Lip Tie in Babies: What's Normal, Signs and Treatment

Key takeaways

Every baby has an upper lip frenulum. In a Stanford study of 100 newborns, most attached partway down the gum or onto the ridge, and short, thin frenula were rare.⁠¹
“Lip tie” has no agreed definition, and the Kotlow grades used to label it are unreliable: only 8 of 100 newborn photos received the same grade every time they were rated.⁠^1,4
In studies of 100, 208 and 264 newborns, how the lip frenulum looked was not linked to breastfeeding problems; in the largest, a mother’s earlier breastfeeding experience mattered more.⁠^2,5,6
No randomized trial of lip tie release has been done, and most studies reporting a benefit released the tongue at the same time.⁠^3,7
The American Academy of Pediatrics, the Academy of Breastfeeding Medicine and the ear, nose and throat specialists’ consensus panel all call the upper lip frenulum normal, and none recommends releasing it to help breastfeeding.⁠^3,4,8
A gap between the upper front teeth is normal in young children and usually narrows with age; pediatric dentists advise no frenulum surgery for a gap before the permanent canines come in.⁠^9,10
Stretching exercises after a release are not recommended, and dangerous bleeding, though rare, has been reported after lip and tongue procedures.⁠^3,11
If feeds still hurt after the first week or so, or your baby is gaining slowly, the first step is a feeding assessment with a lactation consultant and your pediatrician.⁠^3,12

What is a lip tie?

A lip tie is the name given to the upper lip frenulum when it is thought to be tight enough to hold the lip back. The frenulum (also called the frenum) is the small fold of tissue inside the upper lip that joins it to the gum above the upper front teeth.⁠^3,13

The medical names are the maxillary labial frenulum and the superior labial frenulum. The fold itself is normal anatomy: every newborn has one, and it helps keep the upper lip stable.⁠^1,4

What is not settled is when a normal frenulum becomes a “tie.” The term was defined by Lawrence Kotlow, who described a lip tie as a frenulum that restricts the lip’s mobility; the expert panel of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) later agreed that upper lip tie is an inconsistently defined condition.⁠^4,13

Frenotomy
A simple cut or incision of the frenulum.⁠⁹
Frenectomy
Complete removal of the frenulum, including its attachment to the underlying bone.⁠⁹
Frenuloplasty
A more extensive excision that repositions tissue and is closed with stitches or a flap.⁠⁹

Other frenula in the mouth are the one under the tongue (the lingual frenulum, involved in tongue tie), one under the lower lip, and small ones inside the cheeks, called buccal frenula.⁠⁹

What is a normal lip tie in a baby?

A normal upper lip frenulum in a newborn is usually a visible band that runs well down the gum, often to the ridge where the teeth will come in. That look is the rule in babies, not a warning sign.⁠^1,9

When Stanford researchers photographed the frenulum of 100 newborns, every baby had one, 83% attached partway down the gum, and short, thin frenula were “relatively rare,” found in just 6%.⁠¹

Measurements tell the same story. In 150 healthy newborns at Johns Hopkins, the frenulum attached on average about 1.5 mm from the edge of the gum ridge and stretched to about 5 mm when the lip was lifted.⁠¹⁴

Thick frenula are common too. Among 264 consecutive newborns in Finland, 24.2% had a thick frenulum of 2 to 3 mm and 2.7% a very thick one, and neither finding was linked to breastfeeding problems.⁠²

Usually normal in a baby

A frenulum that reaches down to the gum ridge, or into the small bump of gum where the front teeth will be⁠^1,9
A frenulum that looks thick or wide⁠²
A white blister or callus on the upper lip from sucking, which the AAP calls a normal newborn finding⁠³
Small bumps or tags on the frenulum, which are normal variations⁠¹⁵

What may deserve a closer look is how the lip moves, not where the fold attaches. When the Finnish team lifted each baby’s upper lip toward the nose, 8.7% showed marked tightness: in 3.8% from a tight frenulum and in 4.9% from a short upper lip, and even these findings were not linked to feeding problems.⁠²

Why the look misleads. A newborn’s gum ridge has no teeth yet, so the frenulum sits low on it. As the jaw grows and the teeth come in, its attachment ends up higher in relation to the teeth, which is why the papilla-penetrating type is most common in infants and less common in older children.⁠^9,16

How common is a lip tie?

Every baby has an upper lip frenulum, so how common a “lip tie” is depends entirely on where the line is drawn, and there is no agreed line.⁠^1,4

On the four-grade Kotlow scale, raters in the Stanford study placed 39% of newborns at grade 3 and 14% at grade 4, the highest. Kotlow linked higher grades to more severe ties, so by his scale more than half of healthy newborns would be graded as having one.⁠¹

Defined by function instead, a harmful lip tie is rare, in the Finnish researchers’ words. In their cohort, 3.8% of babies had a frenulum that itself felt tight when the lip was lifted, and only 4 of 264 (1.5%) had a lip release by 6 months, 3 of them together with a tongue tie release.⁠²

In young children the numbers fall with age. In 1,313 Brazilian children up to age 5, 25.4% had an attachment classed as abnormal, and the share dropped as children got older.⁠¹⁷

What do lip tie classes and grades (Kotlow 1 to 4) mean?

