Healing of the labial and lingual ligament – to stretch and tear or allow ideal healing?

healing of the labial and lingual ligament

To stretch and tear or allow ideal healing?

There is a lot of commentary in the social media of the notion of stretching and tearing the healing wound after a frenectomy procedure to avoid it ‘re-attaching’.  Unfortunately reading the discussion, what appears to be missing is an understanding of the facts, basic tissue histology and an understanding of wound healing.

So let’s look at this and start with the frenum.  The lingual and labial frena are a type 1 collagen ligament that connects a muscle mass to bone.  This is true for all the frena you see when you pull your cheek out and also the frenum under the tongue.  The histology of the ligament is mainly type 1 collagen, the most abundant collagen fibre in our body, which is very strong and non elastic. There are also fibroblasts, the cells that form the collagen, along with other tissue structures including blood vessels, lymph vessels and nerves. There are a small amount of elastic collagen fibres and the occasional skeletal muscle fibre as well.

This tissue is the same tissue as the ligaments that hold all your muscles onto your skeleton and some muscles to other muscles.  The formation of the tissue, size and shape is initially genetically determined and then enlarges or decreases in life affected by the size and strength of the muscles the ligament attaches to.  When ligament tissue is injured, it heals back to the genetic norm, which is what we want.  If we tear an ankle ligament we want it to heal ideally so we can walk and run again.  If the ligament is allowed to rest and heal, it will do this with minimal scarring and movement limitation.

There is no difference with the lip or tongue.

Let’s imagine you have had an orthopaedic surgical procedure where the surgeon has released a ligament away from bone and muscle.  Now the surgeon and yourself want the area to heal ideally to allow the muscles to move freely and the attachment to the bone to be normally strong, with limited scar tissue.  It is very unlikely that your Surgeon will recommend for you to pull, stretch and tear the wound.  Of course not.  They will want you to rest, allow the wound to heal undisturbed and will introduce physiotherapy to get the muscles working properly and ideally.  If the wound is disturbed, healing will be slower, definitely painful and, due to scar tissue formation, there will likely be limitation of movement.  Not what is wanted.

When a person has a lip or tongue frenum released, whether it be a neonate, child or adult, the ligament will try to heal back to normal because that is what every cell in the tissue is genetically coded to do.  We can’t change this, it is who we are.  This healing process unfortunately has been termed a “re-attachment” by some who I fear do not understand the basic histology of human healing.  The term re-attachment suggests there is something wrong when in fact, it is normal healing and re-forming.

If the wound is left just as it is and there is no attempt to guide the healing process within physiological limits, due to genetic coding it will heal up just as it was pre release.  For a baby, we want the ligaments to heal and to be longer below the tongue and the lip (the lip is less important because we can determine where it heals to through the surgical process) and this can be achieved non-traumatically through correct and targeted physiotherapy.  In all other areas of medicine and surgery, wounds are also left to heal without disruption and mobility is achieved through physiotherapy and there should be no difference in the mouth.

So why then is it OK for some people, many not surgically trained, definitely not trained at a post graduate level, and some not having any medical training at all, to recommended that if a tongue or lip ligament is released it should be stretched, torn and disrupted so it won’t “re-attach”, where no other field of medicine would ever suggest such a thing?  With any wound, repeated disruption causes healing by secondary intention resulting in scar formation and tissue movement limitation.  Stretching a healing ligament without disruption (tearing) actually does nothing, it simply puts tension on the ligament.  This is what a muscle attached to a ligament does naturally and encourages the ligament to form as a stronger tighter mass and has the opposite affect of what is wanted.

So stretching without tearing causes a tighter stronger ligament, tearing disrupts fibre formation which may result in a longer ligament initially but this is counteracted by scar tissue contraction.  We know this histological affect, so why promote doing something if it’s not going to be of any benefit and may have a negative affect and will be uncomfortable for the baby?

The team at Perth Specialist Lip and Tongue Tie Clinic do understand the histology, the anatomy, the physiology and the neurophysiology of the mouth and how a baby feeds.  We aim to treat our babies within well established surgically and scientifically proven protocols to ensure the baby and their parents achieve as ideal an outcome as Mother Nature will allow.  The surgical procedure is based on formal postgraduate specialist training with over thirty years of experience doing these procedures with continual evaluation of outcomes.  The physiotherapy, initiated and supervised by the Internationally Board Certified Lactation Consult and similar qualified Colleagues, is backed by extensive experience and scientific study to be effective.  We perform a minimally traumatic surgical procedure to the tissues, allow rapid healing by primary intention with little to no pain and discomfort and promote ideal healing for ligament anatomy to meet physiological need through targeted effective but gentle physiotherapy –  just like every other surgical specialist team does for the rest of the body.  We are also the only dental based clinic in Perth where the surgeon has formal paediatric medical training, important when doing an invasive surgical procedure on a neonate.

We do not practice unproven theories.

We also know that for a small percentage of babies, the ligament tissue will heal faster than a baby can change the memory of their oral muscles and the ligament heals close to pre-surgical anatomy and shorter than ideal.  Again we are dealing with the power of genetics and it’s not always in our favour.  For some babies a revision of the ligament is needed and should be accepted, not seen as a failure.  Not all medical and surgical procedures are 100% successful despite best efforts and again, the mouth is no different.  There is also a percentage of babies that have a neuromuscular dis-coordination of their oral musculature that is reported in the literature to up to 15 per cent of babies.  This nerve muscle dis-coordination is not amenable to frenum release however the presenting symptoms can be so similar that they indicate a frenum release will help.  It is only when the surgical intervention is unsuccessful or minimally successful, and in time other issues arise, particularly when a baby is moving to purees and solids that the true underlying problem is recognised.  Unfortunately babies don’t come with instruction manuals and some babies will undergo a procedure that in the end was not going to be successful.  If the surgery was done well, then there is no long-term harm but it is always good to stick to the principal of ‘primum non nocer’ (first do no harm).  This paragraph also sums up the absolute need that all babies presenting for frenum release Have To Be thoroughly assessed by a consultant with extensive experience in assessing and identifying a feeding/oromotor dysfunction.  For the dental world, this is not in the expertise of a dentist, dental therapist or a dental nurse.  We are not trained to do it –  even at a specialist level and medical colleagues have confirmed this is mostly true in the medical field.  A baby must be assessed by a qualified practitioner such as an Internationally Board Certified Lactation Consult or similar qualified Colleague, so things like a neuro-muscular dis-coordination can be recognised as early as possible and unnecessary surgery is avoided.  Knowing the degree of functional limitation also directs the degree of frenum release, it is not one procedure that fits all and this is something a dedicated and experienced team can provide.

The summary of this article is that we must accept that there is always more than one way to achieve a goal, however any surgical and post surgical intervention needs to be done with complete understanding of the tissues we are dealing with, the neuro-motor regulation, a thorough understanding of the principals of tissue healing and proven surgical and post recovery protocols.  It is critical a baby is assessed by a qualified practitioner to diagnose the feeding disorder (and this is not the surgeon) and that adequate post operative follow up is provided.  For parents it is really important to ask the team what their qualifications are, what their experience is, where they were trained to do the procedure, know all you can and understand what the aim of treatment is and the realistic outcomes before consenting to treatment.  Our practice data has found the majority of families, approximately 85 % have had improvement, sometimes dramatic.  But even under the most rigid screening and adherence to established protocols, some babies do not improve.  This is alright because a baby, what ever the outcome can be assisted to grow up to be a healthy happy little person, the support and nursing practice just might need to be different.

Perth Specialist Lip and Tongue Tie Clinic
January 2019
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