.You’ve probably heard of a tongue tie before, but if you don’t have one yourself, you may not know much about it. A tongue tie is a common name for a type of connective tissue attaching the underside of the tongue to the floor of the mouth and restricting tongue movements. Tongue ties come in all shapes and sizes, and are just one type of tethered oral tissue (TOT) – they may also be accompanied by lip ties and/or buccal (cheek) ties.
While many of us are born with ties, they often go unnoticed or require no intervention unless they are restricting function. However, for some children and babies, these ties can significantly impact feeding, oral motor, and speech development. In these cases, a tongue tie revision (as well as other TOT revisions) may be necessary. This releases the connective tissue and frees up the tongue’s range of motion. Most dentists or doctors who perform tongue tie revisions recommend a series of daily exercises following the procedure for several weeks to ensure optimal healing and avoid reattachment. But don’t stop there!
While a TOT revision fixes the physical structures in the mouth, it’s important to address the function of the structures that have changed. Remember, your child probably had a tongue tie revision due to challenges with SOMETHING (feeding, speech, etc.). While removing the structural limitations will allow for your child to improve those functional skills, we still have to teach the mouth what those skills are!
Changing the structure usually isn’t enough – it’s a great start, but working with an occupational or speech therapist trained in oral motor interventions helps to teach the mouth new motor patterns and strengthen new areas of the mouth that haven’t been activated before. Just because we give the tongue more range of motion doesn’t mean it will magically understand how to use it! In fact, it is more likely that a child will continue to use his or her tongue exactly the same way as before, since that’s all they know how to do.
So, what oral motor skills need to be addressed post-TOT revision? And why? Here’s a list of some of the common oral motor skills we work on with children following a revision to help them get the most out of the procedure and improve function:
Tongue protrusion
This is the ability to stick out your tongue! A child with an anterior tongue tie may not be able to protrude their tongue beyond their lower teeth, while a child with a more posterior tongue tie may be able to do this without difficulty (which is why these are often missed – but remember, ALL tongue movements are important and should be assessed). Tongue protrusion involves elongation of the transverse muscle of the tongue, which is an important precursor to other more complex tongue movements that we use for eating and speaking. Tongue protrusion is also very important and necessary for clearing unsafe foods from our mouths to reduce choking risk. Children who don’t have this skill may appear to be “picky” eaters, because they’re afraid to put food into their mouths that they might not be able to clear safely.
Tongue retraction
This is the opposite of tongue protrusion, or the ability to pull your tongue back into your mouth. Children with tongue ties may not have much control over their tongues due to limited range of motion, which means that their tongue often rests in one place, which is often slightly forward at the bottom of their mouth. This can contribute to an open-mouth resting posture (see below), and limit the ability to retract the tongue toward the back of the mouth. We use this skill for drawing food and liquid into our mouths, as well as for preventing saliva from becoming drool!
Tongue elevation
This is the ability to touch the roof of your mouth with your tongue. Functional tongue range of motion allows you to reach your palate with your tongue while your mouth is open. This oral motor skill is essential for the tongue-tip reflex for swallowing. Children who are unable to elevate their tongue to the alveolar ridge of their mouth (where the hard palate and soft palate meet) may have difficulty with swallowing, which can lead to excessive drooling, choking or spillage of foods/drinks while eating, and development of a “reverse swallow” pattern, which can have implications for teeth growth and bite alignment (just ask your dentist!). Additionally, children who are unable to elevate their tongues are likely to develop an open-mouth resting posture (see more below).
Tongue lateralization
Once the tongue is able to elongate, it can learn to lateralize. Lateralization is the ability to point the tip of the tongue to the side and back teeth. This skill is extremely important for feeding! We should be born with reflexive tongue lateralization, meaning that our tongue automatically follows a tactile stimulus in our mouth. For example, if you feel a piece of food on your teeth, your tongue should automatically go to it (just watch what it does in relation to your toothbrush the next time you brush your teeth!). Our tongues need to be able to lateralize in order to bring food from the front or midline of our mouths to our back teeth, which help break down more complex foods. Not only does tongue lateralization help us to move food to our molars for chewing, but it helps us to keep it there while our teeth work hard to break down food, so that it doesn’t scatter all over our mouths and create a choking hazard. This skill is essential for the development of a mature rotary chewing pattern. Oftentimes, children who have difficulty with tongue lateralization may use an immature chewing pattern, such as an up-and-down munching motion with the jaw, tongue mashing against the roof of the mouth, or even holding onto foods and sucking on them at the midline of the mouth for an extended period of time. These immature chewing patterns can only handle food textures that melt or break down easily in the mouth, which can limit a child’s ability to eat a variety of foods and textures safely and efficiently. Children who have difficulty with tongue lateralization may compensate for this skill by pushing food onto their back teeth with their fingers, or overstuffing their mouth with food so that they don’t have to manipulate the tongue as much within an open space. Tongue lateralization also helps us to clear food that gets stuck in our mouths discreetly!
Lip closure
Children with TOTs, especially lip ties, may have difficulty closing their lips together appropriately. Their lips may not automatically close together when they are at rest (leading to mouth breathing or drooling), or they may have difficulty with lip strength to contract around eating utensils (spoons, forks, cups, straws, etc.). Some common red flags for difficulty with lip closure include flipping the spoon while eating instead of closing the lips around the spoon, holding the straw between the teeth or at the side of the mouth instead of at midline in between the lips, drooling, mouth breathing, and spillage of food and drinks. Children with poor lip closure may also have difficulty rounding the lips without a tactile cue, and may assume a “flat” lip closure for things like bubble blowing, or even production of different sounds for speech.
Cheek contraction
Children with TOTs may develop tightness in their cheeks (especially when buccal ties are present), or may rely on inefficient patterns for eating to compensate for a tongue tie, which can inhibit activation of the buccinator muscle (the major muscle we contract in our cheeks). Cheek contraction is an important skill that pairs with tongue lateralization to keep food in one bolus on our teeth while breaking it down with our molars so that it doesn’t scatter all over our mouths. Oftentimes, children who don’t develop proper cheek contraction for feeding may not lose the fatty sucking pads in their cheeks (which are needed for nursing), as they continue to rely on inefficient motor patterns for feeding when they transition to solid foods.
Strengthening
It is common for children with TOTs to have generally low oral tone, meaning limited strength in the muscles of their mouths. Remember that our tongue is a muscle, and that we build up strength in muscles by using those muscles! So, if a tongue is tied and has restricted movement, it’s not getting much of a workout. It’s important to help build tone and strengthen the tongue and other muscles of the mouth following a tongue tie revision to reduce fatigue and make eating, drinking speaking, and even breathing with your mouth closed more efficient!
Resting posture
At rest, your lips should be closed, your tongue tip should be lightly touching your incisive papilla (just behind, but not touching, your two front teeth) and the middle of your tongue should be resting up against your alveolar ridge (where the hard palate and soft palate meet). Your teeth should be lightly touching or almost touching. This is what we refer to as optimal resting posture. This posture allows for optimal opening of the airway, as well as normal palate development. Children with TOTs often do not assume an optimal resting posture (rather, they assume an open-mouth resting posture or may compensate by tightly closing their mouth), and this is something that needs to be facilitated post-revision. Concerns related to an open-mouth resting posture include mouth breathing (breathing through the nose allows for filtration of air through the nasal structures and protects the lymphoid tissue in your throat, while breathing through the mouth brings germs right to our tonsils and adenoids – the last line of defense before our lungs!), snoring and sleep apnea, enlarged adenoids and tonsils, development of a narrow or high palate (which can impact facial growth and development), jaw clenching, and jaw pain.