What is Tethered Oral Tissue?

When a baby’s mouth is forming in the womb, the tongue, lip and cheeks are fused to the gums and jawbone with tissue called a frenulum.  As mouth development is completed in the fetus, excessive frenulum tissue dies away to allow the tongue and lip and cheeks to function normally, indicated by optimal ability to move and function once the baby is born.  Everyone has a frenulum under their tongue, under their upper lip, and on parts of their cheeks. It is often normal and without associated medical problems. When tight frenulum tissue fails to die away in the womb, tongue tie (also known as ankyloglossia) and other oral ties (such as to the lip or cheeks) can be present.  It is considered tethered or “tied” if a tight frenulum causes restriction in normal function. It is considered a normal frenulum if there is no restriction in function.

 Above you can see examples of various tongue ties in babies and older children, limiting their ability to raise, or elevate, the tongue.  Note that they can be thick or thin, obvious or more subtle.

 Above is a test you can try at-home to see if you have tongue tie.  First, open your mouth as wide as you can.  Then lift your tongue up towards your top jaw and take note of how far the tongue can lift up.  After that, gently place your finger on the floor of your mouth (the area between your lower jawbone and the undersurface of the tongue) and try to lift up your tongue again. If the elevation is limited, you may want to consult a professional trained in tongue tie diagnosis and treatment to help you assess options for care, especially if you have trouble with things like articulation (pronouncing words), swallowing food and/or choking on food, or have breathing issues or other dental concerns.

Tongue-tie, or ankyloglossia, happens when the lingual (tongue) frenulum tissue that attaches the tongue to the lower jaw is too short or thick, limiting the full movement of the tongue. Research has found this can impact breastfeeding, eating, speech, and oral hygiene (but not necessarily dental caries). Current studies are also looking at the impact of tongue tie on facial growth and oral/dental development, as well as airway development and mouth breathing.

Lip Tie (or a tethered labial frenulum) occurs when the lip (labial) tissue that connects the upper lip to the gums on the upper jawbone is too tight, thick, or short, which can impact breastfeeding and oral development, and spacing of erupting teeth. Current studies are also looking at the impact of a lip tie on speech and breastfeeding difficulties.

Cheek Tie (buccal tie) is when there is restrictive frenulum tissue from soft tissue of cheeks to the bony part of the upper or lower jaw.  There are no current measurement systems available to categorize cheek ties. Research is ongoing right now to better understand the impact of these ties and which may be necessary to treat. 

What causes it?

The cause of oral ties isn't always known. They can run in families (genetic factors) or may occur in babies who have other problems that affect the mouth or face (developmental factors), such as cleft palate or Pierre Robin Sequence. It also can just be a normal variation of development in the womb.

What are the symptoms?

Breastfeeding, eating, breathing, and speech all use various combinations of oral muscles and structures in complex ways.  Every person is different, so a tethered frenulum may cause a problem in one person, but not another person, which makes it hard for medical professionals to make broad treatment recommendations on appearance. Not all ties are associated with every functional problem.  Each patient needs to be looked at individually with a thorough examination that identifies functional problems and symptoms to come up with appropriate treatment recommendations.  Current research is focused on identifying these functional problems and how they can be related to one or more restrictive oral ties.

Below are just some of the ways that people with tethered oral tissue can experience health issues:

• Breastfed babies may have trouble latching or staying on to the mother’s breast to feed, which can lead to poor weight gain and can cause issues with low breastmilk supply for the mother. Bottle-fed babies may have fewer feeding problems when there is a tie because it is generally easier to get milk from the nipple of a bottle than that of a breast.  Babies can have trouble transferring or swallowing milk during breastfeeding or bottle-feeding.

• Maternal nipple pain, prolonged feeding for the baby, short durations between feeds, and clicking noises are other common breastfeeding symptoms research has shown to be related to ties.

• Reflux is common with oral ties in babies.  This is because if the latch is not sufficient, the baby may be clicking and swallowing air (called aerophagia), which can lead to frequent or projectile vomiting and gassiness.  Additionally, tension in the body can impact the digestive tract and lower body.  Addressing oral ties in babies with reflux can help get babies off reflux medicine or prevent the need from starting such medicine in the first place.

• Babies, children, and adults may have an open-mouthed posture when they have oral restrictions.  This may lead to a narrow upper jaw, dental crossbites or other tooth-crowding issues.

