Functional Definition and Clinical Consequences of TOTs
The restriction in the range of motion of muscle groups of the cheeks, lips, or tongue are colloquially known among many disciplinary professionals as tethered oral tissues (TOTs). The variation in root causes of TOTs only contributes to the scholarly contention surrounding diagnostic criteria and semantics.
Complexity in Symptomatic Origins of TOTsThe human mouth contains 7 frena: one in each quadrant of the maxilla and mandible which attaches the gums to the buccinator muscles in the cheeks (superior and inferior buccal frena), one connecting the gums to the lips along the upper (the maxillary labial frenum) and the lower (mandibular labial frenum) jaws, and one underneath the tongue (lingual frenum). A restricted range of motion resulting in overly taught frena is known as a tie, thus restricted range of motion due to overly taught or restrictive frena are known as buccal tie(s), lip tie(s), or tongue tie.
The deep front fascia line begins at the tongue and connects many important anatomical parts through the front of the body including the lungs, diaphragm, and pelvic floor, continuing all the way to the feet (Basic Medical Key, 2016). When the fascia’s level of tension is abnormal, organs may move in or out of their normal locations and overly tense fascia can cause pain. It is intimately connected with muscular function and provides support for nerves throughout the body, and fascial defects (George & De Jesus, 2021). The position of a muscle relative to its connective tissue has a profound impact on intra-muscular mechanics (Yucesoy, et al., 2006). Thus we can understand how the fascia tissue connecting muscles of the orofacial complex can wreak havoc elsewhere in the body if it is restricted, and how releasing its restrictions will have a positive effect throughout the body. As the orofacial complex is comprised of dozens of muscles innervated by the cranial nerves, any dysfunction of any of these nerves may compromise their function. Cranial nerves may be compressed or may not have fully activated in their function due to positional challenges during their time in the womb or a high-intervention birth (Upledger & Vredevoogd, 1983). |
Clinical Consequences of TOTs On Feeding
There is an abundance of research and policy to document the adverse breast/chest feeding impacts of tethered tongues (Academy of Breastfeeding Medicine [ABM], 2014; see also Cho, et al., 2010; do Rêgo Barros de Andrade, et al., 2020; Ferrés-Amat, et al., 2017; Fernando, 1998; Miles, et al., 2004; Forlenza, et al., 2010; Geddes, et al., 2008; Hong, et al., 2010; Hand et al., 2020; Le Réverénd, et al., 2014; McClellan, et al., 2015; Moss, 1997; Edmunds, et a., 2013; Parr, 2018; Pransky, et al., 2015; Rasteniene, et al., 2021; Rike, et al., 2005; Srinivasan, et al., 2019) and tethered lips (D’Onofrio, 2019; see also Kotlow, 2013; Benoiton, Morgan & Baguley, 2016).
While there is very little documentation specifically related to buccal tethers and breast/chest feeding, an understanding of physiology makes it clear. Restrictions in functional range of motion of the buccinator muscles will prevent an infant’s ability to move the corners of their mouth forward as there is lateral tension exerted which prevents these muscles from moving toward the midline, thus inhibiting the infant’s ability to create a seal on the breast tissue (Rathee & Jain, 2021).
Nursing parents of infants with TOTs frequently experience nipple pain and feelings of helplessness (Riordan & Wambach, 2010) as well as sleep deprivation (Fernando, 1998). There is also an increased risk of postpartum depression in parents who wished to nurse their children but struggled or failed (Sá Vieira, et al., 2016; Wedad Saad, et al., 2018).
Dysfunctional cranial nerves can result in an excessive gag reflex (American Osteopathic Association [AOA], 2017). Swallowing requires the use of the muscles of the tongue as well as movement of the mandible, hyoid and other muscles that are interconnected to these bones. If the hyoid bone, which connects several muscles to it including the genioglossus (the muscle responsible for upward tongue movements) is out of its normal alignment, then the tongue can appear to be imbalanced in its muscular ability (AOA, 2017; Messina, 2017). Li, et al. (2020) described cases where compression of the trigeminal nerve during routine adenotonsillectomies caused immediate trigeminocardiac reflex (TCR) in two children, resulting in the activation of the vagus nerve, parasympathetic dysrhythmia (dangerously low heart rate) and sympathetic hypotension (dangerously low blood pressure)—conditions which reversed themselves immediately upon removal of the tool which compressed the nerve. These cases demonstrate the extreme sensitivity of our bodies to the proper functioning of our cranial nerves and the dangers that may accompany their dysfunction.
