Tongue Tie & Lip Release | Samintharaj Kumar

Tongue Tie and Lip Tie Classification

Tongue ties and lip ties can vary considerably in their appearance and anatomy. Some are immediately obvious, while others can be difficult to identify during a simple visual examination.

One of the classification systems used to describe both tongue ties and upper lip ties is the Kotlow classification.

I have been assessing and treating tongue ties and lip ties since 2009. While I find anatomical classifications useful for describing what we see clinically, I do not use the classification alone to determine whether treatment is necessary.

The fundamental question is always whether the frenulum is producing a meaningful functional restriction.

Kotlow Classification of Tongue Tie

The Kotlow classification of tongue tie, or ankyloglossia, is based on the amount of "free tongue" between the attachment of the lingual frenulum and the tip of the tongue.

Class I – Mild Tongue Tie

12–16 mm of free tongue

There is a relatively mild anatomical restriction. Some patients may have normal function despite the appearance of a tongue tie, while others may demonstrate functional difficulties.

Class II – Moderate Tongue Tie

8–11 mm of free tongue

The frenulum extends further towards the anterior part of the tongue and may produce greater restriction of elevation and movement.

Class III – Severe Tongue Tie

3–7 mm of free tongue

There is a more anterior attachment with significant anatomical restriction. Elevation and protrusion of the tongue may be visibly limited.

Class IV – Complete Tongue Tie

Less than 3 mm of free tongue

The frenulum attaches very close to the tip of the tongue. These tongue ties are usually visually obvious and may produce the characteristic heart-shaped appearance when the patient attempts to elevate or protrude the tongue.

Importantly, the Kotlow grade describes anatomy rather than functional impairment.

For this reason, my assessment also looks at tongue elevation, extension, lateral movement, cupping, suction and, in babies, feeding function.

Kotlow Classification of Upper Lip Tie

The Kotlow classification of the maxillary labial frenulum, commonly referred to as an upper lip tie, uses a separate Class I–IV system.

Unlike the tongue-tie classification, which considers the amount of free tongue, the Kotlow lip-tie classification describes where the upper lip frenulum attaches to the gum and palate.

Kotlow Class I Lip Tie – Minimal Attachment

The frenulum has a relatively high attachment within the mucolabial fold, where the inside of the upper lip meets the gum.

This represents a relatively minor anatomical attachment.

Kotlow Class II Lip Tie – Gingival Attachment

The frenulum inserts into the attached gingiva of the upper jaw.

The attachment is more prominent than Class I but does not extend to the papilla between the upper central incisors.

Kotlow Class III Lip Tie – Papillary Attachment

The frenulum extends to the interdental papilla between the upper central incisors.

When the upper lip is elevated, the frenulum may appear broad or prominent and may exert tension on the gingival tissues.

Kotlow Class IV Lip Tie – Papilla/Palaral Attachment

The frenulum extends through the interdental papilla and towards or onto the anterior palate.

This is the most extensive anatomical attachment within the Kotlow classification and is sometimes described as a "Class 4 lip tie".

However, Class IV does not automatically mean that the lip tie requires surgical release.

Does a Kotlow Class III or Class IV Lip Tie Need Treatment?

Not necessarily.

This is particularly important for parents because the words "Class III" or "Class IV lip tie" can sound alarming.

The Kotlow classification primarily tells us where the upper labial frenulum attaches. It does not independently establish that the attachment is causing breastfeeding difficulty or other functional problems.

Upper lip frenula also demonstrate considerable normal anatomical variation in babies and young children.

During a lip-tie assessment, I therefore look beyond the Kotlow grade and consider:

Mobility and flexibility of the upper lip
Ability of the lip to move appropriately during feeding
Feeding symptoms
Maternal symptoms
Oral anatomy
Presence of an associated tongue restriction
Findings from the baby's feeding assessment

Where breastfeeding is the principal concern, assessment by an experienced International Board Certified Lactation Consultant (IBCLC) can be particularly useful.

We do not perform a lip-tie release simply because the frenulum has been labelled Kotlow Class III or Class IV.

Treatment should be based on the overall clinical and functional assessment.

What Is a Posterior Tongue Tie?

A posterior tongue tie can be considerably less obvious than a classic anterior tongue tie.

With an anterior tongue tie, the restrictive frenulum may extend towards the tip of the tongue and can often be seen immediately. In more posterior restrictions, the tissue responsible for restricting movement may be situated further beneath the tongue and may not be obvious during a simple visual examination.

The tongue can therefore appear relatively normal when somebody simply looks inside the baby's mouth.

This is why a tongue-tie assessment should involve more than visual inspection.

I assess the tongue while it is properly elevated, looking at its range of movement and the anatomy of the tissues beneath it. Palpation may also be useful in assessing the degree and location of restriction.

With a suspected posterior restriction, I am particularly interested in function:

Can the tongue elevate adequately?
Can it maintain appropriate contact with the palate?
Is lateral movement present?
Can the baby cup the tongue effectively?
Can the baby create and maintain suction?
Does the baby repeatedly lose suction or click during feeding?
Can the baby maintain an effective latch?
Is milk transfer adequate?

The terminology and diagnosis of posterior tongue tie remain areas of professional debate, and definitions are not completely uniform between clinicians.

For that reason, I do not recommend a tongue-tie release simply because a baby has been given the label "posterior tongue tie".

The diagnosis needs to make sense clinically.

Anterior vs Posterior Tongue Tie

An anterior tongue tie is generally more visually apparent. The frenulum may extend towards the tip of the tongue and visibly restrict protrusion or elevation.

A posterior tongue restriction may be less apparent on visual examination because the restrictive tissue is situated further underneath the tongue.

This creates an important clinical distinction:

How dramatic a tongue tie looks does not necessarily tell us how much functional difficulty it is causing.

A visually prominent frenulum may exist with relatively good function, while a less obvious restriction may warrant further investigation because of significant functional symptoms.

How I Assess Tongue Tie and Lip Tie

Having treated tongue ties and lip ties since 2009, I consider classification useful—but only as one component of the assessment.

I look at three things together:

Anatomy

Where does the frenulum attach?

For the tongue, I may document the anatomical restriction using the Kotlow tongue-tie classification.

For the upper lip, I may describe the attachment using the Kotlow lip-tie Class I–IV classification.

Function

Can the tongue elevate, extend, lateralise and participate normally in oral function?

For an infant, can the baby create and maintain suction and use the tongue effectively during feeding?

For the lip, is there meaningful restriction of mobility?

Symptoms

What difficulties are actually occurring?

For a breastfeeding baby, this may include problems with latch, loss of suction, clicking, prolonged feeding, poor milk transfer or maternal nipple pain and trauma.

My guiding principle remains:

"We do not treat a Kotlow number. We treat a clinically significant functional restriction when the anatomy, examination and symptoms support the diagnosis."

Lip Tie and Tongue Tie Surgery may be done under Local Anaesthetic, IV Sedation or General Anaesthesia.

In the video below, I demonstrate how I perform careful meticulous tongue tie dissection and release in an adult.

** In this instance, I am not using a laser for tongue tie release.