Tongue Tie Types: Parents Questions Answered

A tongue tie (or ankyloglossia) is a malformation of the lingual frenulum - a connective tissue that connects the undersurface of the tongue to the floor of the mouth. As of right now, there is no standard definition of tongue tie types due to a lack of research conducted on the lingual frenulum. The reason for this probably lies in the difficulty of measuring soft tissue due to its deformable nature. As a result, there has been an umbrella of terms created in an attempt to define a tongue-tie, usually describing a lingual frenulum that is either too short, thick, tight, or absent. This is one of the most common congenital developmental malformations, with an incidence rate of around 4% to 11%.

Tongue Tie Symptoms

A tongue-tie restricts movement of the tongue, which can lead to multiple complications, including:

• feeding/breastfeeding issues
• altered speech production
• limited range of tongue motion
• swallowing issues

While a tongue-tie is most commonly associated with breastfeeding problems in newborns, older children report poor speech articulation as their main symptom. This is usually reflected in an imprecise production of lingual sounds and sibilants, including:, t, d, n, l, s, r, z, and th.

Tongue Tie Treatment

A tongue-tie can be surgically treated in one of two ways:

1. Frenotomy (or clipping): the lingual frenulum is divided with a small incision, there is minimal bleeding and no anaesthesia or suturing (preferred for infants, whose lingual frenulum is not yet as thick)
2. Frenuloplasty: the lingual frenulum is divided with a deeper incision, repositioned and sutured back in place (preferred for children above the age of 1)

Clinical studies have proven beneficial effects of surgical intervention on both, breastfeeding, as well as speech production, although complete recovery from frenuloplasty can take a bit longer. In most cases, it must be followed by speech therapy, as speaking habits have already been created with the malformed lingual frenulum, and need to be re-learned after the surgery.

What is the difference between anterior and posterior tongue-tie?

Recently, there has been a distinction made between anterior and posterior tongue tie. Although the definition varies between studies, it generally refers to the differences in length and visibility of the lingual frenulum:

1. Anterior tongue tie: the lingual frenulum extends to the tip of the tongue and is clearly visible
2. Posterior tongue tie: the lingual frenulum is attached to the middle, or the very back, of the tongue, is usually thick and short, and sometimes even invisible

While the effects and symptoms of anterior tongue-tie have been mostly agreed upon, posterior tongue-tie remains controversial in its classification, diagnosis as well as treatment, due to a lack of evidence in existing literature. For this reason, NHS usually does not treat a posterior tongue-tie, and parents are offered feeding techniques instead.

What are the 4 types of tongue-tie?

Based on the exact location of the lingual frenulum, a tongue-tie can be furthermore divided into four types:

• Type 1: attaching to the tip of the tongue (anterior)
• Type 2: attaching 2-4mm behind the tip of the tongue (anterior)
• Type 3: attaching to the mid part of the tongue (posterior)
• Type 4: attaching to the base of the tongue (posterior)

What is Category 4 tongue-tie?

A category 4 tongue-tie is a posterior tongue tie, where the lingual frenulum is attached at the very back of the tongue. It is hardly visible, which is why it is sometimes also referred to as an absent tongue tie.

How do I know if my baby has a posterior tongue-tie?

A tongue-tie in newborns can be detected through various symptoms such as:

• insufficient infant weight gain
• uncomfortable feeding with maternal breast pain
• weak attachment to the breast
• milk spillage
• slow feeding and chocking
• complete loss of breastfeeding

However, symptoms of a tongue-tie may vary greatly between newborns, and in some cases, tongue-ties may be asymptomatic. Due to this, it is essential to get a professional evaluation for a diagnosis.

References

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Lomax, A. (2015) Examination of the Newborn: An Evidence-Based Guide. John Wiley & Sons, Incorporated.

Finigan, V. (2014) Overcoming tongue-tie. Midwives, 17(3), 48-49.

Finigan, V. (2014) Tongue-tied. Midwives, 17(2), 54.

Fraser, L., Benzie, S., & Montgomery, J. (2020) Posterior tongue tie and lip tie: a lucrative private industry where the evidence is uncertain. BMJ.

Ito, Y., Shimizu, T., Nakamura, T., & Takatama, C. (2015) Effectiveness of tongue-tie division for speech disorder in children: Tongue-tie division for speech disorder. Pediatrics international, 57(2), 222-226.

Lalakea, M. L., & Messner, A. H. (2002) Frenotomy and frenuloplasty: If, when, and how. Operative techniques in otolaryngology - head and neck surgery, 13(1), 93-97.

Marchesan, I. Q. (2005) Lingual frenulum: Quantitative evaluation proposal. International Journal of Orofacial Myology, 31(1), 39-48.

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Mills, N., Pransky, S. M., Geddes, D. T., & Mirjalili, S. A. (2019) What is a Tongue Tie? Defining the Anatomy of the In-Situ Lingual Frenulum. Clinical Anatomy, 32(6), 749-761.

Unger, C., Chetwynd, E., & Costello, R. (2020) Ankyloglossia Indentification, Diagnosis, and Frenotomy: A Qualitative Study of Community Referral Pathways. *Journal of Human Lactation, 36(*3), 519-527.

Walsh, J., & Tunkel, D. (2017) Diagnosis and Treatment of Ankyloglossia in Newborns and Infants: A Review. JAMA Otolaryngology-Head & Neck Surgery, 143(10), 1032-1039.

Wang, J., Yang, X., Hao, S., & Wang, Y. (2022) The effect of ankyloglossia and tongue-tie division on speech articulation: A systematic review. International Journal of Paediatric Dentistry, 32(2), 127-293.