There are seven frena or folds of tissue in the mouth, and four of them are in the cheeks and are referred to as “buccal frena.” A frenum is considered a “tie” (tongue-tie, lip-tie, cheek-tie) when it causes a problem. Otherwise, it is a “normal frenum. “Buccal” is pronounced like a “belt buckle.”
So a buccal tie or cheek tie is an abnormally tight frenum in the cheeks. In most cases, a tongue-tie is the most significant frenum in the mouth (breastfeeding/bottle-feeding, speech, solid feeding, and sleep issues), followed by the maxillary lip-tie (think a gap between the teeth or trouble nursing/bottle-feeding). The maxillary or upper jaw buccal frena are the ones that most often cause issues, but occasionally a mandibular buccal frenum can be restrictive as well.
When pulling the cheeks back, you will notice the frenum blanching the gingiva, it might elicit pain from the patient, and it will look like the sail of a sailboat. These factors are important to assess, and if they are tight and causing a problem, it might warrant a release. But appearance alone does not justify their release.
Buccal ties can theoretically interfere with nursing, nipple stabilization, and seal issues (milk leaking out, air swallowing, gas, etc.) in infants (although there is no quality research supporting this statement), can cause gum recession in adults, lead to excessive fascial tension around the mouth (harder to move your lips), and are even the likely cause of dimples! With dimples, the cheek pulls in because the frena are so tight and restrictive.
We always err on the side of caution and try never to overtreat, but at the same time, we don’t want to undertreat if they could be contributing to a real problem the patient is having. We sometimes release buccal ties in infants (maybe 1 in 10 babies we treat for tongue-tie) or children (maybe 1 in 100) unless they are restrictive and the benefits outweigh the risks. As always, it’s up to the parents whether they want to treat the cheek ties or not after a full discussion of risks and benefits.
The biggest risks to releasing buccal ties are bleeding (minimal if using CO2 laser), reattachment (they can grow back together if stretches are not performed properly), and discomfort (not terrible, but still can be uncomfortable). The downsides are possibly increased pain for a baby, but the tongue wound is likely the most uncomfortable because the tongue is doing most of the work with infant feeding and the lips and cheeks are more passive. The other downside is having to stretch the cheeks in addition to a lip and/or tongue release. The cheek stretches would be at the same time as other areas are stretched, so it might add 10 seconds to the stretching routine.
With babies, the tongue is always the primary place to release if a baby is struggling, the lip-tie is secondary and contributes to seal issues (excessive gas, clicking sounds, colic, reflux, milk leaking out, etc.), and the buccal ties are tertiary in importance, but possibly make an impact. We had a baby come from another office who had a lip-tie and a right buccal tie released, but the other dentist left the tongue untouched because they didn’t realize the baby had a posterior or less obvious tongue-tie. They were still struggling, and after a proper tongue release (and we got the left buccal for symmetry, and it was restrictive), they had significant improvements. Learn more about posterior tongue-ties, proper treatment, and checking a baby for tongue-tie properly in other posts.
We give parents the information from the exam, along with the risks, and potential benefits, and we let them decide. We do not charge anything for buccal ties (some dentists do charge, but as there is no research backing them up, you leave yourself open to criticism). It only takes a few seconds extra, maybe 5 sec per tie.
Most babies do well with just a proper lip and tongue release (along with a team approach and effective aftercare stretches), but possibly they could do a little better with buccal tie releases as well if they are restrictive. In summary, check for buccal ties, inform the parents, and use shared decision-making to come up with the best plan for that individual patient.
If you’re a patient and worried your child has buccal ties, or a tongue- or lip-tie, call us at 205-419-4333 or Schedule a Consult.
To learn more about tongue and lip-ties, download a free copy of Tongue-Tied or check out our comprehensive online course Tongue-Tied Academy.