What is a frenectomy, frenulotomy or frenulum extirpation?
A frenectomy, frenulotomy or frenulum extirpation means that the tongue tie or lip tie is removed by means of a surgical instrument. The choice of the instrument depends on the practitioner.
A frenectomy, frenulotomy or frenulum extirpation means that the tongue tie or lip tie is removed by means of a surgical instrument. The choice of the instrument depends on the practitioner.
In the Netherlands children up to 18 years are insured for dental care. The applicable dental rates that are calculated are determined by the Dutch Healthcare Authority. Prices 2024
When you have a Dutch insurance, the consultation or treatment is directly invoiced to the health insurance. You do not have to pay in advance. If you do not have Dutch health insurance, you pay after the consultation. You receive a letter for the insurance which explains about the treatment and costs, so you may can get it reimbursed. Always make sure to check with your insurance if all costs are covered. Extra consults next to the treatment might not be fully covered.
For the costs of a consultation or treatment of therapists other than dentists, you should contact the relevant practitioner.
In this short online lecture, Kirsten Slagter explains how healthcare in the Netherlands is arranged around treatment of a tongue tie.
Mucous membranes heal differently than skin. A wound resurfaces on the skin like a brown crust. Mucous membranes heal white yellowish with a red border around it. Generally, the wound heals within 2 weeks (see photo). Do not remove the new mucous membrane on purpose.
Inflammation rarely occurs. With an inflamed wound, the wound image is more red and swollen. When in doubt always contact your provider.
There is a lot of discussion about the definition and treatment of the different types of ties, and whether there is evidence that a treatment is effective and how much you have to remove from the ties.
Research in the past mostly looked at the most “obvious” and visible tongue tie that had a membrane to the tip of the tongue. But more recent studies by O’Callahan (2013) and Pranksy (2015) show that there is indeed a posterior part, behind the oral mucosa which also needs to be treated to alleviate the (breast) feeding problems. Sometimes there is no visible membrane under the tongue and a sub mucosal or “hidden” tie causes the problems with feeding.
Sometimes only the membrane is cut at the tip and the (hidden) part behind the oral mucosa is not released. An American ENT doctor describes it as if the sail is lowered on a sailing ship, but the mast is left to stand. See the blog (link) of ENT doctor Ghaheri.
A tongue tie and / or lip tie can be released or by means of various surgical instruments. This can be scissors, laser or electro surgery. The choice of the surgical instrument is made by the person who performs the surgery.
An electrotome is a surgical instrument for performing electro surgery. The device consists of two electrodes and a patient plate. By using a high voltage between the two electrodes, this can be used as a surgical knife.
Two positions are possible: a cutting position and a coagulating position. The cutting position loosens the attachment of the tissue. At the coagulating position the wound is immediately ‘closed burned’. Blood vessels are closed by coagulation of tissue; the bleeding comes to a standstill. This leads to better wound healing and therefore less chance of infection.
The advantages of electro surgery are:
Depending on age, the choice is for surface anaesthesia or infiltration anaesthesia. Surface anaesthesia is applied by means of a cotton swab and infiltration anaesthesia is actually inserted into the tissues by a needle and takes about 2 to 3 hours before it is works out.
If necessary, general anaesthesia is the choice of the therapist. However, there are publications in science that advise against general anaesthesia in young children.
See publication Anaesthetic considerations for surgery in newborns: www.tongriem.com/wp-content/uploads/2019/02/narcosevoorbaby.pdf))
There are risks associated with each surgical procedure and complications can occur. The complication that can occur is a bleeding.
If an after-bleeding occurs after treatment, contact your provider immediately.
Check whether a clotting disorder can be a cause. Until the bleeding is stopped by the doctor, try to stop it with gauze or a cloth by pressing the wound for a few minutes. For a more extensive advice protocol see FAQ: What to do in case of a bleeding?
There are risks associated with each surgical procedure and complications can occur. The mouth is a well-circulated area through which a bleeding can occur.
At the time of a bleeding, it must first be checked whether there is a possible clotting disorder or a deficiency of vitamin K use.
If this is not the case, the depth and size of the wound image must be assessed. This can only be assessed by the practitioner. The extent of the bleeding cannot be measured objectively. An attempt must first be made to stop the bleeding by compression or (sterile) gauze. If these are not available, a cloth can also be used. It is important to keep the compression continuous for about 10-15 minutes. Should then the gauze or cloth continue to turn red, the wound image must be reassessed. Depending on the degree of bleeding, you can once again choose compression or suture the wound.
In babies and children, the advice is not to suture, but to apply compression to the wound until bleeding stops. This is because surface anaesthesia was used and the restriction of movement when sutures are placed in the mouth area. If it is necessary to suture, it is important to choose soluble sutures. Sutures should not be placed “too tight” or with too much tension on the wound. This is not desirable in connection with possible restriction of movement.
