I love talking about tethered oral tissues aka ties! I recently wrote a blog post showing how labial ties can impact gum formation, so if you haven’t checked it out yet, you totally should!

Blog Post: A Picture Is Worth A Thousand Words: Oral Ties

It's unfortunate how many babies struggle with feeding due to oral ties and how many parents are left without answers due to improper or incomplete oral assessments. My goal is to spread awareness so parents can be more knowledgeable in how to identify feeding challenges that may be due to tension, restriction or dysfunction. I think knowing what a proper assessment looks like fits that aim.

Now as a lactation professional, it's not within my scope to diagnose ties. I only can observe oral function and tell parents what I see that is outside the expected range. For tied babies, this may present as an inability to lift the tongue, difficulties with tongue lateralization, a lack of tongue cupping, or a sensitive gag reflex to name a few of the issues we can see due to ties.

Want a better understanding of your oral function? Click here to learn more about the FREE DIY oral assessment worksheet.

I must say that these things can be due to other reasons as well, but for this post, we’ll limit our commentary to ties.

There are different placements of lingual frenulums that are categorized as four different types. As a reminder, lingual frenulums are entirely normal, so having a band of tissue that connect the tongue to the bottom of the mouth is typical. With ties, the frenulum is either short, tight or a combination of the two and can present in any of the four different types of frenula.

The one accepted exception is the type one frenulum because it almost always limits the range of motion and function.

To phrase another way, you can have a type two frenulum with a normal range of motion or you can have a type two frenulum (attaching mm behind the tongue tip) that is restricted. You may have a type four frenulum (submucosal), which has an expected and healthy range of motion or one that's short and tight preventing full function.

The type is just a descriptor of the frenulum not classifying the severity of the tie.

With all of that said, ties on type 3 & 4 frenula are often missed because the frenulum doesn't affect the tongue tip the same way that tied type 1 or type 2 frenula do. Also, in cases with type 3 and four frenula that are restricted, the tongue may look like it lifts well and it can be stuck out past the gum line. People, including pediatricians, may incorrectly believe that ability to stick out a tongue means there is no tie.

Ties on type 4 frenula are especially pesky because though it requires a physical assessment of the frenulum just like with other ties, the actual frenulum must be “uncovered” to be able to identify it and assess the elasticity of it. Below is a video by Dr. Ghaheri which shows how a proper tie assessment can uncover a tongue tie on a type 3/4 frenulum.

Just by looking at the video, it may be difficult to see what about that frenulum is tight. That's the thing about tie assessments is that restricted frenulum is not something that you can visualize per se. I do want to note there is blanching of the frenulum during the exam, which we would expect to not occur with an untethered frenulum, but that's about it.

Dr. G and other tie providers who have assessed many of tied and untied babies, know what the proper elasticity of a lingual frenulum is. With their experience, they can easily tell when there is an actual lingual tie or when feeding issues may be due to tension in other oral muscles.

https://www.slideshare.net/nitisarawgi8290/tongue-ppt

Here you can see all of the other muscles that attach to the body of the tongue. Extrinsic tongue muscles, which connect the tongue to other parts of the mouth can be tight or tense. It takes assessing those muscles too to see when the tongue is tight due to tension or tight due to ties.

The last thing I want to leave you with are these cool graphics that show how the muscles of the tongue AND the muscles of other parts of the body anchor to the Hyoid bone. I can make a whole different post about the role of they Hyoid bone but for now, know that it's a free-floating bone to which muscles of the tongue and muscles to other parts of the body connects.

It becomes a bit easier to see how tight oral muscles can have an impact on the range of motion and comfortability in other parts of the body. So when babies struggle to nurse, and we suggest bodywork to help rule out tongue tie, it hopefully makes more sense now.

Would love to hear your thoughts below!

OH AND BEFORE YOU GO!

If you feel that your baby is having difficulties with feeding, let’s schedule a consult! Getting an assessment and a personalized care plan can make a huge difference in both yours and your baby’s human milk feeding journey. You can schedule a consultation here!

Tongue Tie or Nah?

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