Estimated reading time: 36 minutes
Alison Hazelbaker, Ph.D., IBCLC, Columbus, Ohio, USA
Photo: Belle Verdiglione
Tongue-tie and “lip-tie” are terms tripping off many a tongue today. Alison Hazelbaker examines what parents need to know if they suspect their baby may have a tie.
Recently, my second grandson and seventh grandchild was born. One of the first things I did as his grandmother, after the magical first hours slid by, was to check his tongue function. I was looking for a tongue-tie because tongue-tie runs in my family. I was tongue-tied and my two sons were tongue-tied. Luckily, only one out of seven grandchildren has had the condition. My new grandson does not, nor does he have any feeding problems.
A diagnosis of tongue-tie has become increasingly popular in the United States and elsewhere. This is partly a backlash against earlier failure to look for and properly and promptly treat this relatively common congenital anomaly. Unfortunately, the power of social media and the manipulation of parental emotion have caused an increase in diagnosis of the condition, well beyond its actual incidence.
We define tongue-tie as tissue (the frenulum) connecting the underside of the tongue to the floor of the mouth when this tissue compromises tongue mobility. It is a mild congenital anomaly that can cause infant feeding issues. It is NOT true that tongue-tie is the cause of most breastfeeding problems.
The reality is that there are many different causes of breastfeeding issues, most of which are easily remedied. One of the most prevalent causes is simple positioning and latch-on mismanagement. Babies are born to breastfeed. During birth, their reflexes help them to be born, and these same reflexes help them to crawl to the breast and self-attach. Unfortunately, mothers and babies are not given the support they need in certain birth settings to allow this dance between them to unfold naturally.
Helping a mother and baby into a more relaxed, laid back, feeding position can often resolve breastfeeding issues. Tiny adjustments to other positions can often make all the difference too. When improved breastfeeding management does not solve the problem, another cause may be at play. It takes a knowledgeable support person to sort through the possibilities with the parents. Sometimes, breastfeeding challenges have more significant causes, for example torticollis* can mimic tongue-tie and undermine breastfeeding. It is not uncommon for torticollis to be mistaken for a posterior tongue-tie.
Some health care providers claim that as many as 50% of babies have a tongue-tie, most possessing a posterior tie. Please keep in mind that properly performed scientific research has identified true tongue-tie in only 5% of babies and posterior tie in only 30% of that 5%.1
Dr. David Todd, a researcher and neonatologist in Australia, did a three-year study in which he found that 70% of truly tied babies had an anterior tie (one in which the lingual frenulum was attached closer to the tip of the tongue). Only 30% had a posterior tie (one in which the lingual frenulum was attached closer to the base of the tongue). Clearly, the diagnosis of posterior tie has become far too common.
Please keep in mind that properly performed scientific research has identified true tongue-tie in only 5% of babies and posterior tie in only 30% of that 5%.1
Part of the problem is the lack of appropriate screening for the condition. There is only one screening tool for tongue-tie that has been proven through scientific research to accurately identify tongue-tie in babies. This screening tool, the Assessment Tool for Lingual Frenulum Function©™ (ATLFF), was developed over a three-year period in the 1990s and is reproduced below.2
The ATLFF©™ evaluates seven different functional aspects of your baby’s tongue movement, and five appearance aspects. In this way, it has the power to determine if your baby is truly tongue-tied or if your baby has a different cause of tongue-function problems, such as torticollis. This assessment tool is the standard against which all other tongue-tie assessment tools will have to be measured (those are the methodological rules). It is available in several different languages and is currently being translated into Polish and Estonian.
Simply looking under the baby’s tongue or pressing back against the baby’s tongue base will not render an accurate diagnosis.3 Before allowing a health care practitioner to screen your baby, ask how he or she performs an assessment. You always have the right to seek out another health care provider.
You may have heard that behind every anterior tie is a posterior tie. This statement is confusing. Babies do not have two kinds of tongue-tie. The professional who first made this statement meant that treating a tongue-tie by simply nicking the front of the lingual frenulum with a pair of scissors was not enough to restore optimal tongue movement. The practitioner performing the surgery needs to cut far enough back for full restoration. For some babies, this may mean that a diamond-shaped wound will be created near the tongue base, for others, stopping just before the diamond shaped wound occurs is enough. There is currently no scientific evidence that creating the larger diamond-shaped wound is superior to the simple, less deep frenotomy/frenectomy. However, we know that just snipping the very front of the lingual frenulum does not work and the procedure will need to be repeated.
Babies do not have two kinds of tongue-tie.
Treatment for tongue-tie falls into two categories: frenotomy, which consists of cutting into the lingual frenulum with sterile scissors to free up the tongue, and frenectomy, which consists of removing the lingual frenulum by using laser, scalpel, or electrocautery. All of the scientific literature on tongue-tie treatment for breastfed babies is based on simple frenotomy using sterile scissors. Not one of these studies shows any significant risks of the procedure when performed by trained hands. Minimal bleeding may occur: extensive bleeding occurs in less than 1% of babies.
That leads us to talk about the need for proper training. In the USA, there exists no requirement for training to either assess or treat tongue-tied babies. Any health care professional who works with babies is allowed to assess a baby for tongue-tie. Any practitioner who is allowed to perform minor surgery can perform tongue-tie surgery. We must rely on the ethical behavior of practitioners to get training on their own from a formal or informal training program. Please be aware that most physicians are NOT trained to perform frenotomy/frenectomy.
Two formal training programs currently exist: one in the UK and one in Boston in the USA. Other informal trainings have sprung up everywhere; many practitioners learn from another who has more experience. This means there is no standardized approach and no guarantee that the practitioner has met a minimum standard of competence. Please be sure to ask a practitioner to whom you have been referred what kind of training he or she has, how many procedures he or she has performed, and what kind of results he or she has achieved. If he or she performs laser frenectomy, ask if he or she is certified through the Academy of Laser Dentistry.
There is no scientific evidence that proves that laser frenectomy is superior to scissors frenotomy in tongue-tied babies. Before laser became widely available, most tongue-tied babies received scissors frenotomy with excellent results. Currently, most tongue-tied babies throughout the world receive scissors frenotomy.
There are many types of lasers, each suited for different uses. Diode lasers, in particular, leave a larger area of damaged tissue even in the hands of an experienced laser surgeon because they use a hot tip to burn the tissue rather than the laser beam to vaporize the tissue. CO2 laser is the laser of preference when working with the smaller mouth size of an infant.4
Because the lingual frenulum is a connective tissue band containing certain types of fibers that do not stretch with use and is designed to stabilize the tongue in the mouth, it will not change over time or with exercise. If your baby is truly tongue-tied, the only remedy is to cut into the frenulum or remove the tissue. Problems may arise if this tissue is left intact including: speech delay, speech articulation problems, postural stability problems, airway development problems, development of sleep disordered breathing, sleep apnea, malocclusion of the upper and lower teeth, teeth cleaning issues, and swallowing of air, gas, and bloating.2 On the other hand, cutting a lingual frenulum that does not need to be cut may create other problems. Many practitioners have seen excessive scar tissue formation in babies who had a frenotomy/frenectomy and did not need the procedure. This is based on observation and more research is required before we can determine what long-term problems may arise when babies receive a frenotomy/frenectomy when they don’t need it.
Many parents worry about the aftercare “stretching” exercises that are commonly recommended post surgery. It is never appropriate to rub the wound to “break down the scar tissue” or to prevent excessive scar tissue formation. Wound healing science shows that rubbing the wound itself will cause excessive scar tissue to form contributing to the phenomenon of “reattachment.”5 Gentle movements of the tongue in the direction the tongue would normally move during breastfeeding and tongue play suffice. You can ensure your baby performs these movements with some simple strategies that work with the baby’s normal reflexes:
- Tickle the baby’s lips in the middle with the tip of your finger. The baby should stick out his or her tongue in response. Alternately, you can tickle the tip of your baby’s tongue to get tongue extrusion.
