The tissue under the tongue that attaches the floor of the mouth to the tongue is called the lingual frenum. During embryological development, it is programmed to partially disappear from the tip toward the base of the tongue. When this process does not occur properly, the result is a tongue tie.
A tongue tie (or ankyloglossia) is when this attachment interferes with normal mobility and function of the tongue.
The tongue is the only muscle in the body that has one end that moves freely, unattached to any other body structures. In reality it is an important organ made up of 8 different muscles working together.
The unattached end should be free to move in almost all directions, however when it is tethered it can prevent many important oral functions, and have a cascading effect on every organ system in our body.
They restrict development of the face, jaws and airways during childhood
Even before birth, the tongue plays a very important role in moulding and developing the hard palate. A tethered tongue can’t elevate, and this results in the formation of a narrow and high arched palate. Since the top of the palate is the floor or the nose and sinus, this is associated with underdeveloped nasal and sinus airways.
The latest research associates untreated tongue-ties with progressive development of obstructive sleep apnoea due to poor palate development. This problem of abnormal breathing during sleep restricts oxygenation and impacts cardiovascular and respiratory function and also brain development.
Underdeveloped jaws will also result in crooked teeth and other orthodontic problems, and potentially impact facial balance unfavourably.
Breastfeeding problems
In infants, it is often a hidden source of breastfeeding problems. It can interfere with achieving a good, pain free latch during breastfeeding. It can also prevent the back part of the tongue from suctioning to the palate, which is important for creating the vacuum that helps release milk from the breast. This constant elevation of the back part of the tongue in the roof of the mouth is also important for moulding and widening the palate, nose and sinus areas. Good breastfeeding has also been labelled “nature’s palatal expander” for this reason.
When an infant does not achieve a good seal during feeding, they can swallow air. This can lead to stomach distension and results in symptoms often misdiagnosed as acid reflux. This is called aerophagia (or air induced reflux) and will not respond to adult reflux medications that are often prescribed.
Other problems
Besides all the nutritional and immunological benefits of breastfeeding, it also stimulates proper functions of the muscles of the mouth and face.
In fact, evidence suggests that breastfed babies have stronger jaw muscles than their bottle fed counterparts at age 5, despite cessation of breastfeeding much earlier in life.
Tongue-ties that are untreated at birth result in compensatory breastfeeding, or use of bottle feeding introduce dysfunctions of the muscles of the face and mouth. The jaw and tongue muscles do not develop properly, and other muscles of the face become over-active. Abnormal tongue thrust swallowing and lowered tongue posture becomes a habit.
This can contribute to a wide range of myofunctional problems including mouth breathing and forward head posture, and problems with other important functions such as chewing, swallowing and speech.
When the tongue is tethered, it is not free to function properly, and can’t develop the proper tone to suction properly in the palate at rest. The airway will be more collapsible and prone to blockage by the base of the tongue during sleep.
Tongue-ties are also known to introduce compensations in other muscles that affect the entire body posture. They may be a root cause or contributing factor in some chronic head, neck, shoulder pain conditions.
Deciding when to intervene
The appearance of the tongue-tie does not correlate to the degree of problems it will cause. A decision whether to intervene will depend on a carefully history of functional problems and symptoms.
It has often been quoted that the incidence of tongue tie is about 5% of the population, however this is a difficult question to answer properly because tongue-ties are generally not very well examined. Many times they are missed when the attachment does not extend all the way to the tip of the tongue.
In Brazil, all babies are screened for tongue-ties at birth. There are well-documented protocols to comprehensively assess babies for these restricted tissues all the way to the back of the tongue whilst they are in hospital. Research in Brazil has found the incidence to be 29%. This does not imply that they all require intervention.
A lip tie is a remnant of tissue in the middle of the upper lip and the gum. If it interferes with normal mobility of the upper lip, it can prevent a good flange necessary for a good latch and efficient, pain free breastfeeding. Like the tongue-tie, this can also contribute to air-induced reflux or symptoms similar to acid reflux.