Lip tie “classes” or “grades” usually refer to the Kotlow scale, which sorts the frenulum into four grades by where it attaches on the gum. The American Academy of Pediatrics (AAP) calls it an unvalidated grading system.⁠^1,3

The Kotlow grades, and how often each was seen in 100 newborns
Kotlow grade	Where the frenulum attaches
Class 1	Minimal tissue and minimal attachment. Seen in 6% of the newborns.⁠¹
Class 2	Mainly into the gum tissue, where the loose and firm parts of the gum meet. Seen in 41%.⁠¹
Class 3	Just in front of the small bump of gum (the papilla) on the ridge. Seen in 39%.⁠¹
Class 4	Into the papilla, extending back toward the hard palate. Seen in 14%.⁠¹

Kotlow proposed that a higher grade meant a more severe tie and more breastfeeding trouble. The Stanford team, finding that experts could barely tell grades 2 and 3 apart, merged them into a three-type Stanford scale, on which 83% of newborns were type 2.⁠¹

Neither scale is reliable in practice. Only 8 of 100 newborn photos got the same Kotlow grade all 12 times they were rated; in a Rochester study, agreement between raters was fair on the Kotlow scale (kappa 0.302) and better on the Stanford scale (0.458).⁠^1,5

A newer Johns Hopkins scale, HOP-ROC, adds how far the frenulum stretches and how much of the lip is free; it raised agreement to 0.41, against 0.24 and 0.25 for the Kotlow and Stanford scales in the same photos.⁠¹⁸

Above all, no grade predicts feeding trouble. A systematic review found the Kotlow scale unreliable in predicting the severity of breastfeeding difficulties, and in 208 mother–baby pairs the attachment grade was not linked to any breastfeeding outcome. A “class 4” or “severe” label is not, by itself, a reason for surgery.⁠^6,9,19

What causes a lip tie, and is it genetic?

Nothing goes wrong to cause one. The upper lip frenulum forms during development as a remnant of tissue bands in the growing mouth, and every newborn has some degree of it.⁠¹

Differences in its size and shape, including small nodules and tags, are inherent variations that do not represent disease.⁠¹⁵

An unusual frenulum can be one feature of a number of syndromes and developmental conditions, which a clinician looks for as part of a full examination of the face and mouth.⁠^3,20

In ordinary children, age is what changes the frenulum. In 226 children aged 1 to 18, attachment type differed strongly by age but not by sex or ethnic background.⁠¹⁶

What are the signs and symptoms of a lip tie in a baby?

The signs usually blamed on a lip tie are the signs of a hard feed: a shallow latch, an upper lip that curls in, milk leaking, clicking, long feeds, slow weight gain, and nipple pain for the parent.⁠⁹

None of them is specific to the lip. They overlap with tongue tie and with the more common causes of breastfeeding difficulty, which is why the AAP says every family with painful or ineffective feeding should have a complete breastfeeding assessment before any treatment is offered.⁠³

Lip tie signs: what parents are told, and what studies found
What you may be told to look for	What the research found
The upper lip curls in or will not flange out	Proposed as a sign of a tight frenulum, but the AAP says such signs lack supporting evidence. In Finland, a mother’s need to reposition the lip during feeds was not linked to breastfeeding problems overall.⁠^2,3
The frenulum or lip turns white when the lip is lifted	Blanching is one of the proposed signs the AAP says lack evidence, and paleness of the lip when stretched was not linked to feeding problems in 264 newborns.⁠^2,3
A blister or callus on the upper lip	Sucking blisters are a normal finding in newborns and do not suggest a problem.⁠³
A dimple in the lip or a notch in the gum ridge	Both have been proposed as signs of a tight frenulum, and the AAP says both lack support in peer-reviewed research.⁠³
Reflux, gas or colic	The pediatric dentistry policy repeats the idea that a poor seal lets in air; the AAP lists reflux among the proposed signs that lack supporting evidence.⁠^3,9
Nipple pain	Very common in the first days whatever the cause: 34% to 96% of mothers have it, and most of it peaks around day 3 and eases within 7 to 10 days. Frenulum grade was not linked to pain in two studies.⁠^3,5,6
Clicking, leaking, very long feeds, slow weight gain	Real reasons to have a feed assessed and weight checked. The AAP asks pediatricians to work through the many possible causes, from latch and milk transfer to infection and heart conditions.⁠³

Does a lip tie cause breastfeeding problems?

Studies that compared babies’ lip frenula with how breastfeeding went have not found a link.⁠^2,5,6

In 100 newborns in Rochester, New York, the frenulum grade was not related to breastfeeding comfort, pain or latch.⁠⁵
In 208 mother–baby pairs at an Army medical center in Texas, the grade was not related to how long mothers breastfed, their confidence, their pain or the baby’s weight.⁠⁶
In 264 pairs in Finland, 86.4% of mothers reported early breastfeeding problems, yet no lip finding (thickness, attachment, mobility, paleness, a sucking pad) was associated with them. What mattered was experience: 77.8% of mothers without problems had breastfed before, against 50.9% of those with problems.⁠²

Reviews reach the same place. A 2019 systematic review found no randomized trials and called the evidence for routine release poor, and a 2025 review of 17 studies found that most included babies with both lip and tongue ties and lacked objective or long-term breastfeeding outcomes.⁠^7,19

The idea behind lip tie release is that a tight frenulum stops the upper lip from flanging around the breast, weakening the latch. The AAO-HNS panel was split on it: some members saw little evidence, others felt some babies with poor lip eversion may benefit, and the panel agreed the relationship to breastfeeding is unclear.⁠^3,4

If breastfeeding hurts or your baby is not gaining well. Start with skilled feeding support: a feed watched by an International Board Certified Lactation Consultant (IBCLC) and a weight check with your pediatrician, before any decision about a procedure. Our tongue tie guide covers that assessment step by step.⁠^3,12

Can a lip tie affect bottle-feeding?

There is little evidence either way. The studies above measured breastfeeding, not bottle-feeding, and the American Academy of Pediatric Dentistry (AAPD) notes that in severe instances a restrictive frenulum has been associated with breastfeeding and bottle-feeding difficulties.⁠^2,5,9

The same policy says release based on appearance alone cannot be endorsed, so a bottle-fed baby who leaks milk, coughs, chokes, tires early or feeds slowly needs a feeding assessment, not a frenulum check alone.⁠^3,9

A speech-language pathologist or occupational therapist who specializes in infant feeding therapy can assess sucking and swallowing, and our guide to bottle use and oral development covers nipples, flow and positioning.

