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Frenectomy FAQ

Laser Frenectomy FAQ
(also known as tongue-tie or lip-tie revision)

Dr. Evy is the first pediatric dentist in the Austin and San Antonio area to establish a strong network of healthcare providers (lactation consultants, midwives, speech language pathologists, pediatricians, nurses, etc…) to provide comprehensive diagnosis and treatment for tongue-tie and lip-tie.

What is tongue-tie or lip-tie revision?

It is a surgical procedure during which the lip-tie and/or tongue-tie are removed with a soft tissue laser.

Do I need a referral from another doctor?

Yes, we require a referral from a pediatrician, lactation consultant, speech language pathologist, or another healthcare professional that has been working with you to rule out other problems. A study from Australia in 2015 (Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments, Kent et al. Int. J. Environ. Res. Public Health 2015, 12, 12247-12263; doi:10.3390/ijerph12101224) reported that “The most common attributed cause of nipple pain was incorrect positioning and attachment, followed by tongue-tie, infection, palatal anomaly, flat or inverted nipples, mastitis, and vasospasm. Advice included correction of positioning and attachment, use of a nipple shield, resting the nipples and expressing breastmilk, frenotomy, oral antibiotics, topical treatments, and cold or warm compresses. Pain was resolving or resolved in 57% of cases after 18 days (range 2–110).”

Therefore it is essential that you and your baby are receiving the most comprehensive care to fully resolve all the problems associated with difficult breastfeeding. If you have additional diagnostic information from another provider please let us know.

How young is too young to have my baby evaluated for a lip- or tongue-tie?

It is never too young to have your baby evaluated. We examine newborns all the time, sometimes babies are only a day old. It is best to have the procedure at a younger age rather than waiting because your baby can form habits that may require additional therapy in the future and a restricted tongue can cause a cascade of events leading to poor development of the oral-facial structures and abnormal breathing patterns. The baby can form habits and compensations which may require your baby to have additional therapy.

Will the first visit be considered a consultation or an exam visit?

It will be an exam visit since it does include a physical examination of the oral cavity, which is needed for full diagnosis and treatment plan recommendations.

Do you have a referral network for bodywork or other therapists?
Yes, we do. When Dr. Evy made the decision to treat newborn babies, older babies, children, and teenagers with tongue tie and lip tie restrictions, she started a support group with other specialists in the area to treat these issues in a multi-factorial way. Removing a tongue or lip restriction does not cure all the problems babies and children experience by itself, it almost always requires a team approach and different types of therapy to fully rehabilitate these babies. We have a network which consists of lactation consultants (IBCLCs), speech language pathologists, midwives, cranio-sacral therapists, pediatric chiropractors, and myofunctional therapists. Please ask us for a recommendation.
Will just having the surgical procedure conducted on my baby help correct my breastfeeding issues?
Caring for you and your baby is truly a team effort and we highly recommend that you continue to work with your (IBCLC )lactation consultant. For some babies, if there are no other problems with the cranium, head, neck, or back, and your baby is a newborn at the time of the revision, the likelihood of additional nonsurgical therapy is low. However, if there are other problems contributing to an improper latch, changing the anatomy of the frenum (lip tie or tongue tie) by surgical removal alone will not fully alleviate all the symptoms. Some babies require additional therapy, i.e speech language pathology therapy for suck, swallow, range of motion, lateralization of tongue, & strengthening training, craniosacral therapy to release tensions deep in the body to relieve pain and dysfunction, or chiropractic treatment for possible nerve interference and to correct subluxation/misalignment that may exist.
Will any pain medication be given to my baby before conducting the procedure?

Yes, in most cases. Dr. Evy has a low-risk, specially compounded topical anesthetic and local anesthetic available for injection when necessary. Dr. Evy will address this question in a more individualized way once she has examined your baby. For older children, adolescents, and adults, topical and local anesthetic are used for comfort during the procedure.

Can I breastfeed my baby prior to the procedure?

Yes, however, if you are planning on having the surgery done in the same visit, we recommend you feed your baby only a small amount of breastmilk and then wait until after the procedure is completed for a full feeding to prevent regurgitation of the milk.

