April 26, 2018

Tongue Tie Classification and Impact on Breastfeeding

Parents with tongue-tied infants often wonder how tongue tie classification influences decision to perform release as well as impact on breastfeeding. There is often confusion that one Class is worse than another... "My baby has a Class 4" is often uttered with ominous undertones.

However, as with much of medicine, a simplistic 4 level classification scheme over-simplifies what is actually a much more complex situation. At least in my mind, when it comes to infant mouth anatomy, there are 3 factors at play (assuming all other things being equal). These three factors interplay with each other to not only influence breastfeeding ease, but also influence the chance for improvement with any tongue tie release procedure if breastfeeding issues are present.

1. Tongue tie position
2. Tongue tie tethering
3. Palate position

Tongue Tie Position

This component is perhaps the most well-known and unfortunately, perhaps the least important of the 3 factors. The classification scale typically is as follows. Classes 1-2 are often referred to "anterior tongue tie" whereas classes 3-4 are often called "posterior tongue tie."

Class 1: Tongue tie extends all the way to the tip of the tongue

Class 2: Tongue tie extends incompletely to the tip of the tongue
Class 3: Tongue tie is mostly under the mucosal surface, but does have a component that still can be seen.

Class 4: Tongue tie is completely under the mucosal surface and can only be felt rather than seen.

Tongue Tie Tethering

Essentially, this measure evaluates how "long" or how much "slack" is present in the tongue tie, regardless of its position relative to the tongue. Tethering is determined by palpating the tongue tie (easiest to perform by running a finger under the tongue from one side to the other). You can NOT evaluate tethering by just looking at it.

If the tongue tie is "long" with a lot of slack, than the tie is not significantly restricting tongue mobility. (Some would even call this situation a normal lingual frenulum rather than a tongue tie.)

If the tongue tie is "short" with no slack present, than the tie would restrict tongue mobility to the detriment of breastfeeding.

To understand better, let's use an analogy.

If a boat is anchored off the shoreline and the anchor line is very short and pulled tight, than the boat will not move anywhere (movement is restricted).

However, if the boat's anchor line is very long and full of slack, than the boat will still be able to move around (movement is unrestricted).

The boat would be analogous to the tongue and the anchor would be the tongue tie.

With normal breastfeeding, the tongue moves up and down vertically inside the oral cavity. With this action, the nipple is worked against the palate allowing for effective breastfeeding.

Take a look at this ultrasound of a normally breastfeeding infant. In particular, pay close attention to how the tongue moves vertically within the mouth.

As such, if the tongue is tightly tethered to the bottom of the mouth due to a "tight" tongue tie, than the tongue is unable to elevate sufficiently for effective breastfeeding. The infant will compensate by moving the chin up to help bring the tongue up.

Unfortunately, chin elevation results in gumming of the nipples leading to shallow latch and breastfeeding pain.

A tightly tethered tongue tie is also exhausting for the infant as the tongue is moving against a resistance (think running with ankle weights) as well as using accessory jaw muscles.

There is no grading scale per se that I'm aware with respect to the tightness of tongue tie, but I typically use the terms mild, moderate, and severe.

Palate Position

The palate position refers to the roof of the mouth, mainly how high it is relative to the upper gumline. If the roof of the mouth is high, called "high palate," this finding may adversely affect breastfeeding as well as success rate of any tongue tie release procedure.

A high palate is when the roof of mouth (red arrow) is up where
the orange line is instead.
The key idea here is that if a high palate is present, than the tongue has to move vertically a much greater distance to effectively breastfeed.

If the tongue is unable to elevate sufficiently for effective breastfeeding due to the high palate, the infant will compensate by moving the chin up to help bring the tongue up. This may occur even if tongue tie is completely absent!

Unfortunately, just as with for tightly tethered tongue tie, chin elevation results in gumming of the nipples leading to shallow latch and breastfeeding pain.

I should mention that there is a school of thought that tongue tie causes a high palate and that tongue tie release will resolve a high palate over time (I personally am skeptical of this position). In this particular paper, a small association was seen, but association is not causation... and there's no data that tongue tie release would have resolved a high palate.

There is no grading scale per se that I'm aware with respect to the palate position, but I typically use the terms normal, moderate, and severe.

The Interplay of Tongue Tie, Palate Position, and Tethering Severity

For good breastfeeding, a deep latch and effective tongue mobility is required.

Regardless of what "class" tongue tie is present, if the tethering is severe, the tongue's mobility is restricted which would adversely impact breastfeeding. Performing a release would tend to have a significant beneficial impact.

If tongue tie tethering is very mild, doing a tongue tie release procedure may not improve breastfeeding as much as one would hope, regardless of what class tongue tie is present.

HOWEVER, if a very high palate is present, a tongue tie release procedure may not necessarily help resolve breastfeeding issues even if a tightly tethered tongue tie is present.


Let's use an analogy.

Imagine a 5 foot, 6 inch basketball player with 20 pound ankle weights is trying to perform a slam dunk on the basketball rim.

Performing a tongue tie release is like removing the ankle weights. Removing ankle weights should help the basketball player do a slam dunk, but being only 5'6", it is unlikely that removing ankle weights will actually make any difference. It also would not matter if the ankle weights were 100 pounds (severely tethered tongue tie) instead of 20 pounds (mildly tethered tongue tie). The outcome would still be the same.

Similarly, if the high palate is too high, a tongue tie release may not help as much as one would hope regardless of how severe the tongue tie tethering. Watch video for more information.

In infants with a very high palate, it is important to counsel that although doing a tongue tie release may help with breastfeeding difficulties, there is a chance that it will not make any difference. Obviously, the more significant the tethered tongue tie, the greater the chance for improvement with release.

The decision to pursue a tongue tie release is not just about breastfeeding however. There is potential for speech and swallow issues later in life especially with Class 1 tongue ties and even if breastfeeding was not a problem, release is often performed due to these other considerations.

So... Who is the Ideal Candidate for Tongue Tie Release?

The ideal infant who is experiencing breastfeeding difficulties and who would have the greatest chance for improvement with tongue tie release is a Class 1-4 severely tethered tie with normal palate.

Infants who would have the lowest chance for improvement with tongue tie release are those who are Class 4 with mild tethering and a very high palate.

SO... does that mean that an infant with mild tethering and high palate should never get a tongue tie release done? Of course not... Such infants may still benefit from release... it's just that the chance for improvement is lower. The parents need to decide whether the potential benefits outweigh the risks especially when there is a lower chance for success.

These infants may benefit from not only working with a good lactation consultant, but also a good infant feeding specialist in order to achieve the highest possible chance for success.
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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