The rotation of bone and subsequent malformation of muscles resulting from TOTs can adversely impact the innervation of those muscles, and can directly impact muscle function related to sucking, swallowing, chewing, the tongue’s range of motion, and normal resting tongue posture (AOA, 2017). Specifically, cranial nerves V, VII, IX, and XII directly impact an infant’s ability to latch onto the breast/chest with a vacuum seal, the ability to suck normally, swallow normally and also can inhibit the infant from breathing normally.
While there is very little documentation specifically related to buccal tethers and breast/chest feeding, an understanding of physiology makes it clear. Restrictions in functional range of motion of the buccinator muscles will prevent an infant’s ability to move the corners of their mouth forward as there is lateral tension exerted which prevents these muscles from moving toward the midline, thus inhibiting the infant’s ability to create a seal on the breast tissue (Rathee & Jain, 2021).
Nursing parents of infants with TOTs frequently experience nipple pain and feelings of helplessness (Riordan & Wambach, 2010) as well as sleep deprivation (Fernando, 1998). There is also an increased risk of postpartum depression in parents who wished to nurse their children but struggled or failed (Sá Vieira, et al., 2016; Wedad Saad, et al., 2018).
Dysfunctional cranial nerves can result in an excessive gag reflex (American Osteopathic Association [AOA], 2017). Swallowing requires the use of the muscles of the tongue as well as movement of the mandible, hyoid and other muscles that are interconnected to these bones. If the hyoid bone, which connects several muscles to it including the genioglossus (the muscle responsible for upward tongue movements) is out of its normal alignment, then the tongue can appear to be imbalanced in its muscular ability (AOA, 2017; Messina, 2017). Li, et al. (2020) described cases where compression of the trigeminal nerve during routine adenotonsillectomies caused immediate trigeminocardiac reflex (TCR) in two children, resulting in the activation of the vagus nerve, parasympathetic dysrhythmia (dangerously low heart rate) and sympathetic hypotension (dangerously low blood pressure)—conditions which reversed themselves immediately upon removal of the tool which compressed the nerve. These cases demonstrate the extreme sensitivity of our bodies to the proper functioning of our cranial nerves and the dangers that may accompany their dysfunction.
The rotation of bone and subsequent malformation of muscles resulting from TOTs can adversely impact the innervation of those muscles, and can directly impact muscle function related to sucking, swallowing, chewing, the tongue’s range of motion, and normal resting tongue posture (AOA, 2017). Specifically, cranial nerves V, VII, IX, and XII directly impact an infant’s ability to latch onto the breast/chest with a vacuum seal, the ability to suck normally, swallow normally and also can inhibit the infant from breathing normally.
On Orofacial Growth and DevelopmentA labial frenum with too low an attachment point to the gums can become problematic after teeth emerge, when it can pull the gingival margin from the tooth or prevent the closure of a diastema (space between the teeth) during orthodontic treatment and also foster the accumulation of plaque along the gingeva, thus increasing the rate of periodontal recession (Priyanka, et al., 2013; Stylianou, et al., 2020).
Restrictive buccal frena inhibit the ability of the buccinator muscles in cheeks to support optimal oral cavity function (Iwanaga, et al., 2017). They may also contribute to the pocketing of food in oral vestibules (D’Onofrio, 2019; Rathee & Jain, 2021). The buccinator muscle benefits chewing and swallowing with its maximum range of motion and is one of the first muscles activated when an infant begins suckling. As the tongue is considered the architect of the mouth, its inhibited movement and subsequent dysfunctional compensatory behaviors can result in malocclusion (Boyd, 2011; D’Onofrio, 2019; Le Réverénd, et al., 2014; Pirilä-Parkkinen, et al., 2009; Sari & Auerkari, 2018; & Upledger & Vredevoogd, 1983). Lip tethers may also cause central incisors (the front teeth) to rotate, separate or flare (D’Onofrio, 2019). On Subsequent Gastrointestinal ConsequencesThe inability to eat and swallow appropriately can lead to symptoms of aerophagia or subsequent gastroesophageal disease (GERD) (Baird, et al., 2015; Bredenoord & Smout, 2007; Collins, et al. 2019; Fishbein, et al., 2013; Gonzalez Ayerbe, et al., 2019; Granderath, et al. 2007; Hand, et al., 2020; Hibbs & Lorch, 2006; Kotlow 2011, 2016, 2018; Lightdale, et al., 2013; Shepherd, et al., 2013; Siegel 2017; & Watson & Mystkowski, 2008). In the United States, infant GERD is treated with risky pharmaceutical medications that have not been extensively studied in infants, nor are they indicated for use in infants by pharmaceutical manufacturers (Hibbs & Lorch, 2006).
