Walsh BDSc (Hons) PhD DDSc GCEd(HE) FRACDS FFOP (RCPA) FICD, FADI
Specialist in Special Needs Dentistry
School of Dentistry, The University of Queensland

References

1. Henry SW, Levin MP, Tsaknis PJ. Histologic features of the superior labial frenum. Journal of Periodontology. 1976;47(1):25-28.
2. Ross RO, Brown FH, Houston GD. Histological survey of the frena of the oral cavity. Quintessence International. 1990;21:233-237.
3. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. 2017: under review.
4. Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509–518.
5. Thompson RE, Kruske S, Barclay L, Linden K, Gao Y, Kildea SV. Potential predictors of nipple trauma from an in-home breastfeeding programme: a cross-sectional study. Women and Birth. 2016;29:336-344.
6. Kotlow L. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. Journal of Human Lactation. 2013;29:458-464.
7. Santa Maria C, Aby J, Trong MT, Thakur Y, Rea S, Messner A. The superior labial frenulum in newborns: what is normal? Global Pediatric Health. 2017;4(1-6).
8. Kotlow LA. The influence of the maxillary frenum on the development and pattern of dental caries on anterior teeth in breastfeeding infants: prevention, diagnosis and treatment. Journal of Human Lactation. 2010;26(3):304-308.
9. Douglas PS. Making sense of studies which claim benefits of frenotomy in the absence of classic tongue-tie Journal of Human Lactation. 2017;33(3):519–523.
10. Benoiton L, Morgan M, Bauley K. Management of posterior ankyloglossia and upper lip ties in a tertiary otolaryngology outpatient clinic. International Journal of Otorhinolaryngology. 2016;88:13-16.
11. Pransky SM, Lago D, Hong P. Breastfeeding difficulties and oral cavity anomalies: the influence of posterior ankyloglossia and upper-lip ties. International Journal of Otorhinolaryngology. 2015;79:1714-1717.
12. O’Callahan C, Macary S, Clemente S. The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology. 2013;77:827-832.
13. Siegel S. Aerophagia Induced Reflux in breastfeeding infants with ankyloglossia and shortened maxillary labial frenula (tongue and lip tie). International Journal of Clinical Pediatrics. 2016;5:6-8.
14. Ghaheri BA, Cole M, Fausel S, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: a prospective cohort study. Laryngoscope. 2017;127:1217–1223.
15. Kotlow LA. Infant gastroesophageal reflux (GER): benign infant acid reflux or just plain aerophagia? International Journal of Child Health and Nutrition. 2016;5:10-16.
16. Vassar M, Holzmann M. The retrospective chart review: important methodological considerations. Journal of Educational Evaluation for Health Professions. 2013:http//dx.doi.org/10.3352/jeehp.2013.3310.3312.
17. Kaptchuk TJ. Effect of interpretive bias on research evidence. BMJ. 2003;326(1453-1455).
18. Tracy LF, Gomez G, Overton LJ, McClain WG. Hypovolemic shock after labial and lingual frenulectomy: a report of two cases. International Journal of Pediatric Otorhinolaryngology. 2017;100:223-224.
19. Reid N, Rajput N. Acute feed refusal followed by Staphylococcus aureus wound infection after tongue-tie release. Journal of Paediatrics and Child Health. 2014;50:1030-1031.
20. Huang WJ, Creath CJ. The midline diastema: a review of its etiology and treatment. Pediatric Dental Journal. 1995;17(3):171-179.
21. Moore KL, editor. The Developing Human. 4th ed. Philadelphia: WB Saunders; 1988.22. Popvich F, Thompson GW, Main PA. The maxillary interincisal diastema and its relationship to the superior labial frenum and intermaxillary suture. Angle Orthodontist. 1977;47(4):265-271.
23. Mirko P, Miroslav S, Lubor M. Significance of the labial frenum attachment in periodontal disease in man. Part 1. Classification and epidemiology of the labial frenum attachment. Journal of Periodontology. 1974;45(12):891-894.
24. Boutsi EA, Tatakis DN. Maxillary Labial frenum attachment in children. International Journal of Paediatric Dentistry. 2011;21(4):284-288.
25. American Academy of Pediatric Dentistry (AAPD). Guideline on management considerations for pediatric oral surgery and oral pathology. Revised 2015:Accessed online: http://www.aapd.org/media/Policies_Guidelines/G_OralSurgery2.pdf.
26. Townsend JA, Brannon RB, Cheramie T, Hagan J. Prevalence and variations of the median maxillary labial frenum in children, adolescents and adults in a diverse population. General Dentistry. 2013;61(2):57-60.
27. Diaz-Pizan ME, Lagravere MO, Villena R. Midline diastema and frenum morphology in the primary dentition. Journal of Dentistry for Children. 2006;73(1):11-14.
28. Sewerin I. Prevalence and variations of the median maxillary labial frenum in children, adolescents and adults in a diverse population. Acta Odontologica Scandinavica. 1971;29(4):487-496.
29. Lindsey D. The upper mid-line space and its relation to the labial frenum in children and in adults. A statistical evaluation. British Dentistry Journal. 1977;143(10):327-332.

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