• Young children may have difficulties with eating.  They may gag/vomit when eating, be extremely picky or slow eaters, be unable to handle raw vegetables, unprocessed meats, crunchy foods and may hold food in their mouth for prolonged period of time.

• Some older children and adults may have gaps or spaces between the front upper or lower teeth, or have narrow dental arch development of the jawbones which may cause dental crowding and other orthodontic issues.  Ongoing research is focused on determining which dental and occlusion issues are related to ties, and which may be caused by other factors.

• Speech problems can be seen with tongue tie, because full mobility of the tongue is generally required to produce clear speech.  The most common sounds impacted are r,s,z, but t,d,l,n,j, k, g,sh and ch sounds may also be affected.  Some may experience a lisp or “baby talk”. It’s important to remember that even if there are other reasons for speech problems, such as autism, that tongue ties should also be considered for treatment to allow the patient the best chance at achieving normal speech.

• Poor head and body posture can sometimes may be related to tissue restrictions. Examples are skeletal asymmetries, head forward posture, torticollis in babies, or other body tensions.

• Mouth breathing, sleep apnea, or other sleep issues may be related to the tongue, or related to a combination of other mouth and face structures. Your doctors, dentist and health team can work together to help you resolve these symptoms because they could be related.

Tongue-tie symptoms may go unnoticed by patients and families and healthcare professionals in some cases.   Tie-related symptoms may be incorrectly attributed to other factors if a proper evaluation for oral ties is not performed.  Other times children and adults can compensate for the restriction with alternative mouth motions which may lead to other “compensatory” problems.  Physicians, dentists, speech language pathologists, feeding therapists, occupational therapists, physical therapists and other healthcare providers who work with babies may be the first to notice signs or symptoms.

There is no one specific specialist in oral ties.  In general, it is best to involve experts in the area of functional concern, such as a lactation consultant for breastfeeding, a dentist of oral or dental development, a speech language pathologist or occupational therapist for swallow and feeding issues, a speech language pathologist for speech concerns, an ear nose and throat doctor for breathing issues, etc.  Health professionals who have sought out extra training and experience in tethered oral tissues will be in a better position to recognize symptoms, diagnose, and treat patients with this condition.   Often, a team of these and other health professionals are needed to reach a diagnosis to help you find treatment for the root cause of these issues.  

As an example, International board-certified lactation consultants (IBCLCs) are often the first ones to notice a functional issue as they are experienced in normal breastfeeding. The IBCLC will notice dysfunctional breastfeeding behaviours, and work with the dyad to maximise position and latch. After a complete breastfeeding assessment if there continues to be a functional issue the IBCLC will refer the dyad on to a surgeon (doctor or dentist) further diagnosis and possible surgical treatment. 

Your physician, dentist, lactation (or feeding) consultant or doctor will perform a physical examination of your child's mouth, look at the range of motion of the lip, tongue, and cheeks, and take a thorough history to understand his or her associated symptoms. In an older child or adult, they may check how the shape and movements of the tongue have contributed to normal or abnormal dental arch form, tooth spacing or crowding.  In nature, “form follows function”, which means that the tongue is supposed to have a certain shape to allow it to successfully carry out all of its duties, and for the rest of the mouth and facial skeletal structures to form properly.  When there is a tether, there can be obvious and subtle findings that healthcare professionals can identify.  Diagnosis should never be based on appearance alone.

Depending on the age of the patient and the symptoms present for the tie(s), timing and type of treatment can vary.

In newborns with breastfeeding and latch concerns, the earlier a restriction is diagnosed and treated, the better the prognosis. 5-15 days of age is an ideal window for treatment, however a diagnosis can be made at any age.  It is highly recommended that lactation or other feeding therapy support is provided in the lead up to a procedure and the recovery plan.

In children and adults, it is recommended to work with speech, feeding, myofunctional or other types of therapists before considering surgical releases to optimize results of the procedure(s).  This is because the longer a patient has compensated for these oral ties, the less likely a simple release will be sufficient to fix the problem, as the patient will need to learn the best way for their newly mobile tongue and mouth tissue to function.  Also, by working with these therapists, its possible some problems may be resolved without having to consider a surgical option.

