What to expect when your baby has Tethered Oral Tissues (TOTs)

You've taken an important first step. Here's what comes next.

As IBCLCs, our role is to assess feeding function, coordinate conservative treatment, and refer to qualified specialists when surgical evaluation is needed. Diagnosis and surgical treatment decisions are made by licensed medical or dental providers.

Phase	What Happens
1. Active Conservative Management (1–3 weeks)*	Bodywork, oral habilitation exercises, and manual therapies to improve orofunctional range of motion This phase focuses on improving your baby's orofunctional range of motion and addressing restrictions within the body. For many families, this phase alone produces significant improvement — and for some, it resolves the challenges entirely without surgery. What we're doing: Assessing the full spectrum of potential restrictions (frenal, fascial, and neuromuscular) Coordinating bodywork to release tension patterns Beginning oral motor exercises to build range of motion, strength, and coordination Understanding Tethered Oral Tissues Tethered oral tissues (TOTs) encompass any condition restricting functional range of motion within the orofacial complex. This includes: Frenal restrictions: Tongue-tie, lip-tie, and buccal (cheek) ties Fascial restrictions: Tension in the connective tissue that links muscles throughout the body Neuromuscular dysfunction: Cranial nerve involvement affecting the coordination of sucking, swallowing, and breathing These varied causes may occur individually or in combination. Importantly, surgical release only addresses frenal restrictions — bodywork and exercises address the fascial and neuromuscular components that surgery cannot change. About Fascia and the Deep Front Line Fascia is the connective tissue that links muscles throughout the body. The deep front fascia line begins at the tongue and connects through the lungs, diaphragm, and pelvic floor. When fascial tension is abnormal — whether from intrauterine positioning, birth, or other factors — it can significantly impact muscular function and create restrictions that look identical to anatomical tethering. Bodywork helps release this tension, which: Improves range of motion even before any surgical intervention Makes the full extent of any frenal restriction visible to the release provider Prepares the tissue for optimal healing if surgery is needed May resolve functional challenges without surgery in some cases Birth Factors and Cranial Nerve Function Your baby uses six cranial nerves, 22 bones, 34 sutures, and 60 muscles to coordinate sucking, swallowing, and breathing. This intricate system can be affected by: Fetal positioning (breech, transverse, or constrained positions) Prolonged or rapid labor Assisted delivery (vacuum, forceps, cesarean) Cord positioning These experiences can create tension patterns or affect cranial nerve function in ways that impact feeding — even without visible anatomical restriction. Bodywork helps release these patterns so your baby can function optimally. Why this phase matters: Many families see significant improvement during this phase alone. By addressing fascial and neuromuscular restrictions first, we can better determine whether surgical release is truly needed — and if it is, we've prepared your baby's body for the best possible outcome.
2. Surgical Release (1 day)	Frenectomy with a trusted provider, if needed Surgical release addresses the one type of restriction that bodywork and exercises cannot resolve: anatomical frenal tethering. If your baby's progress remains limited after active conservative management, we'll refer you to a qualified provider who can evaluate whether a surgical release of the tethered tissue is indicated. We only refer to providers who: Use evidence-based techniques Understand optimal oral function Have consistently delivered good outcomes for our families You won't be alone. Dr. Miller attends the release appointment with your family to ensure full collaborative care between providers — and to support you and your baby through the process.
3. Continued Habilitation (4–6 weeks)*	Wound care + ongoing exercises to build strength and function Whether or not your baby needed a surgical release, this phase focuses on building the strength and coordination needed for optimal oral function. What to expect: Continued exercises to build strength, coordination, and proper muscle patterning Gradual improvement in feeding, breathing, and/or sleep Regular check-ins to adjust the plan as your baby progresses Myofunctional Development Now that the restrictions have been addressed, your baby's muscles can finally move the way they were designed to — but they've never had the chance to develop strength and coordination in these new ranges of motion. Oral habilitation exercises help your baby: Build strength in the tongue, lips, and cheeks Develop proper coordination for sucking, swallowing, and breathing Establish healthy oral resting posture (tongue up, lips closed, nasal breathing) Create new muscle memory patterns to replace compensatory habits Think of it like physical therapy after a cast comes off — the restriction is gone, but now we need to rebuild what was lost and train the muscles to work properly. Wound Care (If Surgical Release Was Performed) If your baby had a frenectomy, the wound needs to heal in an open, diamond-shaped pattern rather than reattaching. Your releasing provider will give you post-operative instructions, and we'll support you in following them. We'll guide you through: Understanding and implementing the wound care protocol What to look for as the wound heals How to keep your baby comfortable during the process Signs of optimal vs. suboptimal healing Consistent follow-through during this phase is essential to prevent reattachment or restrictive scar tissue. Why finishing matters: Stopping early puts your child at risk for symptom recurrence or incomplete healing. You've already done the hard part — stay the course and your child will reap the benefits.

*Timing may vary depending on individual circumstances and is presented as general guidance only.

Note: The process described above is designed for infants. Treatment for older children may involve different providers, protocols, and timelines. Every case is managed individually based on your child's unique needs — we'll work with you to develop the right plan.