Upper lip tie vs tongue tie: what is the difference?

A tongue tie involves the frenulum under the tongue and can limit how the tongue lifts and extends, which matters because the tongue does the work of drawing milk; a lip tie involves the fold under the upper lip.⁠³

The evidence differs too. For a tongue tie that causes feeding problems not fixed by lactation support, the AAP says frenotomy can reasonably be offered and may ease nipple pain; for the lip, it calls the labial frenum a normal structure that does not need surgery to improve breastfeeding.⁠³

The two do not reliably come together. In the Rochester study, the degree of lip and tongue tethering was modestly inversely related, suggesting they may not cluster in the same babies.⁠⁵

When both are treated, the tongue usually does the work. At a Georgetown tongue tie and breastfeeding clinic, 211 of 224 babies had only the tongue released and 98.1% of them fed successfully after one procedure; 13 (5.8%) also had the lip released.⁠²¹

Most studies reporting better breastfeeding after lip release released the tongue at the same time, which makes the effect of the lip release impossible to separate.⁠^3,7,22

Does a lip tie cause a gap between the front teeth?

A gap between the upper front teeth (a midline diastema) is normal in young children, and most such gaps close as the permanent teeth come in; a prominent frenulum has not been shown to cause a gap that needs early treatment.⁠^4,9

The AAO-HNS panel found no definitive relationship between the frenulum and the gap. Children whose frenulum was released improved no more over time than children who had nothing done, probably because the canine teeth push the front teeth together as they erupt, and scarring from an early release may even make a gap more likely later.⁠⁴

Its consensus: releasing the upper lip frenulum in babies, or in children who still have their baby teeth, will not prevent a gap between the front teeth.⁠⁴

A 2022 systematic review of 11 studies linked the two attachment types that reach the papilla to a gap, and advised waiting until the permanent lateral incisors erupt, because their arrival can close the gap on its own, and treating the gap with orthodontics before any frenectomy.⁠²³

Gaps shrink with age. In 432 children aged 3 to 6 with a gap, gaps were more common and wider in the youngest children, and the frenulum’s attachment moved up as children got older.⁠¹⁰

When a dentist may treat it: the AAPD suggests treatment when the frenulum pulls hard enough that the gum between the teeth turns white as the lip is pulled, or when the gap is wider than 2 mm, which rarely closes on its own. For a gap, it advises no frenulum surgery before the permanent canines erupt, usually at 11 to 12 years, and only after or with orthodontic treatment.⁠^9,24

The Australian Dental Association likewise finds insufficient evidence for releasing a baby’s lip frenulum for orthodontic reasons, including closing a midline gap.⁠¹²

Can a lip tie cause tooth decay?

It has not been shown to. The AAPD says a causal link between a prominent upper frenulum and decay on the front teeth has not been substantiated, and the Australian Dental Association says decay cannot be predicted from how the frenum looks in infancy or early childhood.⁠^9,12

In a 2025 study of 92 children aged 2 to 5, attachments reaching the papilla were more common in children with decay on the front teeth, but decay also appeared with attachments considered low risk, and the authors advised a full caries risk assessment before considering frenectomy.⁠²⁵

What helps is cleaning: for a child with a restrictive frenulum, the AAPD suggests extra care such as wiping the space between the lip and gum after feeds.⁠⁹

Our guide to brushing from the first tooth covers the rest, and white spots on teeth explains an early sign of decay worth showing a dentist.

Does a lip tie affect speech?

There is no good evidence that it does. The Australian Dental Association finds insufficient evidence to support releasing a baby’s lip frenum for speech outcomes.⁠¹²

Even for tongue tie, which involves the tongue that shapes most speech sounds, the AAO-HNS panel concluded that it does not typically affect speech, and the AAP says frenotomy to prevent future speech problems is not evidence based.⁠^3,4

A speech delay or a lisp deserves its own assessment. A speech-language pathologist can tell you what is behind it; see our guides to speech delay, lisps and speech therapy.

Lip tie in toddlers and older children: what changes with age?

The frenulum changes as a child grows. Attachments reaching the gum ridge are most common in babies, and higher attachments become more common with age as the bone of the jaw grows down, away from where the frenulum is fixed.⁠^9,16

In 226 children aged 1 to 18, 26.1% had a frenulum reaching through the papilla, and those children were significantly younger than the children with higher attachments. In 1,313 preschoolers, abnormal attachments became less common with age, and the authors warned that surgery in the first years of life may be overtreatment.⁠^16,17

Tracking children through orthodontic care shows why: the frenulum’s insertion stays almost still while the front teeth and their bone grow down and away from it.⁠²⁶

What if my toddler’s frenulum reaches between the front teeth?

That is common at this age and usually needs nothing. For a gap, the AAPD advises no frenulum surgery before the permanent canines erupt; a 2025 review found surgery advised only when the frenulum gets in the way of cleaning the teeth or helps a gap reopen after orthodontic treatment.⁠^9,27

What about a bottom lip tie or a cheek (buccal) tie?

A high frenulum under the lower lip is mostly a concern in older children and adults: where it pulls on the gum of the lower front teeth it can trap plaque and lead to gum recession, and a dentist may treat it, though controlling gum inflammation lowers the need.⁠⁹

Cheek (buccal) frenula help keep milk and food in place, there are no criteria for calling one restrictive, and the AAO-HNS panel and the Academy of Breastfeeding Medicine (ABM) say surgery to release a buccal tie should not be performed.⁠^4,8

Can an untreated lip tie cause problems later in life?

Rarely, and it cannot be predicted in infancy. The Australian Dental Association says misaligned teeth may arise in a minority of people with a prominent frenum, that bite problems, gum recession and decay cannot be predicted from its appearance in infancy, and that a minority of older children and adults may benefit from a timed release as part of orthodontic care.⁠¹²

Studies of the frenulum and gum recession are inconclusive, and the Stanford team noted a lack of evidence of major effects from a prominent frenulum that persists.⁠^1,20

How is a lip tie assessed, and who should check it?