What options do I have for sedation or general anesthesia for my toddler?
Once the doctor has examined your toddler, she will be able to give you the treatment options available. If your toddler is younger than 14 months, we are almost always able to treat the patient by swaddling. It depends on your level of comfort in regards to physical restriction during the procedure. Since at this age they are usually stronger and more mobile, it does create a certain level of difficulty to treat. There are a couple of dental aids that help us maintain your child’s mouth open during the procedure. A child between 14 to 23 months may need to wait until age two when oral sedation based on your child’s weight can be used. If a child has other dental issues that need to be addressed promptly, general anesthesia may be used to treat both decay and any restrictive attachments of the lip and tongue. Dr. Evy usually does not recommend general anesthesia to treat a tongue-tie or lip-tie unless it is absolutely necessary and the benefits outweigh the risks. Children that are 3 years of age and older can oftentimes be treated with nitrous gas only, few require IV sedation. Dr. Evy will present you with the most adequate option for your baby/child at the time of your visit.
I have a toddler who I think needs to have the procedure conducted, what options do I have as far as sedation or general anesthesia is concerned with the use of the laser?
If your toddler is 14 months or younger, we may be able to treat him/her without any use of oral sedation or general anesthesia. It depends on your level of comfort in regards to physical restriction during the procedure. Since at this age they are usually stronger and more mobile, it does create a certain level of difficulty to treat. There are a couple of dental aids that help us maintain your child’s mouth open during the procedure. Once the doctor has examined your toddler she will be able to give you the treatment options available.

A child between 14 to 23 months may need to wait until age of two when oral sedation based on your child’s weight can be used. If a child has other dental needs (extensive dental decay) that need to be addressed promptly, general anesthesia may be indicated to treat both decay and any restrictive attachments of the lip and tongue. Dr. Evy usually does not recommend general anesthesia to treat a tongue-tie or lip-tie unless it is absolutely necessary and the benefits outweigh the risks.

Is it possible to treat my child without use of sedation, nitrous oxide gas, restraint, or verbal behavior management?
This will depend on the child and the situation. For very young, anxious children with extensive treatment needed, it is not possible to treat without sedation, some sort of passive restraint or verbal guidance. For older children and/or small treatment plans it may be possible to treat without any of the above.

For children that are younger than 3 years of age or those with complicated medical histories, who require immediate or extensive treatment, it is usually necessary to use general anesthesia since they are usually not candidates for in-office IV sedation due to age and weight.

For the dental examination for babies and infants, it is necessary that they are restrained by you the parent or legal guardian so that the doctor can conduct the dental examination. It is normal for children this age to cry and be guarded. It is important that you remain calm and are supportive following the doctor’s recommendations so that the visit can be as short as possible and your child’s apprehension is short lived. For the frenectomy procedure, the baby will be swaddled.

How long does the appointment usually last?

I recommend stating the appointment time is typically 1-1.5 hours because typically that’s how long those appointments last, that way the 20-30 minutes is not misleading and patients don’t expect this time frame.

The examination may take 20-30 minutes including showing you the stretching exercises, giving you all the information about the procedure, and answering questions you may have. The procedure takes a small amount of time and you will be allowed in the room as soon as the procedure is complete. It is important that you read as many materials as possible prior to your appointment including this FAQ page as it will answer many of your questions.

Am I allowed to stay in the room with my baby while the procedure is being conducted?
Due to state laser guidelines and regulations, we have you wait in our special breastfeeding area or in the reception area during the procedure. In addition, Dr. Evy prefers to focus fully on your baby so that we may finish the procedure quickly. We invite
you to trust us and know we will take care of your baby, if the procedure takes a little bit longer than anticipated it usually means it is because we are being as careful as possible and properly removing the tie(s), especially when revising a baby that moves excessively and has very thick or deep ties.
Will my baby bleed extensively?

No. The laser cauterizes and since there are no major arteries or veins within the tie (frenum), there usually is very minimal or no bleeding.

What will happen if I do not conduct the post procedure exercises?
The risk of wound contracture is higher if the exercises are not conducted as instructed. Some individuals claim exercises don’t play a major role in re-attachment; however, well-respected doctors such as Dr. Kotlow, Dr. Margolis, and Dr. Ghaheri
recommend them to increase the success of the revision. At Green Apple, we have seen how proper exercises have produced better results vs no or improper exercises. At the one-week follow-up visit, Dr. Evy will give you feedback on how your baby is healing and make recommendations accordingly. If Dr. Evy suspects re-attachment has occurred already, she may mechanically separate or open the revision area which may set you back another week in healing time. The stretches are meant to be quick, effective, and with gentle to firm pressure. Dr. Evy and/or her team will show you how to do these exercises during your visit.
Is my baby going to be in pain after the procedure? What can I use for pain management?

