What is a Tongue Tie?

The condition known as ankyloglossia has been around for thousands of years. The most recent definition proposed by the International Affiliation of Tongue Tie Professionals (IATP), states that the tongue tie is "an embryological remnant of tissue in the midline between the undersurface of the tongue and the floor of the mouth that restricts normal tongue movement." This connective tissue remnant, the frenum, may prevent the tongue from functioning properly, leading to restrictions in oral motor development, feeding skills, and respiratory habits. In order for the oral structures to meet the criteria for a tongue tie, there must be a true functional limitation. The process of diagnosing a tongue tie is a collaborative one that involves taking an in-depth history, completing in-person pretreatment assessments, and examining the oral cavity and extraoral structures.

What is a Lip Tie?

A lip tie refers to a restrictive labial frenum located under the upper lip that prevents normal movement of the oral tissues. The lip tie can contribute to feeding difficulties for the baby by disrupting the seal around the breast or bottle, resulting in increased air intake, which may present as symptoms of reflux or gas. An abnormally tight labial frenum may cause inability of the upper lip to flange outward, and thus can lead to pain during breastfeeding or difficulty during bottle feeding. Lip ties may appear with blanching in the area where the frenum attaches to the tissue, dimpling on the upper surface of the lip, and/or notching in the gum tissue or bone. Some lip frena are especially thick, tight, or broad. Their shape is highly variable, but the main factor is their impact on function.

A lip tie can very much affect nursing and a quality latch. If the baby has an ineffective seal on the breast (or bottle), there will be a clicking or smacking noise heard when the baby eats. This sound is a sign that air is entering the baby's mouth and the baby is swallowing pockets of air. Aerophagia, or eating air, may result in a distended or hard belly, gassiness and fussiness. The air either comes back up from the belly in the form of burps or spit-up, or passes through and is released as toots. The upper lip should ideally play a passive role during feeding, gently rounding to help maintain an adequate seal around breast or bottle.

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Ties & Infant Feeding

The nursing relationship between mother and baby is vital, and plays a significant role in the baby's health during a critical time of development. A proper functional exam for ties starts with the feeding assessment. How does the baby latch and position at the breast? Red flags that often arise with feeding are low-tone sucking, in which the baby cannot latch or latches poorly, and high-tone sucking, which may result in pain and damage to the nipples due to improper balance or forces of the lips and cheeks. Tongue ties may cause disorganized swallows, producing clicking or smacking sounds while feeding, in addition to gulping, coughing, gagging and choking. We strongly encourage our families to establish care with Lactation Consultants who will support mother-baby dyads on their feeding journeys. Patience, time and effort through therapy are required for successful rehabilitation.

Ties & Whole Body

Coordination of a variety of oral structures along with adequate air flow is required for speech sound production. Limited range of motion when a tongue tie is present can affect the tongue's ability to reach various placement points in the mouth to produce different speech sounds. This can also affect oral resonance, which is a vital part of speech production, articulation, voicing and fluency.
If movement of the tongue is restricted, a person may not be able to raise the back of their tongue to create the "k" and "g" sounds, or have difficulty coordinating their tongue muscles to make "l" and "r.'
Tongue ties may also cause distortion of speech sounds. This is due to the airflow coming from the lungs being directed or restricted in a different way.
Fluency of speech may also be affected because a tie can cause incoordination and inefficiency, which can lead to stuttering.
Speech-related symptoms that can be caused by a tie are
- frustration with communication
- poor speech intelligibility
- speech delays or disorders, particularly errors with sounds "k", "g", "ng", "sh", "ch", "-dge", "th", "l", "r", "s", "z"
It is pertinent to have your child evaluated by a speech language pathologist prior to and after a tongue tie release.

A tongue tie may impair swallowing or tongue movement, greatly impacting development of the oral musculature as well as patterns required for efficient and safe feeding.
Signs and symptoms your child may exhibit are
- gagging, choking with textured foods
- history of difficulty with breast- or bottle-feeding
- extended/ slow feeding, picky eating, needing water to facilitate a swallow
- pocketing food in the cheeks or gums
- slow or poor weight gain
- problems with cleaning teeth surfaces.
Picky eating can be attributed to the child actually having difficulty with basic functional movement of the tongue, thus choosing foods that are “easier” for them to swallow. These kids are also slow eaters – it takes a lot more time to munch a food until it is ready to be swallowed when compared to a normal chew.
In order to obtain optimal results from a tongue tie release, we recommend your child work with an oral myofunctional therapist prior to and after the procedure.

Tongue ties may be associated with snoring, frequent waking, restlessness, bed-wetting, failure to feel refreshed upon waking, and grinding teeth at night.
Children with tongue ties usually mouth breathe. Mouth breathing leads to a host of issues, including oxygen deprivation. Oxygen is the most critical nutrient our bodies need, and chronic oxygen deprivation can lead to chronic inflammation throughout the body, as well as daytime sleepiness and inattention.
Grinding, which was once thought to be related to stress (which it certainly can be), is now thought to be a sign of sleep-disordered breathing (airway obstruction). This could be related to a tongue-tie because the tongue-tie holds the base of the tongue down, instead of allowing it to assume its normal resting position on the palate. As the muscles of the body relax during sleep, the tongue can fall backward and obstruct the airway, causing difficulty breathing. When breathing is obstructed, the brain signals you to move the lower jaw repetitively back and forth (grind) in an effort to arouse you to a lighter state of sleep, and also to try and open your airway for easier breathing.
Many seemingly unrelated issues such as multiple ear infections, sleep-disordered breathing, neck pain, and headaches can result from a tongue tie. Releasing a tongue tie may help a child to sleep more soundly because the tongue will be able to rest on the palate, as it should, rather than fall back and obstruct the child's airway.

Ties & Orofacial Development

Ideally, our tongues should rest up against the roof of the mouth, slightly behind where the top front teeth are or are expected to erupt, and our lips gently closed at rest. This helps direct airflow in and out of the nose, where oxygen is filtered and humidified before entering our lungs. The constant pressure of the tongue against the palate, balanced by the pressure of the lips against the teeth, helps to stimulate growth of our upper jaw. Our tongues are our natural palatal expanders. A tongue tie causes the tongue to be pulled down towards the floor of the mouth, caged in the lower jaw, resulting in abnormal tongue posture, which in turn, impacts orofacial growth and sleep disordered breathing.

As dysfunction continues to affect growth, the dental arches become narrower and this reduces room for the tongue further, which leads to a worsening of breathing and myofunctional disorders. This causes a negative spiral which continues to affect the patient's growth and severity of their malocclusion, and the cycle repeats until the dysfunction is addressed. The many years of poor jaw growth and incorrect muscle use leads to poor tone in the oral and facial muscles, a significant contributor to sleep-related breathing disorders.

A collaborative approach to diagnosing and treating tongue and lip ties is pertinent for successful rehabilitation with optimal results.

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