Laser Frenuloplasty for Nursing Infants

Historically, various surgical and other methods have been employed to address problematic infant latch anatomy. Currently, the most common approach to frenotomy in infants involves clipping the frenulum with scissors, with or without previous clamping.¹ However, with advancements in lasers specifically designed for the water absorption spectrum, these conditions can be successfully treated in a more efficient and predictable manner.

Ankyloglossia is often treated within the first few days after delivery. Pediatricians and dentists widely recognize these lingual reductions as effective. To aid in clinical description, Corrylos developed a classification system for the positions of the lingual frenum.² However, the effect of a tongue tie on nursing is a subjective measure. Clinicians determine the extent of that effect from the chief complaints of the nursing mother.

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Although tongue ties are more frequently associated with breastfeeding difficulties, maxillary anterior lip ties represent another anatomical challenge to infants’ ability to latch. This article examines the indications for and outcomes of treating the maxillary anterior frenulum in infants.

Traditional Treatment for Lip Ties

Conventional surgical techniques for addressing maxillary anterior lip ties can result in inflammation, bleeding, and discomfort for the infant. Therefore, infants who require an upper anterior frenulum release are sometimes treated with local or topical anesthetics. Nonetheless, the presence of postsurgical inflammation and discomfort following these procedures necessitates ample time for proper healing. Decreased referral rates for corrective surgery may be associated with the stress tied to these procedures. Occasionally, the parents of children with lip ties are informed that their child may tear the tissue during a fall or other typical childhood incident, resolving the issue naturally. In addition, mothers may be advised to manage breastfeeding discomfort with various devices or to consider starting bottle feeding instead of choosing surgery. If the child has a significant upper lip tie, mothers are often informed that a frenotomy can be performed later in life if necessary to help align the permanent incisors.

Laser-Assisted Frenuloplasty

As the advantages of incorporating lasers into dental practices become more apparent, dentists are increasingly adopting laser technology. North America dominated market sales of lasers with a revenue of $159 million in 2024 and is expected to continue its dominance for the forecasted future.³ Laser surgery for infants with tethered oral tissues that hinder an ideal latch profile is a relatively new technique in medicine and dentistry. When treated with a laser rather than a surgical blade or scissors, nursing infants do not require sedation, local or topical anesthesia, or sutures. There is minimal bleeding and swelling, and the baby is permitted to nurse immediately after the procedure.

A laser’s wavelength determines the absorption rate characteristics of every tissue and the thermal effects. Research has found that the lasers with the lowest thermal effect damage were Er,Cr:YSGG lasers, which were followed by CO₂ lasers and diode lasers.⁴ Comparative studies have demonstrated that CO₂ lasers offer improved intraoperative bleeding control and shorter surgical times; however, Er,Cr:YSGG lasers achieve faster healing times.⁵ This author performs laser-assisted frenectomies with the Er,Cr:YSGG laser.

Understanding and Treating Maxillary Lip Tie

Although 90% of women report acute breast and nipple pain during the first week of breastfeeding, this pain is considered a clinical norm related to the mechanics of breastfeeding. Breastfeeding pain is a major reason for early cessation of breastfeeding for approximately 35% of women.⁶ In cases of excessive lip ties, the upper lip may struggle to protrude adequately, hindering the formation of a proper seal around the mother’s nipple. The tethered lip may fold inward, resulting in a chewing motion instead of a smooth suckling action. This chewing motion can lead to excessive pain as well as bleeding, bruising, and blistering around the nipple. Furthermore, the compromised seal causes air to be drawn in and swallowed. Inadvertently swallowed air can cause gas and discomfort for the baby.⁶ If nursing problems are not resolved, mothers may turn to bottle-feeding relatively soon after giving birth. These babies may still thrive, but the nursing benefits for both mother and infant will be lost.

A maxillary lip tie will not resolve by itself. If left untreated, the nursing mother will continue to experience pain and other breastfeeding problems.⁷ When examining the causes of breastfeeding problems, the upper attachment to the gingival tissue of the anterior maxillary arch should be included in any differential diagnosis. The Kutlow classifications are well designed to serve as guidelines for the documentation of lip ties. This author’s clinic frequently treats class III and IV lip ties associated with problematic latching, which can be anatomically fleshy or fibrous (Figure 1 through Figure 7). However, the team has learned that categorizing these attachments has proven insufficient as an exclusive means of diagnosing a problematic tie. If a mother experiences pain during nursing, or the child struggles with unlatching, clicking noises, or gas, the child may have an inadequate latch profile. At this author’s practice, severe class IV cases are the most common among mothers who have already ceased nursing or are experiencing pain while nursing. Complaints of pain or unlatching during the first few days of postnatal care should be promptly addressed. Mothers who feel uncomfortable during nursing immediately after delivery are at an increased risk of abandoning nursing as each day passes. The 2010 Infant Feeding Survey reported that the most common reasons for introducing bottles and stopping breastfeeding during the first week included the infant not latching on properly, mothers having painful breasts or nipples, and mothers feeling that they had “insufficient milk.”⁸

Paying attention to the mother’s primary concerns during nursing is crucial because this is key to diagnosing latch failure and the potential of tethered oral tissues. Treating only the upper lip has raised concerns among dentists and physicians. The maxillary frenulum can be very vascular and difficult to correct with traditional surgery, which has led to a reluctance to treat it. Laser-ablated tissues, however, show minimal swelling, allowing infant patients to nurse immediately after surgery and heal more predictably (Figure 8 through Figure 16).