- Rub your baby’s lower gumline with your finger pad from the center of the gum backwards while maintaining gentle contact with the gumline itself. Your baby’s tongue will follow your finger. Repeat this motion three or four times, then switch to the other side.
- Allow your baby to suck on your finger. Keep your finger pad up on the hard palate. This encourages your baby’s tongue to create a central groove or gutter and encourages peristalsis (the wave motion) and lifting of the tongue.
Perform these gentle movements several times per day when your baby is most receptive. Of course, breastfeeding itself generates appropriate movement to assist with proper wound healing. Any exercises should not cause your baby to cry: aftercare therapy should be part of playtime and be fun.
Frenotomy/frenectomy alone will not necessarily address the entire breastfeeding problem. Babies may have breastfeeding issues in addition to tongue-tie. Parents need to work with a professional who is knowledgeable in breastfeeding management post-surgical correction of the tongue-tie for best results and to properly address any other problems the baby may be experiencing. (For instance, if the mother’s milk supply has dwindled due to ineffective stimulation and drainage of milk from the breasts, then the correction of the tie will not in itself address the domino effects of lactation failure that may already have occurred.)
You may have heard or read online that upper “lip-tie” is a common cause of breastfeeding problems. In 93.3% of babies the upper lip frenulum (the tissue connecting the inside of the lip with the gum) looks exactly like those currently considered “lip-tie.”7 The upper lip frenulum, unlike the lingual frenulum, changes over time with growth and development. This frenulum gets smaller, thinner, and will insert higher up on the gumline as the teeth erupt.8,9 By the time a child has permanent teeth, the upper lip frenulum looks nothing at all like it did during infancy.
Can a prominent upper lip frenulum ever cause a breastfeeding problem? We don’t know for sure. It might, but it might not. We don’t have a proper way to assess the upper lip frenulum to determine if it is abnormal. We certainly have no scientific studies that show that cutting the upper lip frenulum resolves breastfeeding problems.
We certainly have no scientific studies that show that cutting the upper lip frenulum resolves breastfeeding problems.
Claims made about “lip-tie” causing dental caries are false. Breast milk does not pool in the mouth nor does it cause cavities.10 There is also no absolute proof that a prominent upper lip frenulum causes a separation between the upper central teeth, known as a diastema. Diastema can be hereditary and is not the cause of any functional problems. It is a sign of beauty in some cultures; in others, orthodontia is used to close the gap for cosmetic purposes alone.
Any claim that all tongue-tied babies also have an upper “lip-tie” is absolutely NOT true. The lingual frenulum and the upper lip frenulum develop at different times during embryonic and fetal life under different influences and processes. The lingual frenulum and the upper lip frenulum should be assessed and treated as separate issues. Functionally, the tongue and the lips link via reflex. When the tongue moves backward in the mouth, the lips move inward and vice versa. A baby who has a retracted tongue, either due to tongue-tie or to torticollis, will often have tense lips. Once the tongue position is corrected, the lips resume their normal position and function.
At breast, the upper lip need only evert (turn outward), rather than flange, despite claims to the contrary. Only the bottom lip flanges during breastfeeding. Do not be misled by claims that both lips flange for proper lip seal at the breast.
Only the bottom lip flanges during breastfeeding. Do not be misled by claims that both lips flange for proper lip seal at the breast.
The lingual frenulum has few blood vessels and pain receptors. Cutting into it without anesthesia causes little discomfort for the baby. The upper lip frenulum has an extensive blood supply and many pain receptors. Cutting into it without anesthesia may generate pain for the baby.
Surgery is invasive. Cutting the lingual frenulum or maxillary frenulum (for “lip-tie”) on a baby who does not need this procedure is considered highly unethical and professionally irresponsible.6 Babies are vulnerable and deserve our protection.
Because the vast majority of babies possess a prominent upper lip frenulum that will grow and change over time, a wait and see approach is valid. Unless it can definitively be proven that the upper lip frenulum is so tight that it truly prevents the upper lip from everting during breastfeeding causing breastfeeding problems, the lingual frenulum should be evaluated and treated first, as needed. Once the tongue position and function have normalized, the upper lip can be reassessed and treated, as needed. Many practitioners have found that treating the lingual frenulum usually resolves the upper lip issues.11
Babies are vulnerable and deserve our protection.
As a parent, you are in a unique position to make decisions for your baby. If you are having breastfeeding problems, seek skilled care from practitioners and counselors who are well informed in breastfeeding management. While an LLL Leader may refer a mother to a specialist if she suspects a problem, diagnosis is outside a Leader’s remit. Seek out information from sources that are well supported by scientific research.
Typically speaking, Facebook groups do not meet scientific criteria. If an information page does not provide sound scientific information with references, then consider the information to be opinion.
Stay away from pages wherein mothers and practitioners are diagnosing tongue-tie and “lip-tie” from pictures or simple descriptions. Tongue-tie is a functional problem and should be assessed using the functional criteria by a professional who has experience identifying these problems and who can make an accurate differential diagnosis.
Stay away from pages wherein mothers and practitioners are diagnosing tongue-tie and “lip-tie” from pictures or simple descriptions.
Anyone who uses scare tactics to goad parents into having their child treated has not done a good job of providing unbiased, evidence-based, and balanced information. Ultimately, it is the parents’ right and responsibility to make the decision to have a tongue-tie or “lip-tie” treated.
As a mother, I was certain that having my sons’ tongue-tie corrected to assist with breastfeeding was a good call. I do not regret those decisions. I made my decisions based on sound, scientific evidence about the risks vs. the benefits. As a health care provider, I would not hesitate to send one of my patients for a frenotomy/frenectomy performed by an experienced surgeon if the baby were truly tongue-tied. I cannot say that I have the same confidence for what is called maxillary or upper “lip-tie.” The scientific evidence does not support routine performance for upper lip revision for breastfeeding issues at this point in time.
As guardians of our babies, all parents and health care providers need to be sure that the benefits of any surgical procedure outweigh its risks. Our vulnerable babies depend on us to do so.
- Todd, D.A. & Hogan, M.J. (2015). Tongue-tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes. Breastfeeding Review, 23(1): 11-6.
- Hazelbaker, A.K. (2010). Tongue-tie: morphogenesis, impact, assessment and treatment. Columbus: Aidan and Eva Press.
- Greenhalgh, T. (2014). How to read a paper, 5th ed. Oxford: John Wiley and Sons, Ltd.
- Kaplan, M., Hazelbaker, A. & Vitruk, P. (2015). Infant frenectomy with 10,600 nm dental CO2 laser. WAGD Newsletter, April: 10-12.
- Darby, I. A., et al. (2014). Fibroblasts and myofibroblasts in wound healing. Clinical, Cosmetic and Investigational Dermatology, 7:301-311.
- Edge, R.S. & Groves, J.R. (2006). Ethics of Health Care, 3rd ed. Clifton Park: Thomson Delmar Learning.
- Flinck, A., Paludan, A., Matsson, L., Holm, A.K. & Axelsson, I. (1994). Oral findings in a group of newborn Swedish children. Int J Paediatr, 4(2):67-73.
- Boutsi, E.A. (2014). The maxillary labial frenum. J Cranio Max Dis, 3:1-2.
- Nagavini, N.B. & Umashankara, K. V. (2014). Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Max Dis, 3:5-10.
- Erikson, P. R. & Mazhari, E. (1999). Investigation of the role of human breast milk in caries development. American Academy of Pediatric Dentistry, 21(2): 86-90.
- Personal communication: Dr. Yvonne Le Fort, Hillary Myers, Dr. Val Finigan.