On Impaired Respiration and Subsequent ImpairmentsIf the tongue cannot functionally elevate to the palate, the active and resting postures of the tongue directly influence the downward growth of the lower jaw and also impair the development of the oropharyngeal airway, thus presenting a risk factor for obstructive sleep apnea syndrome (OSAS) (D’Onofrio, 2019; Lee, et al., 2007). High and narrow palatial arches due to the resultant pressure on underlying orofacial hard tissues by restricted muscles involved with chewing and swallowing and the resulting dysfunctional compensatory behaviors (Rathee & Jain, 2021).
Further, underdevelopment of the muscles of mastication resulting from incorrect chewing patterns subsequent to TOTs may result in a retruded maxilla and mandible (Le Réverénd, et al., 2014,; Boyd, 2011), some of which can even be seen prenatally, and which ultimately result in narrowed airways (Boyd, 2011), contributing to further difficulties breathing. Sleep-disordered breathing is an umbrella term which includes obstructive sleep apnea syndrome (OSAS), upper airway resistance syndrome (UARS) (Lian, et al., 2017) and hypoventilation (Al-Shamrani & Alharbi, 2020), all of which are recognized as common causes of morbidity in children (Sinha & Guilleminault, 2010; Al-Shamrani & Alharbi, 2020). The type of SDB that is most well-researched is OSAS, which affects an estimated 1.2%-5.7% of children (Guilleminault, et al., 1972), although this is thought to be an underestimate of its true prevalence (Gipson, Lu, & Kinane, 2019). There are a wide range of potential adverse impacts from OSAS that affect an estimated 1 billion people worldwide, from hypertension, cardiovascular disease, neurocognitive impairment (Malhotra, et al., 2021), metabolic syndrome (Al-Shamrani & Alharbi, 2020) to learning difficulties, depression, memory loss, and poor growth (Sinha & Guilleminault, 2010). TOTs are clearly shown in the literature to be a precursor for OSAS and its subsequent tonsil and adenoid inflammation (Boyd & Kelly, 2019; D’Onofrio, 2019; Guilleminault, et al., 2016; Huang, et al., 2015; Lee, et al., 2007; Olivi, et al., 2013). The disordered breathing associated with TOTs often incrementally worsens in severity as the individual grows older (Guilleminault, et al., 2016). The postural impacts that may result from a compromised airway due to ankyloglossia includes forward head posture and craniocervical extension, poor standing posture and haunched shoulders (Olivi, et al. 2013). There are postural deficits subsequent to airway protection, resulting in further muscular strain (Ozbek, et al., 1998; Olivi, et al., 2013). Compromised airways tend to result in a higher severity of obstructive sleep apnea (OSA) symptoms, lower hyoid bone position relative to the mandibular plane, a longer and larger tongue than expected, a smaller nasopharyngeal and larger hypopharyngeal cross-sectional area, and finally a higher body mass index (Ozbek, et al., 1998). Adequate buccinator range of motion aids in the comfortable closing of the mouth (Rathee & Jain, 2021) and so tethered buccinators adversely impact the ability to keep the lips closed at rest. Even in the absence of other symptoms, mouth breathing during sleep is a known risk factor for OSA, the collapsibility of the upper airway and increased disease severity (Kim, et al., 2011; Guilleminault, et al. 2016). The impacts of SDB spread far and wide. Children with SDB have a 40% increased risk for needing special education services (Besson, 2015) and suboptimal orofacial development, and are also at risk of an increased body mass index (Ozbek, et al., 1998). Further, mouth breathing and OSA can result in poor gut microbiota and related subsequent immunological challenges (Sekirov, et