A lip tie cannot be diagnosed from how the frenulum looks: the AAPD and the Stanford study both say release based on appearance alone cannot be endorsed. A proper assessment looks at feeding and at how the lip and tongue move.⁠^1,9

Watch a whole feed. A lactation consultant observes the latch and milk transfer; the Australian Dental Association lists a breastfeeding observation by an IBCLC among the steps before tongue tie is diagnosed.⁠^3,12
Check growth and milk transfer. Weighing before and after a feed, and weight plotted on the World Health Organization growth standards.⁠³
Examine the whole mouth and face. Tongue movement, the palate, the jaw and any features of a syndrome, not just the lip.⁠³
Test how the lip moves. Lifting the lip toward the nose shows whether the frenulum or a short lip restricts it, and newer scales measure stretch, not just attachment.⁠^2,18
Rule out other causes. Nose and airway problems, reflux and differences in the face and jaw can all make feeding hard.⁠^4,9

Pediatrician or family doctor
Examines your baby, checks growth and coordinates the team; the AAP asks pediatricians to work with lactation professionals.⁠³
Lactation consultant (IBCLC)
Watches the latch and the whole feed and helps with positioning and attachment.⁠^3,12
Pediatric dentist or ENT
Assesses the mouth’s anatomy and, if a procedure is ever needed, can perform it as part of the team.⁠³
Speech-language pathologist
Assesses sucking, swallowing and oral-motor skills; some specialize in breastfeeding problems.⁠⁴

At home you can gently lift your baby’s upper lip to look. You will almost always see a frenulum, often reaching the gum ridge, and that alone is not a diagnosis.⁠¹

What do the AAP, AAPD and other experts say about lip ties?

The major professional statements agree that the upper lip frenulum is a normal structure, and none supports releasing it routinely to help breastfeeding.⁠^3,4,8,9,12

Professional positions on the upper lip frenulum
Organization	What it says
American Academy of Pediatrics, clinical report (2024)	Labial and buccal frena are normal structures unrelated to breastfeeding mechanics and do not need surgery to improve breastfeeding; no randomized trial of lip release has been done.⁠³
American Academy of Otolaryngology–Head and Neck Surgery, consensus statement (2020)	An upper lip frenulum is normal in a baby; lip tie is inconsistently defined, has an unclear relationship to breastfeeding, and is being overdiagnosed in some communities.⁠⁴
Academy of Breastfeeding Medicine, position statement (2021)	The upper labial frenulum is a normal structure with poor evidence that intervention improves breastfeeding, so release cannot be recommended.⁠⁸
American Academy of Pediatric Dentistry, policy (revised 2022)	Release based on appearance alone cannot be endorsed, and for a gap, no frenulum surgery before the permanent canines erupt.⁠⁹
Australian Dental Association, policy statement (amended 2025)	Insufficient evidence to support releasing the lip or cheek frena in infants for breastfeeding, speech or orthodontic problems, including closing a midline gap.⁠¹²

What does the research say about lip tie treatment?

No randomized controlled trial of upper lip frenulum release has ever been done, so there is no reliable success rate for lip tie release.⁠^3,19

What exists are observational studies. The AAP calls the ones it reviewed severely limited: they had no control group, in babies who tend to improve over time anyway; no validated measure of the lip’s effect; and the tongue released at the same time as the lip.⁠³

An Oregon cohort of 237 babies reported better breastfeeding after release, but 75% had both lip and tongue released, only one baby had the lip alone, and there was no comparison group.⁠²²
A 2022 case series of seven babies with an isolated lip tie reported easier breastfeeding afterward; its authors call for randomized trials.⁠²⁸
At a Georgetown clinic, only 5.8% of treated babies needed a lip release to feed successfully.⁠²¹
In the Finnish cohort, 4 of 264 babies had a lip release by 6 months, and the researchers could not confirm a reason to operate on the lip in any baby.⁠²

The research base is thin. A 2023 systematic review found that most articles about lip tie alone were editorials, commentaries, perspectives or consensus statements rather than studies.⁠²⁹

How is a lip tie released, and is laser better than scissors?

A lip tie release is a frenotomy (a cut) or a frenectomy (removal of the frenulum), done with scissors, a scalpel or a laser. The AAO-HNS panel notes that these terms are often used interchangeably, although they are distinct techniques with different billing codes.⁠^4,9

For babies, laser has not been shown to be better. The AAP found no comparative data supporting routine laser use over clipping in infants under 6 months, and the AAO-HNS panel found insufficient evidence that any technique, laser included, is superior.⁠^3,4

Across six randomized trials of upper lip frenectomy (324 patients), a 2025 meta-analysis found that diode laser reduced pain on the first day, bleeding and operating time compared with a scalpel, with low to very low certainty. The AAP found no such comparison in babies.⁠^3,30

Technique can change the cost: the AAO-HNS panel notes that different techniques may have cost implications for families.⁠⁴

What are the risks of lip tie surgery?

Serious complications are rare but real. Surgeons in North Carolina reported two cases of shock from blood loss after outpatient lip and tongue frenulectomy that needed CPR and blood transfusion, and the ABM notes case reports of life-threatening bleeding after frenotomy.⁠^8,11

The AAPD lists the other possible complications of frenulum procedures: heavy bleeding, a mucus cyst, reattachment, a blood collection under the tissue, numbness, infection and scarring.⁠⁹

Scarring matters for teeth too: some authors suggest that scarring from a release in childhood may make a gap between the permanent front teeth more likely.⁠⁴

Before any frenotomy, the AAP asks the clinician to take a “time out” to:⁠³

Get signed consent⁠³
Discuss the alternatives, including waiting and more lactation support, and the risks and benefits⁠³
Discuss and provide pain control⁠³
Confirm the baby had the vitamin K injection after birth⁠³
Explain aftercare and follow-up⁠³

Mothers in the Finnish study described “just in case” and “along with a tongue-tie” as typical reasons for lip releases in their earlier children; a release done for those reasons carries these risks without a shown benefit.⁠^2,3

Are stretches needed after a lip tie release?