We also know that lip ties can allow pooling of milk in near the upper front teeth and can very occasionally contribute to a pattern of decay that can be seen in infants nursed through the night.
Beyond breastfeeding, a common concern is whether a lip tie could be contributing to a gap between the two front teeth. Since gaps are favourable between the baby teeth (to allow space for the eruption of the permanent teeth), this gap is not a good reason on own to release a lip tie. Since lip-ties tend to occur in the presence of tongue-ties, a consultation can still be worthwhile to assess for tongue-ties and dysfunction and discuss longer term options.
It seems unlikely that lip-ties contribute to speech problems in isolation. They tend to occur in conjunction with tongue-ties that are more likely to be associated with these problems.
he main reasons for releasing lip ties beyond infancy would be when they interfere with normal relaxed lip closure at rest or with myofunctional therapy exercises that are designed to promote normal function of the oral and facial muscles.
Dr Lim has received training and observed skilled clinicians who each have different tools of choice yet all achieve good outcomes.
In the long term, more important that the tool of choice is to find a skilled clinician who understands that this procedure is more than a quick snip. The aim should be to restore function as fully as possible.
The release needs to be thorough to allow the back of the tongue to elevate in addition to being able to protrude the tongue forward. It should be followed up with active wound management to prevent reattachment and scarring.
A good sign when choosing a provider is to look for someone who encourages follow-up consultation with professionals such as lactation consultants, speech pathologists, orofacial myofunctional therapists and body workers. This will ensure more complete rehabilitation of normal tongue function.
Dr Lim has chosen to invest in a Waterlase iPlus 2.0 laser for surgical release.
The advantages for this include:
- Greater control of bleeding which is helpful in achieving thorough release
- Bactericidal – kills bacteria, reducing chances of infection
- Biostimulation – the light energy encourages wound healing
- Less heat, and greater speed and efficiency than more commonly available soft tissue diode lasers
Leading practitioners in tongue-tie release (including those Dr Lim has trained with) tend to agree in their perception that bodywork is of benefit before and after frenum release.
Eliminating areas of tightness in all the adjacent muscles that have been compensating for poor tongue function prior to release helps to achieve the best access and most optimal release and function possible. Many babies have torticollis or birth strains developed from the birth process which should be addressed as these may also be contributing to breastfeeding troubles.
In certain cases where the appearance of a tongue tie is more subtle, bodywork may on occasion allow better function of the tongue, avoiding the need for the procedure. This situation has been labelled a "Faux Tie" by Internationally Board Certified Lactation Consultant (IBCLC) and Craniosacral Therapist, Alison Hazelbaker.
We will provide a list of professionals suitably qualified for you to seek this gentle touch therapy if you wish to proceed with this option.
To find out more about the concept of bodywork, please view the video following in the next FAQ below.
Further information about body work and tongue-tie release can be found on the Ankyloglossia Bodyworkers website
Releasing tongue restrictions is similar to removing a cast on the arm that has been worn a lot time. It is just one piece of the puzzle. Rehabilitation is necessary to restore full function.
For the very young infant, working on optimising breastfeeding can be the best therapy to promote normal function. However since babies have been noted to have very active sucking and swallowing movements from 18 weeks gestation, they may have a degree of compensated function. Other times the back of the tongue does not have the tone to function properly due to months of disuse. A lactation consultant or speech/feeding specialist are the most appropriate person to assist with tongue exercises and suck training.
The child or adult patient will require orofacial myofunctional therapy exercises to establish more normal muscle patterns of the lips and tongue.
Ideally these should begin prior to release to ensure the tongue is aware of the desired the movements. At minimum exercises should be followed for one month after release to keep the tongue moving and prevent reattachment and scarring of the wound.
Full rehabilitation of tongue function from swallowing to nasal breathing with good oral rest posture during sleep will take longer. We offer Myobrace therapy for children and Myofunctional Therapy within the practice and will discuss your various options during your consultation.