Tethered Oral Tissues (TOTs)/Tongue Ties

Tethered oral tissues (TOTs) are a category of congenital conditions that include tongue ties, lip ties, or even buccal (cheek) ties. They are characterized by an unusually tight, thick, or shortened band of tissue (frena/frenum) that connects two structures of the mouth, limits range of motion, and results in functional limitations.

What are Tongue Ties?

A tongue tie, also called Ankyloglossia, is a type of tethered oral tissue where a thick, tight, or short band of tissue (lingual frenum) tethers the bottom of the tongue to the floor of the mouth and restricts tongue movement. Infants, children, and adults with tongue ties will have functional limitations that may impact breast or bottle feeding, eating, swallowing, breathing, postural control, and/or speaking. There are two type of tongue ties:

Anterior tongue ties: This type of tongue tie is relatively easy to see, as it is separated from the tongue itself. It is most obvious when raising the tongue to the roof of the mouth.
Posterior tongue ties: This type of tongue tie is located within the tongue organ and is more difficult to see.

How can you identify TOTs?

TOTs may be difficult to directly and visually identify. It is also important to note that everyone has a lingual frenum. A tongue tie is diagnosed and treated based on the individual’s functional limitations rather than solely based on the tongue’s appearance. Common symptoms or functional limitations of TOTs are:

- Difficult or painful breastfeeding
- Difficulty transitioning to solids
- Picky eating
- Difficulty with articulation of speech
- Trouble with sleep
- Mouth breathing
- Acid reflux
- Tightness in the muscles of the head, neck, and shoulders
- Poor oral hygiene
- Separation or misalignment of the two middle (top and bottom) teeth

What causes TOTs?

These tissues are a result of an overgrowth of facia in the oral cavity that should have been broken down before birth. In some cases, the tissue (frenum) remains tightly attached, creating a “tethered” cord of tissue. The reason for this is largely unknown, although some cases have been linked to various genetic factors. It also often runs in families.

Treatment of TOTs:

The optimal treatment of TOTs involves two parts: the release of the TOT (a procedure called a frenectomy or frenuloplasty) by a knowledgeable provider, and oral motor, feeding, and/or body work therapy before and after the procedure to improve functional limitations. Ultimately, both are needed to optimize function.

If you think your child has a TOT:

Occupational therapists and speech therapists at PediaSpeech conduct an in-depth evaluation to help determine whether your child has functional limitations as a result of a TOT. If so, they will begin treatment and advise on next steps, including recommendations of preferred providers who can perform the procedure to release the TOT. After the release, the occupational and/or speech therapist will provide continuing post-care and therapy to improve function.