Tongue Tie

What is a tongue tie?

Tongue Tie

A tongue tie may lead to various oral health problems, as discussed further in this article

A tongue tie is a common but often overlooked condition.  The lingual frenum (or lingual frenulum) is the cord that stretches from under the tongue to the floor of the mouth. When this cord is short or restricted it affects the mobility of the tongue.  A severely restricted tongue tie is often referred to as Ankyloglossia.  There are different types of tongue tie and different levels of restriction.  Often times, people mistake the ability to stick the tongue out as far as they can as meaning they are not tongue tied.  This could not be farther from the truth.  The tongue needs to be able to ELEVATE across the roof of the mouth with light suction without using the muscles of the neck and floor of the mouth. Just because there is mobility in one direction with the tongue does not mean normal mobility in all directions.

Is Being Tongue Tied Hereditary?

According to dated studies, Ankyloglossia (Type I and II) affect nearly 5% of the population.  Current clinical research is indicating that the percentage is much higher when you account for Type III and IV, as recent studies are showing a genetic  link.  Unfortunately diagnosing tongue tie is NOT in the curriculum of dental students, doctors, ENT’s, sleep physicians, Speech Language Pathologists, Dental Hygienists, or anyone else.   It is truly only understood by those who have gone above with extra graduate education in this field.  Tongue tie is very common, but often not diagnosed.

Why is it a concern?

A restricted lingual frenum can limit the range of motion of the tongue and adversely affect breathing, chewing, swallowing, the health of the teeth, teeth alignment, and speech.  In infants, a tongue tie may severely impede the ability to breastfeed successfully.  Bottle feeding requires a completely different movement of the tongue that often leads to a high, narrow arched palate and a tongue thrust swallow.  In children, a tongue tie may lead to difficulties such as the inability to chew foods properly, gagging or choking, delayed speech development, crowding of the teeth, decay, and drooling.  In adults, a tongue tie can interfere with the airway, crowded or misaligned teeth, and can be associated with issues such as sleep apnea, and strokes.  Other problems include contribute to periodontal disease, gum recession, tooth mobility, and decay.


Infant Concerns Associated with a Tongue Restriction

Mother breast feeding her infant

Mother breast feeding her infant

  • Breast feeding difficulties
  • Failure to Thrive
  • Difficulty with the introduction of solid foods
  • Weight gain problems
  • Gas, fussiness, reflux
  • Gagging/lots of spitting up
  • Difficulty latching
  • Slips off breast easily (weak latch)
  • Refusing to nurse
  • Colic/excessive crying
  • Shallow latch/poor latch
  • “Clicking” sound while eating (breast or bottle)
  • Upper lip tucks in when feeding (instead of flaring out)

Children Concerns Associated with a Tongue Restriction

  • Open mouth breathing
  • Open mouth posture
  • Sloppy eating
  • Difficulty chewing food and moving it around in the mouth. (This is where other facial muscles begin to compensate)
  • Misarticulation
  • Poor oral hygiene
  • Delayed Tooth Eruption and or crowding of the teeth, open bites and crossbites.
  • Developmental changes in the face and jaw
  • Higher incidence of tongue thrust
  • Higher incidence of a high narrow upper palate (which directly affects the nasal cavity)



Adult Problems Associated with a Tongue Restriction

Adults must contend with a lifetime of bad habits that have compensated for inadequate tongue mobility.

  • Malocclusion (crooked teeth)
  • Protrusion of the lower jaw
  • Inability to open the mouth wide
  • Misarticulation of soundssleep-apnea
  • Upper airway obstruction
  • Sleep breathing disorders
  • TMJ and Muscle tension
  • Upper back, neck tension
  • Dental Decay from not being able to use the tongue to swipe food from tooth surfaces
  • Kissing



How can it be corrected?

In order to correct a tongue tie that is limiting and restrictive, a simple surgical procedure called a frenectomy may be needed.  The doctors I refer out to for frenectomy procedures are highly skilled and laser trained, and understand all aspects of a tongue tie release including posterior tongue ties.  Austin, Texas is fortunate to have 2 pediatric board certified specialists who are highly skilled in this procedure for the kiddos.

The Importance of  Myofunctional Therapy BEFORE and AFTER a Tongue Tie Release

It is strongly recommended to set up a consultation with an orofacial myologist prior to the scheduled surgery. This will allow the therapist time to work on strengthening and toning the muscles prior to the surgery leading to a better outcome, as well as teaching specific exercises to be done in the days following the surgery.