An infant with a tethered upper lip tends to develop muscle memory regarding the position it can assume during nursing. This may be the first instance of muscle memory that develops in a newborn. A frenulum freed from a restricted tether enables the upper lip to establish new muscle memory for a more efficient position. After lip ablation, mothers are instructed to lift and pull the upper lip forward to create a more effective seal. This guidance applies to both nursing and bottle-fed infants. After a few days, the infant will establish a new muscle memory for the more efficient lip position. This new muscle memory helps to facilitate proper healing. Cases have been observed in which treated lip ties have partially regenerated; however, because of the new muscle memory, they do not interfere with effective nursing. In these instances, the frenulum is thinner and appears less restrictive than it did before the procedure.

Practice Survey of Lip Tie Releases

To determine the success and validity of laser-assisted lip tie releases, the author’s practice conducted a patient survey. After many years of treating infants with inadequate nursing latches, the practice had compiled a substantial database of relevant cases for inclusion. They surveyed 276 cases in which an upper lip tie release was the only treatment performed to enhance latching, documenting the infant’s sex, age, and status of breastfeeding, bottle feeding, or both, along with the mother’s chief complaints. The patients included in the survey were roughly split by gender and averaged 5.7 weeks in age. Although the average age of the exclusively breastfed babies treated was 5.5 weeks, the average age of the bottle-fed infants treated was 6.5 weeks. This difference may result from a greater demand for assistance from breastfeeding mothers. According to the data, gas distress was the most frequently reported chief complaint among mothers experiencing latch issues, followed by unlatching, clicking sounds, frequent spitting up, pain when nursing, nipple blisters, infant weight loss, and nipple bleeding. This is not an exhaustive list of symptoms indicative of a failing latch; however, these complaints were the most commonly encountered in the survey.

Immediately after laser frenuloplasty procedures, the mother and infant are transferred from the operating room to a quiet office where they can escape the “bad energy” associated with the surgical area and allow the baby to nurse or bottle feed. The overwhelmingly positive feedback received during these postoperative feeding sessions warrants some scrutiny because of the emotional release that the mothers experience. Therefore, from the initial group of 276 cases used in the survey, 104 were randomly selected for a postoperative review. A somewhat lengthy list of postoperative survey questions could have been included for clinical review; however, the primary purpose of infant ablation surgery is to enhance nursing, and medicine and dentistry simply require an answer to the fundamental question, “Did the procedure work?” Of the respondents to the postoperative review, 100% reported that their babies recovered well from the laser surgery, 97% reported that their baby continued to demonstrate an improved latch, and 99% indicated that they would recommend the procedure to other mothers. If the success of frenuloplasty in nursing infants is determined by the extent to which the initial chief complaints were resolved, then the responses to this simple survey indicate that the answer to that question is overwhelmingly yes. 

Conclusion

Five studies using different diagnostic criteria have found that the prevalence of tongue ankyloglossia was 4% to 10%.⁹ With better diagnostic criteria for inadequate latch profiles that include maxillary anterior frenulum tethering, the reported incidence of lip tie will likely increase. The success rate achieved by this author’s practice is promising and emphasizes the effectiveness of lasers as tools in these surgical procedures. Numerous studies have affirmed the health benefits of long-term nursing for both infants and mothers. As more dentists incorporate lasers into their practices, lip tie reductions are likely to become standard procedures performed to support breastfeeding. 

About the Authors

John Blaich, DMD
Fellow
World Clinical Laser Institute
General Dentist
Poplar Bluff, Missouri

Adeeti S. Mishra
Undergraduate Pre-dental Student
Saint Louis University
Saint Louis, Missouri

Figures and Images

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Fig. 1

A typical class III lip tie, where the attached mucosa shows blanching during the protrusive movement of the upper lip.

Fig. 2

A less common but more severe class IV lip tie with a fleshy structure that is interfering with maxillary development.

Fig. 3

A more fibrous tether, with noticeable blanching at the attached mucosa when raising the upper lip in a protrusive movement.

Fig. 4

Examples of excessive lip ties that are thin and fibrous.

Fig. 5

Examples of excessive lip ties that are thin and fibrous.

Fig. 6

Views of excessive lip ties following initial tooth eruption.

Fig. 7

Views of excessive lip ties following initial tooth eruption.

Fig. 8

Preoperative and 3-month postoperative views of an extremely fibrous case that was corrected with laser frenuloplasty.

Fig. 9

Preoperative and 3-month postoperative views of an extremely fibrous case that was corrected with laser frenuloplasty.

Fig. 10

Preoperative and immediate postoperative views of excessive maxillary frenula in infants that were treated with laser frenuloplasty.

Fig. 11

Preoperative and immediate postoperative views of excessive maxillary frenula in infants that were treated with laser frenuloplasty.

Fig. 12

Preoperative and immediate postoperative views of excessive maxillary frenula in infants that were treated with laser frenuloplasty.

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Preoperative and immediate postoperative views of excessive maxillary frenula in infants that were treated with laser frenuloplasty.

Fig. 14

Preoperative and immediate postoperative views of excessive maxillary frenula in infants that were treated with laser frenuloplasty.

Fig. 15

Preoperative and immediate postoperative views of excessive maxillary frenula in infants that were treated with laser frenuloplasty.

Fig. 16

Eighteen-month postoperative view of a healed maxillary frenum following laser frenuloplasty.