Most children appear to experience some minor discomfort for a couple of days after the local anesthesia from the procedure has worn off. Tylenol (dosage on packaging) should be sufficient and be taken for the first or second day. The child can eat whatever foods he/she can tolerate while avoiding acidic (ie. Lemon, ketchup, tomato sauces), spicy or particularly hot food. However, lots of freeze pops, popsicles and ice cream cones are recommended in order to move the tongue around as much as possible. The wound under the lip and tongue will be sore (ie canker sore) for a few days and in two weeks look almost normal. Stretching & Massaging Exercises for Tongue & Lip Tie Release Tongue Tie Release: Your goal is to have the frenum heal and re-form as far back as possible. The release tongue will look like a diamond shape. Wait 6 hours before starting your first stretches. With a clean finger, lift the tongue at the top of the diamond in the middle of the tongue. Your goal is to see the whole diamond open up and lengthen. It may bleed slightly when it is stretched. Repeat these stretches 5x/day at various times a day for two weeks. Encourage the child to move the tongue as much as possible by sticking it out and holding it for 10 seconds, sticking tongue out and move tongue toward right cheek holding 10 seconds and move tongue towards left cheek and hold 10 seconds, open wide and lift the tongue up to ‘paint the roof of the mouth’, make clicking noises (tick tock), place peanut butter or honey on upper lip and lick from lip. Repeat these stretches 5x/day at various times a day for two weeks. The released area will form a wet scab after the first day. It will appear white or yellow and it will be soft because it is wet. This area is what you will be pressing against. The healing will be happening under the scab, just like a scrape anywhere else on your body. The white area will get smaller each day. Even though the white scab will heal you MUST continue the stretches, or the tissue will be more likely to re-attach and the procedure may need to be repeated. Lip Tie Release: The goal is for the frenum to heal and reform as high as possible. Pull the lip up as high as possible, high enough to press against the nose. You want to see the whole white triangle. Press gently against the wound to massage it and keep the triangle open. It may bleed slightly when this is done. Repeat 5x/day at various times for 2 weeks. The released area will form a wet scab after the first day. It will appear white or yellow and soft because it is wet. This area is what you will be pressing against. The healing will be happening under the scab, just like a scrape anywhere else on your body. The white area will get smaller each day, but healing is still happening. Even though the white scab will heal you MUST continue the stretches, or the tissue will be more likely to re-attach and the procedure may need to be repeated. If you have any questions or concerns, please call Dr. Mike at 207-536-5835 or email a picture at info@207pd.com

Most babies appear to experience some discomfort for the first two days after the procedure. Tylenol (acetaminophen) may be given to help with discomfort for babies over 3 months of age; ibuprofen (Motrin or Advil) is NOT recommended. If your child is under 3 months of age and seems to be exceptionally uncomfortable try applying a cold washcloth to their upper lip. If that does not help, please call Dr. Mike. The healing site will change colors (off white, yellow, green, red, etc.) but if you detect very white or very red try to take a picture and call Dr. Mike at the number on the bottom of this page. If you are concerned about anything contact us for help. Stretching and Massaging Exercises: Doing the exercises as instructed allows for proper healing by reducing the risk of reattachment and therefore the need for repeat surgery. These exercises must be done at least 5 times a day for 2 weeks . Wash your hands thoroughly; assure that your fingernails are short. Exercise details: Start 5 hours after the procedure; try to avoid doing them right before or after feeding. Before a diaper change is often a good time. Lay your baby on his/her back with his/her head towards you, and feet pointing away. THE LIP: stretch: 5 light pull ups (vertical) lifting the upper lip towards the nose massage: 5 light rubs at fold (horizontal) as if brushing their gums with your finger THE TONGUE: stretch: 5 firm rubs at diamond (vertical) running from behind where their bottom front teeth will come in, along the floor of their mouth, to the base of their tongue, up towards the tip of their tongue and back down in reverse. There may be a few drops of blood as the area stretches but this is normal. Breastfeeding is one way to stop the bleeding. In the unlikely event that bleeding continues, using a napkin or paper towel to apply pressure on the wound. About one week after your appointment, please email a photo of the frenectomy site to info@207pd.com so we can evaluate how things are healing. In the event of an emergency, Dr. Mike can be reached after hours by calling (207) 370-8541 PLAY TIME: Post-Op Tongue Exercises – Physiotherapy After a tongue tie release (revision) you must also provide tongue strengthening exercises. Even though the new release and stretching which you were taught to do will insure the best possible freedom for mobility, there may still be a problem of muscle coordination and strength. Approximately 3 month prior to birth, your infant was sucking and using his/her tongue in utero. So after birth there was already 3 months of developmentally restricted tongue muscle movement. Therefore we need to train the tongue to move and exercise to allow for the proper 3- dimensional movement of the tongue muscles. We will encourage this as PLAY TIME. 4 times a day for 6 weeks, you will find a time to do the following exercises to encourage your baby to extend and point the tongue, create a central groove of the tongue to encourage side grasping or holding of your nipple and also right and left lateral movement (to help move breast milk and food around the mouth) which was inhibited by the restrictive tongue tie. There are many types of tongue exercises which your IBCLC can teach you. I have found these to be the easiest for my patients. REMEMBER THIS IS CONSIDERED PLAY TIME