No. The AAP says postoperative stretching exercises are not evidence based and are not recommended, and that stretches in which parents open the wound to prevent reattachment may cause oral aversion.⁠³

The ABM found no evidence for stretching or manipulating the wound after a frenotomy, and no evidence or safety guidelines for putting substances on it; the AAO-HNS panel found no evidence for any standard aftercare routine.⁠^4,8

The AAPD notes that some studies report benefits from exercises after tongue tie release, but they were small and had no control groups, and pain after surgery in a newborn can itself lead to oral aversion.⁠⁹

Good follow-up matters more. The ABM calls clinical follow-up after a frenotomy imperative: a check for bleeding, pain, infection, oral aversion and any change in feeding, with more breastfeeding help if needed.⁠⁸

Does insurance cover lip tie release?

Often it can. The AAP says frenotomies can be covered by medical and dental insurance, most babies have medical coverage soon after birth, and some state Medicaid programs cover the procedure, some only with approval in advance.⁠³

Prices vary. When the AAP searched online in 2023, practitioners were asking several hundred dollars, often without telling parents that an ear, nose and throat (otolaryngology) visit is covered by Medicaid and commercial insurance.⁠³

Before booking, ask which procedure and billing code is planned, whether the provider bills your insurance, and what the total will be; the AAO-HNS panel notes that the procedure names carry different billing codes.⁠⁴

Why are so many babies being diagnosed with lip ties?

Experts think lip tie is being overdiagnosed: the AAO-HNS panel agreed that in some communities it is.⁠⁴

Much of what parents hear comes from outside medicine. In a survey of 323 parents at a pediatric ENT clinic, 59.8% had heard of lip tie; of those, 17.1% had a child who had lip tie surgery, 91.2% believed it causes breastfeeding problems, and 68.4% had learned about it from nonmedical sources such as social media, family and friends.⁠³¹

The AAP adds that information online mixes reliable guidance with personal stories, targeted advertising for frenotomy and misinformation, such as presenting normal sucking blisters as a sign of a tie, and that concern has been raised that unnecessary procedures may have a financial motive.⁠³

When should you see a doctor about a lip tie?

Talk to your child’s doctor when there is a feeding, growth or tooth problem, not because of how the frenulum looks. In a baby, these are the signs:⁠^3,9

Feeds still hurt after the first week to 10 days
Most early nipple pain eases to mild levels within 7 to 10 days, so pain that lasts, or cracked nipples, needs a feeding assessment.⁠³
Your baby is not gaining weight as expected
Weight gain on the WHO growth standards is part of every assessment of a baby who feeds poorly.⁠³
Feeds are very long, or your baby coughs, chokes or tires
Coughing, choking, color change and early tiring at feeds are on the AAP’s list to review.⁠³
Bleeding that will not stop after a procedure
Get urgent care: rare cases of dangerous blood loss have been reported after lip and tongue procedures.⁠¹¹

In an older child, ask the dentist about it when:⁠⁹

A gap wider than 2 mm stays as the permanent teeth arrive
Gaps that wide rarely close on their own.⁠⁹
The gum between the front teeth turns white when the lip is pulled
That is one of the AAPD’s reasons to consider treatment.⁠⁹
The frenulum makes the front teeth hard to keep clean
Getting in the way of cleaning is a reason a 2025 review found for advising surgery.⁠²⁷

Find a feeding specialist near you.

Speech-language pathologists who assess feeding, sucking and swallowing in babies and children, by city and state.

Browse the DrSensory Therapy Directory →

What should you ask before agreeing to a lip tie release?

Ask the provider

What exactly is the release expected to change, and what is the evidence for that outcome?
What feeding assessment has been done, and by whom?
Is the lip restricting function, or is it the tongue, and how was that tested?
What happens if we try skilled feeding support first?
Which procedure is planned, frenotomy or frenectomy, and with what instrument?
What are the risks, what aftercare do you advise, and why?
What will it cost, and is a covered option available?

If your child has already had a release, that decision was made with the information you had. If feeding is still difficult, go back to your lactation consultant and pediatrician; the ABM advises that more breastfeeding help be available after any frenotomy.⁠⁸

Frequently asked questions

Do all babies have a lip tie?

All babies have an upper lip frenulum, the fold that joins the lip to the gum. In a Stanford study of 100 newborns, every baby had one, and most attached partway down the gum; a frenulum like that is normal, not a tie.⁠¹

Can a lip tie correct itself?

The frenulum does not disappear, but it changes: as the jaw grows, its attachment ends up higher above the teeth, and attachments classed as abnormal become less common through the preschool years.⁠^9,17

Should a lip tie be released to help breastfeeding?

Major bodies say no. The AAP says the lip and cheek frena do not need surgery to improve breastfeeding, and the Academy of Breastfeeding Medicine says release cannot be recommended because the evidence is poor.⁠^3,8

When should a lip tie be corrected?

Rarely in infancy. For a gap between the front teeth, pediatric dentists advise waiting until the permanent canines erupt, and treating the gap with orthodontics first; a frenulum that blanches the gum or makes cleaning hard may be treated sooner.⁠^9,27

What does a lip tie look like?

You see a band of tissue running from inside the upper lip down the gum, often to the ridge where the front teeth come in. That is the usual look in newborns; how the lip moves matters more than where the band attaches.⁠^1,2

Is a lip tie genetic?

An unusual frenulum can be one feature of some syndromes and developmental conditions, but in most children its size and shape are ordinary variations, and its attachment type relates to age rather than sex or ethnic background.⁠^15,16,20

Does a lip tie cause reflux or gas?

