Imagine trying to speak, eat, or swallow, but something is holding your tongue back—literally. That’s what happens when a condition known as tongue-tie, or ankyloglossia, affects the movement of your tongue. This arises when a small band of tissue known as the lingual frenulum, which connects the bottom of your tongue to the floor of your mouth, is too tight, short, or restrictive. While a normal frenulum allows for smooth, easy movement of the tongue, a restrictive frenulum can make everyday functions like chewing, swallowing, and speaking difficult or uncomfortable. In growing children, ankyloglossia can also lead to misaligned bites and imbalanced jaw growth. In infants, it can interfere with breastfeeding, leading to challenges for both mother and baby. Understanding tongue-tie and its potential impact can help you and your healthcare provider identify early signs and pave the way for effective treatment.
What is a Lingual Frenulum?
The term "frenulum" or “frenum” refers to a connective tissue band that attaches one part of the mouth to another. The lingual (tongue) frenulum is a band or fold of tissue that typically contains elements that make it small but mighty: epithelial fibers, collagen fibers, elastin fibers and occasionally muscle fibers. It connects the underside of the tongue to the floor of the mouth, helping to limit excessive movement, and provide stability during various functions such as eating, speaking, and swallowing.
What Causes Tongue-Tie?
Ankyloglossia, also known as tongue-tie, is a condition where the lingual frenulum is too short, thick or tight. It is a congenital condition, meaning it is present at birth, but its exact cause remains unknown. While no single factor has been pinpointed, some cases of tongue-tie seem to run in families, suggesting a potential genetic link. Ankyloglossia is more common in males compared to females, and has a prevalence ranging from 4-10%.
Risks of Tongue-Tie
Ankylglossia is associated with several oral health and functional issues. While tongue-tie may seem like a minor issue, it can pose a range of challenges for individuals of all ages. These challenges can impact daily life in various ways, from feeding difficulties to speech impediments and even social interactions. Let's explore some of the key risks associated with tongue-tie:
Breastfeeding problems
In infants, a tongue-tie can interfere with proper latch during breastfeeding, leading to poor feeding, discomfort for the mother, and inadequate nutrition and weight gain for the baby.
Speech difficulties Tongue-tie can interfere with the ability to make certain sounds which require the tongue to raise or extend— including (but not limited to) "t," "d," "z," "s," and "l." This may result in speech impediments, such as lisping.
Poor oral hygiene In children and adults, tongue-tie can make it difficult for the tongue to sweep food debris from the teeth and gums. This can contribute to tooth decay (cavities) and inflammation of the gums (gingivitis).
Gingival recession When the lingual frenulum attachment puts excessive tension on the gum tissue, this can lead to gingival recession (gum recession) behind the lower front teeth.
Challenges with eating and swallowing Tongue-tie can make it difficult to lick an ice cream cone, lollipop, or even your lips. This is because the restricted tongue movement makes it hard to extend the tongue and create certain shapes and movements. Chewing and swallowing rely on the tongue to move food around for proper breakdown and safe swallowing. Tongue-tie can hinder this, creating trouble swallowing and potentially leading to choking or gagging.
Difficulty playing instruments Certain instruments, such as wind instruments, require precise tongue movements to create specific sounds, which can be challenging with tongue-tie.
Discomfort and pain If the frenulum is too tight, it can cause tension or pain during normal activities like speaking or eating, especially in cases where the frenulum interferes with the natural motion of the tongue.
Imbalanced growth
When the tongue is restricted and does not rest in the correct position, it can affect the growth and development of the jaws. Ideally, the tongue rests on the roof of the mouth. This resting position helps guide the growth of the upper jaw. In people with ankyloglossia, the tongue is often positioned low in the mouth. Because the tongue isn't able to sit high and apply pressure against the sides of the upper jaw during growth, the upper jaw can become narrow and underdeveloped. Studies also suggest that low tongue posture can create extra pressure on the lower jaw (mandible), pushing it forward and causing the teeth and bite to misalign. Some studies show that severe cases of tongue-tie may lead to what is called a Class III malocclusion (misaligned bite), where the lower jaw grows too far forward compared to the upper jaw.
