A lip tie is a developmental fold of oral mucosa (the skin of the mouth) in the midline under the lip. It forms during the first trimester of pregnancy. This structure is called a frenum or frenulum. It often extends from the top of the gum under the lip to the bottom of the gum. It is a normal part of human anatomy and can be long, short, tight or slack. However, it can create issues for some people and treatment may be recommended to overcome these issues.
The frenulum does not have any important structures inside it such as blood vessels, nerves or muscles and not having a frenulum is not an issue.
When the frenulum is tight and causes issues or restricts the movement of the lip, it is called a lip tie. When there are no issues or functional restrictions, we tend to avoid using the word “tie”, but this has caused some confusion amongst health care workers. Some people believe that everyone has a tie, and the word “tie” is synonymous with a “frenulum”. But we prefer to use the term “tie’ when it relates to a restriction.
The earliest sign that a lip tie may be an issue is when a baby cannot breastfeed properly and in particular cannot latch on to the breast so bobs on and off, or cannot form a good seal around the nipple and swallows too much air (known as aerophagia) which then leads on to reflux. This reflux can be obvious, and vomitus is seen or can be ‘silent reflux’ where no vomitus is observed. When an excess of air enters the baby’s stomach, the baby becomes very windy, and uncomfortable. This is often witnessed with crying during a feed, tension in the baby’s body, arching the back and clenching the fist above the head. The baby then has an inadequate amount to feed, until the air is expressed, and then the baby is hungry again and wants to feed again. Parents then complain that they are feeding their baby with very short feeds which are very frequent. This is sometimes referred to as ‘cluster feeding’. This is exhausting for parents and becomes a really significant issue if there are older children to look after.
Lip tie commonly manifests itself as a gap forming between the upper central incisor teeth. This in known as a diastema. It can be the first sign that orthodontic issues will develop as the gap will cause a mal-alignment of the upper teeth relative to the lower teeth. The adjacent teeth can also erupt in to the wrong position and be crooked in appearance or crowded. The gap seen I the baby teeth is often then seen in the adult teeth particularly if the lip tie is thick and grows all the way to in between the central incisor teeth. We often see gaps which are 2-3mm wide. If the lip tie is treated early, there will be no gap caused by the tie.
If a lip tie is left between the teeth and not treated, it can become tender when brushing the upper front teeth resulting in a poor brushing technique, plaque being left on the teeth and tooth decay resulting. Modifying the brushing technique may resolve this issue but this can be very difficult for a child to undertake.
In less common circumstances we have seen lip ties create a flat smile with a thin lip appearance, affect the way that the lips close together and be associated with speech mispronunciations such as /p/, /b/ and /m/. Problematic feeding from a spoon can be associated with lip function issues but this is very rare.
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