That has been proposed, but the AAP says reflux as a sign of a tight lip frenulum lacks supporting evidence in the peer-reviewed literature.⁠³

Is a class 4 lip tie a reason for surgery?

Not by itself. The Kotlow grades are unreliable between examiners, 14% of healthy newborns were rated grade 4 in one study, and no grade has been shown to predict feeding problems.⁠^1,19

Can a lip tie cause a speech delay?

There is no good evidence that it does, and the Australian Dental Association finds insufficient evidence for releasing a baby’s lip frenulum for speech. A speech-language pathologist is the right person to assess a delay.⁠¹²

Is laser lip tie release better than scissors?

Not for babies, as far as the evidence shows: the AAP found no comparative data supporting laser in infants, and the AAO-HNS panel found no technique shown to be superior.⁠^3,4

Who can diagnose a lip tie?

No single test diagnoses it. A pediatrician, a lactation consultant, and where needed a pediatric dentist, an ear, nose and throat specialist or a speech-language pathologist assess feeding and how the lip and tongue move together.⁠^3,12

Can a lip tie grow back after a release?

Reattachment is one of the known complications of frenulum procedures, the AAO-HNS panel found few data even on how often a tongue tie comes back after frenotomy, and the AAP says stretching exercises to prevent it are not recommended.⁠^3,4,9