al., 2010). Children born with TOTs also may have challenges with speech articulation (Baxter & Hughes, 2018; Bruderer et al., 2015; D’Onofrio, 2019; Daggumati, et al., 2019; Ito, et al., 2015; Kent, 2021; Lalakea & Messner, 2003; Le Réverénd, et al., 2014; Messner & Lalakea, 2002, Ostapiuk, 2006; & Walls, et al., 2014), which is known to carry increased risks for academic, emotional, and/or social challenges (Hitchcock, et al., 2017). Additionally, it is estimated that up to 95% of those with obstructive sleep apnea experience attentional deficits (Youssef, et al., 2011). Incidentally, roughly 6.1 million (9.4%) of children in the United States have already been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), 62% of whom are taking ADHD medication (CDC, 2021d). As we now know that the symptoms leading to ADHD diagnoses may also be attributed to obstructive sleep apnea (Blesch & McCoy, 2016; Besson, 2015; Youssef, et al., 2011), the exact number of children that may be taking stimulant medication to treat a neurological impairment that may instead be remedied by correcting the oral dysfunction which contributes to their disordered breathing has yet to be clearly defined. However, if 98% of those with SDB demonstrate at least some ADHD symptoms that it could be expected that the rate of ADHD diagnoses would steadily decline over time if the SDB were reduced or prevent with treatment. |
Confounding Factors
When too few variables are included in research design, the outcomes presented may appear to be in conflict with the conclusions reached in other research that utilizes different variables. This may be the result of differing disciplinary paradigms, or it may be an oversight due to the siloed nature of disciplinary scholarship. As healthcare providers are trained in more general anatomy and bodily functions and processes, sciences addressing the body as a whole with a fundamental interrelatedness of its parts has been relegated to the disciplinary sidelines of scholarly publications and thus is easily forgotten or simply not understood by well-meaning primary physicians. We know that the mouth, face, and temporomandibular joint are functionally inseparable (Upledger & Vredevoogd, 1983), as the systems within them are complex and inter-reliant. It is relevant to consider that there may be other conditions babies are facing aside from tongue, lip or buccal frenal tethers that may be impeding their ability to move their tongues, lips, or cheeks freely. These sometimes occur in conjunction with frenal tethers, but other times they occur on their own. It can be a challenge for a release provider that has only been educated about tethered frena to identify these other structural sources for restricted range of motion in the orofacial complex, leaving infants susceptible to unnecessary surgeries which may result in the further restriction of their oral tissues due to scar tissue or increased fascia restriction.
A relatively common condition that afflicts infants’ ability to nurse is congenital muscular torticollis. This occurs when the sternocleidomastoid (SCM) muscle causes a lateral head tilt to one side with the chin rotating toward the other side (Herman, 2006; AOA, 2017). Stellwagen, et al. (2008) found that 73% of newborns have one or more asymmetries in the face, head, or neck, including a 16% rate of torticollis. Torticollis was experienced after a fetus was “stuck” in its intrauterine position for 6 weeks or more during pregnancy. Longer second stage labors, the use of forceps during delivery and birth trauma was associated with moderate facial asymmetry. Birth trauma itself was associated with moderate cranial and mandibular asymmetries. A combination of these asymmetries was found in 10% of newborns studied.
