I worked with a baby last week who had a version of tongue-tie that I've
seen before and felt stymied by. The classic condition has the frenulum
attached near the tip of the tongue, and often close to the base of the
lower alveolar ridge as well, with a thin web stretched in between. Upon the
effort to extend the tongue, the tip will notch and/or the edges curl up to
form the classic "heart" shape. The tongue tip cannot extend over the gum or
lips.

The second version I've seen, however, is sort of "subterranean." I will see
a web at the juncture of the tongue and floor, but it does not have a lot of
depth to it, and on the outside it does not reach to the tongue tip. As baby
tries to extend, I see what seems almost like a "cord" that starts as the
outer web, but then goes into the tongue and continues under the surface to
the tip. The tautness of the cord during extension will cause notching or
heart shape, and yet on the outside there is little to see for clipping. Can
you picture a cord being pulled tight to support a tent, and how you would
see the affect of the cord through the tent fabric, though not see the cord
itself because it is on the underside? You only see the cord where it exits
the tent and enters the ground in staking.

The baby I saw was having latch problems. He could reach his tongue out even
to his lips, but his tongue notched and formed a heart shape when he tried
to lift it. Latch just didn't happen easily. It looks like mom and baby will
be able to work through without more intervention, but only time will tell
for sure. I've seen other babies like this as well; there is a degree of
functional impairment that defies the mild look of the outer frenulum. If
the restriction causes too many problems, I'm not sure how it could be
released.

As I looked at this latest baby, trying to picture what could be done, I
realized that a doctor would have a very hard time getting in there to cut,
and would have little to cut in depth-- would it be enough to sever the cord
that runs beneath the surface, or would more need to be done? Is this the
dividing line between frenotomy (clipping, easily done) and frenectomy
(removal, more invasive surgical procedure)?

I would love to glean the thoughts of others who have seen these troublesome
variations.

Lisa Marasco IBCLC

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