Follow-up by a paediatrician with babies or children is desirable. This is to measure any other body functions. Adults are also advised to consult a doctor if desired.
Follow-up of the wound must be performed by the practitioner.
For practitioners, the following steps are important if a complication occurs after or at the time of release:
Analyze what happened, when and what the consequences are for the patient.
Inform colleagues (directly involved) of the complication.
Consult with colleagues who may take over the treatment relationship (if patient wishes).
For babies, children and adults, because of the fast wound healing of the mucous membranes in the mouth area, re-treatment may be necessary. This is only if the healed tissue is too tight again.
It may also be possible that the previous practitioner has not removed enough of the tongue tie and or the lip tie. Also due to compensation behaviour, no or insufficient aftercare it may be that some degree of regrowth has occurred.
During the consultation, the dentist or doctor examines whether there is a tongue tie and / or lip tie present and whether the problems could be related to this. She then explains what this means and gives advice about a possible treatment. If desirable, a release can take place in the same appointment. The health record and the intake form will first be discussed before a release is performed. Depending on age, superficial anaesthesia is applied with a cotton swab or local anaesthesia with a syringe and needle. Depending on the age, instruction of aftercare and exercises take place before the actual release itself. After the release for baby’s, a Lactation Consultant IBCLC assists with bottle or breast feeding and helps you to get on your way home, after the wound has been checked. There is too little time for a complete consultation of the Lactation Consultant IBCLC. The focus of the actual appointment is on consulstation and/or treatment.
If you breastfeed and are currently using a nipple shield, please bring it. Also bring some expressed breast milk or formula in a bottle if you can. The baby may not drink immediately from the breast because of the different feeling in his/her mouth from the tongue tie release
When bottle fed, bring some formula. Handy is if you bring some hot water in a thermos can.
It is not necessary for the baby to drink or have a complete feeding, it is just for comfort and may get rid of the strange taste.
Come if possible with two people, for example your partner, family or friends. Other children can be distracting (not for the doctor, but for your own attention).
If the baby’s BSN or health insurance numbers are not yet known when making the appointment please bring them to the appointment at the practice, so the secretary can write them down.
After the procedure you will receive an aftercare card with the mobile number of the Lactation Consultant present at your appointment. You can contact her with any questions regarding the procedure. She will then contact Dr. Kirsten Slagter,(DSS,PhD), or Dr. Suzanne Wink (GP).
These questions may include:
Any concerns about (breast) feeding please contact the Lactation Consultant.
If you are worried about the appearance of the wound you can send a video or photo to whatsapp or messenger of the Lactation Consultant or info@tonguetieclinic.com.
If you are worried about the general health of your child, always contact your general practitioner as well.
A laser in dentistry is an instrument that emits (electromagnetic) radiation. After absorption into tissues, the effect of this radiation becomes noticeable and effective. The clinical choice for a laser type depends on the goal you want to achieve. Coagulation lasers are used to stop bleeding, for example. Working in a completely different way are water lasers, which make treatment techniques possible through the irradiation of water. Lasers provide a controlled depth of cut and a controllable degree of bleeding.
An electrotome is a surgical instrument for performing electro surgery. (See frequently asked question: what is an electrotome?)
Laser therapy does not show a significant difference compared to electro surgery for the treatment of soft tissue management in dentistry with regard to tissue damage, wound healing, pain, bleeding and tissue permeability.
Scissors are often used to remove ties. It’s only a cutting instrument and will therefore not “remove “tissue. It only makes the tie loose. Also is there more chance of bleeding because there is no coagulation component.
The choice is therefore always made by the practitioner which surgical instrument is used.
Pain and discomfort, see this FAQ.
Temporarily more throwing up because the baby drinks more effectively, the stomach may not yet have been used to the new amount so quickly.
There may be some swallowed blood after the treatment. That doesn’t do any harm. A little green / black solidified blood can be in the diaper.
More saliva.
Temporarily bad smell from the mouth. This is because the ties are removed and scalded at the same time.
Temporarily more difficult to latch on, more painful latching on, refusal of breast or bottle, also look at the FAQ about remedying compensation behaviour.
Suction blisters can stay for a while, your child is used to drinking in a compensatory way and it can take some time before it is gone. It does no harm.
Your baby can be very grumpy the first 24-48 hours. Also read the frequently asked question(link) about it.
Fever; in fever, the body temperature is 38 degrees or higher. It is very unlikely that this is due to the treatment, rather though another infection. It is important that your child is not drowsy and continues to drink well. If refusing milk give milk from a bottle or with syringe.
For children under 3 months with a fever you should always warn your doctor.