- ADDITIONAL REFERENCES
Infant suck and tongue-tie
Aarts, C., Hornell, A., Kylberg, E., Hofvander, Y., & Gebre-Medhin, M. (1999). Breastfeeding patterns in relation to thumb sucking and pacifier use. Pediatrics, 104, e50.
Agency for Healthcare Research and Quality. (2015). Treatments for ankyloglossia and ankyloglossia with concomitant lip-tie. Comparative Effectiveness Review, Number 149. AHRQ Publication No. 15-EHC011-EF.
Amir, L.H. (2005). Tongue-tie: a view from down under. Pediatric Alert, July 28, 81.
Amir, L.H., James, J.P., & Beatty, J. (2005). Review of tongue-tie at a tertiary maternity hospital. Journal of Pediatric and Child Health, 41, 243-245.
Amir, L.H., James, J.P., & Donath, S.M. (2006). Reliability of the Hazelbaker assessment tool for lingual frenulum function. International Breastfeeding Journal, 1, 3.
Ardran, G. M., Kemp, F. H., & Linda, J. (1958). A cineradiographic study of breastfeeding. British Journal of Radiology, 31, 156-162.
Arvedson, J.C., & Brodsky, L. (2002). Pediatric swallowing and feeding: assessment and management. (2nd ed.). Albany: Singular Publishing Group/Thomson Learning, Inc.
Avery, J.K., & Chiego, D.J. (2006). Essentials of oral histology and embryology. (3rd ed.). St. Louis: Mosby Elsevier.
Ballard, J.L., Auer, C.E., & Khoury, J.C. (2002). Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics, 110, e63.
Bauchner, H. (2008). Does frenulotomy improve breast-feeding? Retrieved January 27, 2009, from http://general-medicine.jwatch.org/cgi/content/full/2008/710/1.
Bell, W. H. (1989). Surgical correction of dentofacial deformities. Philadelphia: W. B. Saunders.
Bhaskar, S. N. (Ed.). (1991). Orban’s oral histology and embryology. (11th ed.). St. Louis: Mosby Year Book.
Bjornsson, A., Arnason, A., & Tippet, P. (1989). X-linked cleft palate and ankyloglossia in an Icelandic family. Cleft Palate Journal, 26, 3-8.
Block, J. R. (1968). The role of the speech clinician in determining indications for frenulotomy in cases of ankyloglossia. New York State Dental Journal, 34, 479-481.
Boiron, M., Da Nobrega, L., Roux, S., Henrot, A., & Saliba, E. (2007). Effects of oral stimulation and oral support on non-nutritive sucking and feeding performance in infants. Developmental Medicine & Child Neurology, 49, 439-444.
Bosma, J.F. (1985). Postnatal ontogeny of performance of the pharynx, larynx, and mouth. American Review of Respiratory Disease, 131 (supplement), S10-S15.
Bosma, J.F., Hepburn, L.G., Josell, S.D., & Baker, K. (1990). Ultrasound demonstrations of tongue motions during suckle feeding. Developmental Medicine and Child Neurology, 32, 223-229.
Bowen, C. (2000). Tongue-tie, ankyloglossia or short fraenum. Retrieved January 16, 2009, from http://www.speech-language-therapy.com/tonguetie.html.
Breastfeeding and birthing: do birthing practices affect breastfeeding? (2007). INFACT Newsletter, Winter, 1-2.
Breward, S. (2004). Tongue tie and breastfeeding: assessing and overcoming the difficulties. Community Practitioner, 79, 298-299.
Brinkman, S., Reilly, S., & Meara, J.G. (2004). Management of tongue-tie in children: a survey of paediatric surgeons in Australia. Journal of Pediatric and Child Health, 40, 600-605.
Broad, F. E. (1972). In the beginning was the word: suckling and speech. Bulletin of the Federation of New Zealand Parents Centers, 53, 4-6.
Broad, F. E. (1972). The effects of infant feeding on speech quality. New Zealand Journal of Medicine, 76, 28-31.
Brookes, M., & Zeitman, A. (1998). Clinical embryology: a color atlas and text. Boca Raton: CRC Press.
Broussard, D.L.; & Altschuler, S.M. (2000). Central integration of swallow and airway-protective reflexes. American Journal of Medicine, 108, 62S-67S.
Buryk, M., Bloom, D. & Shope, T. (2015). Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics, DOI: 10.1542/peds.2011-0077.
Butlin, H., & Spencer, W. (1900). Diseases of the tongue. London: Cassel and Company, Ltd. 1-21, 30-35, 50-51.
Chapman, D. (2008). Using ultrasound for a loser look at breastfeeding: pre and post-frenulotomy. Journal of Human Lactation, 24:460.
Cho, A., Kelsberg, G., & Safranek, S. (2010). Clinical inquiries: When should you treat a tongue-tie in a newborn? Journal of Family Practice, 59(12):712a-b.
Cinar, F. & Onat, N. (2005). Prevalence and consequences of a forgotten entity: ankyloglossia. Plastic and reconstructive Surgery, 115, 355-356.
Corbin-Lewis, K., Liss, J.M., & Sciortino, K.L. (2005). Clinical anatomy & physiology of the swallow mechanism. Clifton Park: Thomson Delmar Learning.
Coryllos, E., Watson Genna, C., & Salloum, A.C. (2004). Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby Newsletter, Summer, 1-6.
Crook, C.K., & Lipsitt, L.P. (1976). Neonatal nutritive sucking effects of taste stimulation upon sucking rhythm and heart rate. Child Development, 47, 518-522.
Cunha, R.F., Silva, J.Z., & Faria, M.D. (2008). Clinical approach of ankyloglossia in babies: report of two cases. The Journal of Clinical Pediatric Dentistry, 32, 277-281.
Daly, S.E.J., Kent, J.C., Owens, R.A., & Hartmann, P.E. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis. Experimental Physiology, 81, 861-875.
Defabianis, P. (2000). Ankyloglossia and its influence on maxillary and mandibular development. The Functional Orthodontist, 17, 25-33.
DePorte, J. V., & Parkhurst, E. (1945). Congenital malformations and birth injuries among the children born in New York State, outside of New York City, in 1940-1942. New York State Journal of Medicine, 45, 1097-1100.
Dollberg, S., Botzer, E., Grunis, E., & Mimouni, F.B. (2006). Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, pospective study. Journal of Pediatric Surgery,41, 1598-1600.
Dollberg, S., Manor, Y., Makai, E., & Botzer, E. (2010). Evaluation of speech intelligibility in children with tongue-tie. Acta Pediatrica, 100:e125-7.
Dollberg, S., & Botzer, E. (2011). Neonatal tongue-tie: myths and science. Harefuah, 150(1):46-9.
Dovel, J. (2010). Teaching tongue-tied students: ankyloglossia in the instrumental classroom. Music Educators Journal, 96:49-52.
Edmunds, J., Hazelbaker, A.K., Murphy, J.G. & Phillipp, B.L. (2012). Tongue-tie. Journal of Human Lactation, 28(1);14-17.
Ekenze, S.O., Ikechukwu, R.N., & Oparaocha, D.C. (2005). Surgically correctable congenital anomalies: prospective analysis of management problems and outcome in a developing country. Journal of Tropical Pediatrics, 52, 126-131.
Evans, C. (1978). Muscles involved in oral-motor function. In J. M. Wilson (Ed.), Oral-motor function and dysfunction in children (pp. 79-95). Chapel Hill: University of North Carolina.
Fanibunda, K., Adams, A. (1998). Are the features of ankyloglossia limited to the lingual fraenum. Dental Update, September, 296-297.
Fessler, D.M.T., & Abrams, E.T. (2004). Infant mouthing behavior: the immunocalibration hypothesis. Medical Hypotheses, 63, 925-932.
Fernando, C. (1998). From confusion to clarity. Concord, New South Wales: Tandem Publications.
Ferris-Amat, E., et al. (2016). Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Medicina oral, patología oral y cirugía buccal, 21(1); e39-e47.
