The topic of tongue and lip ties seems to come up often in many breastfeeding related Facebook discussions.
‘Ties’ is a collective term that refers to tongue tie, upper lip tie and maybe even buccal (cheek) ties.
The presence of the frenulum (band of connective tissue) underneath the upper lip is known as the labial (or maxillary) frenulum.
The presence of a labial frenulum is normal.
If the labial frenulum happened to affect function of the upper lip, it could be referred to as an upper lip tie.
It has been suggested that some breastfeeding problems (e.g. poor latch or ‘reflux’ signs and symptoms) may be contributed to by an upper lip tie.
However, to date there is insufficient evidence to either support or refuse these claims.
4 Facts About Breastfeeding And Upper Lip Ties
This article explores the evidence about breastfeeding and upper lip ties.
#1: Presence Of Labial Frenulum Is Normal
It has been suggested that where the labial frenulum inserts onto the upper gum is indicative of a class of an upper lip tie.
For example, the Kotlow classification scale notes that a class 3 maxillary lip tie is when the labial frenulum inserts ‘just in front of the anterior papilla’, and a class 4 maxillary lip tie is when the labial frenulum has an ‘attachment just into the hard palate or papilla area’.
However, what the Kotlow (and other scales) actually show is the range of normal labial frenulums.
A study of over 1,000 newborns who weren’t having any particular problems found:
- 6.7% had ‘buccal’ insertions of the labial frenulum (class 1 or 2 ‘Kotlow’ attachment)
- 76.7% had ‘crest of alveolar ridge’ insertions (class 3 ‘Kotlow’ attachment)
- 16.7% inserted ‘palatally’ (class 4 ‘Kotlow’ attachment).
All these findings show the range of normal labial frenulums.
#2: Labial Frenulums Change
While most babies have a class 3 or 4 ‘Kotlow’ attachment, only 21.2% of children with primary teeth, 10% with mixed (baby and permanent) teeth and 5.6% with permanent teeth (11-12 years of age) do.
#3: There Is No Diagnostic Criteria For Upper Lip Tie
Since the presence of a labial frenulum is normal, it’s not appropriate to call it an upper lip tie unless it’s clearly causing a functional problem.
So, with all the above in mind, when would a labial frenulum be called an upper lip tie in a baby? The truth is that this is anyone’s guess at the moment as we do not have any valid diagnostic criteria for it.
Evidence is significantly lacking with regards to when it may be helpful to release a baby’s labial frenulum.
This is because studies that have included releases of labial frenulums have not released ‘upper lip ties’ and tongue ties separately but rather have released them together.
Hence, it cannot be determined if results of such studies are due to the tongue tie release, the ‘upper lip tie’ release or both.
#4: Upper Lip Only Needs To Rest In A Neutral Position For Effective Breastfeeding
For effective breastfeeding, the upper lip does not have to flange out like the lower lip – it only needs to rest in a neutral position.
If the criteria used for diagnosing an upper lip tie were that the upper lip needed to flange out like the lower lip does when breastfeeding, then the vast majority of babies would have upper lip tie!
Finally, the high prevalence of the Kotlow class 3 and 4 amongst babies can lead to misdiagnosis during the first few years of age and result in unnecessary surgical correction.
As Nagavini indicates:
“Therefore, it is very important to distinguish between a wide normal frenulum and an abnormal one in young children, and knowledge about the frenulum types in children is highly essential among the clinicians to avoid unnecessary surgical intervention.”