With the supine sleep position recommended by the AAP to reduce SIDS, babies with these asymmetries are at a higher risk for developing deformational posterior plagiocephaly (Stellwagen, et al., 2008; Herman, 2006; AOA, 2017). Outcomes are best when treatment begins as soon as possible to birth and continue within the first three months afterwards. If treatment is not sought, deformable changes to the cervical spine can occur, with the severity of the deformity increasing with the baby’s age along with the severity of the SCM tightness (Sargent, et al., 2019). |
The rotation of bone and subsequent malformation of muscles in these regions can adversely impact the innervation of those muscles, and can directly impact muscle function related to sucking, swallowing, chewing, the tongue’s range of motion, and normal resting tongue posture (AOA, 2017). Specifically, cranial nerves V, VII, IX, and XII directly impact an infant’s ability to latch onto the breast/chest with a vacuum seal, the ability to suck normally, swallow normally and also can inhibit the infant from breathing normally. These nerves may be compressed or may not have fully activated in their function due to positional challenges during their time in the womb, or through physical traumas during birth such as birthing in a posterior position (sunny side up), being born surgically (cesarean section), by having an assisted birth either with tools such as forceps, or by a physician forcibly pulling the infant from the birth canal by their head (Upledger & Vredevoogd, 1983). Dysfunctional cranial nerves can also result in an excessive gag reflex (AOA, 2017). Swallowing requires the use of the muscles of the tongue as well as movement of the mandible, hyoid and other muscles that are interconnected to these bones. If the hyoid bone, which connects several muscles to it including the genioglossus (the muscle responsible for upward tongue movements) is out of its normal alignment, then the tongue can appear to be imbalanced in its muscular ability (AOA, 2017; Messina, 2017). Li, et al. (2020) described cases where compression of the trigeminal nerve during routine adenotonsillectomies caused immediate trigeminocardiac reflex (TCR) in two children, resulting in the activation of the vagus nerve, parasympathetic dysrhythmia (dangerously low heart rate) and sympathetic hypotension (dangerously low blood pressure)—conditions which reversed themselves immediately upon removal of the tool which compressed the nerve. These cases demonstrate the extreme sensitivity of our bodies to the proper functioning of our cranial nerves and the dangers that may accompany their dysfunction.
These fetal or birth challenges are commonplace within these United States. Surgical (cesarean or c-section) births occur at a staggering rate of 22-39% depending on the state one resides in (CDC, 2021a), with an overall average of roughly 32% (CDC, 2021b). The World Health Organization estimates that just 10-15% of surgical births are medically necessary (WHO, 2015). Babies born using forceps or a vacuum delivery have decreased in frequency since the 1990s but were still accounting for a combined 3% of births in 2019 (Michas, 2021). With the rate of non-physiologic birth so high in the U.S., along with the fact that TOTs continue to be ignored by most major healthcare disciplines, it is little wonder that while an average of 84% of parents start out breast/chest feeding their newborns, by 6 months only 26% of these parents have successfully nursed their babies without supplementation (CDC, 2021c), contrary to national and worldwide recommendations that infant should receive nothing but human milk prior to the introduction of solid complementary foods around 6 months of age (National Institute of Child Health and Human Development, 2017). Chiropractors, osteopathic physicians, or physical therapists can make gentle adjustments to the placement of the bones and their surrounding tissues to correct some of these challenges, sometimes with great results on the nursing infant to improve their feeding at the breast (Watson Genna, 2015). Some providers also perform craniosacral therapy, a gentle hands-on method which evaluates and enhances the body’s craniosacral system using a soft touch that is generally no firmer than the weight of a nickel. The craniosacral system includes the cerebrospinal fluid and membranes that protect and surround the brain and spinal cord, as well as the fascia within the body. These practitioners gently release restrictions within this system, thus improving functioning of the central nervous system (including the cranial nerves) and many functions of the body, including but not limited to neck and back pain, motor-coordination impairments, as well as infantile colic (Upledger Institute International, 2021) and tethered oral tissues (Berg-Drezin, 2016). |
Myofascial release (often provided by physical, massage, or craniosacral therapists) can also benefit the fascial restrictions due to TOTs. The deep front fascia line begins at the tongue and connects many important anatomical parts through the front of the body including the lungs, diaphragm, and pelvic floor, continuing all the way to the feet (Basic Medical Key, 2016). When the fascia’s level of tension is abnormal, organs may move in or out of their normal locations and overly tense fascia can cause pain. It is intimately connected with muscular function and provides support for nerves throughout the body, and fascial defects (George & De Jesus, 2021). In fact, it has been shown that the position of a muscle relative to its connective tissue has a profound impact on intra-muscular mechanics (Yucesoy, et al., 2006). Thus we can understand how the fascia tissue which creates the frena (Mills, et al., 2019) can wreak havoc elsewhere in the body if it is restricted, and how releasing its restrictions will have a positive effect throughout the body.
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Collateral Impacts
In addition to the myriad impacts of TOTs outlined above, the domino-effect of restricted oral function impacts seems to have no end. Below is a small selection of some of these more commonplace and evidence-supported impact of tethered oral tissues on the individual, the family, and on society at large.
How many babies are being misdiagnosed or insufficiently treated for their TOTs, and what might this impact be upon families worldwide? We are beginning to learn of the experiences of parents facing this dilemma.
