Tongue and Lip Ties

Also called Lingual and Labial Frenum Restrictions or Tethered Oral Tissue (TOTS)


Ankyloglossia, also known as tongue-tie, is a congenital anomaly which may decrease mobility of the tip or blade of the tongue.  It is caused by and unusually thick, tight or short lingual frenum - a membrane connecting the underside of the tongue to the floor of the mouth (Hall and Renfrew, 2015).

Some tongues are restricted all the way to the end, but a tight frenulum can occur anywhere down the tongue - including right at the back behind the mucosa, which is called a 'posterior tie'.  To the untrained, inexperienced eye - the tongue can look normal!

Prevalence of tongue-tie in the United States is 3-4% among newborns. More boys than girls are affected.  Normally, there are seven oral frenums: the maxillary midline labial frenum, the mandibular midline labial frenum, the right and left upper and lower labial frenums and the lingual frenum.  The primary function of the frenums is to keep the lips and tongue in harmony with the growing bones of the mouth during fetal development.  The frenums of most concern are the frenums found under the tongue and upper & lower lips.  New research is suggesting the frenums found along the buccal corridor - upper and lower jaws along the cheek area - can cause sucking problems in infants. 

Remember the tongue acts like scaffolding to the hard palate and dental arches. The tongue helps form the palate in utero when the infant drinks amniotic fluid.  Therefore the negative influence of the tongue restriction starts early!  If the tongue is restricted we note an undesirable palatal shape. 

There are many variations and differing degrees of severity.  Dr. Larry Kotlow, DDS's classification system is used most widely: 

Tongue Tie:

Class 1 :

Class 2:

Class 3:

Class 4:

Pictures courtesy of Kotlow, DDS


Restricted lingual and labial frenums can cause detrimental effects in an infant's ability to latch on to the breast during breastfeeding.  Often clicking sounds during feeding can be heard caused by the tongue's recoil indicating the baby is repeatedly breaking the seal or suction during feeding.  Reflux is then observed as air is sucked into the baby's belly.  Failure to thrive, malnutrition and colic can occur.

Proper breastfeeding promotes adequate oral motor development which has a positive effect on growth and craniofacial development.  During feeding, intense movement of the lips, tongue, upper and lower jaws and cheeks occurs.  The jaw movements involved in extraction of milk from the breast provide stimulation for growth of the temporomandibular joint which encourages forward growth and development of the orofacial complex (Pires, Giuliani & de Silva 2012) . 

The muscles involved in breastfeeding, particularly the masseters (jaw muscles) are the same muscles that will carry out chewing, swallowing and speaking.  When sucking, chewing and swallowing are performed correctly, they also play a role in the development of the upper and lower jaws, along with genetic and environmental factors, to the stability of dental occlusion, function and muscle balance (Pires, Giugliani & de Silva 2012).

The tongue is one of the most critical organs in our bodies.  It has the ability to shape our palate, the way our teeth are seated in our mouth, our posture, our speech, the opening of our airway and our facial growth and development.  The correct placement in the oral cavity is critical and essential in developing the upper jaw, the shape of our face and our upper airway nasal passages. 

When a tongue restriction or tongue-tie is present, the tongue tip, blade or sides of the tongue can't reach vertically to make contact with the hard palate to create a light suction.  This causes a low and forward tongue resting posture which can eventually lead to many seemingly unrelated ailments such as tongue thrust, facial pain, posture problems, TMJ pain, digestive problems even obstructive sleep apnea and upper airway resistance syndrome.


When the upper lip is restricted is can also cause multiple concerns.  As with tongue-ties there are various levels of restriction.  Dr. Larry Kotlow's classification system is seen here:

Class 1: Normal

Class 2:

Class 3:


Class 4:

Pictures courtesy of Kotlow, DDS

These restrictions of the upper and lower lip can cause difficulty with the infant latching onto the breast: the lips need to flange and extend 1 - 1.5 inches beyond the nipple.  This allows for a wide mouth to create the seal while sucking.  Without adequate lip seal, slipping off the breast, nipple pain and trauma, blocked ducts, nipple infections, short frequent and unproductive feedings and ultimately failure to thrive will result.  Prematurely switching to bottle feeding shortly ensues. 

As the child grows and upper lip tie is not released, dental carries may eventually develop due to the infant's inability to remove residual milk between the lip and the facial surface of the upper front teeth.  The pull of the frenum can also pull on the gingival tissue causing a space between the front teeth called a diastema (as seen in the class 4 picture above).


When the tongue or lip frenum is released as an infant, no general anesthesia is warranted.  Stretching of the area is conducted three times a day for 3 seconds for three weeks post-op.  Some practitioners recommend using coconut oil directly on the breast while feeding to help with stretching.  Hylands Teething Gel can be used on the wound site during manual stretching.  Stretching of the site will ensure reattachment does not occur.  It is recommended to practice the stretching exercises with the infant for one week before the procedure to desensitize the baby to the particular movements. 

Tummy Time is extremely important post-op ( as it provides many benefits to the infant:

  • Decreases reflux
  • Maximizes head control
  • Mobilizes tongue, throat and postural muscles important to breastfeeding and development
  • Promotes optimal head shape
  • Promotes health and resiliency



Lactation consultants (IBCLCs) also recommend providing the infant with body work from a cranio osteopath, cranio sacral therapist or chiropractor.  This important work eliminates the tension and compression caused by the restriction, achieves better opening and head position and improved airway changes.   

With a child or adult, direct stretching is applied post-op for 2-3 weeks with pre-op stretching conducted for one week for optimum results.  A cold compress can be placed under the chin for 20 minutes.  Alternating between cold and warm will be helpful: cold to reduce swelling and warm to relax the muscles. 

Hypericum, a homeopathic remedy for healing can be used. 


Taken from; Tongue Tie - from Confusion to Clarity by Carmen Fernando

For Infants:

  • Impact upon milk supply
  • Termination of breastfeeding
  • The baby failing to thrive
  • Poor bonding between baby and mother
  • Sleep deprivation
  • Problems with introducing solids

Maternal Experience:

  • Pain
  • Nipple damage, bleeding, blanching, or distortion of the nipples
  • Mastitis, nipple thrush or blocked ducts
  • Severe pain with latch or loosing latch
  • Sleep deprivation from baby being unsettled
  • Depression or a sense of failure

For Children:

  • Inability to chew age appropriate solid foods
  • Gagging, choking or vomiting foods
  • Persistent food fads
  • Difficulties related to dental hygiene
  • Delayed development of speech
  • Dental problems starting to appear
  • Strong incorrect habits of compensation being acquired

For Adults:

  • Inability to speak clearly
  • Clicky jaws
  • Pain in jaws
  • Migraines
  • Retruded jaw
  • Effects on social situations, eating out, kissing, relationships
  • Dental health, a tendency to have inflamed gums, increased need for fillings and extractions
  • Difficulty keeping dentures in place


There are possible genetic links of tongue-tie and other midline defects.  According to Dr. Ben Lynch, doctor of Naturopathic Medicine ( who is one of the foremost experts in the MTHFR gene and how it affects your health, states that the MTHFR gene provides instructions for making an enzyme called methylenetetrahydofolate reductase.  This enzyme converts the folic acid or folate we consume into a usable form in our body.  Dr. Lynch feels that pregnant moms are deficient in the needed vitamin B9.  We get Vitamin B9 from eating leafy green vegetables, red meat, poultry seafood, liver and eggs. 

Go to the Tongue Tied Babies Support Group (TTBSG) page on Facebook for more information.