Cutting the Ties That Bind by Dr. Ben Curtis

Cutting the Ties That Bind 

Using dental lasers to alleviate tongue-tie

by Dr. Ben Curtis

As a pediatric specialist, my heart is with kids and providing them with the best possible experience. This is why I use a Waterlase iPlus all-tissue laser (Biolase) instead of conventional surgery to perform lingual frenectomies for tongue-tie procedures. The use of a laser (which I like to describe as a “fancy flashlight”) is faster, safer and more patient-friendly— and achieves better outcomes—than traditional methods.

Lingual frenectomies are usually performed on children, whom I like to call “little surprises” because the smaller they are, the more surprises they hold for us. It’s worthwhile to be aware of preoperative issues you may not have thought of; I will address some of those below, along with my experience on some of the benefits of dental lasers.

Tongue-tie is a common oral condition that can be genetic. A baby born with tongue-tie, or ankyloglossia, will have an overly short, thick or tight frenulum that restricts the tongue’s range of motion. Because tongue-tie tethers the bottom of the tongue to the floor of the mouth, it can interfere with many aspects of health, including breastfeeding, chewing, swallowing, breathing and dental health.

Common signs and symptoms of tongue-tie in a newborn can include nipple pain and trauma in the mother, as well as trouble with the infant staying latched, clicks when breastfeeding and poor milk transfer, which can lead to issues with weight gain and milk supply. While providers may take a wait-and-see approach to mild tongue-tie, when untreated in older children it can lead to problems with dental occlusion, orthodontic health and speech articulation, as well as the inability to develop a proper airway, which has been linked to asthma, sleep disorders, allergies and ADD/ADHD.

In the case studies that follow, we will look first at the case of a newborn. The second case study, of a 10-year-old, illustrates what can go wrong when tongue-tie is not addressed at an early age.

Case 1: Newborn patient
This patient (Fig. 1) was referred to me by the pediatrician, who suspected tongue-tie because of the baby’s failure to latch onto the mother’s breast.

Initially, the mother was unable to breastfeed because the baby was a patient in the neonatal intensive care unit (NICU) after a difficult birth. Instead of breastfeeding, the baby was fed pumped breast milk with a bottle, but even after she was released from the NICU she would not latch. The patient also struggled with the bottle and would smack and click on the nipple, leaking milk from the corners of her mouth. She ingested a lot of air when feeding and became bloated with gas afterward, which caused her to fuss until the gas had passed.

The lingual frenum exam showed the baby was unable to elevate the tongue to 25% when crying or to 50% with finger pressure. A severe finger-sweep barrier was apparent when running the finger across the floor of the mouth. Her finger-sucking ability was very weak: She smacked on the finger and the tongue lacked continuous wave motion. The frenum tissue appeared thick, short and inelastic (Fig. 2), and the same was true of the maxillary labial frenum (Fig. 3).

A Waterlase iPlus laser with a MZ5 tip on the “frenectomy rapid cut” setting was used to release the lingual frenum. No topical or local anesthetic was used because of the potential for acute toxic methemoglobinemia, a blood disorder in which too little oxygen is delivered to the cells. The tongue was lifted with a groove director to isolate the frenum tissue. Hemostasis was controlled with gauze and the laser’s “bandage” setting. Movement and function were verified once the procedure was complete (Fig. 4). The maxillary labial frenum was also released in a similar manner (Fig. 5).

After the frenectomies, the mother reported the baby had no bloating or gas and was less fussy and more comfortable (Figs. 6–8). Most importantly, however, bottle feeding was much improved.

Cutting the Ties That Bind
Fig. 1
Cutting the Ties That Bind
Fig. 2
Cutting the Ties That Bind
Fig. 3
Cutting the Ties That Bind
Fig. 4
Cutting the Ties That Bind
Fig. 5
Cutting the Ties That Bind
Fig. 6
Cutting the Ties That Bind
Fig. 7
Cutting the Ties That Bind
Fig. 8

Case 2: 10-year-old patient
The mother in this case was aware of tongue-tie when the patient was an infant, but did not have a frenectomy performed at that time. As the child grew, however, so did the mother’s concerns about the patient’s tongue-tie, and she worried it might be contributing to airway and other issues, including irritability, poor-quality sleep, respiratory issues and articulation issues. The mother also noticed the patient’s tongue didn’t appear to move as much as her own or those of her other children.

The lingual frenum exam showed the patient was unable to elevate the tongue more than 25% and struggled to elevate it even to that degree. She was also unable to move the tongue laterally over the occlusal surfaces of the teeth. A severe finger-sweep barrier was apparent when running the finger across the floor of the mouth. Also, when extended, the frenum tissue rubbed on the lower incisors (Figs. 9 and 10).

Although the otolaryngologist who removed the patient’s tonsils offered to conduct the lingual frenectomy procedure at the same time, the patient was referred to me by an orthodontist because of the mother’s preference that the frenectomy be performed with a laser. The lingual frenum was released using a Waterlase iPlus with an MZ5 tip on a “frenectomy rapid cut setting.” Before the procedure, the patient was administered a small amount of 2% lidocaine with 1:100,000 epinephrine injected directly into the lingual frenum (about 0.1 carpule total). Hemostasis was controlled with gauze and the laser’s “bandage” setting (Figs. 11 and 12).

