The (too) short tongue tie
When I type the term lingual frenulum into Google, I get over 19,000 search results. Many of the search results on the first few pages are about the effects of breastfeeding and how I can recognize a tongue tie that is too short.
So there has been quite a lot written on the subject, but then again there has been relatively little. In the specialist literature, the topic of oral bands or oral restrictions, as you will find there, is described rather little and if it is, then often only briefly touched on without going into depth.
Yet it is an important topic. A topic which is not at all seldom of importance, not only in breastfeeding, but also in further development. A topic that can cause a lot of suffering and frustration. Or insecurity. That's why I would like to talk about the (too) short tongue tie here, but also about the lip tie.
What is the lingual frenulum anyway? When is it too short and what are the different forms?
For a long time it was assumed that the lingual frenulum was simply a firm band of tissue located in the middle of the oral mucosa under the tongue.
Recent studies have found that this assumption is too simplistic and does not capture the anatomy of the lingual frenulum. Furthermore, the lingual frenulum is not the same in every person, but can have different portions.
It is always a fascial ligament that lies under the oral mucosa. It is also possible that the oral mucosa attaches to the tongue further forward than the fascial band itself does. In addition, it is also possible that the fascia, along with the portion of oral mucosa, sits further forward on the tongue.
Furthermore, it is possible that the lingual frenulum has a muscular component. Thus, the muscle "protrudes" somewhat into the fascia and the oral mucosa. This usually makes the lingual frenulum very firm and thick.
The manifestations in the appearance and attachment points, but also in the functional restriction can be very different. For example, there are children who show no problems at all with a tongue tie that is set far forward (it does not have to stay that way). On the other hand, there are other children who show a very extensive problem and difficult situation with a very far back fixed lingual frenulum.
There are different scales for the classification. There is an additional distinction between an anterior tongue tie, i.e. one that is set far forward, and a posterior tongue tie, which is hidden in the oral mucosa.
Why should I also look for the labial frenulum?
Often oral restrictions, that is, restrictions in the mouth area, do not occur alone. If the lingual frenulum is significantly restricted, it is not uncommon for the labial frenulum and/or the buccal frenulums to also cause problems and have restrictions.
It therefore makes sense to always consider the entire mouth area with tongue, lips, cheeks and palate in its function.
Where does a restriction caused by the lingual and/or labial frenulum come from?
The lingual frenulum is already formed in utero. Its function in the first weeks of pregnancy is to stabilize the tongue and prevent it from falling back towards the trachea.
After the first trimester of pregnancy, the lingual frenulum usually regresses. The tongue now gains function. First movements become possible, swallowing and sucking are already practiced and the movements become increasingly coordinated.
There are many theories on the cause of the lack of regression of the lingual frenulum in utero, not all of which have yet been scientifically confirmed. A genetic component seems to be proven. In general, other causes such as the effect of folic acid during pregnancy, as well as the effects of certain hormones and enzymes are discussed.
In the presence of a restricted, firm labial frenulum, a firm, short lingual frenulum often occurs in addition. Rarely, only the labial frenulum is restricted.
What are the indications of a shortened lingual frenulum in babies?
When I look up tongue tie in Google, I mainly find articles on the topic of shortened tongue tie in babies and how to recognize it. In general, it is never important to judge the lingual frenulum by appearance alone. The function is always important as well, as is the current situation and past history.
However, there are some indications that make clarification of a restriction of the lingual (and labial) frenulum a good idea. Sometimes many factors occur together, sometimes only a single aspect is applicable.
Sometimes restrictions are not visible in the baby period or problems are not interpreted correctly. Oral restrictions can also be detected during the introduction of baby food or speech development, as well as tooth formation.
Nevertheless, I would like to mention a few typical indications which can (but do not have to) point to a shortened, restricted tongue, lip or even cheek frenulum:
- abnormalities in weight development; in this context, insufficient milk production, no effective breast emptying
- sore nipples, frequent milk retention
- deformed nipples after breastfeeding
- restlessness or sleepiness in the baby
- Sucking blisters on the upper lip
- significant flatulence, very strong spitting up
- Excessive milk production due to constant stimulation; very many breastfeeds
- Grasping the breast difficult or not possible
- Clicking noises during breastfeeding
- Ran-away behavior during breastfeeding
- lower chewing rests on the breast, chewing movements
- Open mouth when sleeping
For more on effective breastfeeding, check out my post 7 Signs You Can Tell Your Baby Is Breastfeeding Effectively.
Keep in mind that many of these abnormalities can also come from incorrect latch-on, as well as some other causes. Here it is important to look at the overall situation, the latch-on, as well as the tongue and mouth area in its function.
Problems do not only occur during breastfeeding, but also during bottle feeding. It is not uncommon for restrictions in the oral area to be the reason for switching to bottle feeding.
What can I do if my baby has a too short lingual frenulum and is struggling with restrictions?
First of all, such a restriction must be recognized. To do this, I would recommend that you seek advice and guidance from someone who has received appropriate training in this area. Not everyone has enough expertise and experience in this. For me it is important to see that the cutting of the lingual frenulum, i.e. the frentotomy itself, is only a small part. With small babies, the combination with breastfeeding counseling and body therapy, as well as speech therapy if necessary, makes sense depending on the individual situation.
An evaluation of the tongue or even lip frenulum should not be based solely on visual findings. The tongue should be considered in its function. Not every tongue tie causes problems, not every visible tongue tie is shortened or restricted.
In order to discuss a course of action that makes sense for you, turn to someone who is knowledgeable on this subject. Here you can discuss your individual approach and questions. The procedure for tongue tie problems should always be done as a team with therapists, lactation consultants, doctors and other specialists. This will ensure optimal success.
It makes sense to assess function with the help of assessments in order to create comparability and better traceability. Which sheet is used here varies.