In very rare cases there is a coagulation disorder or anatomical variation that causes bleeding and will be solved immediately after the treatment.
One does not go home after the treatment before the wound is checked. In a baby, it is not expected that the wound starts bleeding at a later stage. In adults and older children, this may happen incidentally after the anaesthesia has worn off (anaesthesia contains vasoconstriction components). Most patients find that the numbness from the injection wears off after about two-three hours.
What can happen at home is that some scar tissue comes loose, scar tissue contains blood vessels. The wound wants to heal, and it should heal, but at the same time you don’t want too much scar tissue, which may restrict the mobility of the tongue again.
What to do: Slowly remove any clot or blood with a gauze before doing something similar to the one below. Keeping a baby upright and make sure that he or she is not too hot.
Do not rinse with water.
Press dry with a gauze for 3 minutes without letting go. If the wound is not dry another 5 minutes with small pressure.
Options for on the gauze: Strong tea is blood vessel narrowing and also xylometazoline (regular nasal spray).
A baby may immediately drink milk again.
If the wound is not dry after 10 minutes of pressure, please call the mobile number of the lactation consultant at the Tongue Tie Clinic (number on the card given to you). You must then return to the clinic after consultation with the therapist (1-way).
For treatments at a location other than the the Tongue Tie Clinic, the agreements with that doctor apply.
Prior to the procedure, the doctor will numb the tongue or lip tie locally with surface anaesthesia on a cotton swab.
Overall anaesthesia or infiltration anaesthesia does not outweigh the disadvantages in babies and young and children.
A paracetamol suppository may be given before the procedure (this is not necessary) or afterwards. Paracetamol is given among other for the muscle pain after the treatment. This is also a possibility prior to the aftercare exercises. If desired, you can get pain relief/paracetamol in our clinic after the treatment.
Paracetamol is a relatively harmless medication that has a fever-reducing and analgesic effect. You can give this on the basis of age and weight.
According to most package leaflets, the use of paracetamol should be given in consultation with a doctor under three months. However, it is indicated in pain, acute and postoperative. https://www.drugs.com/paracetamol.html
Rectal (suppository) is the most user-friendly. You can insert the suppository by sliding the tip up to 1 cm past the anus. Sometimes it is useful to hold the buttocks of your child together for a few seconds so that the suppository is not expressed.
You can buy paracetamol at the pharmacy and some drug stores. It’s also possible to get the paracetamol in our clinic. Because paracetamol can also be given to reduce fever, sales for children under the age of 3 months are not recommended with this indication. At a body temperature of 38 degrees or higher below three months you should always warn a doctor. The paracetamol is therefore exclusively given to relieve pain and discomfort.
Under the three months; 60 mg three times a day rectally
From three to 12 months; 120 mg three times a day rectally
From 1 year or from 10 kilos; 240 mg three times a day rectally
The paracetamol remains active around 6-8 hours. If necessary giving paracetamol can be repeated.
It is possible that 24-48 hours after surgery, babies can be irritable and tearful.
Rarely, it may take longer. If babies refuses the breast or bottle, you can give milk orally with a spoon or syringe, or a small medicine cup placed to the lower lip so that you can gently drip some milk into the mouth. A baby will ultimately want to drink again, but may have trouble getting used to the new mobility of his/her tongue. Temporarily the baby may also latch on with a nipple shield (watch this video).
If the baby is still very upset an acetaminophen (paracetamol) suppository can be given. 60 mg depending on the weight. When in doubt about the amount of medication always consult a doctor.
If you have any questions do not hesitate to call your Lactation Consultant. (Or the lactation consultant present if you had an appointment at the Tongue Tie Clinic, you will find her telephone number on the aftercare card.)
Treating tongue- and lip tie is relatively speaking, a minor surgical procedure and an attempt to improve the present situation. This applies to babies, children and adults.
It remains, however, always a surgery.
In general, the younger the patient at the time of the treatment, the more likely symptoms will improve.
However, the degree of success in infants can also be affected by other factors such as childbirth and how the baby drank the breast or bottle prior to treatment. Babies need to re-learn how to use their tongue as they have established compensatory behaviours such as jaw clenching to obtain the milk. Sometimes it takes several days or weeks before results are seen. Often babies can be irritable the first 24-48 hours and can refuse the breast or bottle. If the baby refuses the breast, use a bottle, teaspoon or syringe so that the baby receives some milk.
It is strongly advisable to make an appointment with a Lactation Consultant and/or other therapists if feeding remains problematic, ask the Lactation Consultant who was present at the release which therapy is most suitable. For example, physiotherapy, speech therapy or chiropractic/osteopath/craniosacral care. It is also advisable to have a check up on the wound within a week with somebody who has knowledge.
