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Infant, Toddler & Child Frenectomy

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Airway-Centric Pediatric Dentistry

Dr. Karen is an Airway-Centric Pediatric Dentist with a vast scope of knowledge in tethered oral tissues as well as sleep disordered breathing and growth modification implementation. She has pursued intense continuing education in CO2 laser surgical corrections, breathing pattern assessment, oromyofunctional training, habit cessation therapy and lactation understanding. You must work with a provider with a vast scope of understanding and knowledge, along with a collaborative team approach to provide the ultimate outcomes for your child. 

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Check out Dr. Karen, 

Lip & Tongue-tie Release Specialist on
The Untethered Podcast

Dr. Karen has dedicated herself to countless continuing education courses, laser courses and clinical shadowing of the leaders in tethered tissue releases. As always, her commitment to excellence and precision is met with Dr. Karen’s deliberate consideration of all aspects of the procedure, the reasons for its need, the surgical release technique, as well and her management of wound healing. 

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Dr. Karen practices with a collaborative team approach in her patient care. She provides her parents with names of various, highly trained, skilled and experienced professionals in nursing evaluations, cranio-sacral therapies, speech therapies, feeding therapies and myofunctional therapies to provide the most ideal development of your. 

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Dr. Karen and her collaborative team look forward to working with your children in providing the most optimal oral health, right from the start, when it matters most!

Key points for Dr. Karen’s airway-centric pediatric dental practice:

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  1. Tongue to spot

  2. Lips sealed

  3. Nasal breathing 

  4. Proper posture
     

All of these correct behaviors lead to appropriate craniofacial development. It is for the maintenance of these key points to proper growth and development that Dr. Karen provides tethered tissue releases and much more!

Dr. Soroush Zaghi, a highly specialized otolaryngologist and sleep surgeon, to give a lecture on pediatric sleep disordered breathing and maxillofacial development, while paying special attention to tongue-tie

This is video is helpful to show how facial structure matters from a young age in regards to mouth breathing and the craniofacialrespiratory complex.

Myths about Tongue Ties

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  • "Tongue-ties do not actually exist."

  • "Tongue-ties are a fad diagnosis."

  • "Ties do not affect anything."

  • "Ties will go away in time on their own."

  • "If you can stick your tongue out past your lips there is no tie."

  • "ALL ties should be treated."

  • "The Revision will cure everything instantly."

  • "There are NO tongue-tie experts."

  • "Dentists over diagnose them so they can pay for their fancy lasers."

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Additional Resources/References:

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Image: The craniofacial-respiratory complex. (From Garg et al. [33]

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Tongue tie assessment

Image: Dr. Saroush Zaghi, MD, The Breathe Institute

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Image: Extrinsic Muscles, Netters Anatomy Book

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Dosing for Infants and Children