EXERCISES performed at a different time than the stretching exercises (which are done 4 times a day for 2 weeks). Tongue Pointing (Extension): Place finger pad on the bottom lip and gently tap and stroke it down towards the lower jaw. This will encourage the tongue to extend out of the mouth and point. This should be done several times a day to encourage the extension muscles of the tongue to strengthen. Side to Side Motion: Place your finger pad on the top surface of the front gum area of the lower jaw and gently slide your finger tip from the middle where the bottom front teeth will be to the right back molar area then slowly back to the starting point and then slide to the left side. This will encourage the tongue to move laterally as the tongue freedom improves and strengthens after the tongue tie release. Tongue Grooving: This will stimulate the sides of the tongue to contract and rise up to form a central groove to help latch onto the nipple and allow for a path for the breast milk to flow towards the back of the throat for swallowing. This is accomplished by placing your finger with the finger pad towards the roof of the mouth and allowing your baby to suck and you can encourage strength by playing a gentle tug-of-war with your finger and the sucking of the tongue. Flange Exercise: Using the same position as above, leave your finger in place (up to the first knuckle) at the roof of the mouth right behind where the front teeth will be and as your baby sucks, gently free the curled under lip with your other free hand and curl the lip up and out.

POST-OPERATIVE INSTRUCTIONS Nitrous Oxide (Laughing Gas): Once nitrous oxide is no longer inhaled, it wears off in a few minutes and will be out of your child’s system upon discharge after the procedure - most patients do not experience side effects Although very rare, side effects are possible and may include headaches, fatigue, nausea and vomiting - know that these are only temporary and usually subside quickly once the effect of nitrous oxide diminishes Numbness (Local Anesthesia): The sensation of cheeks, tongue, and lips being numb after the appointment is typically the most challenging aspect for a child to understand It may take anywhere between 1-4 hours for the numbness to wear off, generally around 2 hours Avoid eating foods that are hard, sticky, or crunchy until it wears off (soft food diet is encouraged) until sensation has returned Monitor your child closely so that they do no bite their tongue, cheek or lips As sensation returns, the tingly feeling may cause a change in your child’s behavior, they may become upset, cry, or play with the area - reassure your child that it will feel normal soon Fillings (Resin Based Composites): If your child is numb, please follow the post-op instructions for numbness Avoid sticky, hard candies and chewing on ice to prevent breaking the filling or crown If the filling was on a front tooth, avoid using front teeth to bite directly into hard foods (i.e. apples, carrots, and corn on the cob) Your child’s bite may feel a little different after fillings are placed and may take a day or two to get used to it Occasionally, a filling may come out days, weeks, or years after it is placed This is more common in front teeth than back teeth Most commonly caused by a new cavity forming around the filling If a filling does come out, or a tooth chips, be sure to call so that we can determine if your child should be seen for evaluation It is important to note that resin fillings are prone to recurrent decay (new decay around the filling margin) and daily flossing and brushing twice a day is a must For any discomfort, Tylenol or Ibuprofen is recommended; follow dosing instructions on the packaging Extractions: Your child will be numb so please follow the post-op instructions for numbness Have your child bite on the provided gauze until bleeding is controlled, which may take up to 30 minutes after the procedure Any heavy bleeding was controlled prior to discharge, however some oozing is normal If bleeding continues after removing the gauze, replace the gauze with a new piece If bleeding continues for 2 hours after discharge, or becomes heavy, please contact us GEL FOAM: a type of dissolvable dental sponge that is white in color placed in extraction sites that will help form a blood clot. Do not be alarmed if the gel foam falls out, your child swallows or spits it out. Avoid sippy cups, bottles, straws and pacifiers for the first 24 hours after the procedure as the sucking action may prolong bleeding Avoid salty, spicy, acidic or crunchy foods for the first 24 hours as this may irritate the extraction site (cold and/or soft foods are a great choice - i.e. ice cream, apple sauce, mac and cheese, etc.) Do not rinse the extraction site for 24 hours following the procedure, but continue normal hygiene routine otherwise Do not allow your child to participate in strenuous activities for the first 24 hours after the procedure as this may increase bleeding from the extraction site For any discomfort, Tylenol is recommended; follow dosing instructions on the packaging Crowns (Stainless Steel/Silver Caps or Zirconia): Your child will be numb so please follow the post-op instructions for numbness To seat the crown correctly, work must be done just below the gumline; expect your child’s gums to be sore for 2-3 days following placement of the crown Your child’s gums may be red, irritated, or bleed when brushing for up to two weeks following placement - to help with healing, keep the area clean by gently brushing 2-3 times a day and flossing It may take a few days for your child to adjust to the crown, do not let your child pick or pull at the crown as continuous force and pressure can pull it off leaving the underlying tooth structure unprotected Your child should avoid sticky, hard candies (i.e. taffy, starbursts, caramels, lollipops etc.) for the life of the crown - although it is cemented to the tooth structure, these sticky foods can cause the crown to become loose or fall off In the case that a crown falls off be sure to call so that we can determine if your child should be seen for evaluation The crown will fall out when the tooth does For any discomfort, Tylenol or Ibuprofen is recommended; follow dosing instructions on the packaging If you have any questions or concerns, please us at 207-536-5835.

