How is a tongue tie detected, specifically in relation to the frenulum's attachment to the tongue and the floor of the mouth?

How to Detect a Tongue Tie

A tongue tie (ankyloglossia) is detected by examining the lingual frenulum's attachment point, length, and how it restricts tongue mobility, not simply by noting the presence of tissue connecting the tongue to the floor of mouth, as everyone has this structure.

Anatomy and Normal Variation

The lingual frenulum is a normal anatomical structure that everyone has - it's the tissue that connects the underside of the tongue to the floor of the mouth. What distinguishes a tongue tie from normal anatomy is:

• Attachment point: In tongue tie, the frenulum attaches closer to the tip of the tongue
• Length: The frenulum is abnormally short, tight, or thick
• Functional limitation: The frenulum restricts normal tongue movement

Clinical Assessment

Visual Examination

• Observe the tongue at rest and during attempted movement
• Note if the frenulum attaches near the tip of the tongue rather than further back
• Look for a heart-shaped or notched appearance of the tongue tip when elevated

Functional Assessment

• Ask the patient to lift their tongue to the roof of their mouth
• Have them try to touch the tongue to the upper teeth or beyond
• Observe if the tongue tip elevates or if it remains tethered down
• Note any unusual tongue shape during movement (like a "W" shape)

Measurement Techniques

• The Bristol Tongue Assessment Tool (BTAT) provides a standardized assessment with good reliability 1
• Measure the distance between the uppermost point of lingual frenulum and its insertion into the oral floor
  • A measurement of <1.5 cm often indicates restricted tongue movement 2

Clinical Implications

Tongue ties can cause:

• Speech and articulation difficulties
• Feeding problems (especially breastfeeding in infants)
• Periodontal issues and malocclusion
• Potential contribution to upper airway collapse in some OSA patients 3

Diagnostic Pitfalls

• Common misconception: Assuming any visible tissue connecting the tongue to the floor of mouth indicates a tongue tie
• Reality check: The presence of a frenulum is normal; it's the attachment point, length, and functional limitation that define a tongue tie
• Assessment error: Focusing only on appearance without evaluating function

When to Consider Treatment

Treatment (frenuloplasty or frenotomy) should be considered when:

1. There is clear functional limitation of tongue movement
2. The patient experiences symptoms related to the restricted movement
3. The benefits of intervention outweigh the risks

Research indicates that frenuloplasty is "a safe, quick, effective, and economical method" for treating ankyloglossia 4, but should only be performed when clinically indicated based on functional assessment, not merely anatomical appearance.