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  • What are tethered oral tissues such as tongue-ties, lip-ties and buccal-ties?"
    bands of tissue from the underside of the tongue, top of the lip to the bone above the central teeth, and from the lip to the bone on the sides of arch, near the baby molars these tissues are generally thought to not have appropriately experienced apoptosis (the process by which tissue is created and then removed by cellular activity, in this case, to mold a body form) tethered tissues can be thin bands or thick and fibrous (too thin, too short, too thick) they limit range of motion of the tongue, lip and cheeks in the function of eating, speech and facial development a tongue-tie can limit the elevation range of motion of the tongue; often the floor of the mouth compensates with the tongue due to their tethered relationship tethered structures can influence the growth and development of the arches, thereby influencing facial growth patterns we do not outgrow tethered oral tissues—they do not stretch to accommodate; one learns to compensate in function if left undiagnosed and/or untreated frequency of occurrence: tongue-tie > lip-tie > buccal-tie if you see a tongue-tie, look for a lip-tie
  • What causes tethered oral tissues?
    occurs during fetal development and has hereditary influences most commonly attributed to a lack of apoptosis around week 12 in utero Folic Acid is a very important pre-natal vitamin encouraged to prevent more serious midline birth defects; it has an influence in limiting the apoptosis of the midline tongue-tie tissues possible association with MTHFR boys > girls occurrence seen in babies with “stork bites”, birth marks
  • Common symptoms in babies with tethered oral tissues:
    irritability & fussiness during/after nursing struggle to create & maintain a latch (they are often releasing, rooting again and trying to reattach) blanched perioral tissues from “clamping” to maintain a latch from a limited range of motion of the lips and tongue tightly pursed lips with blanching; the lips cannot naturally evert to draw the nipple deep into the mouth clamping/pinching of the nipple (moms struggle with this painful attempt to hold on to the latch and generally see sore patterns to their nipples) continuous struggle to latch and maintain that latch causes frequent interruptions to the natural suck-swallow-breathe pattern seen in nursing babies; this constant disattachment from the breast causes the babies to draw in gulps of air as they were attempting to suck milk, leading to aerophagia and reflux-like symptoms as the milk ingested is frequently vomited up frequent nursing attempts/ longer duration of nursing because of the struggle to properly latch falls of the breast during nursing clicking sounds often heard from a disruption in the suck attempt (disruption to the suck-swallow-breathe pattern) lip blisters develop upper lip tenting noted
  • What are common symptoms noted in a nursing mother?
    breast pain/nipple pain during nursing attempts mastitis from plugged milk ducts (milk is letdown, but not consumed appropriately, leaving engorged breasts) cracked/blistered nipples they can feel the clamping/biting of the baby to hold on and draw milk out thrush infectious patterns may recur audible clicking sounds heard frequently from baby
  • What are common symptoms in a toddler with tethered oral tissues?
    difficulty chewing & managing the bolus of food: slow eaters, messy eaters, easily gag with food consistencies difficulties swallowing solids & liquids: excessive drooling, frequent stones develop in salivary glands sleep disturbances: tossing/turning/spinning in bed; upward posturing of the head as though searching for air; nocturnal bruxism (grinding at night is heard); snoring during sleep difficulty with speech sounds most commonly affecting: D/L/N/T/TH/S/Z difficulty clearing food from teeth (can increase cavity risks from all surfaces because the food is left in proximity to tooth structures); decreased oral hygiene concerns chronic sinus & ear infections from improper swallow patterns leaving stagnancy in the very proximal nasal passages and horizontal eustachian tubes -open mouth breathing (consequential influence in vertical facial growth pattern; long-face growth)
  • What are common symptoms in children & teens left with tethered oral tissues?
    Many of the same symptoms seen in toddlers persist in these age groups with concern of longer duration and longer adverse influence on repeated frequent symptoms and alterations to facial growth patterns. chronic sinus/ear infections open mouth breathing with influence on a long-face growth pattern snoring/grinding increases cavity risk from decreased oral hygiene performance recession of gingival tissues
  • What are the craniofacial growth/postural patterns likely seen in continued tethered oral tissues?
    long adenoid facies open mouth resting posture—leads to nasal disuse (this is true! If you don’t breathe through your nose, dyfunction/disuse occurs in which you then have to be retrained in how to breathe again through your nose!) forward head skeletal posture high vaulted palate from the tongue not resting in the roof of the mouth; tongue tip not hitting the spot just behind the front teeth (keep in mind that the tongue is the most natural palatal expander and if an alteration occurs to its proper position in the roof of the mouth, narrowing occurs as seen in pacifier and digit habits) scalloped tongue pattern to the lateral borders
  • What symptoms do you seen in adults that have yet not corrected or been diagnosed with tethered oral tissues?
    speech impediments tension in neck, shoulders and back frequent migraines sleep disturbances (snoring/clenching/grinding, sleep disordered breathing patterns, possible development of obstructive sleep apnea)
  • What if no symptoms are recognized by myself or health care professionals?
    In these cases, we generally have learned to compensate. Our jobs from birth are to survive and this drive to survive, often leads to compensatory measures to thrive compensations seen in nursing, early food management/swallow patterns and speech/articulation these compensations are continued and maintained during the lifetime until addressed with oromyofunctional therapy before and after tethered tissue releases (if you have been functioning on limited, but compensated, range of motion, myofunctional therapy is a MUST before and after releases for reducing the incidence of scar tissue and/or reattachment of the tethered structures)
  • What are the behavioral effects of prolonged tethered oral structures?
    Sleep disturbances affecting proper brain growth and development (most rapidly occurring before 5 years of age), learning abilities and mood disruptions Acid reflux Anxiety/ADHD/mood disorders Oral fixation behaviors/habits