POST-OPERATIVE INSTRUCTIONS Conscious Sedation: The medication used during this type of dental sedation will remain in your child’s system for 4-6 hours after discharge and requires close supervision Your child may seem off and possibly be off balance until the medication fully works out of their system - please assist your child while walking, using the bathroom, etc. until the medication effects have diminished to prevent accidental injury or falls Following sedation procedures, do now allow your child to attend school, daycare, or participate in strenuous activities for the remainder of the day Encourage your child to rest, hydrate, and eat upon discharge to facilitate the medication effects to diminish Nitrous Oxide (Laughing Gas): Once nitrous oxide is no longer inhaled, it wears off in a few minutes and will be out of your child’s system upon discharge after the procedure - most patients do not experience side effects Although very rare, side effects are possible and may include headaches, fatigue, nausea and vomiting - know that these are only temporary and usually subside quickly once the effect of nitrous oxide diminishes Numbness (Local Anesthesia): The sensation of cheeks, tongue, and lips being numb after the appointment is typically the most challenging aspect for a child to understand It may take anywhere between 1-4 hours for the numbness to wear off, generally around 2 hours Avoid eating foods that are hard, sticky, or crunchy until it wears off (soft food diet is encouraged) until sensation has returned Monitor your child closely so that they do no bite their tongue, cheek or lips As sensation returns, the tingly feeling may cause a change in your child’s behavior, they may become upset, cry, or play with the area - reassure your child that it will feel normal soon Fillings (Resin Based Composites): If your child is numb, please follow the post-op instructions for numbness Avoid sticky, hard candies and chewing on ice to prevent breaking the filling or crown If the filling was on a front tooth, avoid using front teeth to bite directly into hard foods (i.e. apples, carrots, and corn on the cob) Your child’s bite may feel a little different after fillings are placed and may take a day or two to get used to it Occasionally, a filling may come out days, weeks, or years after it is placed This is more common in front teeth than back teeth Most commonly caused by a new cavity forming around the filling If a filling does come out, or a tooth chips, be sure to call so that we can determine if your child should be seen for evaluation It is important to note that resin fillings are prone to recurrent decay (new decay around the filling margin) and daily flossing and brushing twice a day is a must For any discomfort, Tylenol or Ibuprofen is recommended; follow dosing instructions on the packaging Extractions: Your child will be numb so please follow the post-op instructions for numbness Have your child bite on the provided gauze until bleeding is controlled, which may take up to 30 minutes after the procedure Any heavy bleeding was controlled prior to discharge, however some oozing is normal If bleeding continues after removing the gauze, replace the gauze with a new piece If bleeding continues for 2 hours after discharge, or becomes heavy, please contact us GEL FOAM: a type of dissolvable dental sponge that is white in color placed in extraction sites that will help form a blood clot. Do not be alarmed if the gel foam falls out, your child swallows or spits it out. Avoid sippy cups, bottles, straws and pacifiers for the first 24 hours after the procedure as the sucking action may prolong bleeding Avoid salty, spicy, acidic or crunchy foods for the first 24 hours as this may irritate the extraction site (cold and/or soft foods are a great choice - i.e. ice cream, apple sauce, mac and cheese, etc.) Do not rinse the extraction site for 24 hours following the procedure, but continue normal hygiene routine otherwise Do not allow your child to participate in strenuous activities for the first 24 hours after the procedure as this may increase bleeding from the extraction site For any discomfort, Tylenol is recommended; follow dosing instructions on the packaging Crowns (Stainless Steel/Silver Caps or Zirconia): Your child will be numb so please follow the post-op instructions for numbness To seat the crown correctly, work must be done just below the gumline; expect your child’s gums to be sore for 2-3 days following placement of the crown Your child’s gums may be red, irritated, or bleed when brushing for up to two weeks following placement - to help with healing, keep the area clean by gently brushing 2-3 times a day and flossing It may take a few days for your child to adjust to the crown, do not let your child pick or pull at the crown as continuous force and pressure can pull it off leaving the underlying tooth structure unprotected Your child should avoid sticky, hard candies (i.e. taffy, starbursts, caramels, lollipops etc.) for the life of the crown - although it is cemented to the tooth structure, these sticky foods can cause the crown to become loose or fall off In the case that a crown falls off be sure to call so that we can determine if your child should be seen for evaluation - the crown will fall out when the tooth does