Impact on Orthodontic Treatment
Orthodontic treatment often involves repositioning the teeth, bite, and sometimes the jaws to achieve proper function and alignment. The lingual frenulum can impact orthodontic treatments and results in various ways. These include:
Poor oral health risks A restricted lingual frenulum can present oral health challenges and risks during orthodontic treatment. If the tongue’s mobility is limited, it may affect the patient’s ability to keep their mouth and teeth clean, resulting in an increased risk of cavities and gum disease. There is also a risk of gingival recession (gum recession) behind the lower front teeth in cases where frenulum attachment puts excessive tension on the gum tissue.
Orthodontic options and results Tongue-tie is associated with a reduced upper canine width, high-arched palate, and narrow palate. These conditions often lead to overcrowding of teeth, crossbite, a narrow dental arch, and narrow smile esthetics. Though early orthodontic intervention can typically address these issues in growing children, options to address conditions like these become more limited for adults.
Orthodontic relapse
Restricted motion of the tongue caused by a tight frenulum can lead to altered oral behaviors, such as mouth breathing, improper swallowing, and tongue thrusting. These habits can place unwanted pressure on the teeth. This can lead to relapse, in which teeth shift back to their previous positions after orthodontic treatment. Additionally, a tongue that is unable to rest properly against the roof of the mouth can prevent the proper development and growth of the upper jaw. Even after orthodontic treatments such as braces or clear aligners, if the underlying problem isn’t addressed, the tongue can still apply pressure in ways that cause the teeth to shift back to their original positions, leading to treatment results not lasting.
Relationship of Tongue-Tie to Obstructive Sleep Apnea (OSA)
The relationship between tongue mobility and airway function is complex. In 2020, Clinical Consensus Statements were developed by pediatric otolaryngologists with the intention to promote appropriate, evidence-based care for infants and children with tongue-tie. This expert panel reached agreement on several statements that clarify the diagnosis and management of ankyloglossia. According to the team, ankyloglossia alone does not cause obstructive sleep apnea (OSA). While a narrow palatal arch (narrow palate) has been shown to contribute to OSA, only a single small study has been cited as evidence of a direct association between ankyloglossia itself and OSA. The Clinical Consensus Statements noted that a restricted tongue sometimes serves to prevent posterior collapse of the tongue, and that if the frenulum is released, it could lead to worsening OSA. It is also important to note that cases of congenital micrognathia (severe recession of the lower jaw), as in Pierre Robin sequence, are sometimes treated by adhering or stitching the tongue to the lip, creating a tongue-tie. This tongue-lip-adhesion procedure is performed to help with breathing difficulties and to protect these infants from choking by tongue swallowing. More research is needed and can hopefully aim to assess airway function as it relates to tongue mobility.
How is Tongue-Tie Measured?
Tongue-tie can be evaluated in several ways. One common way to measure tongue-tie is by using a specific frenulum ruler to directly assess the length of the frenulum. This method involves measuring the distance from the tip of the tongue to the base of the frenulum and has been shown to be both accurate and reliable in clinical settings. Another approach is an indirect evaluation that looks at the maximum mouth opening, both with and without the tip of the tongue touching the incisive papilla (the area just behind the upper front teeth). These can be useful ways to identify potential issues with the frenulum, indicating that it may be too tight or restrictive.
How is Tongue-Tie Classified?
Classifying tongue-tie is essential for understanding the severity of the condition and determining the best course of action for treatment. Classification typically focuses on the attachment of lingual frenulum and the tongue's mobility. Several systems are used to classify the attachment of the lingual frenulum, with two of the most widely recognized being the Coryllos Classification and the Kotlow Classification. These systems help healthcare providers assess the degree of restriction and guide treatment decisions, especially in dentistry and pediatric care.
The Coryllos Classification categorizes the frenulum into four types based on its point of attachment. This system outlines Types I through IV:
Coryllos Type 1 (Type I) The lingual frenulum is attached to the tip of the tongue. The frenulum is thin and elastic, and anchors the tip of the tongue to the ridge behind the lower teeth.
Coryllos Type 2 (Type II) The lingual frenulum is fine and elastic. Attachment is 2 to 4 millimeters from the tip of the tongue to the floor of the mouth, close to the ridge behind the lower teeth.
Coryllos Type 3 (Type III) The lingual frenulum is attached to the middle of the tongue and the middle of the floor of the mouth. The frenulum is usually thicker and stiffer.
Coryllos Type 4 (Type IV) The lingual frenulum attaches at the base of the tongue. It is typically not visible, but can often be felt by the examiner as tight fibers that are anchoring the tongue. This type is thick, inelastic, and submucosal. It restricts movement at the base of the tongue.