Modern treatments for these conditions usually involve advanced techniques for release with lasers or sharp surgical tools, to preserve normal tissue, reduce scarring, and return to normal function as fast as possible.  It should be made clear that the surgical release is only one part of the treatment, and that aftercare will require exercises and stretches to allow for proper healing.  This aftercare may require weeks or more time depending on the individual case.   Families should be prepared and understand their commitment to rehabilitation prior to engaging in surgery.  Patients with special healthcare needs, syndromic conditions, neuromuscular or neurological impairment or other medical issues should be medically cleared prior to any surgical treatment by their pediatrician or other specialists, to assure that optimal outcomes and goals are achieved and to prevent complications. 

While you wait and see, you can also:

• Talk to a lactation consultant if you are having breastfeeding problems.

• Consult a speech therapist if your toddler is having speech or eating problems.

• See a dentist for dental evaluation if this hasn’t happened yet in a baby or child with teeth

• Undergo an assessment with your pediatrician and/or an ear, nose and throat doctor if there are concerns about breathing, swallowing, sleep apnea, hearing, or speech.

Tongue-tie, lip-tie, and cheek-tie are conditions that, while potentially challenging to diagnose, can often be managed effectively with early intervention and a team-based care approach.

What is Tethered Oral Tissue?

When a baby’s mouth is forming in the womb, the tongue, lip and cheeks are fused to the gums and jawbone with tissue called a frenulum.  As mouth development is completed in the fetus, excessive frenulum tissue dies away to allow the tongue and lip and cheeks to function normally, indicated by optimal ability to move and function once the baby is born.  Everyone has a frenulum under their tongue, under their upper lip, and on parts of their cheeks. It is often normal and without associated medical problems. When tight frenulum tissue fails to die away in the womb, tongue tie (also known as ankyloglossia) and other oral ties (such as to the lip or cheeks) can be present.  It is considered tethered or “tied” if a tight frenulum causes restriction in normal function. It is considered a normal frenulum if there is no restriction in function.

 Above you can see examples of various tongue ties in babies and older children, limiting their ability to raise, or elevate, the tongue.  Note that they can be thick or thin, obvious or more subtle.

 Above is a test you can try at-home to see if you have tongue tie.  First, open your mouth as wide as you can.  Then lift your tongue up towards your top jaw and take note of how far the tongue can lift up.  After that, gently place your finger on the floor of your mouth (the area between your lower jawbone and the undersurface of the tongue) and try to lift up your tongue again. If the elevation is limited, you may want to consult a professional trained in tongue tie diagnosis and treatment to help you assess options for care, especially if you have trouble with things like articulation (pronouncing words), swallowing food and/or choking on food, or have breathing issues or other dental concerns.

Tongue-tie, or ankyloglossia, happens when the lingual (tongue) frenulum tissue that attaches the tongue to the lower jaw is too short or thick, limiting the full movement of the tongue. Research has found this can impact breastfeeding, eating, speech, and oral hygiene (but not necessarily dental caries). Current studies are also looking at the impact of tongue tie on facial growth and oral/dental development, as well as airway development and mouth breathing.

Lip Tie (or a tethered labial frenulum) occurs when the lip (labial) tissue that connects the upper lip to the gums on the upper jawbone is too tight, thick, or short, which can impact breastfeeding and oral development, and spacing of erupting teeth. Current studies are also looking at the impact of a lip tie on speech and breastfeeding difficulties.

Cheek Tie (buccal tie) is when there is restrictive frenulum tissue from soft tissue of cheeks to the bony part of the upper or lower jaw.  There are no current measurement systems available to categorize cheek ties. Research is ongoing right now to better understand the impact of these ties and which may be necessary to treat. 

What causes it?

The cause of oral ties isn't always known. They can run in families (genetic factors) or may occur in babies who have other problems that affect the mouth or face (developmental factors), such as cleft palate or Pierre Robin Sequence. It also can just be a normal variation of development in the womb.

What are the symptoms?

Breastfeeding, eating, breathing, and speech all use various combinations of oral muscles and structures in complex ways.  Every person is different, so a tethered frenulum may cause a problem in one person, but not another person, which makes it hard for medical professionals to make broad treatment recommendations on appearance. Not all ties are associated with every functional problem.  Each patient needs to be looked at individually with a thorough examination that identifies functional problems and symptoms to come up with appropriate treatment recommendations.  Current research is focused on identifying these functional problems and how they can be related to one or more restrictive oral ties.