POST-OPERATIVE INSTRUCTIONS General Anesthesia: Please follow the post-op instructions provided by the anesthesia provider Dr. McCarty For specific procedures please see the post-op instructions provided Numbness (Local Anesthesia): The sensation of cheeks, tongue, and lips being numb after the appointment is typically the most challenging aspect for a child to understand It may take anywhere between 1-4 hours for the numbness to wear off, generally around 2 hours Avoid eating foods that are hard, sticky, or crunchy until it wears off (soft food diet is encouraged) until sensation has returned Monitor your child closely so that they do no bite their tongue, cheek or lips As sensation returns, the tingly feeling may cause a change in your child’s behavior, they may become upset, cry, or play with the area - reassure your child that it will feel normal soon Fillings (Resin Based Composites): If your child is numb, please follow the post-op instructions for numbness Avoid sticky, hard candies and chewing on ice to prevent breaking the filling or crown If the filling was on a front tooth, avoid using front teeth to bite directly into hard foods (i.e. apples, carrots, and corn on the cob) Your child’s bite may feel a little different after fillings are placed and may take a day or two to get used to it Occasionally, a filling may come out days, weeks, or years after it is placed This is more common in front teeth than back teeth Most commonly caused by a new cavity forming around the filling If a filling does come out, or a tooth chips, be sure to call so that we can determine if your child should be seen for evaluation It is important to note that resin fillings are prone to recurrent decay (new decay around the filling margin) and daily flossing and brushing twice a day is a must For any discomfort, Tylenol or Ibuprofen is recommended; follow dosing instructions on the packaging Extractions: Your child will be numb so please follow the post-op instructions for numbness Have your child bite on the provided gauze until bleeding is controlled, which may take up to 30 minutes after the procedure Any heavy bleeding was controlled prior to discharge, however some oozing is normal If bleeding continues after removing the gauze, replace the gauze with a new piece If bleeding continues for 2 hours after discharge, or becomes heavy, please contact us GEL FOAM: a type of dissolvable dental sponge that is white in color placed in extraction sites that will help form a blood clot. Do not be alarmed if the gel foam falls out, your child swallows or spits it out. Avoid sippy cups, bottles, straws and pacifiers for the first 24 hours after the procedure as the sucking action may prolong bleeding Avoid salty, spicy, acidic or crunchy foods for the first 24 hours as this may irritate the extraction site (cold and/or soft foods are a great choice - i.e. ice cream, apple sauce, mac and cheese, etc.) Do not rinse the extraction site for 24 hours following the procedure, but continue normal hygiene routine otherwise Do not allow your child to participate in strenuous activities for the first 24 hours after the procedure as this may increase bleeding from the extraction site For any discomfort, Tylenol is recommended; follow dosing instructions on the packaging Crowns (Stainless Steel/Silver Caps or Zirconia): Your child will be numb so please follow the post-op instructions for numbness To seat the crown correctly, work must be done just below the gumline; expect your child’s gums to be sore for 2-3 days following placement of the crown Your child’s gums may be red, irritated, or bleed when brushing for up to two weeks following placement - to help with healing, keep the area clean by gently brushing 2-3 times a day and flossing It may take a few days for your child to adjust to the crown, do not let your child pick or pull at the crown as continuous force and pressure can pull it off leaving the underlying tooth structure unprotected Your child should avoid sticky, hard candies (i.e. taffy, starbursts, caramels, lollipops etc.) for the life of the crown - although it is cemented to the tooth structure, these sticky foods can cause the crown to become loose or fall off In the case that a crown falls off be sure to call so that we can determine if your child should be seen for evaluation The crown will fall out when the tooth does For any discomfort, Tylenol or Ibuprofen is recommended; follow dosing instructions on the packaging