I have been brewing a fair few blog posts in my mind on this subject over the last year or so. Quite cathartic to have a forum to vent (sorry all those of you who have been in with your beautiful babies and heard me on a rant about any one of these parts of the politics and pathology of tongue tie treatment in Ireland!)
Tongue tie classification
Currently the classification system for tongue tie that we hear can go from the mild-moderate-severe as a grading system, but oddly with this one, we only ever hear “mild” on referrals – which is most interesting; if I was to ever collect this data as I can be sure that if “mild” is mentioned, the baby will always have a complete tongue tie..
The current accepted classification system that we all use classifies the ties into anterior (or close to the front of the mouth) and posterior (closer to the back).
Currently the descriptive terms are generally accepted as follows:
- Anterior type 1 – accepted as 100% tie to the tip
- Anterior Type 2 – slightly behind the tip
- Anterior type 3- further back – some include this as a posterior tie
- Posterior type 4- under the mucosa/ the invisible, palpable tie
But why do some in one type do well, while others do not?
Well, what the current classification does not address are:
- The attachment to the tip of the tongue,
- The attachment to the floor of the mouth
- The position of the muscle (genioglossus) underneath the tie.
I think the latter has more of an impact than we realise on the outcome of a frenotomy, and what I have found is that one seems to dictate the other.
These three components are all hugely variable between babies, but there is still a pattern if you look (and feel!).
These anatomical features are also critical to outcome prediction.
The more tongue ties I see, the more I think that the anatomy is what dictates function, and therefore the function post release, as well as the concept of “reattachment” (dreadful term; next blog!)
So why don’t we use anatomy instead? Well, why not!? Just because an old system exists is no reason to plod on with the same old system. Time moves on, and education and experience improves both our understanding and patient care.
So how should we classify them?
Tongue ties need to be classified and descriptively rather than anterior and posterior types (which doesn’t make sense given what these terms mean). I have broken it down into 3 concepts.
Anterior should be thought of as “Classic”
Posterior should be thought of as “Submucosal”
2. Think bidimensionally!
Don’t think of ties in one dimension. When looking at a tie what matters most is whether the tie is vertical or oblique – I think this is what dictates the outcome.
Oblique attachments inevitably have the genioglossus muscle right behind the tie, not leaving a whole lot of room for division as I am limited by the presence of the muscle (no, we don’t divide the muscle!). (Think the “Eiffel tower” type)
3. Tension= poor function!
On division (And sometimes before, with manual examination or using a retractor), the fibrous composition of a tie can be commented upon. Some are tighter than others, and this isn’t new science.. but the tight ones seem to get an immediate result when it comes to maternal discomfort.
Having a more accurate terminology is far more useful in identifying the babies that will need extra support, providing better information to assess outcome, help to manage expectations, and most importantly help us to further understand and improve our service to these babies and their mums.
Confused or clarified?