  • What are the functional effects of prolonged tethered oral structures?
    Improper muscle coordination Open mouth resting posture—open mouth breathing pattern established with likely nasal disuse occurring Food/swallow management concerns Lisp/speech concerns leading to frustrations in communication Large, inflamed tonsils and adenoids Elongated soft palate causing obstruction to the back of throat (snoring audible during sleep; grinding at night) Decreased oral hygiene performance Crowded teeth/ narrow, high-vaulted maxillary arch Discrepancies in arches—tethered tongue can limit the forward growth pattern of the lower arch Blocked nasal passages from enlarged nasal turbinates; nasal disuse from continued mouth breathing Forward head postures altering skeletal and muscle balance adversely influencing alterations to the natural S-shaped spine Chronic sinus/ear infections Acid reflux Sleep disturbances (sleep disordered breathing; obstructive sleep apnea)
  • Who corrects tethered oral structures and how?
    newborns often diagnosed by medical/dental providers. Often at the request of IBCLC/lactation consultants or a mother’s intuition. ENT/pediatrician/pediatric or general dentist performed with traditional scalpel or more commonly used now, a CO2 laser to provide coagulation and titrated approach to tissue removal, lessening harm to surrounding structures in floor of mouth in a small baby
  • What collaborative team efforts are encouraged for babies, children and adults?"
    Infants: IBCLC, chiropractor, craniosacral therapist, physical therapist Child/teen: speech language pathologist--SLP (often also qualified in feeding therapies and certified oromyofunctional therapy), chiropractor, craniosacral therapist Feeding Specialist: speech language pathologist, occupational therapist, certified oromyofunctional therapist) Airway/Sleep: ENT, Sleep Physician (pediatric patterns of SDB differ from adults); Pediatrician, Airway-Centric Pediatric Dentist/Orthodontist, Oral Surgeon, Pediatric Neurologist Musculo-skeletal needs: Pediatric & Adult chiropractor, physical therapist, occupational therapist; craniosacral therapist
  • What should I expect for pain management during the procedure?
    Compound topical is applied to the lip and or tongue surfaces where the restricted tissues lie; in cases of deep, fibrous attachments, a tiny amount of lidocaine with epinephrine is administered. On occasion, if greater diamond-shape exposures remain, it may be prudent to place a few resorbable sutures to better approximate the edges for ideal wound healing (less scar tissue formation or reattachment) CO2 laser provides coagualation at the same time that it ablates (cuts), so many times, little concerns of bleeding follow said procedure
  • What should I use at home to manage any discomfort?
    Tylenol, ibuprofen; homeopathic methods (frozen breast milk, arnica, camila, coconut oils) A follow-up visit is required for any laser release procedure to examine the wound site, healing and progress with the mandatory wound-stretching exercises
  • Should I expect there to only be 1 release attempt?
    Yes, but this is not always the case. For our youngest patients, we are deliberate in only 1 experience for all involved. It is prudent for newborns to begin nursing promptly and effectively consume milk providing growth Some circumstances arise of thicker, fibrous attachment that may warrant a 2nd revision attempt. These are not immediate as the wound should heal prior to re-entry. On occasion, more wriggly toddlers (age-appropriate), may require a 2nd entry as they may reach their limits faster, especially during a more dense, fibrous attachment release. Please keep in mind that Dr. Karen has always limited the number of clinical visits for all her patients as a standardized approach to her practice. She is very considerate of the ability of a child to tolerate chair time for a brief interim and follows the same protocol in these circumstances to avoid burn-out or angst developing with numerous medical/dental procedures
  • Is a follow-up visit necessary?
    Yes! And this is exactly what we all need. This 1-week post-surgical appointment allows us to chat with parents to determine any progress in pre-surgical symptoms/concerns. Has your child (and family) seen alleviation of symptoms? Was the release appropriate to provide release. We can evaluate wound healing and review of exercises for optimal results. A follow-up visit for this surgical procedure also allows Dr. Karen to evaluate technique and make modifications to her approach. This is a standard clinical self-assessment Dr. Karen has always practiced without you even knowing it! Verifying the margins of all previous dental treatment and the success rates of all pulpal medicaments is how Dr. Karen has increased the success of her treatment—self awareness of technique and approach makes providers stronger!
  • What is the importance of wound stretches and is it really necessary?
    Yes! It is imperative that you go into a release procedure prepared for this post-operative management technique wounds heal by contraction; the purpose of the release was that there was a pre-existing limit to the range of motion and now we are “opening/broadening” this tight attachment and through exercises and stretching of the “diamond-shaped” wound, we are re-training the healing process to NOT return to its original position, but to allow for secondary intention healing to a new width/depth more optimal for free range of motion if you are being advised that pre- and post-operative wound stretches are not necessary, please consult with me. It will spare you a reattachment frustration and is in the best interest of your child—our priority!
  • What are recommended wound-care exercises & stretches
    What are recommended wound-care exercises & stretches: INFANTS/NEWBORNS (4 times daily minimum) TODDLERS (2 times daily minimum) SCHOOL-AGE CHILDREN-ADULTS (3 times daily minimum) use gentle, but firm pressure in an upward direction to LIFT the lip and/or tongue massage with upward strokes (you are trying to keep it open, but not re-open the healing wound); do not be too firm or too frequent as we are trying to heal into a large space via secondary intention healing—where the two ends of the wound are not brought together on purpose with a suture Stretches: a physical “lifting” of the wound to prevent reattament/readhesion of the wound Exercises: elevation of tongue exercises as learned via your mandatory pre- and post- operative oromyofunctional therapy sessions. These include elevations, lateralizations, tongue to spot; tongue to palate proper swallow results
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