Fleiss, P. M., Burger, M., Ramkumar, H., & Carrington, P. (1990). Ankyloglossia: a cause of breastfeeding problems? Journal of Human Lactation, 6 (Supplement 1), 128-129.
Forlenza, G.P., Paradise Black, N.M., McNamara, E.G., & Sullivan, S. E. (2009). Ankyloglossia, Exclusive Breastfeeding, and Failure to Thrive Lead to Child Abuse Investigation (Unpublished).
Fancis, D.O., Krishnaswami, S. & McPheeters, M. (2015). Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics, DOI: 10.1542/peds2015-0658.
Friend, G.W., Harris, E.F., Mincer, H.H., Fong, T.L., & Carruth, K.R. (1990). Oral anomalies in the neonate, by race and gender, in an urban setting. Pediatric Dentistry, 12, 157-161.
Furer, R. (2008). Subfunctional tongue and upper lip release in nursing babies. Israel: Self-published.
Garbin, C.P., et al. (2016). Evidence of improvedmilk intake after frenotomy: A case report. Pediatrics, 132(5): e1413-17.
Garcia Pola, J., Gonzalez Garcia, M., Garcia Martin, J.M., Gallas, M., & Leston, J.S. (2002). A study of pathology associated with short lingual frenum. Journal of Dentistry for Children, 69, 59-63.
Garliner, D. (1968). Effects of unrecognized abnormal swallowing. Journal of the Canadian Dental Association, 34, 301-304.
Garliner, D. (1981). Myofunctional therapy. Philadelphia: W. B. Saunders.
Geddes, D.T., Chadwick, L.M., Kent, J.C., GArbin, C.P. & Hartmann, P.E. (2009). Ultrasound imaging of infant swallowing during breast-feeding. Dysphagia, DOI 10.1007/s00455-009-9241-0.
Geddes, D.T., Kent, J.C., Mitoulas, L.R., & Hartmann, P.E. (2007). Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development, 84, 471-477.
Geddes, D.T., Kent, J.C., Mitoulas, L. R., & Hartmann, P.E. (2008). Tongue movement and intra-oral vacuum in breastfeeding infants. Early Human Development, 84, 471-477.
Geddes, D.T., Langton, D.B., Gollow, I., Jacobs, L.A., Hartman, P.E., & Simmer, K. (2008). Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics, 122, e188-e194.
Gewolb, I.H., Bosma, J.F., Taciak, V. L., & Vice, F.L. (2001). Abnormal developmental patterns of suck and swallow rhythms during feeding in preterm infants with bronchopulmonary dysplasia. Developmental Medicine and Child Neurology, 43, 454-459.
Glass, R.P., & Wolf, L.S. (1994). Incoordination of sucking, swallowing, and breathing as an etiology for breastfeeding difficulty. Journal of Human Lactation, 10, 185-189.
Griffiths, D.M. (2004). Do tongue ties affect breastfeeding? Journal of Human Lactation, 20, 409-414.
Griffiths, M. (2006). Tongue ties and breastfeeding [Letter to the Editor]. Archives of Diseases in Childhood, 91, 542.
Hall, D.M. & Renfew, M.J. (2005). Tongue tie. Archives of Diseases in Childhood, 90(12), 1211-1215.
Hall, D.M. & Renfew, M.J. (2006). Tongue tie: more research needed [Letter to the Editor]. Archives of Diseases in Childhood, 91, 542.
Hazelbaker, A.K. (1993). The assessment tool for lingual frenulum function: use in a lactation consultant private practice. (Master’s thesis. Pacific Oaks College, 1993). Self-published.
Hazelbaker, A.K. (1994). Tongue-tie. Columbus: A.B.R.E.A.S.T. Seminars.
Hazelbaker, A.K. (2003). The impact of craniosacral therapy on infant sucking dysfunction: a pilot study. Unpublished.
Hazelbaker, A.K. (2005). Newborn tongue-tie and breast-feeding [Letter to the Editor]. Journal of the American Board of Family Practice, 18, 326.
Hazelbaker, A. (2010). Tongue-tie: morphogenesis, impact, assessment and treatment. Columbus: Aidan and Eva Press.
Hedberg Nyqvist, K., Farnstrand, C., Eeg-Olofsson, K., & Ewald, U. (2001). Early oral behaviour in preterm infants during breastfeeding: an electromyographic study. Acta Pediatrica, 90, 658-663.
Herbst, J.J. (1983). Development of suck and swallow. Journal of Pediatric Gastroenterology and Nutrition, 2 (Supplement 1), S131-S135.
Hillan, R. (2008). Division of tongue-tie: wicked and barbaric? The Practising Midwife, 11, 22-25.
Hogan, M., Westcott, C., & Griffiths, M. (2005). Randomized, controlled trial of division of tongue-tie in infants with feeding problems. Journal of Paediatric and Child Health, 41, 246-250.
Hong, P., et al. (2010). Defining ankyloglossia: a case series of anterior and posterior tongue ties. International Journal of Pediatric Otorhinolaryngology, 74(9):1003-6.
Huang, Y., Quio, S., Berkowski, JK. A. & Guilleminault, C. (2015). Short lingual frenulum and obstructive sleep apnea in children. International Journal of Pediatric Research, 1:003.
Hyashi, Y., Hoashi, E., & Nara, T. (1997). Ultrasonograhic analysis of sucking behavior of newborn infants: the driving force of sucking pressure. Early Human Development, 49, 33-38.
Inoue, N., Sakashita, R., & Kamegai, T. (1995). Reduction of masseter muscle activity in bottle-fed babies. Early Human Development, 42, 185-193.
Jacobs, L.A., Dickenson, J.E., Hart, P.D., Doherty, D.A., & Faulkner, S.J. (2007). Normal nipple position in term infants measured on breastfeeding ultrasound. Journal of Human Lactation, 23, 52-59.
Jang, S., et al. (2011). Relationship between the lingual frenulum and craniofacial morphology in adults. American Journal of Orthodontics and Dentofacial Orthopedics, 139(4):e361-7.
Jean, A. (1984). Brainstem organization of the swallowing network. Brain, Behavior and Evolution, 25, 109-116.
Kaban, L. (1990). Pediatric oral maxillofacial surgery. Philadelphia: W. B. Saunders.
Kantaputra, P.N., et al. (2011). Cleft lip with cleft palate, ankyloglossia, and hypodontia are associated with TBX22 mutations. Journal of Dental Research, 90:450-55. DOI: 10.1177/0022034510391052
Karabulut, R., Sonmez, K., Turkyilmaz, Z., Demirogullari, B., Ozen, I.O., Bagbanci, B., Kale, N., & Basaklar, A.C. (2008). Ankyloglossia and effects on breast-feeding, speech problems and mechanical/social issues in children. B-ENT, 4, 81-85.
Kent, J.C., Mitoulas, L.R., Cregan, M.D., Ramsay, D.T., Doherty, D.A., & Hartmann, P.E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117, e387-e395.
Khoo, A.K., et al. (2009). Nipple pain at presentation predicts success of tongue-tie division for breastfeeding problems. European Journal of Pediatric Surgery, 19(6):370-3.
Kidd, H.R. (1976). Examination of the mouth. Canadian Family Physician, 22, 59-62.
Klockers, T. (2007). Familial ankyloglossia. International Journal of Pediatric Otorhinolaryngology, 71, 1321-1324.
Koletzko, S., Sherman, P., Corey, M., Griffiths, A., & Smith, C. (1989). Role of infant feeding practices in development of Crohn’s disease in childhood. British Medical Journal, 298, 1617-1618.
Kotlow, L.A. (1999). Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Pediatric Dentistry, 30, 259-262.
Kotlow, L.A. (2004). Using the Erbium:YAG laser to correct an abnormal lingual frenum attachment in newborns. The Journal of the Academy of Laser Dentistry, 12, 22-23.