Who can I turn to? Where can I get support?
Unfortunately, it is not so easy to find out who is really qualified on the topic of oral restrictions. Not everyone who writes on the website that tongue tie treatment or assessment is part of the service is sufficiently trained in this area.
It often helps to ask exactly how much experience is available in this area. So when it comes to a doctor/physician, you could ask how much separation is done daily/weekly/monthly and how tongue function assessment is done. It is also a good idea to ask what, if any, measures are recommended before and after the procedure.
You can find a list of qualified specialists on the website www.defagor.de. DEFAGOR is the German Society for the Treatment of Oral Restrictions e.V. However, this list by far does not include everyone who is well versed in the subject.
Frequently asked questions regarding the tongue tie
There are a few questions that come up again and again regarding the tongue tie; both in my breastfeeding support sessions and in various forums or groups on Facebook. I would like to address a few of those questions here. If you also have questions about it or have encountered questions that I don't mention here, feel free to write them to me in the comments and I'll add to the article accordingly.
How common is a shortened lingual frenulum?
The reported frequency of a shortened lingual frenulum varies widely. The data vary roughly between 3% and 32%, which already makes a considerable difference.
Studies vary in their definition of what is considered a shortened lingual frenulum. In many designs, only those are recorded that are actually placed very far anteriorly and show the typical cardiac tongue, where the tip is fixed and the side goes up. Thus, the posterior lingual bands are typically disregarded.
So a conclusive assessment of how often restrictions occur due to the lingual frenulum cannot be made at this time. Especially since it is important to consider not only the ligament as such, but the entire function and situation. Here, study work must certainly still be done, which is not at all easy due to the lack of specialized personnel, time and money.
Is cutting guaranteed to bring improvement?
A sometimes sobering and frustrating answer. But unfortunately, there is no guaranteed improvement. The deciding factors are whether the tongue tie is anterior or posterior, the age of the baby, the timing of the cut, the type and quality of the cut, preparation and follow-up that took place, and other factors.
The likelihood that separation will improve is very high for anterior lingual frenulum. In posterior lingual frenulum, separation sometimes does not bring the hoped-for improvement; not all problems are always solved. However, a general improvement of the situation is likely here as well.
So it should always be weighed up whether and when the severance is useful.
We currently have no problems. Should we nevertheless separate as a precaution?
Opinions differ widely on this. Problems caused by short oral bands can occur in the future, but they don't have to. My personal opinion is therefore to keep an eye on the situation, but only to tackle the issue if there are problems or difficulties.
In addition, the separation itself plays only a small role in the treatment of the restrictions. Many factors can therefore be influenced, for example, with the help of lactation consultants, body therapists and speech therapists, as well as other specialists.
Is the lingual frenulum stretchable?
The tongue tie is only stretchable to a minimal extent, namely 3%. So if the tongue tie is 3cm long, this is not even 1mm. The stretchability of the tongue band is therefore negligible.
Problems caused by tight, short tapes also do not grow out and disappear with increasing age. At most, children sometimes learn to cope better with restrictions. In some cases, restrictions become visible later in feeding, speech development or sleeping, to name just a few affected areas.
Is cutting with scissors/scalpel or with laser more useful?
Opinions also differ on the method of separation used. Statistics have shown that the experience and safety of the treating physician is more important.
So if you are unsure about which method is appropriate or you have questions about a method, it is best to discuss it with a trained and experienced doctor.
My child can stick out his tongue. Does this mean that he/she does not have a tongue tie that is too short?
Unfortunately, it is not that simple. Sticking out the tongue is only one possible movement; the other movements, as well as various additional factors, must also be considered.
Technical terms related to the lingual frenulum
- Ankyloglosson/ Ankyloglossia/ Ankyloglossum: Medical term for the shortened lingual frenulum as a congenital developmental disorder of the tongue.
- Frenulum linguae: Medical term for the lingual frenulum
- Oral restrictions: Restrictions in the mouth area, e.g., caused by shortened, fixed ligaments
- Frenotomy: severing of the lingual frenulum
Sources and further literature
In my research I used some books and professional articles. If you want to learn more about the topic, you can find more information there:
- Professional article from the European Institute for Breastfeeding and Lactation (EISL) as PDF: www.stillen-institut.com/media/2016-07-18-das-zu-kurze-zungenband-de.pdf
- Further article from EISL on the topic of tongue tie: www.stillen-institut.com/de/zungenband.html
- Article in the breastfeeding encyclopedia on the shortened lingual frenulum: www.still-lexikon.de/verkuerztes-zungenbaendchen/
- Article on the short lingual frenulum by lactation consultant Katharina von Herff: www.stillberatung-vonherff.de/das-zu-kurze-zungenband
- Article on the short lingual frenulum by lactation consultant Ulrike Guhr: www.natuerlich-eltern.com/zungenband/
- Various information about oral restrictions can be found on the DEFAGOR site: www.defagor.de/
- English Wikipedia article on the lingual frenulum: en.wikipedia.org/wiki/Frenulum_of_tongue
- Study on the structure of the frenulum and a restricted tongue frenulum (English): onlinelibrary.wiley.com/doi/10.1002/ca.23343
I have read other study results summarized in various articles and reference books. Books used include:
In addition, I used the handouts for the presentations from the 2019 Tongue Tie Symposium and 2020 Tongue Tie Symposium by Gold Learning.
What are your thoughts on the topic of tongue tie? What are your touch points and your experiences?
What other questions do you have about the tongue tie that I haven't addressed in the article?
I look forward to reading from you in the comments.
- Cover image: https://pixabay.com/photos/ice-cream-dessert-sweet-food-2588541/
- Image 1: https://pixabay.com/photos/kids-funny-tongue-emotions-4813443/
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