Tongue tie, medically known as ankyloglossia, is a common congenital condition where the lingual frenulum restricts the tongue’s normal range of motion. This tissue tethers the underside of the tongue to the floor of the mouth. When this restriction causes functional problems, it can interfere with feeding, speech, and oral development. This article explores the characteristics, identification, and treatment of the less-obvious posterior variant.
Defining Posterior Tongue Tie
Posterior tongue tie (PTT) involves a lingual frenulum that is short, thick, or inelastic, restricting the tongue’s movement. The attachment point is farther back from the tongue tip, attaching to the base of the tongue rather than the tip, which characterizes the more visible anterior tongue tie (ATT). Often, the restrictive tissue is hidden underneath a thick layer of mucous membrane, making it difficult to see visually. This submucosal nature is why PTTs are sometimes missed during a quick visual check.
This anatomical difference means that unlike an anterior tie, a posterior tie may not result in a visibly notched or heart-shaped tongue tip when lifted. Instead, a qualified practitioner often feels the restriction as a tight, fibrous band when sweeping a finger along the floor of the mouth. The limited function occurs because the frenulum prevents the posterior two-thirds of the tongue from properly elevating and extending. Failure to fully release this deep, restricted fascia can lead to persistent functional issues.
Common Signs and Functional Impact
The most common signs of a posterior tongue tie relate to feeding difficulties in infants. These occur because the baby cannot create an effective seal or use the tongue’s necessary wave-like motion to extract milk. A poor latch often results in the baby chewing or clamping down on the nipple, causing pain, cracking, or damage for the breastfeeding parent. During feeds, a clicking sound may be heard as the baby’s tongue loses suction.
Swallowing excessive air during inefficient feeding can lead to uncomfortable symptoms for the infant, such as excessive gas, fussiness, colic, and reflux. The functional restriction may prevent the baby from transferring enough milk, resulting in poor weight gain or failure to thrive. For the parent, the baby’s inability to fully drain the breast can negatively impact milk supply and increase the risk of blocked ducts or mastitis.
If the condition is not addressed in infancy, restricted tongue mobility can lead to long-term issues affecting speech and oral development. Older children may struggle to articulate certain sounds that require fine tongue movements, including ‘r’, ‘l’, ‘t’, ‘d’, ‘s’, and ‘z’. The chronically low resting posture of the tongue, unable to rest against the palate, can influence the development of the upper jaw, potentially leading to a narrow palate or dental crowding.
Identification and Professional Diagnosis
Diagnosing a posterior tongue tie requires a multi-disciplinary approach and relies heavily on a functional assessment rather than visual inspection. Professionals typically involved in the evaluation include International Board Certified Lactation Consultants (IBCLCs), specialized pediatric dentists, and Ear, Nose, and Throat (ENT) physicians. The process begins by observing a feeding session to assess the baby’s latch, suck pattern, and overall efficiency.
The physical examination is important for PTT because the restriction is often hidden from view. The provider uses palpation, gently sweeping a finger under the tongue to feel for the tight, inelastic band of tissue. This determines the degree of restriction and the tongue’s ability to lift and extend. Standardized tools, such as the Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF), may be used to score both the anatomical appearance and the functional movement of the tongue.
Corrective Procedures and Post-Care
The standard treatment for a symptomatic posterior tongue tie is a frenotomy or frenuloplasty, often referred to as a frenulum “release.” This procedure involves precisely releasing the restrictive lingual frenulum to restore full range of motion to the tongue. It can be performed using sterile scissors, a scalpel, or a soft-tissue laser, depending on the practitioner’s preference and the patient’s age.
Following the release, the post-operative care regimen of stretching exercises is important for success. These stretches are designed to prevent the two cut edges of the wound from reattaching, a process known as re-tethering, which can happen rapidly as the body heals. Parents are typically instructed to perform the exercises four to six times a day for several weeks to keep the resulting diamond-shaped wound site open.
The exercises involve gently but firmly lifting the tongue up toward the palate to place tension on the healing site. This movement helps the wound heal by “secondary intention,” meaning it heals from the bottom up with flexible tissue rather than scarring back together. Follow-up therapy with a lactation consultant, feeding therapist, or bodyworker is often recommended to help the infant learn how to use their newly freed tongue muscles.