On the day of the procedure babies don’t usually experience discomfort. The discomfort usually sets in on day two and can last up to day five post-revision. However, every baby is unique and therefore every baby experiences the healing process and the level of discomfort differently. We recommend skin to skin contact with your baby and allow your baby to latch on your beast as much as possible whether for feeding or just for soothing/comfort. You can freeze some breast milk and place small shavings of it in your baby’s mouth and allow it to melt. Some parents report using Hyland’s teething gel/tablets, rescue remedy, or arnica with success. We have a tongue-tie remedy available at our office that contains several herbs to help your baby with discomfort. In addition, based on your baby’s weight, you will have a calculated dose of infant’s Tylenol in your post-op instructions should your baby develop a mild fever or need it for pain management.

What else can I expect post-surgery?

Some babies may sleep more in the days following the revision and breastfeed less often, we suspect this is their way of dealing with the healing process. Some babies may have shorter and more frequent breastfeeding episodes. You may notice a great latch on the day of the revision and then not as great during the days following the revision due to soreness setting in and new oral musculature starting to be used post-revision when the tongue has more freedom to move. This is similar to training for a marathon with one leg having restrained musculature, if those muscles are freed you will not be able to run the same way until you re-train and strengthen those muscles that have now been freed. Many times the tongue needs time to adjust or even needs retraining if it has been compensating for a while. Remember, sucking begins in-utero so even though your baby may be a newborn, he/she may still need time to adjust or he/she may need to have therapy to strengthen the oral musculature.

In addition, your baby may also cry during the stretching exercises and this is normal considering you are stretching tissue in an open wound. You may see minimal bleeding during the exercises but this is usually not a concern since it stops quickly, very few parents have reported bleeding. Increased drooling has been observed as a side effect of the surgery but it returns to normal as the wounds heal.

Does my insurance cover the procedure?
We usually don’t find out until your claim is processed by your insurance company. Over time, we have learned that each plan is unique with different stipulations, deductibles, and coverage (certain insurance plans require (or highly recommend) a pre-authorization prior to the procedure). We highly recommend you contact your insurance plan and ask about coverage for the procedure. Keep in mind, we are a dental office and therefore we only bill claims to specific Dental PPO plans. Therefore, when
contacting your insurance plan, have them look at dental code coverage. We are NOT contracted with any medical plans including any HMOs and do not file any medical claims.

Please understand that we file dental claims as a courtesy. We do not have a contract with your insurance company, only you do. We are not responsible for how your insurance plan handles its claims or for what benefits they pay on a claim. We can only
assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will cover in your dental claim. We cannot be responsible for any errors in filing your insurance as we file claims as a courtesy to you.

We highly recommend you contact your insurance plan to check the status of a claim. Please remember any estimates in your treatment plan are just that, an estimate, and we will not know how much your insurance reimbursement is until your insurance plan processes your claim.

Does my baby need to be active on dental insurance for the procedure to be covered?
Yes and no. Typically insurance plans for newborn babies will retroactivate the effective date to the date of birth if the patient is added during the enrollment period. For other patients, the patient would need to be active for the insurance to consider covering the procedure. Coverage depends on the patient’s insurance plan, including the plan’s guidelines and limitations for the procedure. An insurance plan will usually not consider a claim for reimbursement if your baby is not active on the plan on the date of service.
Does medical insurance cover the procedure?
We are a dental office and we are not in contract with any medical insurance plans, so we encourage you to call your specific insurance plan to find out. We do not file any claims to medical insurance plans.
Will you bill my medical insurance?

We are a dental office and we do not have medical contracts with your medical insurance plan and therefore we are unable to file a claim for you. However, we will provide medical superbills upon request. A medical superbill will have the dental
procedure codes translated to medical codes, which you can then provide to your medical insurance for possible reimbursement. We encourage you to contact your insurance plan for any additional questions.

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