Kummer, A. (2005). Ankyloglossia: to clip or not to clip? That’s the question. The ASHA Leader, 10, 6-7, 30.
Kupietzky, A., & Botzer, E. (2005). Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management. Pediatric Dentistry, 27, 40-46.
Labbock, M.H. & hendershot, G.E. (1987). Does breast-feeding protect against malocclusion? An analysis of the 1981 child health supplement to the national health interview survey. American Journal of Preventative Medicine, 3, 227-232.
Lalakea, M.L., & Messner, A.H. (2002). Frenotomy and frenuloplasty: if, when, and how. Otolaryngology-Head and Neck Surgery, 13, 93-97.
Lalakea, M.L., & Messner, A.H (2003). Ankyloglossia: does it matter? Pediatric Clinics of North America, 50, 381-397.
Lalakea, M.L., & Messner, A.H (2003). Ankyloglossia: the adolescent and adult perspective. Otolaryngology-Head and Neck Surgery, 128, 746-752.
Lau, C., & Kusnierczyk, I. (2001). Quantitative evaluation of infant’s nonnutritive and nutritive sucking. Dysphagia, 16, 58-67.
Leith, D.E. (1985). The development of cough. The American Review of Respiratory Disease, 131, S39-S42.
Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders. (2nd. ed.). Austin: Pro-Ed.
Lowe, A.A. (1984). Tongue movements ─ brainstem mechanisms and clinical postulates. Brain, Behavior and Evolution, 25, 128-137.
Lucas A., Morley, R., Cole, T. J., Lister, G., & Lesson-Payne, C. (1992). Breastmilk and subsequent intelligence quotient in children born preterm. Lancet, 339, 261-64.
Luz, C. L. F., Garib, D. G., Arouca, R. (2006). Association between breastfeeding duration and mandibular retrusion: a cross-sectional study of children in the mixed dentition. American Journal of Orthodontics and Dentofacial Orthopedics, 130, 531-534.
Mangelsdorf, M. (1986). Effective suckling and how to encourage it. Breastfeeding Review, 8, 28-33.
Marchesan, I.Q. (2004). Lingual frenulum: classification and speech interference. International Journal of Orofacial Myology, 30, 31-38.
Marmet, C., Shell, E., & Aldana, S. (2000). Assessing infant suck dysfunction: case management. The Journal of Human Lactation, 16, 332-336.
Marmet, C., Shell, E., & Marmet, R. (1990). Neonatal frenotomy may be necessary to correct breastfeeding problems. Journal of Human Lactation, 6 (Suppl. 1), 117-121.
Marmet, C., & Shell, E. (1984). Training neonates to suck correctly. American Journal of Maternal Child Nursing, 9, 401-407.
Martinelli, R., et al. (2015). The effects of frenotomy on breastfeeding. Journal of Applied Oral Science, 23(2):153-57.
McBride, C. (2005). Tongue-tie. Journal of Pediatric and child Health, 41, 242.
McTavish, W.K., & Matthews, R.L. (1960). Airways: the key to early facial growth and malocclusions. Self-published.
Medoff-Cooper, B., McGrath, J.M., & Shults, J. (2002). Feeding patterns of full-term and preterm infants at forty weeks postconceptional age. Journal of Developmental & Behavioral Pediatrics, 23, 231-236.
Meier, P. (1988). Bottle and breast-feeding: effects on transcutaneous oxygen pressure in preterm infants. Nursing Research, 37, 36-41.
Meintz-Maher, S. (1988). An overview of solutions to breastfeeding and sucking problems. Franklin Park: La Leche League International.
Meyer Palmer, M., & Vandenberg, K.A. (1998). A closer look at neonatal sucking. Neonatal Network, 17, 77-79.
Messner, A.H., & Lalakea, M.L. (2000). Ankyloglossia: controversies in management. International Journal of Pediatric Otorhinolaryngology, 54, 123-131.
Messner, A.H., & Lalakea, M.L. (2000). Anklyloglossia: incidence and associated feeding difficulties. Archives of Otolaryngology Head and Neck Surgery, 126, 36-39.
Messner, A.H., & Lalakea, M.L. (2002). The effect of ankyloglossia on speech in children. Otolaryngology Head and Neck Surgery, 127, 539-545.
Meyer Palmer, M., & VandenBerg, K.A. (1998). A closer look at neonatal sucking. Neonatal Network, 17, 77-78.
Meyer Palmer, M. (2002). Recognizing and resolving infant suck difficulties. Journal of Human Lactation, 18, 166.
Miller, A.J. (1986). Neurophysiological basis of swallowing. Dysphagia, 1, 91-100.
Miller, M.J., Martin, R.J., Carlo, W.A., Fouke, J. M., Strohl, K.P., & Fanaroff, A.A. (1985). Oral breathing in newborn infants. Journal of Pediatrics, 107, 465-469.
Mizuno, K., & Ueda, A. (2006). Changes in sucking performance from nutritive sucking to nutritive sucking during breast- and bottle-feeding. Pediatric Research, 59, 728-731.
Moore, J. R., (1985). Surgery of the mouth and jaws. Boston: Blackwell Scientific Publications.
Moore, K.L., & Persaud, T.V.N. (1998). The developing human: clinically oriented embryology. (6th ed.). Philadelphia: W.B. Saunders Company.
Mueller, D. T., & Callanan, V.P. (2007). Congenital malformations of the oral cavity. Otolaryngologic Clinics of North America, 40, 141-160.
Mukai, S., Mukai, C., & Asaoka, K. (1991). Ankyloglossia with deviation of the epiglottis and larynx. Annals of Otolaryngology, Rhinology and Laryngology, 100, 3-20.
Naimer, S.A., Biton, A., Vardy, D., & Zvulunov, A. (2003). Office treatment of congenital ankyloglossia. Medical Science Monitor, 9, 432-435.
Nanci, A. (2008). Ten Cate’s oral histology: development, structure, and function. (7th ed.). St. Louis: Mosby Elsevier.
Nazif, M. M., & Ready, M. A. (1987). Oral disorders. In H. W. Davis, & B. J. Zitelli (Eds.), Atlas of pediatric physical diagnosis (pp. 18.1-18.13). St. Louis: C.V. Mosby Co.
Newman, L.A., Cleveland, R.H., Blickman, J.G., Hillman, R.E., & Jaramillo, D. (1991). Videofluoroscopic analysis of the infant swallow. Investigative Radiology, 26, 870-873.
Nicholson, W. L. (1991). Tongue-tie (ankyloglossia) associated with breastfeeding problems. Journal of Human Lactation, 7, 82-84.
Notestine, G. E. (1990). The importance of the identification of ankyloglossia (short lingual frenulum) as a cause of breastfeeding problems. Journal of Human Lactation, 6 (Suppl. 1), 113-115.
Nowak, A.J. , Smith, W.L., & Erenberg, A. (1995). Imaging evaluation of breast-feeding and bottle-feeding systems. Journal of Pediatrics, 126, S130-S134.
O’Bladen, M. (2010). Much ado about nothing: two millennia of controversy on tongue-tie. Neonatology, 97:83-9.
O’Callahan, C., Macary, S. & Clemente, S. (2013). The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology, 77(5):827-32.
Olivi, G., Signore, A., Olivi, M. & Genovese, M.D. (2012). Lingual frenectomy: functional evaluation and new therapeutical approach. European Journal of Pediatric Dentistry, 13(2):101-6.
O’Shea, M. (2002). Licking the problem of tongue-tie. British Journal of Midwifery, 10, 90-92.
O’Shea JE, Foster JP, O’Donnell CPF, Breathnach D, Jacobs SE, Todd DA, Davis PG. (2014). Frenotomy for tongue-tie in newborn infants. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD011065. DOI: 10.1002/14651858.CD011065.
