What exactly is a buccal tie?
Understanding the frenula has become pivotal to supporting breastfeeding. Although there is still much to learn, the evidence is beginning to come together. We mostly know what the frenula are made of and what their purpose is, and we are starting to get a feel for the role they plays for us as caretakers of the breastfeeding relationship. The buccal frenula appears to be the last frontier in oral frenula, and it is a little different from either the lingual (tongue) or labial (lip) frenula.
What are frenula? In general, a frenulum is “a connecting fold of membrane serving to support or restrain”. When thinking about the anatomy of the oral cavity and its frenula, most people think about labial and lingual frenula. Any oral frenulum, very generally speaking, can be thought of as a portion of mucosal tissue that attaches a hard bit of the oral cavity to a soft bit of the oral cavity.[1] The lingual frenulum is under the tongue (soft bit), attaching it to the lower gumline (hard bit) and the labial frenulum (there are actually two buccal frenula) are located at the center of the upper and lower lip, also attaching to the gumline. In breastfeeding support, it is the frenulum of the upper lip that we hear about most often.
Ok great, but what is the buccal frenulum? The buccal frenula are less well known. They sit between each cheek (soft bit) and the gum (hard bit). Try putting a (clean) finger into your mouth between your upper cheek and gum. Start at the back of your mouth and move to the front of your mouth, pushing up toward the junction of your cheek and your gum as you move forward. When you get close to your canine teeth, you may run into a little bump or a tight-feeling bit of tissue that connects your cheek (the soft bit) to your gum (the hard bit). That’s a buccal frenulum. Actually there’s one that connects each lower cheek to your lower gum as well, but those have not come up in lactation circles….yet, so this discussion is limited to the maxillary (upper) buccal frenulum. Specifically the buccal frenulum can be defined as “a fold of mucous membrane at the posterior labial vestibule [that] attaches the lips and the cheeks to the alveolar mucosa, gingiva, and underlying periosteum.”[2]
This topic has been surprisingly neglected in human physiology research, and it wasn’t until 2017 that a group from Japan dissected fresh cadaver heads and reported what they found in the buccal frenula – apparently preserved cadavers make it hard to see the different layers, which may have contributed to the late exploration of this oral structure. Iwanaga and his colleagues looked at labial and buccal frenula and found that the buccal frenula was entirely muscular, corresponding to the lateral border of the lower portion of the incisivus labii superioris muscle. It is unlike the labial frenulum, which is formed by taut connective tissue without any muscular component.[3]
So that tells us what a buccal frenulum is: a structure that connects the cheek and lip to the gum, and is made out of muscle, different from the lingual and labial frenula. But that only gets us so far. When doing an oral exam on an infant, you may have felt a tightness at that site, or a 'buccal tie'. Is that a problem? What does it mean when a baby has tightness in their buccal frenula? Should it be surgically corrected?
We will explore these questions and some possible answers in the next segment of this series.
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[1] Priyanka, M., Sruthi, R., Ramakrishnan, T., Emmadi, P., & Ambalavanan, N. (2013). An overview of frenal attachments. Journal of Indian Society of Periodontology, 17(1), 12. [2] Kim, J. B., & Yoon, H. B. (1999). Treatment of Heavy Mandibular Buccal Frenum Using Apically Positioned Flap Under Deep Sedation in Children. The Journal of The Korean Academy Of Pediatric Dentistry, 26(1), 69-76. [3] Iwanaga, J., Takeuchi, N., Oskouian, R. J., & Tubbs, R. S. (2017). Clinical anatomy of the frenulum of the oral vestibule. Cureus, 9(6).