Sources

Santa Maria C, Aby J, Truong MT, Thakur Y, Rea S, Messner A. The superior labial frenulum in newborns: what is normal? Global Pediatric Health. 2017;4:2333794X17718896. doi:10.1177/2333794X17718896 (PMID 28812052). Checked October 22, 2026.
Show the passageHide the passage
100 newborns at Stanford: “All newborns have some degree of superior labial frenula”; Kotlow grades “6% rated as grade 1, 41% rated as grade 2, 39% rated as grade 3, and 14% rated as grade 4”; “only 8 of 100 photographs had the same rating all 12 times they were evaluated”; “short thin frenula are actually relatively rare”.
Niemelä L, Lohi V, Aitamurto S, Lehtinen A, Aikio O. Upper lip frenulum findings and breastfeeding problems in healthy newborns. JAMA Network Open. 2026;9(5):e2613308. doi:10.1001/jamanetworkopen.2026.13308 (PMID 42149590). Checked October 22, 2026.
Show the passageHide the passage
264 consecutive mother–infant pairs in Oulu, Finland: “No associations between distinct maxillary frenulum findings and breastfeeding problems were found.” “Maternal inexperience, rather than infant’s upper lip-tie anatomy, was associated with breastfeeding problems”; “The upper lip-ties of 4 infants (1.5%) had been operated on during the 6-month follow-up period.”
Thomas J, Bunik M, Holmes A, Keels MA, Poindexter B, Meyer A, Gilliland A; American Academy of Pediatrics. Identification and management of ankyloglossia and its effect on breastfeeding in infants: clinical report. Pediatrics. 2024;154(2):e2024067605. doi:10.1542/peds.2024-067605 (PMID 39069819). Checked October 22, 2026.
Show the passageHide the passage
The maxillary labial frenulum is “a normal oral structure present in all infants”; “Kotlow has described an unvalidated four-type grading system”; “No randomized controlled trials of labial maxillary frenulum release have been performed”; “Labial and buccal frenae are normal oral structures unrelated to breastfeeding mechanics and do not require surgical intervention to improve breastfeeding.” “Postoperative stretching exercises are not evidence-based and are not recommended.”
Messner AH, Walsh J, Rosenfeld RM, Schwartz SR, Ishman SL, Baldassari C, et al. Clinical consensus statement: ankyloglossia in children. Otolaryngology–Head and Neck Surgery. 2020;162(5):597–611. doi:10.1177/0194599820915457 (PMID 32283998). Checked October 22, 2026.
Show the passageHide the passage
The American Academy of Otolaryngology–Head and Neck Surgery panel reached consensus that “Presence of an upper lip frenulum is normal in an infant”, “Upper lip tie is an inconsistently defined condition”, “Upper lip tie has an unclear relationship to breastfeeding difficulties”, “In some communities upper lip tie is being overdiagnosed” and “Upper lip frenotomy in infants or children with primary dentition will not prevent the occurrence of an upper interincisor diastema”.
Shah S, Allen P, Walker R, Rosen-Carole C, McKenna Benoit MK. Upper lip tie: anatomy, effect on breastfeeding, and correlation with ankyloglossia. Laryngoscope. 2021;131(5):E1701–E1706. doi:10.1002/lary.29140 (PMID 33006413). Checked October 22, 2026.
Show the passageHide the passage
100 healthy newborns: “There was no correlation between maxillary frenulum grade and comfort with breastfeeding, pain scores, or latch.” “Inter-rater reliability showed fair agreement (κ = 0.302) using the Kotlow scale and better agreement using the Stanford classification (κ = 0.458).”
Haischer-Rollo GD, Lu K, Drumm C, Fagiana A, Bowe SN, Aden J, Demarcantonio M. Superior labial frenulum attachment site and correlation with breastfeeding outcomes. Laryngoscope. 2022;132(12):2498–2504. doi:10.1002/lary.30059 (PMID 35234285). Checked October 22, 2026.
Show the passageHide the passage
208 mother–infant pairs: “Our study shows no correlation between SLF attachment grade and breastfeeding outcomes to include length of breastfeeding, maternally reported confidence, maternal pain, or infant weight.”
Hopkins EE, Dieterich R. Scoping review of breastfeeding outcomes and practices for infants with an upper lip tie. Journal of Perinatal Education. 2025;34(3–4):166–181. doi:10.1891/JPE-2023-0027 (PMID 41262407). Seventeen articles: “Most research included infants having both lip and tongue ties.” “studies lacked an assessment of objective breastfeeding outcomes and long-term breastfeeding success”. Checked October 22, 2026.
LeFort Y, Evans A, Livingstone V, Douglas P, Dahlquist N, Donnelly B, et al.; Academy of Breastfeeding Medicine. Academy of Breastfeeding Medicine position statement on ankyloglossia in breastfeeding dyads. Breastfeeding Medicine. 2021;16(4):278–281. doi:10.1089/bfm.2021.29179.ylf (PMID 33852342). Checked October 22, 2026.
Show the passageHide the passage
“The upper labial frenulum specifically is a normal structure with poor evidence for intervention improving breastfeeding and therefore cannot be recommended.” “Evidence is lacking to support the prescribing of post-procedural manual manipulation or stretching at or near the incised area after a frenotomy procedure.”
American Academy of Pediatric Dentistry. Policy on management of the frenulum in pediatric patients. The Reference Manual of Pediatric Dentistry, 2025:80–85 (revised 2022). Checked October 22, 2026.
Show the passageHide the passage
“Infants have the highest prevalence of papillary penetrating phenotype.” “the release of the maxillary frenulum based on appearance alone cannot be endorsed”; “most diastemas in the primary and mixed dentitions are normal, are multifactorial, and tend to close with maturity; therefore, any surgical manipulation of the frenulum is not recommended before the permanent canines erupt”.
Khan Z, Bhatnagar A, Perveen Z, Rajput D, Mishra P, Yeluri R. Association of maxillary labial frenum attachment and insertion with midline diastema in children with primary dentition: a cross-sectional study. Cureus. 2025;17(8):e89892. doi:10.7759/cureus.89892 (PMID 40951249). 432 children aged 3 to 6: “Midline diastema was more prevalent and larger in younger children, decreased with age”. Checked October 22, 2026.
Tracy LF, Gomez G, Overton LJ, McClain WG. Hypovolemic shock after labial and lingual frenulectomy: a report of two cases. International Journal of Pediatric Otorhinolaryngology. 2017;100:223–224. doi:10.1016/j.ijporl.2017.07.013 (PMID 28802376). “We describe two cases of hypovolemic shock occurring after outpatient frenulectomy requiring emergent interventions of cardiopulmonary resuscitation and blood transfusion.” Checked October 22, 2026.
Australian Dental Association. Policy statement 2.13: ankyloglossia and oral frena. Amended by the ADA Board, October 24, 2025. Checked October 22, 2026.
Show the passageHide the passage
“There is insufficient evidence to support the surgical release of the labial or buccal frena in infants to assist with breastfeeding difficulties, speech outcomes, or orthodontic issues including midline diastema closure.” “Malocclusion, gum recession and dental decay cannot be predicted based on the anatomical appearance of the frenum in infancy or early childhood.”
Kotlow LA. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeeding. Journal of Human Lactation. 2013;29(4):458–464. doi:10.1177/0890334413491325 (PMID 23821655). “The author has defined and identified the restrictions of mobility of this tissue as a lip-tie”. Checked October 22, 2026.
Ray S, Golden WC, Walsh J. Anatomic distribution of the morphologic variation of the upper lip frenulum among healthy newborns. JAMA Otolaryngology–Head & Neck Surgery. 2019;145(10):931–938. doi:10.1001/jamaoto.2019.2302 (PMID 31436823). 150 healthy newborns: “alveolar edge to frenulum gingival attachment, 1.53 (0.85) mm; frenulum length on stretch, 5.19 (1.68) mm”. Checked October 22, 2026.
