Figure 5 and 6: Both of these frenulums are extremely thick and extend over the maxilla and connect into the roof of the mouth. The picture on the left has a lip that is unrestricted and able to flange, but the picture on the right has a frenulum that restricts the lip ability to flange. Revision of these frenulums would NOT prevent a space between the teeth.
Figure 3 and 4: These labial frenulums are tighter and more restricted as the lip is reflected up and back towards the nose. Notice the blanching or white area in the gums and inability to roll up and back with ease.
Figure 7 and 8: The picture on the left has a functional frenulum that allows for easy access to the upper teeth and improved hygiene. The picture on the right has a frenulum that is extremely thick, puts tension on the gums between the two front teeth and can make oral hygiene very challenging. When brushing this area, the child may pull away because the gum tissue is very sensitive to a toothbrush.
Figure 11 and 12: The same patient immediate post-frenulectomy showing a level lip position and uniform display of the gingiva. The right side shows the revision site immediate post-frenulectomy with a laser. Notice no blanching between the front teeth and fillings placed on front teeth.
Lip frenulum’s have very little if any impact at all in regard to speech. The upper lip is involved in the “B” and “P” sound and is made as the lips come together in contact. In a normal resting position the lips should be able to gently touch one another. The tongue can have a much greater impact on speech and jaw development, which will impact speech and articulation more profoundly than any lip frenulum.
Lip frenulums can present as thicker, shorter and extend over the maxilla and onto the hard palate. At times this specific presentation can lead to great challenges for the parent to brush the upper teeth and can possibly impact the esethics or smile of the child. It is extremely difficult to predict how the presentation of a labial frenulum can impact future hygiene and smile. If the lip is difficult to reflect back to access the teeth so they can be brushed, the risk for plaque buildup can be increased. Lip ties do NOT cause dental decay, but the longer plaque sits on those teeth and the more carbohydrates the bacteria in the plaque have access to it can lead to demineralization (white chalky lines on teeth) and dental caries or a cavity. When plaque sits on the teeth for too long the bacteria in the plaque use these carbohydrates and produce acid. This acid will breakdown and weaken the organic structure of the enamel of the teeth and over a period of time, lead to a white, chalky line under the plaque and then decay. Proper hygiene and diet are extremely important at a young age to help minimize or avoid these problems. Starting to brush once the first tooth erupts is a good practice and seeing a pediatric dentist at or around the 1st birthday is another great way to help monitor and avoid preventable dental issues.
Lip frenulum’s (maxillary frenulum) are located between the upper jaw or maxilla and the inside of the upper lip. These lip frenulum’s can be broken down into 4 categories, but the most important aspect, in regard to breastfeeding, is how the frenulum impacts the ability for the lip to flange and function. The frenulum can vary in thickness, length and connection point from the lip and upper jaw. As you can imagine with so many variables trying to precisely diagnose a lip tie can be complex.
When assessing an infant to determine if a lip frenulum is negatively impacting nursing a simple exam to assess the range and ease of lip motion can be performed. The infant’s upper lip should roll out and up towards the tip of the nose with little resistance and minimal to no blanching of the frenulum in the area of where it connects to the maxilla. If the lip functions well, it will roll back and the tip of the lip will be able to contact or come into very close contact with the nose tip. During nursing the infant must breathe through their nose and the lip does not even need to flange back as far as the tip of the nose.
Figure 1 and 2: Both of these labial frenulums allow for the upper lip to flange up and back towards the nose with little to no resistance and do not blanch the gum tissue. These are normal and functional frenulums.
One of the most common questions about lip frenulum’s revolves around a space or gap between the front teeth and the frenulum. Spacing in infant and children’s teeth is extremely beneficial and ideal. These baby teeth that are spread out and have spaces are easier to clean and the space between the baby teeth will be later occupied by the much wider adult teeth. Genetics play a large part in spacing between the front two teeth and is referred to as a diastema. If the child’s parent or grandparent has a prominent space between the two front teeth or the gap was corrected through braces or cosmetic dentistry, the infant will likely have a diastema as well later on in life. Revising or fixing the frenulum as an infant will NOT resolve the genetic cause of this diastema.
Figure 9 and 10: The left picture shows an upper lip that is held tight to the upper jaw when smiling the inside of the upper lip is seen and the smile shows very little gingiva. The same patient on the right side shows a thick frenulum and dental decay on the front teeth.
If during the exam of the upper lip, the lip is unable to flange to just shy of the tip of the nose and blanching is seen on the gentle rolling back of the lip, the lip frenulum may be restricted and negatively impact the seal or ability for the mouth to have a wide gape or opening.