Older babies may want a paracetamol suppository to make them feel more comfortable after the procedure. Depending on their weight, 60-120 mg. Check at your pharmacy.
After the release, you may notice things that may last a little longer, such as lip swelling, drooling, gagging, or other discomfort or peculiarities.
* Granulation tissue; This is a small lump of extra scar tissue that can form on the wound. If you suspect you see this, send a photo, it is not serious and if it is a hindrance to drinking it can still be removed.
* Drooling; Because the swallow has to be learned again after tongue tie release, it is possible to notice drooling for a while in a child or baby.
* Reattachment; After the treatment, the wound simply wants to heal with scar tissue. With doing aftercare you hope the wound does not close too quickly or too tightly. If too much reattachment occurs, the tongue or lip mobility can be limited again. When you live abroad it is the adviceble to check the healing with somebody knowledgable in a week, that can also be done at our clinic if you can stay a few days, but has to be arranged with making the appointment for treatment. In The Netherlands you can call the Tongue Tie Clinic for an appointment.
* Muscle pain; After the treatment the adults and older children notice (muscle) pain or discomfort in the jaws, tongue and throat sometimes as well. See the FAQ about pain relief.
* Baby spits more; Because the baby drinks more effectively, it may be that the stomach is not used to the amounts and it spits back up, but it may also be that the baby is still drinking air for a while.
* Smelly breath / mouth; We sometimes hear this from parents and can last from a few days to a week, it’s ussualy no problem whatsoever.
* Swollen upper lip; This can last for up to 5 days after lipband treatment.
* Quivering jaws remain visible longer; Because the tongue, after it has come loose, many of the muscles still need to be trained, it may be that the compensation continues with the jaw muscles, but compensation behavior may also need a chiropractor or manual therapist to remedy it. See the FAQ about compensation behavior and videos explaining this.
* You have to help lips flange out; The baby is not used to flanging the lip, this may be helped.
* Suction blisters still present; They can be present for longer, especially on the upper lip.
* Crying doing aftercare; What we hear from parents and notice at the aftercare consultation that the baby cries with the aftercare exercises, but stops as soon as you stop or start feeding or changing diaper and such.
* White plaques/debris on tongue still visible; Because the palate is often high and the tongue is not well trained to stay up, even at rest, the white plaques/ debris on the taste buds remains.
* Bottleteat; We notice that the teats with a broad base cannot go deeper into the mouth, so a teat that can go deeper and gives more mouthfilling, such as the smaller, narrower types, is often better.
* Baby stays upset longer than 48 hours, crying, drinking worse. In the older baby who has had to compensate for a long time with a tongue tie. Before the treatment, often these babies were fussy and drinking poorly and found there own “technique”. Treatment of compensation behavior is often necessary. See FAQ compensation behavior. People often give painkillers for longer. But one also has to take into account a normal virus infection occurs at the same time. You can go to the doctor with a fever, see the FAQ about fever.
* Gagging may still be present after the release.
* A baby cannot swallow the tongue after the release.
* Apnea are also observed in babies . It is not directly related to the release. Tongue tie can be related, read the research.
In older babies, children and adults with a tongue tie, compensatory oral habits may be present. During pregnancy, a baby swallows amniotic fluid with a tongue tie, which means that hiccups may already be present. An older child and adults have exhibited compensatory behaviors for years as surrounding muscles and tissues compensate for the limited functional movement of the tongue. Think of moving food in the mouth from side to side, swallowing well without choking, wiping your teeth after eating and talking. Often the patient swallows with his tongue forward instead up and back, which is called a tongue thrust. This can affect the position of the teeth, jaws and the overall body posture.
The preparation for a treatment is therefore twofold:
1. Compensatory movements in the head and neck region can be quite “stuck” and therefore better checked and treated by a special therapist before a tongue tie release. We hear from patients that they have this done by a physiotherapist, manual therapist, orofacial therapist, chiropractor or osteopath for complaints such as incorrect posture, stiff neck, jaw clenching, grinding and headaches. Treating a tongue tie alone is not sufficient if the surrounding muscles keep the compensating behaviour and restrict functional movements.
2. Treatment also improves if the patient goes to a specialized speech therapist in OMT (oromyofunctional therapy) before and after the treatment. This can help to analyze incorrect oral habits and swallowing and train or unlearn these. If an OMT speech therapist is not available, the Kieferfreund app is an option to train and practice (see www.kieferfreund.com and https://www.tonguetieclinic.com/tongue-tie-therapy/https://www.tonguetieclinic.com/tongue-tie-therapy/)
Click here to see what treatment of an older child/adult looks like.
Click here to see what the treatment for a baby/young child looks like.
We use Ultracaine D-S forte for anesthesia.
Ultracaine D-S forte does not affect breastfeeding, because anesthesia is only locally applied and absorbed.
