Tongue-Tie

Tongue-tie is a condition where the piece of tissue that connects the tongue to the floor of the mouth is too short, thereby restricting the tongue's range of motion. Tongue-tie can cause breastfeeding difficulties, speech impediments, and sleep apnea. A restricted tongue can additionally alter facial development. As your child grows, the tongue typically rests in the roof of the mouth, contacting the palate. Tongue-tie causes the tongue to adopt a lower resting position. The lower resting tongue position interferes with the palatal development, causing it to be abnormally high and arched. Because the roof of the mouth is the floor of the nose, a high-arched palate makes breathing through the nose difficult.

What we offer at Sleep and Brain

At Sleep and Brain, we strive to diagnose and treat a tongue-tie early in life before the damaging effects occur. Our physician will conduct a detailed history and specialized examination to determine if an underlying tongue-tie is present and contributing to your health concerns. 

The detailed clinical history will, in part, include the following:

• Speech issues

  • Hard to understand

  • Stuttering

  • Unable to speak fast

  • Speech delay

  • Trouble with sounds

• Breastfeeding issues

  • Painful nursing

  • Poor latch

  • Losing milk out of the corner of the mouth

  • Gagging

  • Nipple damage

  • Plugged ducts, engorgement, and mastitis

  • Frequent feeding every 30 to 60 minutes

• Feeding issues

  • Hard time transitioning to solid foods

  • Slow eater

  • Grazes on food throughout the day

  • Choking on food

  • Aversion to specific textures of foods

  • Unable to open the mouth widely

  • Poor weight gain

• Sleep issues

  • Restless sleep

  • Bedwetting

  • Grinds teeth

  • Sleeps in strange positions

  • Snores

  • Reflux

  • Mouthbreathing

• Brain issues

  • ADHD

  • Anxiety

  • Headaches

In addition to a tongue-tie, it is possible to have a lip-tie and cheek-tie. Collectively, tongue-ties, lip-ties, and cheek-ties are called TOTs, or tethered oral tissues. The lip-tie can also contribute to nursing problems and independently make breastfeeding painful and difficult for mom. The significance of cheek-ties is unknown. In addition to taking a detailed clinical history, we will conduct a specialized physical examination evaluating for all the tethered oral tissues listed below: 

• Tongue-Tie

  • Anterior

    • Kotlow Free Tongue Measurement

      • The length of the "free tongue," which is the portion of the tongue extending past the attachment of the lingual frenulum.

        • Less than 16 mm

    • Tongue To Incisive Papilla

      • The ability of the tongue to reach the incisive papilla (just behind the upper central incisors) during elevation.

        • Less than 50%

  • Posterior

    • Kotlow Free Tongue Measurement

      • Limited ability to elevate to the incisive papilla may indicate posterior restriction if no significant anterior tether is visible

    • Lingual Palatal Suction

      • The tongue's ability to form a suction seal with the palate.

    • Floor of Mouth or Neck Compensation

      • The degree of compensation by the floor of the mouth and neck muscles during tongue movement. Observes tension or elevation of the floor of the mouth and neck as the tongue attempts elevation or protrusion.

    • Neck Tension

      • The restricted tongue cannot move freely, particularly in elevation, suction, or protrusion. Neck muscles and floor-of-mouth muscles (e.g., mylohyoid, digastric, and geniohyoid) work harder to lift or move the tongue.

        • Strained Neck Muscles

          • Tightening or activation of neck muscles, particularly the sternocleidomastoid, during swallowing or tongue movement.

        • Head Tilting or Posturing

          • Tilting or extending. the head backward to aid tongue elevation, further engaging neck and jaw muscles.

        • Fatigue and Discomfort

          • Overuse of neck and jaw muscles can lead to fatigue, discomfort, or even pain during activities like feeding or speaking.

• Lip-Tie

  • Kotlow Lip-Tie Classification:

    • Class I: Attachment in the mucosa.

    • Class II: Attachment within the gingiva.

    • Class III: Attachment at the junction of the gingiva and the anterior teeth.

    • Class IV: Attachment extending to the hard palate, causing significant restriction.

  • Functional impact such as ineffective latch during breastfeeding, air intake during feeding, or speech articulation problems.

• Buccal-Tie

  • There is no universal classification system for buccal ties

  • Functional impact such as breastfeeding issues (e.g., poor latch, painful feeding), difficulty with chewing or speech articulation, and oral discomfort.

Low tongue posture on a Cone Beam CT can have structural, functional, and behavioral causes in addition to tongue tie. Structural issues such as tongue tie, enlarged adenoids or tonsils, high-arched palates, small jaws, craniofacial abnormalities, or reduced oral space from a large tongue or misaligned teeth can limit tongue space, forcing it to rest lower. Functional problems like chronic nasal congestion, sleep apnea, or weak tongue muscles due to neurological conditions can also contribute. Behavioral factors, including mouth breathing, thumb sucking, improper swallowing patterns, or habits like tongue-thrust swallowing, may further exacerbate the issue.

Once a tethered oral tissue is confirmed, we can offer treatment remedies to undo the tie and rehabilitate the muscle.

• A frenectomy is a fast and straightforward surgery to loosen the lingual frenulum. We can refer you to surgeon with expertise freeing tethered oral tissues if necessary.

• We may also recommend beginning sleep apnea therapy to help you breathe more comfortably at night.

  • Positive airway pressure

  • Mandibular advancement splint

  • Palate expansion

  • Allergy evaluation and treatment

  • Surgery

    • Maxillo-mandibular advancement

    • Bone-based palate expansion