Townsend JA, Brannon RB, Cheramie T, Hagan J. Prevalence and variations of the median maxillary labial frenum in children, adolescents, and adults in a diverse population. General Dentistry. 2013;61(2):57–60. PMID 23454324. 284 people: “variations of the MMLF are inherent and do not represent a pathologic condition, nor do they require biopsy for diagnostic purposes”. Checked October 22, 2026.
Boutsi EA, Tatakis DN. Maxillary labial frenum attachment in children. International Journal of Paediatric Dentistry. 2011;21(4):284–288. doi:10.1111/j.1365-263X.2011.01121.x (PMID 21348902). 226 children aged 1 to 18: “mucosal (10.2%), gingival (41.6%), papillary (22.1%), and papillary penetrating (26.1%)”; “ethnic background and gender are not associated with maxillary labial frenum attachment type, whereas age is strongly associated”. Checked October 22, 2026.
Kramer PF, de Amorim LM, de Moura Alves N, Ruschel HC, Bervian J, Feldens CA. Maxillary labial frenum in preschool children: variations, anomalies and associated factors. Journal of Clinical Pediatric Dentistry. 2022;46(1):51–57. doi:10.17796/1053-4625-46.1.9 (PMID 35311982). Checked October 22, 2026.
Show the passageHide the passage
1,313 children aged 0 to 5: “25.4% exhibited abnormal frenal attachment”; “The reduction in the prevalence of the outcomes with the increase in age suggests that surgical interventions in the first years of life may constitute overtreatment.”
So RJ, Jenks C, Ryan MA, Tunkel DE, McKenna Benoit MK, Walsh JM. Upper lip tie: a novel classification scale with improved inter-rater reliability. Laryngoscope Investigative Otolaryngology. 2022;7(5):1611–1617. doi:10.1002/lio2.889 (PMID 36258882). “Our novel scale yielded the highest inter-rater reliability of 0.41, compared to 0.24 and 0.25 under the Kotlow and Stanford systems.” Checked October 22, 2026.
Nakhash R, Wasserteil N, Mimouni FB, Kasirer YM, Hammerman C, Bin-Nun A. Upper lip tie and breastfeeding: a systematic review. Breastfeeding Medicine. 2019;14(2):83–87. doi:10.1089/bfm.2018.0174 (PMID 30681376). “No RCT were found, and the evidence for routine ULT release in infants with breastfeeding difficulties is poor.” Checked October 22, 2026.
Delli K, Livas C, Sculean A, Katsaros C, Bornstein MM. Facts and myths regarding the maxillary midline frenum and its treatment: a systematic review of the literature. Quintessence International. 2013;44(2):177–187. PMID 23444184. Checked October 22, 2026.
Show the passageHide the passage
“The maxillary frenum is highly associated with a number of syndromes and developmental abnormalities.” “Studies on the cause of gingival recession due to the maxillary frenum are inconclusive.”
Towfighi P, Johng SY, Lally MM, Harley EH. A retrospective cohort study of the impact of upper lip tie release on breastfeeding in infants. Breastfeeding Medicine. 2022;17(5):446–452. doi:10.1089/bfm.2021.0140 (PMID 35235369). Checked October 22, 2026.
Show the passageHide the passage
“The majority (98.1%) of infants receiving a lingual frenulum release alone had successful feeding after only one procedure, and only 5.8% of all infants receiving any intervention required a maxillary frenulum release for successful feeding”.
Ghaheri BA, Cole M, Fausel SC, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: a prospective cohort study. Laryngoscope. 2017;127(5):1217–1223. doi:10.1002/lary.26306 (PMID 27641715). Checked October 22, 2026.
Show the passageHide the passage
“One hundred seventy-eight (75%) infants underwent surgical treatment of both upper lip-tie and tongue-tie. One infant (0.4%) received only lip-tie release”; “The study design did not incorporate a control group”.
Tadros S, Ben-Dov T, Catháin ÉÓ, Anglin C, April MM. Association between superior labial frenum and maxillary midline diastema: a systematic review. International Journal of Pediatric Otorhinolaryngology. 2022;156:111063. doi:10.1016/j.ijporl.2022.111063 (PMID 35248905). “Superior labial frenectomy should be delayed until permanent lateral incisors have erupted, as this can spontaneously close the physiological MMD.” Checked October 22, 2026.
American Dental Association (MouthHealthy). Permanent tooth development (eruption chart). Upper teeth erupt: “Central incisor 7-8 yrs.” “Lateral incisor 8-9 yrs.” “Canine (cuspid) 11-12 yrs.” Checked October 22, 2026.
Yilgör NY, Şimşek Derelioğlu S, Eser Tuna P, Şengül F, Aslan İnce NN. Association between maxillary labial frenum attachment types and early childhood caries: a cross-sectional study. Oral Health & Preventive Dentistry. 2025;23:569–575. PMID 41001957. Checked October 22, 2026.
Show the passageHide the passage
92 children aged 2 to 5: “clinicians should focus on comprehensive caries risk assessment before considering surgical interventions such as frenectomy”.
Schuepbach I, Vento C, Denes BJ, Antonarakis GS, Kiliaridis S. Longitudinal changes of the insertion of the maxillary labial frenum in children and adolescents undergoing orthodontic treatment. American Journal of Orthodontics and Dentofacial Orthopedics. 2023;163(6):786–792. doi:10.1016/j.ajodo.2022.06.027 (PMID 36653243). Checked October 22, 2026.
Show the passageHide the passage
“The MLF remains stable compared with the PP, whereas the maxillary incisal edge moves away from the PP, indicating increased vertical growth of the alveolar process.”
Weissman G, Mimouni FB, Kratunova E, Elbahary S. Maxillary labial frenulum: a scoping review of classification, diagnosis and evidence-based treatment. Journal of Dentistry for Children. 2025;92(3):118–128. PMID 41373049. Checked October 22, 2026.
Show the passageHide the passage
Sixteen studies: “Midline diastema often resolves naturally, questioning the necessity of early frenectomy. Surgical intervention is only advised when MLF impedes oral hygiene or contributes to orthodontic relapse.”
Freeman CG, Ohlstein JF, Rossi NA, McIntire JB, Neve LD, Daram S, Pine HS. Labial frenotomy for symptomatic isolated upper lip tie. Cureus. 2022;14(12):e32755. doi:10.7759/cureus.32755 (PMID 36686132). Checked October 22, 2026.
Show the passageHide the passage
“Seven infants with isolated upper lip tie and breastfeeding difficulty were taken to the operating room for labial frenotomy.” “Larger-scale randomized controlled studies are necessary to further evaluate this topic.”
Carnino JM, Walia AS, Lara FR, Mwaura AM, Levi JR. The effect of frenectomy for tongue-tie, lip-tie, or cheek-tie on breastfeeding outcomes: a systematic review of articles over time and suggestions for management. International Journal of Pediatric Otorhinolaryngology. 2023;171:111638. doi:10.1016/j.ijporl.2023.111638 (PMID 37352592). Checked October 22, 2026.
Show the passageHide the passage
“the majority of studies describing only lip-tie or tongue-tie were editorials, commentary, perspectives, or consensus statements”.
Atya A, Alkabazi M, Shanab A, Aldieb E, Amrani AE, Alsharif M, Elhadi M. Efficacy of diode laser versus conventional scalpel in labial frenectomy: a systematic review and meta-analysis of randomized controlled trials. Odontology. 2026;114(3):1126–1138. doi:10.1007/s10266-025-01280-5 (PMID 41369715). Checked October 22, 2026.
Show the passageHide the passage
Six trials, 324 participants: “Evidence certainty ranged from low to very low due to the small sample size and heterogeneity of the data.”
Bacon BR, Carr MM. Maxillary frenulum and “lip tie”: what parents understand. OTO Open. 2023;7(3):e71. doi:10.1002/oto2.71 (PMID 37674624). 323 parents: “Most parents (91.2%, 176) thought ‘lip tie’ caused breastfeeding problems.” Sources included “nonmedical sources, such as social media, family, and friends (68.4%, 132)”. Checked October 22, 2026.

Medical disclaimer. This page is for general educational purposes and does not constitute medical or dental advice, diagnosis, or treatment. Always consult a qualified healthcare provider about your child.

Lip Tie in Babies: Signs and Treatment