Ostapiuk, B. (2006). Tongue mobility in ankyloglossia with regard to articulation. Annales Academiae Medicae Stetinensis, 52 (Supplement 3), 37-47.
Page, D.C. (2001). Breastfeeding is early functional jaw orthopedics. The Functional Orthodontist, 18, 24-27.
Palmer, B. (2005). Snoring and sleep apnea: how it can be prevented in childhood. das schlafmagazin, 3, (Aug), 22-23. Retrieved May 1, 2009 from http://www.dasschlafmagazin.de
Parida, P.K. (2008). Ankyloglossia (tongue tie) [Electronic version]. Internet Journal of Otolaryngology, 8, 9-9.
Phillips, V.T. (1992). Correcting faulty suck: tongue protrusion and the breastfed infant. The Medical Journal of Australia, 156, 508.
Power, R.F., & Murphy, J.F. (2015). Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance.Archives of Diseases in Children, 100(5):489-94.
Pransky, S.M., Lago, D. & Hong, P. (2015). Breastfeeding difficulties and oral cavity anomalies: the influence of posterior ankyloglossia and upper-lip ties. International Journal of Pediatric Otorhinolaryngology, http://dx.doi.org/10.1016/j.ijporl.2015.07.033
Prieto, C.R., Cardenas, H., Salvatierra, A.M., Boza, C., Montes, C.G., & Croxatto, H.B. (1996). Sucking pressure and its relationship to milk transfer during breastfeeding in humans. Journal of Reproduction and Fertility, 108, 69-74.
Qureshi, M.A., Vice, F. L., Taciak, V. L., Bosma, J.F., & Gewolb, I.H. (2002). Changes in rhythmic suckle feeding patterns in term infants in the first month of life. Developmental Medicine & Child Neurology, 44, 34-39.
Ramsay D.T., & Hartmann, P.E. (2005). Milk removal from the breast. Breastfeeding Review, 13, 5-7.
Ramsay, M., Gisel, E.G., McCusker, J., Bellavance, F., & Platt, R. (2002). Infant sucking ability, non-organic failure to thrive, maternal characteristics, and feeding practices: a prospective cohort study. Developmental Medicine and Child Neurology, 44, 405-414.
Rendon-Macias, M.E., Cruz-Perez, L.A., Mosco-Peralta, M.R., Saraiba-Russell, M.M., Levi-Tajfeld, S., & Morales-Lopez, M.G. (1999). Assessment of sensorial oral stimulation in infants with suck feeding disabilities. Indian Journal of Pediatrics, 66, 319-329.
Rowen-Legg, A. (2015). Ankyloglossia and breastfeeding. Canadian Pediatric Society Position Statement, 20(4):209-13. Ruffoli, R., Giambelluca, M.A., Scavuzzo, M.C., Bonfigli, D., Cristofani, R.,
Gabriele, M., Giuca,M.R., & Giannesi, F. (2005). Ankyloglossia: a morphofunctional investigation in children. Oral Diseases, 2, 170-174.
Segal, L., Stephenson, R., Dawes, M., & Feldman, P. (2007). Prevalence, diagnosis, and treatment of ankyloglossia: methodologic review. Canadian Family Physician, 53, 1027-1033.
Shafer, W. G., Hine, M. K., & Levy, B. M. (1974). A textbook of oral pathology. Philadelphia: W. B. Saunders.
Shepard, J.W., Geffler, W.B., Guilleminault, C., Hoffman, E.A., Hoffstein, V., Hudgel, D.W., Surratt, P.M., & White, D.P. (1991). Evaluation of the upper airway in patients with OSA. Sleep; 14(4):361-71.
Smith, T.L. & Smith, J.M. (2001). Electrosurgery in otolaryngology─head and neck surgery: principles, advances, and complications. Laryngoscope, 111, 769-780.
Smith, W. L., Erenberg, A., & Nowak, A. (1988). Imaging evaluation of the human nipple during breast-feeding. American Journal of Diseases in Children, 142, 76-78.
Smith, W. L., Erenberg, A., Nowak, A., & Franken, E. A. (1985). Physiology of sucking in the normal term infant using real-time ultrasound. Radiology, 156, 379-381.
Sperber, G.H. (2001). Craniofacial development. Hamilton, Ontario: BC Decker, Inc.
Srinivasan, A., Dobrich, C., Mitnick, H., & Feldman, P. (2006). Ankyloglossia in breastfeeding infants: the effect of frenotomy on maternal nipple pain and latch. Breastfeeding Medicine, 1, 216-224.
Steehler. M.W., Steehler, M., & Harley, E.H. (2012). A retrospective review of frenotomy in neonates and infants with feeding difficulties. International Journal of Pediatric Otorhinolaryngology, 76(9):1236-40.
Stevenson, R.D., & Allaire, J.H. (1991). The development of normal feeding and swallowing. Development and Behavior: The Very Young Child, 38, 1439-1453.
Stice, E., Stewart Agras, W., & Hammer, L.D. (1999). Risk factors for the emergence of childhood eating disturbances; a five year prospective study. International Journal of Eating Disorders, 25, 375-387.
Suter, V.G., & Bornstein, M.M. (2009). Ankyloglossia: facts and myths in diagnosis and treatment. Journal of Periodontology, 80(8):1204-19.
Tait, P. (2000). Nipple pain in breastfeeding women: causes, treatment, and prevention strategies. Journal of Midwifery & Women’s Health, 45, 212-215.
Takemoto, H. (2001). Morphological analyses of the human tongue musculature for three-dimensional modeling. Journal of Speech, Language, and Hearing Research, 44, 95-107.
Thomas, J. & McClay, J.E. (2015). Breastfeeding: what to do about ankyloglossia, lip-tie. AAP News, 36(6):11
Todd, D. (2014). Tongue ties: Divide and conquer? To divide and prevent an interruption in breastfeeding. Australian Breastfeeding Association Seminars for Health Professionals.
Todd, D., & Hogan, M.J. (2015). Tongue tie in the newborn: early diagnosis and division prevents poor breastfeeding outcomes. Breastfeeding Review, 23(1):11-6.
Velanovich, V. (1994). The transverse-vertical frenuloplasty for ankyloglossia. Military Medicine, 159, 714-715.
Voloschin, L.M., Althabe, O., Olive, H., Diena, V., & Repezza, B. (1998). A new tool for measuring the suckling stimulus during breastfeeding in humans: the orokinetogram and the Fourier series. Journal of Reproduction and Fertility, 114, 219-224.
Walker, M. (1989). Management of selected early breastfeeding problems seen in clinical practice. Birth, 16, 150-151.
Wallace, H., & Clarke, S. (2006). Tongue tie division in infants with breast feeding difficulties. International Journal of Pediatric Otorhinolaryngology, 70, 1257-1261.
Ward, N. (1990). Ankyloglossia: A case study in which clipping was not necessary. Journal of Human Lactation, 6 (Suppl. 1), 126-127.
Warden, P. J. (1991). Ankyloglossia: A review of the literature. General Dentistry, August 1991, 252-253.
Watson Genna, C. (2002). Tongue-tie and breastfeeding. Leaven, 38, 27-29.
Watson Genna, C. (2008). Supporting sucking skills in infants. Sudbury: Jones and Bartlett Publishers.
Webb, A.N., Hao, W., & Hong, P. (2013). The effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Internatioanl Journal of Pediatric Otorhinolaryngology, 77(5):635-46.
Weber, F., Woolridge, M. W., & Baum, J. D. (1986). An ultrasonographic study of the organization of suck and swallow. Developmental Medicine and Child Neurology, 28, 19-24.
Wiessinger, D. & Miller, M. (1995). Breastfeeding difficulties as a result of tight lingual and labial frena: a case report. Journal of Human Lactation, 11(4):313-16.