Once the procedure was complete (Figs. 13–15), the patient was ecstatic with the increased movement and function, now being able to move her tongue in ways she never had before. At the two-week follow-up check, the mother reported that the patient had been able to eat better and her speech was much clearer. Additionally, the patient reported she had very minimal discomfort the first day, which was managed with a single dose of Tylenol.

Cutting the Ties That Bind
Fig. 9
Cutting the Ties That Bind
Fig. 10
Cutting the Ties That Bind
Fig. 11
Cutting the Ties That Bind
Fig. 12
Cutting the Ties That Bind
Fig. 13
Cutting the Ties That Bind
Fig. 14
Cutting the Ties That Bind
Fig .15

Advantages of laser-assisted surgery
Tongue-tie has traditionally been treated with surgery; scissors, scalpels and even fingernails have been used. However, surgery can cause a lot of bleeding, stress and unnecessary risk. In recent years, many providers have turned to laser-assisted surgery as a minimally invasive alternative. Laser surgery requires no sutures, causes virtually no bleeding or inflammation, and minimizes the risk of pain and infection. Newborns can even nurse immediately after the procedure, which takes less than a minute.

Studies have demonstrated the benefits of laser surgery over conventional surgery. These include reduced perioperative bleeding, shorter operative times, minimal pain, reduced need for analgesics, and a decrease in functional discomfort while chewing and speaking. While laser surgery has advantages over conventional approaches, to ensure the best results it’s important to take preoperative factors that may affect patient outcomes into consideration.

In some cases, the pediatric dentist may be a newborn’s first encounter with a medical professional outside of the obstetrics unit. In my practice, it’s not uncommon for newborn patients to be referred directly from the hospital. Because many pediatric dentists may be unaccustomed to dealing with newborns, I offer the following tips for identifying, managing and avoiding some of the surprises these pint-sized packages—and bigger ones—may present.

Professional tips
  • Vitamin K status. At birth, infants have naturally low levels of Vitamin K, which helps with coagulation, so newborns can be at risk for a condition called Vitamin K deficiency bleeding. Infants are usually given a Vitamin K booster shot within 24 hours of birth, but to prevent spontaneous bleeds, it’s important to screen patients to ensure that they have received this booster.
  • Anesthetics. The use of topical anesthetics for patients under 12 months of age should be either eliminated or used very cautiously because of infants’ higher risk of the blood disorder acute toxic methemoglobinemia. Similarly, injections of local anesthetics such as lidocaine HCL should not be administered to infants under six months of age.
  • Floppy airway. A weak airway, also known as floppy airway (congenital tracheomalacia), occurs when the walls of the windpipe collapse. Though the symptoms—which include noisy breathing, especially when there is increased airflow, for instance when the baby is crying—normally resolve by 18 to 24 months, the condition poses an aspiration risk during the procedure and postoperatively.
  • Gagging and vomiting. While frequent vomiting is normal in patients under the age of 12 months, it is not normal in older children and can be a symptom of tonguetie. Whatever the age, however, a higher risk of vomiting during the procedure puts the patient at increased risk of aspiration.
  • G-tube patients. Infants who are fully or partially fed through a gastrostomy tube, which delivers nutrition directly to the stomach, or even those who are being considered for a G-tube, are naturally at higher risk for aspiration. In some of these cases, the failure to thrive may be because of tongue-tie.
  • Bleeding conditions. Bleeding conditions such as hemophilia, thrombocytopenia, von Willebrand disease, liver disease and some medications pose bleeding risks that require careful management, as well as special precautions before and after the procedure. Consultation with a specialist such as a hematologist is recommended.
  • Anatomy. When it comes to bleeding risks, it’s important to familiarize yourself with the ducts and blood vessels of the mouth (i.e., lingual arteries and veins) so you know what to avoid. While a laser is safer than a scalpel because it has a small active zone and you can turn it off instantly, it’s still best to be prepared.

I believe the future of dentistry lies with dental lasers, and as they become more commonplace, they will emerge as the gold standard treatment for frenectomies and many other procedures. However, as I’ve pointed out here, the key to successful outcomes depends not only on the right technology but also on being prepared for the surprises our youngest patients might hold in store.

Author Bio
Ben Curtis Dr. Ben Curtis attended Texas A&M University, where he graduated summa cum laude with a degree in biomedical sciences. He attended dental school at Texas A&M University Baylor College of Dentistry in Dallas and completed his pediatric specialty residency at Children’s Medical Center Dallas, Scottish Rite Hospital for Children and Baylor College of Dentistry.

As a resident, Curtis was named provider of the month for the Children’s Medical Center system—the only resident to ever have received this award. He also was honored with the American Academy of Pediatric Dentistry Samuel D. Harris Research and Policy Fellowship.

Curtis, a board-certified pediatric dentist, owns and practices at Curtis Kids Dentistry in Canton, Texas. He is a diplomate of the American Board of Pediatric Dentistry and an advisor, speaker and trainer for Biolase.

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