The Kotlow Classification focuses more on the tongue length from the tip to the frenulum attachment:
Clinically acceptable Normal, free tongue length > 16 millimeters.
Kotlow Class I: Mild The tie is 12 to 16 millimeters from the tip of the tongue. Slight restriction.
Kotlow Class II: Moderate The tie is 8 to 11 millimeters from the tip of the tongue. Noticeable restriction.
Kotlow Class III: Severe The tie is 3 to 7 millimeters from the tip of the tongue. Significant restriction.
Kotlow Class IV: Complete The tie is less than 3 millimeters from the tip of the tongue. Severe restriction.
In addition to these classifications, a thorough evaluation also considers the tongue's functional ability to move. Tools like the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) are sometimes used to assess how well the tongue is functioning in terms of mobility, which can further guide treatment decisions.
Classification systems help healthcare professionals like dentists, orthodontists, pediatricians, speech pathologists, orofacial myologists, and lactation consultants understand the degree of tongue restriction and determine whether intervention is necessary to improve tongue mobility and function.
What is a Posterior Tongue-Tie?
Posterior tongue-tie (also referred to as posterior ankyloglossia) refers to a condition where the lingual frenulum is attached farther back under the tongue. This has been a subject of debate among healthcare providers due to the lack of consensus on a clear definition. Some healthcare professionals feel that posterior ankyloglossia does not represent a true clinical condition and should not be treated as such. Because the condition is often harder to diagnose and lacks universally accepted criteria, there is limited evidence to support the effectiveness of frenotomy (surgical release of the frenulum) for posterior tongue-tie. Currently in the United States, posterior tongue-tie remains a controversial condition. While it is recognized by some healthcare providers, particularly those in the fields of pediatrics, speech therapy, dentistry, and lactation, there is no universal agreement on whether it represents a true condition that requires treatment. Without a clear understanding of what constitutes posterior ankyloglossia and reliable evidence to demonstrate its treatment benefits, many experts remain cautious about recommending surgical intervention for posterior ankyloglossia.
Treatment for Tongue-Tie
In significant cases of tongue-tie, treatment may be necessary. The two primary treatment options for akyloglossia are frenotomy (frenulotomy) and frenuloplasty, both of which aim to improve tongue mobility.
A frenotomy is a simple procedure that releases the tongue, allowing it to move freely. It’s sometimes called a frenulotomy or frenectomy, Latin terms that refer to very similar things:
Frenulotomy (frenotomy) means dividing or partially removing the frenulum.
Frenulectomy (frenectomy) means removing the frenulum.
Frenuloplasty means rearranging the frenulum.
Frenectomy vs. Frenuloplasty
Technically, frenotomy refers to an incision or snip in the frenulum that frees the tongue from the floor of the mouth. It is a fairly simple procedure that involves making a small incision in the frenulum to release the tension. It’s often performed on infants with mild to moderate tongue-tie and can provide immediate relief, especially in cases where breastfeeding is affected. The procedure is quick, with most babies able to feed right after the treatment.
Frenectomy technically refers to complete excision and removal of the frenulum, including its attachment to underlying bone. It is a more invasive procedure and may be difficult to perform on small children. Frenectomy is typically used for severe cases of tongue-tie, where the frenulum is significantly restricting tongue movement.
Frenuloplasty refers to an extensive frenulum excision that usually involves repositioning of the muscle, and is typically closed by what is called a “Z-plasty” or a local flap with placement of sutures. Frenuloplasty is a more complex procedure used for more severe cases of tongue-tie or when a revision is needed after a frenotomy.
Depending on the case, these procedures can be performed using a scalpel, surgical scissors, or laser surgery. Laser frenectomy has grown in popularity because it offers precision, minimal bleeding, and faster recovery times. Regardless of the method used, most patients see improvements in tongue mobility immediately. The procedures are all well tolerated and typically done as outpatient procedures. Complication rates are low, with research suggesting no difference in reoperation rates between frenotomy and frenuloplasty.