Myofunctional therapy  after a tongue tie release is a key element in helping to eliminate reattachment and ensure that the tongue muscles become strong and active.  The tongue may be more mobile, but it has NO CLUE what to do.  The tongue has been anchored down to the floor of the mouth and must learn new exercises to assist it with vertical movements, elevation, suction, cupping, and retraction and protrusion.  The tongue must learn how to work independently of the lower jaw, and achieve an appropriate tongue rest position with the teeth apart. Over the years, individuals with tongue-tie develop strong abnormal habits to compensate for the tongue being attached on the floor of the mouth.   An orofacial myologist with experience in proper tongue rest posture can help with learning correct placement for articulation, and while eating, drinking and swallowing.

Teaching the tongue its new, correct position is also pivotal in helping to avoid future TMJ issues, bite dysfunctions, tension headaches, and mouth breathing. A low tongue rest is often accompanied with increased occlusal vertical dimension and changes in the craniofacial dentoskeletal structures.

Remember, just because the structure has changed (free tongue), doesn’t mean that the behavior and function will.

Thirdly, an orofacial myoloist can eliminate a tongue thrust that may accompany a restricted lingual frenum.

Please contact me if you suspect a tongue tie or if you have a frenectomy scheduled.

Classifications of Tongue Ties

There are different tongue tie classification systems and assessment tools.  The type of classification system used is not critical as it is merely a description of where the tie attaches to the tongue.  What is important is to understand is that there are varying degrees of tongue ties and they can affect all of us in different ways.

One way to classify tongue ties is according to where the frenum (cord of tissue) is attached on the base of the tongue. Such as the classification system listed here.

Class I – Class 1 ties are attached on the very tip of the tongue. This would be considered an anterior tongue tie. The appearance of the tongue tip often resembles a heart shape when elevated.  These are the ones that most people think of when they talk about tongue ties.

Class II – Class 2 ties are a little further behind the tip of the tongue about 2-4 mm and attaches on or just behind the alveolar ridge (jaw bone). They also fall under the classification of anterior tongue tie.

Class III – Class 3 ties are closer to the base of the tongue and attach to the mid-tongue and the middle of the floor of the mouth.  These ties are generally tighter and less elastic.

Class IV – Class 4 ties are the MOST COMMONLY MISSED ties. The front and sides of the tongue elevate, but the mid tongue can not. These are also known as posterior tongue ties and must be felt to be diagnosed.

The Kotlow assessment tool classifies tongue ties/restrictions into four categories based on the length of the free tongue (the distance from the tip of the tongue to the attachment of the frenum).

Tongue Tie Classification

Classification of Tongue Ties

What is a LIP TIE?

An upper lip-tie is the piece of tissue under the upper lip (the labial frenulum) that attaches the upper lip to the maxillary gingival tissue at the midline.  Most people have a frenum that attaches to the maxillary arch, but the degree of restriction varies. Severe restrictions that limit movement of the upper lip which may make it more difficult for babies to maintain a good seal when breast feeding.

4 Classifications of Lip Ties

Class I – Minimal visible Attachment

Class II – Attachment primarily into the gingival tissue

Class III – Inserts just in front of anterior papilla

Class IV – Attachment just into the hard palate or papilla area

Infant Lip Tie

Kotlow’s 4 classifications of lip tie in infants

Children Lip Tie

Kotlow’s 4 classifications of lip tie in children

IT IS IMPORTANT TO NOTE that there is more to diagnosing a lip tie then simply looking at it.  Mother and baby’s symptoms need to be considered if present.

Problems Associated with Breastfeeding and Lip Ties in Infants

  • Weight gain problems
  • Gas, fussiness, reflux
  • Gagging/lots of spitting up
  • Difficulty latching
  • Slips off breast easily (weak latch)
  • Refusing to nurse
  • Colic/excessive crying
  • Shallow latch/poor latch
  • “Clicking” sound while eating (breast or bottle)
  • Upper lip tucks in when feeding (instead of flaring out)

Signs in Breastfeeding Mother

  • Pain for mother during nursing
  • Breastfeeding issues (thrush, clogged ducts, mastitis, bleeding or cracked nipples, vasospasms, tell-tale “lipstick shape” after nursing)
  • Over-supply/under-supply of milk (from baby not emptying breast completely)

For nursing moms I strongly suggest working closely with a skilled lactation consultant (ICBLC) who has knowledge of suck, swallow, and tongue training.  It may also be necessary to consult with an osteopath or craniosacral therapist to assure their are no additional problems with the cranium, head, neck or back.

See the following PubMed articles on breastfeeding and dental arch relationships in infants: (Association of breastfeeding and three-dimensional dental arch relationships in primary dentition) (Influence of feeding patterns on the development of teeth, dentition and jaw in children)