Tongue Ties, Lip Ties, and Cheek Ties

April 3, 2018

I have been seeing a lot of babies with tongue ties (ankyloglossia) coming through our local early intervention evaluation clinic lately because of the effect it has on breastfeeding. As a graduate student, I was taught that tongue-ties usually do not affect speech, so when I saw that there was a continuing education class by Robyn Merkel-Walsh (and co-author Lori Overland) on Tethered Oral Tissue (TOTs) addressing the impact of tongue and lip ties on feeding and speech coming to a town near me, I knew I had to attend. Here are the highlights of the course (written with permission and editing from Robyn Merkel-Walsh MA, CCC-SLP/COM®):

What are tongue, lip, and cheek ties?

  • A tongue-tie occurs when the piece of tissue that connects the tongue to the floor of the mouth (called the lingual frenum or frenulum) is either too short or too tight and therefore restricts normal tongue movement to some degree. (Mayo Clinic, 2016) Tongue-tie can also be the result of the frenulum being in an atypical location.
  • A lip tie occurs when the piece of tissue that connects the lip to the gum (called the labial frenum or frenulum) is attached too close to the teeth or extends beyond the teeth into the hard palate. This restricts movement of the lip and affects the appearance of the face. The vast majority of people with a lip tie also have a tongue tie.
  • A third type of tie, known as a buccal tie, occurs when the tissue between the cheek and gums (buccal frena or frenula) is too thick or too tight. This restricts the ability of the cheeks to be used for feeding and speech.

What issues are caused by tongue, lip, and cheek ties?

  • All stages of feeding may be affected by TOTs across the lifespan including breastfeeding, bottle feeding, spoon use, eating solids, cup drinking, and straw use.
  • Speech sound production can be affected by ties. Research is emerging. Depending on the location and severity of the tie(s), every consonant in the English language has the potential to be impacted, though some sounds are more typical than others such as /s/ or /z/ (Marchesan, 2004). Older children who have been in speech therapy for many years, without fully correcting their sound production, may have tongue, lip, or cheek ties that are preventing them from progressing any further.
  • Tongue-ties are associated with sleep-disordered breathing, which can range from snoring to obstructive sleep apnea. (Guilleminault, Huseni, and Lo, 2016). Obstructive sleep apnea in infants has been associated with sudden infant death syndrome (SIDS). Follow the link to learn about the potential implications of sleep-disordered breathing in children.
  • Reflux in babies is a red-flag for a tongue-tie. The improper sucking pattern causes the baby to swallow air (aerophagia), leading to reflux. (Siegel, 2016)
  • The resting posture of the tongue should be inside the mouth, behind the top front teeth, with the mouth closed. This allows breathing through the nose, where the air can be filtered. When the tongue is restricted, it can cause open mouth posture/mouth breathing, which doesn’t allow the nasal turbinates to do their job. This results in the potential for more bacteria and viruses to enter the body, leading to the potential for illness.
  • Appropriate lingual resting posture is a natural palatal expander (quoted from Linda D’Onofrio, SLP). A restricted tongue that does not assume typical resting posture can cause the palate to become vaulted and narrow which leads to differential dental eruption. This is described in detail in the book by Hanson & Mason text entitled Orofacial Myology (2004).  This cycle increases the chance of orthodontia as the child gets older.

What is the role of the speech-language pathologist (SLP) in the treatment of ties?

  • The American Speech-Language Hearing Association (ASHA) states in the OMD Practice Portal that SLPs cannot “formally” diagnose a tongue, lip, or cheek tie or decide if surgery is warranted; however many SLPs find that the surgeons rely on them to help make this decision based on functional issues. The role of the SLP with TOTs includes: 1) the assessment of structure and description of suspected anomalies associated with TOTs (ex. note the location of the frena or tightness thereof) and 2) the diagnosis and treatment of the functional impact of TOTs on feeding and speech. This evaluation and descriptive report can be helpful to a physician or dentist in making the diagnosis and determining if there is a need for frenectomy (the procedure that releases TOTs).
  • SLPs can design and carry out a pre-operative program to acclimate the client and family to the oral sensory-motor treatment before surgery. Proper implementation before the surgery and immediately following it can reduce the chance of reattachment and scarring.
  • SLPs can design and carry out a post-operative program for neuromuscular re-education of the mouth for feeding and speech after surgery. Clients with a history of ties may use compensatory movements for feeding and eating that they will need to overcome.
  • This is detailed in Functional Assessment and Remediation of Tethered Oral Tissue which was co-authored by Merkel-Walsh & Overland.

Whom should parents contact if they suspect that their child has a tongue, lip, or cheek tie?

  • The first step is a functional assessment. Too often releases are performed without this and it makes post-operative care more difficult. Functional assessments are conducted by IBCLCs, SLPs, OTs, and RDHs depending on the age of the patient and the symptoms presented. There is not a TOTs leader but rather a TOTs team. The Ankyloglossia Bodyworkers is a good referral source as are the IAOM and TalkTools® (see below).
  • Once a functional assessment is conducted, the patient/parents of the patient should seek a referral to an otolaryngologist (ENT), oral surgeon, or dentist with expertise in TOTs to make the diagnosis and perform the revision if it is deemed necessary. Organizations such as the International Consortium Of Oral Ankylofrenula Professionals (ICAP) and the International Affiliation of Tongue-tie Professionals (IATP) have lists of providers.
  • The age of the patient and what is being affected (e.g. speech, breastfeeding, dental eruption, fascial restriction etc.) by TOTs determines which other professionals should be consulted. In addition to the aforementioned professionals, TOTs impacts the whole body; therefore, chiropractors and physical therapists can assist with patient care. Craniosacral therapy and TummyTime® are often used with TOTs patients.

Other facts about ties:

  • Babies born prematurely are at higher risk of tongue, lip, and cheek ties because there is less time for the tissue to detach.
  • In earlier generations, babies had their tongues clipped before leaving the hospital. The procedure hadn’t yet been perfected, and breastfeeding became less popular as more women entered the workforce. As a result, the practice fell out of favor. As breastfeeding has increased in recent years, the identification of tongue and lip ties has been on the rise. (Ghaheri, 2014)
  • Well-meaning doctors often test for tongue-tie by having the child stick out his/her tongue, assuming that if the tongue can protrude, it isn’t restricted; however, this misses all of the functional postures required for feeding and speaking.
  • Frena tissue is collagen-based. It cannot be stretched. No amount of stretching will “fix” TOTs, but pre- and post-op therapy can assist with function.
  • Brazil now has a Frenum Inspection Law based on the correlation of SIDS and ankyloglossia in their country. All babies must be inspected for tongue-tie before leaving the hospital and if diagnosed, will have a revision. (Martinelli, Marchesan, and Berretin-Felix, 2012)

To learn more about tethered oral tissues, check out these links:


Compiled from information from the TalkTools workshop: Functional Assessment and Remediation of Tethered Oral Tissues (TOTs), authored by Robyn Merkel-Walsh and Lori Overland, as presented by Robyn Merkel-Walsh, MA, CCC-SLP.