Tongue-Tie in Infants
The group of pediatric otolaryngologists who developed the Clinical Consensus Statements in 2020 aimed to promote evidence-based care for infants and children with ankyloglossia. These statements provide guidance on the diagnosis, management, and treatment of ankyloglossia in children ranging from infancy to 18 years old. For infants, ankyloglossia should be assessed through a thorough history, which includes lactation history, as well as a physical examination that involves both inspection and palpation of the tongue. Ideally, infants should be evaluated by a lactation consultant before undergoing a lingual frenotomy. Certain conditions may serve as contraindications for this procedure, including retrognathia (a condition where the lower jaw is recessed), micrognathia (small jaw), neuromuscular disorders, hypotonia (low muscle tone), and coagulopathy (a disorder affecting blood clotting).
Tongue-Tie in Children and Adults
In children and adults, ankyloglossia can lead to social or mechanical challenges, such as difficulty licking, trouble keeping teeth clean, a gap between the lower central incisors, or feelings of social embarrassment. For some, frenotomy or frenuloplasty may significantly improve their quality of life by resolving these issues. Importantly, there is no maximum age for performing frenotomy or frenuloplasty, meaning the procedure can be considered at any age if appropriate. For older children who are having the procedure to address speech issues, it is advised to consult with a speech pathologist before performing the frenotomy or frenuloplasty (a more extensive procedure to correct the tongue tie).
Myofunctional Therapy and Tongue-Tie
After procedures to release a tongue tie, tongue exercises and therapy are often recommended to help with recovery and improve tongue function. Myofunctional therapy can be a helpful addition after a tongue-tie release. While a frenotomy or frenectomy makes the tongue less restricted, it often does not automatically move properly after the procedure. This is because the tongue muscle has adapted to being restricted over time. Myofunctional therapy uses specific exercises to improve the function of the tongue, lips, and jaw muscles. It helps address problems that developed because of the tongue-tie and retrains the tongue to move correctly.
Although expert opinions vary on whether pre- and post-procedure regimens should include stretching, massaging, or other exercises to prevent reattachment of the frenulum, many providers have concluded that exercises after tongue-tie release have provided functional improvements in speech, feeding, and sleep. For school aged children, oral exercises have been advocated as a safe and potentially effective adjunct to improve tongue movements with or without surgical intervention.
The tissue after a tongue-tie release can sometimes heal in a way that causes the tongue tie to reattach or create scar tissue, limiting the tongue’s function again. Some providers advocate that myofunctional exercises can help reduce the risk of reattachment by encouraging proper tongue movement. Dr. Danielle Godley, an Indiana orthodontist at Godley Family Orthodontics, evaluates each of her patients for tongue-tie. When she recommends frenectomy or frenotomy for her patients, Dr. Godley says that many of the the local specialists she works with who perform these procedures, as well as the orofacial myologist at her office, always recommend a regimen of tongue stretches and movements following the release. "In our experience, it appears to help in preventing re-attachment, allows the tongue to start learning new movements, and reduces the risk of needing a second surgery," she says.
Myofunctional therapy is provided by a trained therapist, such as a myofunctional therapist, orofacial myologist, or speech therapist who specializes in this area. It’s often recommended after a tongue tie release to help the patient make the most of their new range of motion, retrain the tongue, and avoid future issues. If you or your child is having a tongue tie release, it’s a good idea to discuss myofunctional therapy with your healthcare provider to see if it’s a good addition to the treatment plan.
Conclusion
In conclusion, the lingual frenulum (lingual frenum) is a natural part of the mouth. A tight or restrictive frenulum can have a significant impact on a person's ability to speak, eat, and maintain good oral health. Early diagnosis and intervention for ankyloglossia can make a world of difference in ensuring happy feeding, clear speech, good oral health, stable orthodontic outcomes, and overall well-being.
If you or your child are experiencing difficulties related to tongue-tie, seek guidance from a healthcare provider—such as a dentist, pediatrician, orthodontist, or otolaryngologist. They can help identify the best course of action based on the severity of the condition. For infants struggling with breastfeeding, a lactation consultant or feeding expert can offer valuable support and non-surgical solutions. By addressing tongue-tie early, you can ensure better long-term oral health and functional outcomes.
Resources
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ABOUT THE AUTHORS
Dr. Danielle Godley is a Board Certified Orthodontist practicing in Zionsville, IN. Utilizing advanced technology and modern techniques, she serves both children and adults at her orthodontic office, Godley Family Orthodontics.
Dr. Raina Chandiramani is Orthodontist and Owner at Louisville Orthodontics, serving local communities surrounding Prospect, KY. She blends her extensive training and experience to deliver personalized, cutting-edge orthodontic care to each of her patients.
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