Wilson, S.L., Thach, B.T., Brouillette, R.T., & Abu-Osba, Y.K. (1980). Upper airway patency in the human infant: influence of airway pressure and posture. Journal of Applied Physiology: Respiration, Environmental, and Exercise Physiology, 48, 500-504.
Wilton, J. M. (1990). Sore nipples and slow weight gain related to a short frenulum. Journal of Human Lactation, 6 (Suppl. 1), 122-123.
Winberg, J. (2005). Mother and newborn baby: mutual regulation of physiology and behavior-a selective review. Developmental Psychobiology, 47, 217-229.
Wolf, R.P. & Glass, L.S. (1992). Feeding and swallowing disorders in infancy: assessment and management. Tucson, Arizona: Therapy Skill Builders.
Woolridge, M. W. (1986). Aetiology of sore nipples. Midwifery, 2, 164-171.
Woolridge, M. W. (1986). The anatomy of infant sucking. Midwifery, 2, 164-171.
Wright, J.E. (1995). Tongue-tie. Journal of Pediatric and Child Health, 31, 276-278.
Zarem, H. A. (1978). Diseases and injuries of the oral region. In S. S. Gellis, & G.M. Kagan (Eds.), Current pediatric therapy. Philadelphia: W. B. Saunders.
Beebe, B & Lachman, F. M. (2014). The origins of attachment. New York: Routledge Taylor and Francis Group.
Castellino, R. (2000). The stress matrix: implications for prenatal and birth therapy. Journal of Prenatal & Perinatal Psychology & Health, 15(1):31-62.
Cozolino, L. (2014). The neuroscience of human relationships. New York: W.W. Norton & Company.
Eliot, L. (1999). What’s going on in there?: How the brain and mind develop in the first five years of life. New York: Bantam Books.
Janov, A. (2011). Life before birth: the hidden script that rules our lives. Chicago: NTI Upstream.
Karen, R. (1998). Becoming attached. New York: Oxford University Press.
Levine, P. & Kline, M. (2007). Trauma through a child’s eyes. Berkeley: North Atlantic Books.
Nathanielsz, P. W. (1999). Life in the womb: The origin of health and disease. Ithaca: Promethean Press.
Page, G.G. (2004). Are there long-term consequences of pain in newborn or very young infants? The Journal of Perinatal Education, 13(3): 10-17.
Porges, S. (2011). The Polyvagal theory: Neurophysiological foundations of emotions, attachment, communication and self-regulation. New York: W.W. Norton & Company.
Rothschild, B. (2000). The body remembers. New York: W.W. Norton & Company.
Schore, A. (1994). Affect regulation and the origin of the self. Hillsdale: Lawrence Erlbaum Associates.
Siegel, D. (2012.) Pocket guide to interpersonal neurobiology. New York: W.W. Norton & Company.
Siegel, D. (2012). The developing mind. New York: Guilford Press
Cobb, C.M., & Vitruk, P.(2015). Microbial decontamination of three different implant surfaces using a super-pulsed CO2 (10,600) laser: An in vitro study. The Academy of Laser Dentistry Meeting, Feb. 5-7, Palm Springs, CA.
Convissar, R. (2011). Principles and Practice of Laser Dentistry. St. Louis: Mosby Elsevier.
Kaplan, M., Hazelbaker, A.K. & Vitruk, P. (2015). Infant frenectomy with 10,600 nm dental co2 laser. WAGD Newsletter, April.
Vitruk, P. (2014). Oral soft tissue laser ablative & coagulation efficiencies spectra. Implant Practice US, November.
Zeinoun, T., et al. (2001). Myofibroblasts in healing laser excision wounds. Lasers in Surgery and Medicine, 28:74-79.
Vogel, A., & Venugopalan, V. (2003). Mechanisms of pulsed laser ablation of biological tissues. Chemical Review, 103(2):577-644.
Waynant, R.W. (2001). Lasers in Medicine. Boca Raton: CRC Press.
Maxillary Frenum and Lip “tie”
Abraham, R., & Kamath, G. (2014). Midline diastema and its aetiology: a review. Dent Update. 41(5):457-60.
Addy, M., et al. (1987). A study of the association of frenal attachment, lip coverage and vestibular depth with plaque and gingivitis. J Periodontol. 58:752-7.
Boutsi, E.A. (2014). The maxillary labial frenum. J Cranio Max Dis, 3:1-2.
Ceremello, P.J. (1953). The superior labial frenum and the midline diastema and their relation to growth and development of the oral structures. Am J Orthod. 39:120-39.
Chan, L., & Hodes, D. (2003). When is an abnormal frenulum a sign of child abuse? Arch Dis Child. Doi: 10.1136/adc.2003.031534.
Chandrashekar, L., Kashinath, K.R., Suhas, S. (2014). Labial ankyloglossia associated with oligodontia: a case report. J Dent. 11(4):481-4.
De Carvalho Stroppa, S., et al. (2014). Surgery management of rare hypertrophic frenum in an infant: a case report. Case Reports in Dentistry. http://dx.doi.org/10.1155/2014/168192.
De Morais, J. F., et al. (2014). Postrentention stability after orthodontic closure of maxillary inter incisor diastemas. Journal of Applied Oral Science, 22(5):409-15.
Delli, K., Livas, C., Sculean, A., Katsaros, C., & Bornstein, M. (2013). Facts and myths regarding the maxillary miline frenum and its treatment: A systematic review of the literature. Germany Quintessence International, 44(22):177-87.
Desai, A.J., et al. (2015). Bilateral pedicle approach for esthetic management of upper labial frenum. Journal of Interdisciplinary Dentistry. 5(1): 27-30.
Dewel, B.F. (1946). The normal and the abnormal labial frenum: Clinical differentiation. J Am Dent Assoc.33:318-29.
Dewel, B.F. (1966). The labial frenum, midline diastema, and palatine papilla: A clinical analysis. Dent Clin North Am. 10:175-84.
Diaz-Pizan, M.E., & Lagraverere, M. O. (2006). Midline diastema and frenum morphology in primary dentition. J Dent Child, 73: 11-14.
Dodge, J.A., & Kernohan, D.C. (1967). Oral facial digital syndrome. Arch Dis Child. 42:214–9.
dos Santos, V.I., et al. (1985). Prevalence of different types of upper labial frenum in the deciduous dentition. Rev Fac Odontol Sao Paulo. 23:129-35.
Flinck, A., Paludan, A., Matsson, L., Holm, A.K. & Axelsson, I. (1994). Oral findings in a group of newborn Swedish children. Int J Paediatr 4(2):67-73
Gartner, L.P., & Schein, D. (1991). The superior labial frenum: a histological observation. Quintessence Int. 22(6):443-5.
Greenhalgh, T. (2014) 5th edition. How to read a paper. Oxford: John Wiley and Sons, Ltd.
Hazelbaker, A. (2010). Tongue-tie: morphogenesis, impact, assessment and treatment. Columbus: Aidan and Eva Press.
Henry, S.W., Levin, M.P., & Tsaknis, P.J. (1976). Histologic features of the superior labial frenum. J Periodontol 47:25-8.
Huang, W., & Creath, C. (1995). The midline diastema: a review of its etiology and treatment. Pediatric Dentistry, 17(3):171-9.
Jenista, J.A. (2001) Mandibular frenulum as a sign of infantile hypertrophic pyloric stenosis. 2001;138:447. J Pediatr.138:447–7.
Kaimenyi, J.T. (1998). Occurrence of midline diastema and frenum attachments amongst school children in Nairobi, Kenya. Indian J Dent Res. 9:67-71.
Kakodkar, T., et al. (2008). Clinical assessment of diverse frenum morphology in permanent dentition.
The Internet Journal of Dental Science. 7(2). http://ispub.com/IJDS/7/2/4074.
