The Language Of Tongue-Ties

sarah hornsby tongue-ties Jan 13, 2025

Is it possible that there's a language of tongue-ties? I definitely think there is, and here's why:

Have you ever traveled to a different country where they didn’t speak your language and tried to communicate with people there? It can be incredibly challenging!

I’m a native English speaker, and I have traveled to places like Mexico, Thailand, India, and France, and the language barrier can be tough, to say the least.

Did you know that speaking the language of tongue tie is much the same?

As a professional who is fluent in speaking “the language of tongue-tie,” I can tell you firsthand that communicating with other professionals and providers can feel like speaking a different language. 

To understand what I mean, let’s look at the history and evolution of our tongue-tie grading systems.

Dr Kotlow – Kotlow's Classification of Ankyloglossia

Dr. Lawrence A. Kotlow, a pediatric dentist based in Albany, New York, was instrumental in advancing the understanding and treatment of ankyloglossia, commonly known as tongue-tie.

In 1999, he introduced a classification system to assess and grade the severity of tongue-tie in infants and children, aiming to standardize diagnosis and inform treatment decisions.

Kotlow's Classification of Ankyloglossia:

  • Class I (Mild Ankyloglossia): 12 to 16 mm of free tongue.

  • Class II (Moderate Ankyloglossia): 8 to 11 mm of free tongue.

  • Class III (Severe Ankyloglossia): 3 to 7 mm of free tongue.

  • Class IV (Complete Ankyloglossia): Less than 3 mm of free tongue.

This system measures the length of the "free tongue," defined as the distance from the insertion of the lingual frenum (the membrane connecting the underside of the tongue to the floor of the mouth) to the tip of the tongue.

By quantifying this distance, practitioners can better determine the functional limitations imposed by the tongue-tie and decide on appropriate interventions.

Dr. Kotlow's work has been pivotal in highlighting the impact of tongue-tie on various functions, including breastfeeding, speech, and oral development.

His classification system provides a practical framework for clinicians to evaluate the necessity and timing of surgical procedures, such as frenectomy, to release the tongue-tie.

If you work with a dentist or pediatrician who uses the Kotlow Tongue-Tie grading system from 1999, and you use the modern grading system from 2024, then you will be speaking completely different languages!

The Kotlow grading scale is not “bad,” but we have evolved beyond it when it comes to grading and assessing tongue ties in children and adults.

Let’s look more at where we’ve been and where we are today.

Dr Irene Marchesan’s Lingual Frenulum Protocol

Building on Dr. Kotlow's classification system, Brazilian speech-language pathologist Dr. Irene Queiroz Marchesan developed a more comprehensive evaluation protocol incorporating anatomical and functional aspects of the lingual frenulum.

In 2012, Dr. Marchesan published the "Lingual Frenulum Protocol," which introduced a scoring system to assess the frenulum's characteristics and its impact on oral functions.

This protocol evaluates various elements, including tongue mobility, habitual position, and speech articulation, aiming to provide a holistic understanding of how the frenulum affects oral functions.

Dr. Marchesan's protocol was designed to address the limitations of previous assessments that focused primarily on visual inspection.

Her approach offers a more nuanced diagnosis by including functional evaluations and facilitating targeted interventions. This methodology has been influential in Brazil and internationally, enhancing the precision of ankyloglossia assessments and informing treatment strategies.

When Dr Marchesan published her protocol in 2012, it was incredibly groundbreaking and forward-thinking.

However, if I am speaking with a doctor today who is using this grading system, they may have a difficult time understanding my language related to our modern-day 2024 tongue-tie grading systems.

Dr Audrey Yoon’s Tongue Range of Motion Ratio (TRMR)

Dr. Audrey Yoon, an orthodontist and sleep specialist, expanded upon the foundational work of Dr. Kotlow and Dr. Marchesan by introducing the Tongue Range of Motion Ratio (TRMR) in 2017.

This system assesses tongue mobility by calculating the ratio between the maximal interincisal mouth opening (MIO) and the mouth opening with the tongue tip positioned at the maxillary incisive papilla (MOTTIP).

The TRMR offers a functional perspective on ankyloglossia, emphasizing the tongue's range of motion rather than only focusing on its anatomical characteristics.

In her study involving 1,052 subjects, Dr. Yoon proposed a grading scale for ankyloglossia based on TRMR values:

  • Grade 1: TRMR > 80% (normal function)

  • Grade 2: TRMR between 50% and 80% (mild restriction)

  • Grade 3: TRMR < 50% (moderate restriction)

  • Grade 4: TRMR < 25% (severe restriction)

This functional classification system allows clinicians to objectively evaluate the impact of tongue-tie on oral function, facilitating more precise diagnosis and tailored treatment plans. By focusing on tongue mobility, Dr. Yoon's approach complements the anatomical assessments of her predecessors, providing a comprehensive framework for understanding and managing ankyloglossia.

We still use the TRMR Grading Scale in 2024, even though it was published in 2017. Many doctors who are up-to-date with modern terminology and grading systems will be speaking this language, and it’s the tongue-tie language I also speak.

But there’s more! Let’s look at the most cutting-edge way of assessing tongue tie – again, it’s actually not even about the lingual frenum, it’s about tongue mobility.

Dr Zaghi - Lingual Palatal Suction (LPS) Grading Scale:

In 2021, Dr. Soroush Zaghi and colleagues advanced the assessment of ankyloglossia by introducing the Lingual Palatal Suction (LPS) grading scale, a functional metric designed to evaluate posterior tongue mobility. 

This development is built upon the earlier frameworks mentioned above.

Lingual Palatal Suction (LPS) Grading Scale:

  • Grade 1: Significantly Above Average

  • Grade 2: Above Average

  • Grade 3: Below Average

  • Grade 4: Significantly Below Average

The LPS grading scale assesses the tongue's ability to achieve and maintain suction against the palate, a movement that reflects the functional capacity of the posterior tongue. This method provides a more comprehensive understanding of tongue mobility by incorporating both anterior and posterior assessments.

Dr. Zaghi's research demonstrated a significant correlation between LPS measurements and subjective reports of tongue mobility, indicating that the LPS grading scale is a reliable tool for evaluating posterior tongue function. By addressing the limitations of previous assessments that focused primarily on the anterior tongue, this approach offers a more holistic evaluation of tongue-tie and its impact on oral functions.

So, as you can see, there really is a special “language” when it comes to understanding, discussing, identifying, and measuring a restriction in the lingual frenum.

When it comes to treating patients and teaching MyoMentor students, my goal is to help them find tongue-tie release providers who speak the same language.

I always want to work with dentists who speak the language of tongue-tie grading and assessing from 2024 and I hope you do too!

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