I see a pattern of adults in my practice who present for upper lip-tie consultation. Their concern is that it is contributing to re-opening of space between the upper front central teeth after braces.

I will often determine the tongue is the bigger contributor to instability, compared to lip-tie. This photo is of one such patient.

These patients most usually have had healthy premolar teeth removed to alleviate dental crowding, and then the teeth are retracted back with braces to close the extra spaces.

In contrast to developing the jaw and tongue space, and making more room for the teeth to fit, this situation can compound the problem of poor tongue space, and oral dysfunction. It perpetuates lowered tongue posture and tongue thrust. In this photo, you can see how the tongue naturally rests against the back of the teeth. And these constant pressures at rest and during swallowing contribute to orthodontic instability, and in this case re-opening of dental spaces each and every day whilst the retainer is not worn.

When we don’t address poor jaw structures in childhood, it sets up a situation that is analogous to holistic dentist Dr Felix Liao’s book title – six-foot tiger in a three-foot cage. During sleep, the tongue will thrust forward with the mouth open or fall back into the throat – both situations disturbing sleep and creating chronic stress.

It’s not surprising that this patient has suffered with unrefreshed sleep, lethargy and excessive daytime sleepiness, anxiety, insomnia, teeth grinding, poor concentration and mild depression. Many of these symptoms have been present since childhood.

There are many clues that could have highlighted a need for early intervention long before the braces, including childhood mouth breathing. There is also a hidden-tongue tie that is most likely to have to contributed to the poor jaw development, poor sleep, perception of being tongue-tied during speech, and neck tension.

Extracting teeth to relieve dental crowding is not always the best answer.

In her case, I have proposed myofunctional therapy to help retrain normal resting posture, as she did find she could breathe more deeply when her tongue was sitting on her palate (as opposed to thrusting low and forward).

But we can do better by paying attention to the underlying oral dysfunctions (such as mouth breathing and tongue-ties) that contribute to crooked teeth and orthodontic instability, earlier.

The earlier we can address these, the greater potential we may be able to help improve many facets of a patient’s life, far beyond straight teeth. 

Tongue tie release – should my child have this done under GA at the time of ENT surgery?

Having a tongue tie release whilst a child is under for other surgery like removal of adenoids and tonsils or the insertion of grommets can seem an attractive option.

But I don’t always think this option is the best for every single child.

This is because I’ve seen frequent cases where a release has been rushed through to the time of GA and there is a lot of scar tissue, the tongue is still restricted, and a child still needs further release. This scarring makes it not as easy a release, as without it.

Some of the factors that I consider when answering this question are:

👅 One of the keys to minimising scarring and reattachment is for the tongue to be moving well whilst the area is healing. This happens best when a child has had some pre-hab therapy in the form of oromotor, feeding or myofunctional therapy. Has the child been adequately prepared? Or will they be able to do better prehab therapy once airway obstruction is removed? Will they be better able to do post-op tongue exercises to minimise reattachment when they are not sore and recovering from other surgery?

👅 What is the child’s temperament? How anxious will they be? As parents, it’s natural to feel apprehensive about them having a surgery in the chair. It’s best not to share your thoughts with them and discuss them directly with us. We’re experienced treating many children in the chair from age 4 years with good co-operation and are pretty good at predicting who will cope well.

👅 How thorough will the release be with the ENT surgeon? Personally, if my child was having a release under GA, I wouldn’t want anything less than a technique including stitches, used by ENT colleague Dr Soroush Zaghi. Refer to this link for surgical photos – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6437727/. Since I’m not familiar with anyone local using this approach, with an older child that can sit in the chair, I tend to prefer full control of the release to achieve the best functional outcome in combination with therapy.

👅 In select cases, there may be benefit in getting the most severely restrictive anterior tongue ties released sooner to help facilitate better therapy, even knowing they may need a subsequent release later.

👅 If a child is too young to sit in the chair and follow instructions, a release under GA could be a good interim option when there are significant functional concerns related to reduced tongue mobility.

To make the most fully informed decision on what is right for you child, it is best to have an individualised assessment, and a second opinion from your ENT surgeon.

8-month-old – one week review post upper lip and tongue tie release

It’s fascinating to see the subtle influence the muscles of the mouth and face have on a child’s facial development and appearance over the years, or sometimes even sooner.

This young man had a long history of feeding issues, but ties had been dismissed as mild by several medical and child health professionals.

More recently the family came to see us for a further opinion as they felt something was not quite right. He was posturing his lower jaw forward all the time, and he was struggling to swallow solids.

We confirmed upper lip and tongue tie and proceeded with release.

One week post release, he was feeding better on the breast and swallowing solids easier.

Mum feels his face is more relaxed and she reports he is no longer posturing his lower jaw forward. These photos before (left) and one week after (right) upper lip and tongue tie release tend to support her observations.

Any surgical procedure carries risk, and individual results may vary. Before proceeding with this surgery, you should seek a second opinion with an appropriately qualified practitioner.

If a child is unable to elevate the tip of the tongue to their palate, without touching the teeth when asked, this can be described as tongue motor immaturity.

It could be a marker of disturbed breathing during sleep.

A comprehensive study analysing the jaw, dental and oral muscle characteristics of 100 children with persistent obstructive sleep apnoea after removal of adenoids and tonsils found that 24% of these children could not lift the tip of the tongue to the palate. Sleep studies demonstrated these children tended to have more severe breathing disturbances compared to those who could.

This tends to highlight that we must pay attention to how well the tongue works. This is because the bulk of the tongue is formed by the genioglossus muscle which is the main muscle responsible for keeping our throat open during sleep.

The study also found that mouth breathing was a common finding in these children, affecting 62% of children.

More common than nasal abnormalities like cartilage hyptonia (18%), deviated nasal septums (5%) or nasal obstruction (32%), was the contribution of tongue tie/restricted tongue mobility (40%) and narrow palate (42%). These factors contributed to low tongue posture and could be a factor in the lack of tongue to palate seal and persistent of mouth breathing.

In practice, I have observed this lack of tongue coordination/tone is often also linked to issues including poor speech articulation, difficulties chewing and swallowing meat, or glue ear, and even difficulties hearing in this child’s case.

If you want to read more about the study, here is the link.

Prevalence of malocclusions and oral dysfunctions in children with persistent sleep-disordered breathing after adenotonsillectomy in the long term

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