Kotlow, L.A. (2004). Oral diagnosis of abnormal frenum attachments in neonates and infants: Evaluation and treatment of maxillary frenum using the Erbium YAG Laser. J Pediatr Dent Care. 10:11–4.
Kotlow, L.A. (2010). 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, 26(3):304-08.
Kotlow, L.A. (2013). Diagnosing and Understanding the Maxillary Lip-tie (Superior Labial, the Maxillary Labial Frenum) as it Relates to Breastfeeding. J Hum Lact. 29(4): 4458-464.
Kutcsh, V. K. & Bowers, R. J. (2012). Balance: a guide for managing dental caries for patients and practitioners. Llumina Press: Tamarac, FL.
Lawande, S.A., & Lawande, G.S. (2013). Surgical management of aberrant labial frenum for controlling gingival tissue damage: a case series. International Journal of Biomedical research. 4(10):574-8
Lindsey, D. (1977). The upper midline space and its relation to the labial frenum in children and in adults. Br Dent J. 143:327-32.
Maguire, S., et al. (2007). Diagnosing abuse: A systematic review of torn frenum and other intra-oral injuries. Arch Dis Child. 92:1113-7.
Martin, R.A., & Jones, K.L. (1998). Absence of the superior labial frenulum in holoprosencephaly: A new diagnostic sign. J Pediatr. 133:151–3. Mazzocchi, A,& Clini, F. (1992). Indications for therapy of labial frenum. La Pediatria Medica e Chirurgica, 14(6):637-40.
Mintz, S.M., Siegel, M.A., Seide,r P.J. (2005). An overview of oral frena and their association with multiple syndromes and nonsyndromic conditions. Oral Surg Oral Med Oral Pathol Oral RadiolEndod. 99:321–4.
Mohan, R., et al. (2014). Proposed classification of medial maxillary labial frenum based on morphology. Dent Hypotheses; 5:16-20.
Nagavini, N.B. & Umashankara, K. V. (2014). Morphology of maxillary labial frenum in primary, mixed, and permanent dentition of Indian children. J Cranio Max Dis, 3:5-10.
Noyes, H.J. (1935). The anatomy of the frenum labia in newborn infants. Angle Orthod, 1:3-8.
Paramala, B.K., & Prithviraj, D.R. (2012). A comparative study of mandibular incisor relation to the lingual frenum in natural dentition and in complete denture wearers. J Indian Prosthodont Soc. 12(4):208-15.
Placek, M., Skach, M. & Mrklas, L. (1974). Significance of the labial frenum attachment in periodontal disease in man. Part I. Classification and epidemiology of the labial frenum attachment. J Periodontol. 45:891–4.
Priyanka, M., Srithi, R., & Ambalavanan, N. (2013). An overview of frenal attachments. J Indian Soc Periodontal. 17(1):12-15.
Pushpavathi, N., & Nayak, R.P. (1997). The effect of mouth breathing, upper lip coverage, lip seal and frenal attachment on the gingiva of 11-14 year old Indian school children. J Indian Soc Pedod Prev Den. 15:100-3.
Ross, R.O., Brown, F.H., & Houston, G.D. (1990). Histologic Survey of the frena of the oral cavity. Quintessence Int. 21(3):233-7.
Senders, C.W., et al. (2003). Development of the upper lip. Arch Facial Plast Surg. 5(1):16-25.
Sewerin, I. (1971). Prevalence of variations and anomalies of upper labial frenum. Acta Odontol Scand, Oct; 29(4): 487-96.
Suter, V.G., et al. (2014). Does the midline diastema close after frenectomy? Quintessence Int. 45(1):57-66.
Teece, S. (2004). Torn frenulum and non-accidental injury in children. EMJonline. Doi:
Townsend, J. A., et al. (2013). Prevalence and variations of the median maxillary labial frenum in
children, adolescents, and adults in a diverse population. General Dentistry. March/April; 57-60.
White, J.A., Bond, I.P., & Jagger, D.C. (2013). A novel solution to the fraenal notch of maxillary dentures.
Eur J Prosthodont Restor Dent. 21(3):120-6.
Young, C. (2015). Upper lip tie, Fall guy…Analytical Armadillo, http://www.analyticalarmadillo.co.uk/2015/01/upper-lip-tie-fall-guy.html?m=1. Retrieved 9-8-16.
* We live in a time in which we spend many of our waking hours sitting. We sit to work, eat, to be entertained. All this sitting has led to poor posture, which leads to muscular imbalance in our lower body. These muscular imbalances, in turn, cause our babies to adopt positions while they are inside growing that create tension in their necks. This condition, called “acquired soft tissue torticollis,” can mimic tongue-tie and undermine breastfeeding. If your baby shows a head-turning preference to one side over the other, has neck tension, flattening on the back of the head, one eye or ear that looks higher, larger or farther forward than the other and/or feels like he is biting you during breastfeeding, torticollis might be the cause. Torticollis responds to a multi-pronged treatment approach.
Assessment Tool for Lingual Frenulum Function (ATLFF)™
© Alison K. Hazelbaker, PhD, IBCLC, FILCA, 1993, 2009, 2012, 2016
|Function Item score: _______
Appearance Item score: _______
Combined Score: _______ / _______
|Baby’s name:||Baby’s age:|
|Date of assessment:|
|Lateralization||Cupping of tongue|
|2 Complete||2 Entire edge with a firm cup|
|1 Body of tongue but not tongue tip||1 Side edges only OR moderate cup|
|0 None||0 Poor OR no cup|
|Lift of tongue||Peristalsis|
|2 Tip to mid-mouth||2 Complete anterior to posterior|
|1 Only edges to mid- mouth||1 Partial OR originating posterior to tongue tip|
|0 Tip stays at alveolar ridge OR tip rises only to
mid-mouth with jaw closure AND/OR mid-tongue
|0 None OR Reverse peristalsis (tongue-thrust)|
|Extension of tongue||Snap back|
|2 Tip over lower lip||2 None|
|1 Tip over lower gum only||1 Periodic|
|0 Neither of the above OR anterior or mid-tongue
humps AND/OR dimples
|0 Frequent OR with each suck|
|Spread of anterior tongue|
|1 Moderate OR partial|
|0 Little OR none|
|Appearance of tongue when lifted||Elasticity of frenulum|
|2 Round OR square||2 Very elastic (excellent)|
|1 Slight cleft in tip apparent||1 Moderately elastic|
|0 Heart shaped||0 Little OR no elasticity|
|Length of lingual frenulum when tongue lifted||Attachment of lingual frenulum to tongue|
|2 More than 1 cm OR absent frenulum||2 Posterior to the juncture between the body and blade of the tongue|
|1 1 cm||1 In front of the juncture between the body and the blade of the tongue|
|0 Less than 1 cm||0 At the tip with or without notching|
|Attachment of lingual frenulum to inferior alveolar ridge|
|2 Attached to floor of mouth|
|1 Attached to the backside of the inferior alveolus|
|0 Attached to ridge of inferior alveolus|
|14 = Perfect Function score regardless of Appearance Item score. Surgical treatment not recommended.
11 = Acceptable Function score only if Appearance Item score is 10.
<11 = Function Score indicates function impaired. Frenotomy should be considered if management fails. Frenotomy necessary if Appearance Item score is < 8.
Alison Hazelbaker, PhD, IBCLC, FILCA, CST, RCST, long-time La Leche League Leader and International Board Certified Lactation Consultant, maintains a private practice in Columbus, Ohio, USA, where she provides free screening of babies for tongue-tie. During her Master’s degree program, she developed the Assessment Tool for Lingual Frenulum Function©™ and performed the first prospective study on the impact of tongue-tie on breastfeeding. She authored Tongue-tie: Morphogenesis, Impact, Assessment and Treatment and is currently writing a primer for parents on tongue-tie. Alison mothered five children through breastfeeding and has eight grandchildren.