Below are just some of the ways that people with tethered oral tissue can experience health issues:

• Breastfed babies may have trouble latching or staying on to the mother’s breast to feed, which can lead to poor weight gain and can cause issues with low breastmilk supply for the mother. Bottle-fed babies may have fewer feeding problems when there is a tie because it is generally easier to get milk from the nipple of a bottle than that of a breast.  Babies can have trouble transferring or swallowing milk during breastfeeding or bottle-feeding.

• Maternal nipple pain, prolonged feeding for the baby, short durations between feeds, and clicking noises are other common breastfeeding symptoms research has shown to be related to ties.

• Reflux is common with oral ties in babies.  This is because if the latch is not sufficient, the baby may be clicking and swallowing air (called aerophagia), which can lead to frequent or projectile vomiting and gassiness.  Additionally, tension in the body can impact the digestive tract and lower body.  Addressing oral ties in babies with reflux can help get babies off reflux medicine or prevent the need from starting such medicine in the first place.

• Babies, children, and adults may have an open-mouthed posture when they have oral restrictions.  This may lead to a narrow upper jaw, dental crossbites or other tooth-crowding issues.

• Young children may have difficulties with eating.  They may gag/vomit when eating, be extremely picky or slow eaters, be unable to handle raw vegetables, unprocessed meats, crunchy foods and may hold food in their mouth for prolonged period of time.

• Some older children and adults may have gaps or spaces between the front upper or lower teeth, or have narrow dental arch development of the jawbones which may cause dental crowding and other orthodontic issues.  Ongoing research is focused on determining which dental and occlusion issues are related to ties, and which may be caused by other factors.

• Speech problems can be seen with tongue tie, because full mobility of the tongue is generally required to produce clear speech.  The most common sounds impacted are r,s,z, but t,d,l,n,j, k, g,sh and ch sounds may also be affected.  Some may experience a lisp or “baby talk”. It’s important to remember that even if there are other reasons for speech problems, such as autism, that tongue ties should also be considered for treatment to allow the patient the best chance at achieving normal speech.

• Poor head and body posture can sometimes may be related to tissue restrictions. Examples are skeletal asymmetries, head forward posture, torticollis in babies, or other body tensions.

• Mouth breathing, sleep apnea, or other sleep issues may be related to the tongue, or related to a combination of other mouth and face structures. Your doctors, dentist and health team can work together to help you resolve these symptoms because they could be related.

Tongue-tie symptoms may go unnoticed by patients and families and healthcare professionals in some cases.   Tie-related symptoms may be incorrectly attributed to other factors if a proper evaluation for oral ties is not performed.  Other times children and adults can compensate for the restriction with alternative mouth motions which may lead to other “compensatory” problems.  Physicians, dentists, speech language pathologists, feeding therapists, occupational therapists, physical therapists and other healthcare providers who work with babies may be the first to notice signs or symptoms.

The final deliverable will be the intellectual property of the non-profit group ICAP, and will be provided free of charge to anyone who wants it via downloadable PDF.  Research is about collaboration and making these types of resources available to everyone, for the sake of improving patient care outcomes.

The projected date of completion of the MIF deliverable is May 2, 2024 with availability for download by the end of May 2024. 

This project is a joint venture between the International Consortium of oral Ankylofrenula Professionals (ICAP), the ICAP Committee for Interprofessional Research, Education and Ankyloglossia Science (CIREAS) with coordinated involvement from the Australasian Society for Tethered Oral Tissues (ASTOT).  CIREAS is the custodian of project development, and all queries can be submitted to Dr. Raymond Tseng.  ASTOT specific queries can be directed to Dr. Sharon Smart. 

sample text

This project is a joint venture between the International Consortium of oral Ankylofrenula Professionals (ICAP), the ICAP Committee for Interprofessional Research, Education and Ankyloglossia Science (CIREAS) with coordinated involvement from the Australasian Society for Tethered Oral Tissues (ASTOT).  CIREAS is the custodian of project development, and all queries can be submitted to Dr. Raymond Tseng.  ASTOT specific queries can be directed to Dr. Sharon Smart. 

This project is a joint venture between the International Consortium of oral Ankylofrenula Professionals (ICAP), the ICAP Committee for Interprofessional Research, Education and Ankyloglossia Science (CIREAS) with coordinated involvement from the Australasian Society for Tethered Oral Tissues (ASTOT).  CIREAS is the custodian of project development, and all queries can be submitted to Dr. Raymond Tseng.  ASTOT specific queries can be directed to Dr. Sharon Smart.