Welcome to Part 2 of puzzling out the buccal frenula!
We’ve talked about what the buccal frenulum is in Buccal Frenula and Breastfeeding: Part 1. Buccal frenula are mainly muscle compared to the lingual and labial frenula, which are largely type 1 collagen. That means buccal frenula are generally more stretchy than labial or lingual frenula.
Let’s widen our lens. Why do these tiny spots in oral anatomy matter to breastfeeding parents and babies? Or do they at all? What should lactation support providers know about the buccal frenula—or, in general, about the musculature of the face? Let me state frankly that I don’t think our science has clear answers to these questions yet. So, we are approaching this as per Jonathan Van Ness (which this has nothing to do with breastfeeding—it's a podcast) just getting curious about the whole thing.
If this kind of discussion interests you, or if you are looking to find new techniques in your lactation practice, consider coming to a workshop, explore other professional topic blog posts, find opportunities for mentorship, or follow Teaching Babies to Nurse on Facebook for updates. | Buccal Frenula and Oral Anatomy: The buccal frenula (one on each side) are located around the canine teeth, and connect the cheek to the gum. A complex web of oral anatomy attaches around this area. The muscles of the mouth (11 of them in the buccolabial group) sweep down the front of the face and in from the sides, and come up over the chin to control the movements of the mouth. |
Getting familiar with these muscles, even if you don’t learn to speak their names, can help build a sense of how they are laid out. There are loads of good anatomy sites like this one that can help.
Here’s a table where the muscles of the buccolabial group are listed, along with their very general purposes. At the bottom, I’ve listed all of the muscles of the modiolus (more about that in a minute).
Here’s the thing about the muscles of the face—specifically, those controlling the mouth: they are skeletal muscles. And most skeletal muscles connect bone to bone so that they can facilitate skeletal movement (like the bicep). But the muscles that are controlling the mouth don’t have a bone to connect to on one side, right? They are anchored on a bone, but then have to pull on the mouth. So rather than both connecting to bones, they connect to bone on one end, and to an anchor on the other, like the frenula.
The Modiolus: Another structure worth an introduction is the modiolus, which helps with anchoring on the oral end of the facial muscles. Most of us in lactation are at least broadly familiar with the frenula. But until very recently, I know I had never heard of the modiolus, and I have been in lactation circles for quite some time! The modiolus is a cone-shaped spiraling-together (like spokes on a wagon wheel) of nine muscles of the face near the corner of the mouth, forming a dense, egg-shaped mobile mass. You can feel it if you press around on your cheek near the corner of your mouth. This complex structure measures about 4 millimeters across at its apex and branches out for about 20 millimeters above and below its apex. It provides the muscles that move the mouth some structure at the end without bone. [1] It’s not quite as rigid as a bone, but the modiolus provides those skeletal muscles with the anchor they need to do their work.
Buccal Frenula and Breastfeeding: Against this backdrop, let’s slide back into talking about buccal frenula. In babies, we sometimes find that the buccal frenula are tight– meaning if you try to lift the cheek from the gum, you can feel some resistance, or what can feel like a tight string of fiber connecting the gum above where the canine teeth will be and the cheek. Sometimes, babies who have tethered oral tissue under their tongue and at the center of their lip also have tight buccal frenula. The important question to ask ourselves when we find tethering at the buccal frenula is whether the tension is the cause or a symptom of a dysfunctional suck. Like any other frenulum, if a buccal frenulum is tight, it can interfere with the movement of the baby’s mouth, and therefore could be the cause of the dysfunction suck. In this case, the couplet might benefit from surgical reduction and suck retraining. But, surgical reduction is less likely to improve the suck if instead it is a symptom of the dysfunctional suck, caused by the baby using compensatory muscles instead of the tongue to draw milk.
There is some precedent for surgically treating the buccal tie. In the dental literature, reduction of buccal frenula is discussed as a means of fitting dentures.[2] But there is less clarity about whether reducing buccal ties actually helps nursing babies. In fact, the consensus statement by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) recommends against it.[3]
We have been working with babies with tight frenula that have been reduced, and those that have not been reduced for some time now at Teaching Babies to Nurse. We definitely don’t have all the answers, but we have noticed a few things: 1) if a buccal tie is reduced with a tongue and lip tie all at the same time, we’ve seen babies get a bit destabilized and confused at the breast, and 2) what feels like a buccal tie can often melt away with the right attention to the body, either directly at the site of the buccal frenulum, or in other areas of the body.
This is what we think: when a baby is not sucking ‘correctly’, for whatever reason, they are using compensatory muscles, often those that move the lips. So, it would make sense that muscle use could drive buccal tension either directly through overuse of the buccinators, or indirectly through overuse of the muscles that come together in the modiolus, which lies in close proximity to, and is integrated with the buccinators.
That would mean that the tight buccal frenula that we feel as being thick or stringy is actually a symptom of a dysfunctional suck, and not the cause. Especially considering that the buccal frenula are, unlike the other frenula, made entirely of muscle.
Granted, there is so much we don’t understand about buccal frenula, but there are a few things we are beginning to puzzle out, (with a shout out to our colleague, Shaina Holman PhD DDS at Holman Family Dental Care and some delightfully nerdy conversations about buccal frenula):
Buccal ties happen, but the need for surgical intervention seems to be quite rare
When buccal frenotomies are performed, we find it less destabilizing to perform the release in two procedures, especially if both tongue and lip are also being released
Often, what we are feeling as tension at the buccal frenula can be effectively addressed with a combination of bodywork and suck retraining so that the overuse of compensatory muscles is reduced.
Of course, there is always more to learn (thankfully!), and we will continue to stay curious and try to find the patterns in our treatment.
There's one more blog about buccal frenula that's coming up. In part 3 we will talk more about what to do if you feel a tight buccal frenulum.
Thanks always to Emily Esmaili for her clinical partnership and for being a fellow puzzler.
[1] Al Jabbari, Y. S. (2011). Frenectomy for improvement of a problematic conventional maxillary complete denture in an elderly patient: a case report. The Journal of Advanced Prosthodontics, 3(4), 236-239. [2] Messner, A. H., Walsh, J., Rosenfeld, R. M., Schwartz, S. R., Ishman, S. L., Baldassari, C., ... & Satterfield, L. (2020). Clinical consensus statement: ankyloglossia in children. Otolaryngology–Head and Neck Surgery, 162(5), 597-611.
[3] Al-Hoqail, R. A., & Abdel Meguid, E. M. (2009). An anatomical and analytical study of the modiolus: enlightening its relevance to plastic surgery. Aesthetic plastic surgery, 33(2), 147-152.