Edmunds, Fulbrook and Miles (2013) conducted a hermeneutic phenomenological study of 10 women to explore their experiences of nursing a child with tongue-tie. Common themes discovered was the dissonance between the parents’ expectations of nursing and the challenges they ultimately faced. Six distinct phases were found in common for parents interviewed; “Expectations; Something is wrong; Questioning; seeking advice; no real answers; Symptoms and perseverance; Approaching the wall- it’s all too much; and finally, Relief” (p. 190). These women noted that they had received conflicting advice about breastfeeding from their health professionals, as well as about tongue-tie management, which added to their confusion and frustration. Further, where these women gave birth, there was no diagnostic tool or standard assessment technique used to screen for tongue-tie and no consistent treatment protocols. If one were to extrapolate this data to all the parents with babies who have just a tongue-tie, and one were to accept the low end of its estimated prevalence, even 4% of parents worldwide would be a staggering number facing this frustration and confusion, though that number is surely much higher when you account for all the infants with TOTs, with or without tethered frena. |
Evidence-Supported Treatment
As the potential impacts of TOTs are so varied, so too should be treatment. Oral function represents only one part of the feeding dyad, and a baby with poor oral function may gain weight well if they have a nursing parent with an abundant milk supply and sensitive let down reflex, as in this circumstance the baby needs only to swallow the milk poured into their mouth. Clearly, treatment cannot be one-size-fits-all. There are simply too many variables involved for TOTs treatment to be that black and white. The evidence discussed in this review supports the integration of a variety of treatment approaches for individualized treatment planning based upon the needs of the individual with tethered oral tissues.
Pre and Post Habilitative CareMyofunctional therapy has been shown to reduce scar retraction after a surgical release (Ferrés-Amat, et al., 2017) in addition to its obvious benefit in the habilitation of orofacial function. Infants cannot technically receive a diagnosis of myofunctional disorder due to their young age (and thus symptoms have not persisted long enough to warrant a diagnosis), but age-appropriate exercises to address orofacial dysfunctions seem to serve much the same end; however their efficacy is much harder to track with empirical data gathering techniques due to variability in functional development between infants. With no documented risks associated with therapeutic exercise to encourage optimal functioning combined with the mitigation of scar tissue risk (which may re-tether the tissues) makes myofunctional therapy or an infant-adapted form of habilitative exercises to promote the same optimal function should be a regular part of all TOTs treatment, prior to and after surgical release. Indeed, if a tongue is tethered such that the muscles within it have not have adequate opportunity to strengthen or develop coordination, then pre-hab exercises only make logical sense to prepare the orofacial complex for the work it’s got coming after the tethered tissues are free. It does not make logical sense that freedom from tethers will somehow mean that the intricate coordination between dozens of muscles will somehow spontaneously happen without guidance and exercise.
Beyond the physical therapies required to prepare the tongue, lips, and cheeks for optimal mobility and function, the rest of the body must also be prepared. The fascial connection between tethered muscles and others, the cranial nerves impacted by modern-day birthing practices, the postural deficits resulting from TOTs, and the subsequent skeletal impacts of muscles being pulled out of place dictate that it is only logical to include bodywork such as chiropractic (Miller, et al., 2009) or osteopathic treatment (Herzhaft-Le Roy, et al., 2016) as well as craniosacral (Berg-Drazin, 2016) or myofascial therapy. When the body is able to move properly, all of its parts will benefit from improved mobility as well. It is not uncommon for providers recommending these pre-surgical therapies (to strengthen weakened muscles, encourage their optimal functional movements, and release tension throughout the body) to see improvement in orofacial function prior to surgical release. Surgical ReleaseThe methods used to treat tethered oral tissues discussed within the scholarly literature are almost exclusively limited to surgical release, dating back to what is essentially the dawn of recorded history. While pediatricians can and sometimes do perform releases on infants (In the United States- in some other countries, IBCLCs are able to perform frenotomies as well), it is generally a simple in-office frenotomy during a regular appointment. By and large, dentists and otolaryngologists seem to be the most common release providers worldwide, each using whichever method is preferred by the individual provider. All of these options may work very well when they are employed with skill and diligent patient selection. All of these options may also not work at all when they are improperly performed or are performed as the sole source of treatment for babies with cranial nerve dysfunction or fascia tension.
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