Frenulum (plural: frena)
A [normal/typical] frenulum is a fibro-mucosal tissue fold, which consists of collagen and fascia and connects soft tissue to the bone in order to support or limit movement. There are many different frena connecting semi-mobile structures in different parts of the body including: the tongue, lips, cheeks, digestive tract, internal structures of the brain, and both male and female genitalia.
A 3-dimensional structure of connective tissue consisting of closely packed collagen fibers that surround, reinforce, and/or allow movement of all structures of the body including: muscles, tendons, ligaments, joints, blood vessels, organs, and nerves.
The tongue is an intricate and vital organ that plays a fundamental role in swallowing, breathing, chewing, and speaking. Additionally, the tongue guides the shaping of the hard palate of the mouth (important for optimal oral posture, breathing and sleeping), airway structures, dentition (the arrangement of teeth), cranial shape, facial angles, symmetry of the face, and impacts full body development and function. For learning purposes, the image below separates the tongue into anterior and posterior sections.
Tethered Oral Tissues (TOTs)
Tethered Oral Tissues (TOTs) is a term describing the abnormal/atypical restriction of the frenulum (frena) of the oral cavity due to atypical size, thickness, tightness, or location, which may impact the the movement and function of the oral tissues. Although it is normal for everyone to have frenulum in the oral cavity, when the tightness or restriction impacts function, this is when therapy and surgical intervention may be necessary. There are a total of 7 frena in the oral cavity that could have a possible restriction: One Lingual-Tie (Tongue-Tie), Two Labial-Ties (Upper & Lower Lip), and Four Buccal-Ties (two upper cheek-ties & two lower cheek-ties ).
Lingual-Tie, Tongue-Tie, or Ankyloglossia - All three terms describe what is commonly called a tongue-tie. Tongue-ties are typically identified as Anterior and/or Posterior.
Anterior Tongue-Tie: A visible frenulum connecting the tip of the tongue (anterior portion of tongue) to the base of the mouth (mucosa floor of the mouth) resulting in restricted movement of the tongue. This type of tongue-tie is typically easier to diagnose and may result in a heart shaped dimple at the tip of the tongue. In the image below, Grade 3 and 4 are examples of Anterior Tongue Ties.
Posterior Tongue-Tie: The posterior tongue-tie is more difficult to diagnose due to it appearing to be “hidden” because of its position. The frenulum is typically deeper in the mucosa of the floor of the mouth and needs to be “diagnosed” by an experienced professional through a functional assessment. The image below is an assessment method using lingual palatal suction, which exposes the posterior ankyloglossia and how it can impact mobility of the posterior (back) 1/3 of the tongue.
Two Labial (1 Upper and 1 Lower Lip)
Four Buccal (2 Maxillary and 2 Mandibular Cheek)
A surgical procedure removing the restrictive frena in order to enhance movement and function of the oral tissues. Typically, the provider will use a laser and/or scissors to complete the frenectomy and “release” the soft tissues.
This term is used interchangeably with frenectomy by providers, practitioners, and families.
At times, some individuals may require more than one release/frenectomy due to reattachment of the frena. Additional releases/frenectomies are also known as revisions.
*It is important to note, that these images are to give you an example of what TOTs may look like. You can NOT diagnose TOTs from looking at a picture. You must do a functional assessment to see if the frenulum is impacting function by a trained health care professional.*
The symptomatology of a person with Tethered Oral Tissues may vary slightly depending on the individual circumstances. However, if a person experiences TOTs, their body will compensate for the restriction(s) and those compensations may evolve into more complex issues as they age. Below is a diagram listing some typical symptoms that may occur in a person with TOTs throughout the lifespan: infant, breastfeeding mother, child, and adult.
The Team Approach
Who's on the team?
Treating oral ties and/or oral dysfunction is not simply a “tongue” issue. The tongue is an intricate and vital organ that plays a fundamental role in swallowing, breathing, chewing, and speaking. Additionally, the tongue guides the shaping of the hard palate of the mouth (important for optimal oral posture, breathing and sleeping), airway structures, dentition (the arrangement of teeth), cranial shape, facial angles, symmetry of the face, and impacts full body development and function. The fascia that is tight, tense, and anchoring the tongue to the floor of the mouth, is often connected to other tension/tightness throughout the body which restricts movement and impacts the ability to grow and develop optimally. Sooo… One little snip and it’s fixed… is not the answer, unfortunately. Instead, working with a “team” of practitioners to help guide you and work with you on their specialized “piece of the puzzle”, is the best way to ensure optimal results for your family! As each person has a unique set of circumstances, each “team” will also vary to address your individual circumstances. This chart may help you to familiarize yourself with some of the possible practitioners that could be on your “team”.
Please note: All practitioners in a field may not be familiarized with or specialized in treating TOTs (tongue-ties/oral-ties). Being a practitioner (in any field) that treats TOTs requires additional training outside of a typical degree program. Therefore, when looking for someone to add to your team, it is important to ensure that they have specialized training in treating individuals with TOTs!
Optimal Timing of Release
Does every tongue-tie need to be surgically released? No! If the “tie” or frenulum is not impacting your little one’s function, then there is no reason to surgically intervene. However, if you have concerns about feeding, oral function, and/or are experiencing any symptoms associated with TOTs, this is an example of the process you could follow to determine the optimal timing for the procedure.