Posterior tongue tie,
why it is missed
Posterior tongue tie is a common reason families come to the National Tongue Tie Centre after being told their child has no tongue tie. It requires a slightly different assessment technique to identify.
What is a posterior tongue tie?
Tongue tie is commonly classified into four types based on where the frenulum attaches to the underside of the tongue. Anterior ties (Coryllos Types 1 and 2) attach close to the tip of the tongue and are usually visible on routine inspection. Posterior ties (Types 3 and 4) attach further back toward the base of the tongue, beneath a layer of mucous membrane, making them invisible to visual inspection alone.
A posterior tongue tie is also called a submucosal tongue tie because it sits beneath the mucosa and can only be reliably identified by palpation: running a finger along the floor of the mouth to feel the tight band beneath the surface. This technique requires specific training, and not all practitioners performing tongue tie assessments have it.
A common misconception is that posterior tongue tie means a tie at the back of the tongue. It does not. All tongue tie frenula run along the underside of the tongue, not the back. A posterior tongue tie refers to the posterior component of that frenulum, the part further from the tip. Sometimes the posterior component is the only restriction present. Sometimes there is an anterior component as well, with the posterior tissue continuing on behind it. A Coryllos Type 1 tie has tissue equivalent to Types 2, 3 and 4 continuing behind it, a Type 2 has Types 3 and 4 behind it, and a Type 3 has Type 4 behind it. A Type 4 is the posterior-most presentation on its own. The classification describes how far forward the clinically significant restriction extends, not a series of separate, unrelated ties.
It is important to understand that where a frenulum attaches is only one part of the clinical picture. The height of the frenular insertion on the underside of the tongue and the elasticity of the tissue itself are equally important in determining how much a tie restricts tongue movement. A Coryllos Type 3 or 4 tongue frenulum is present in up to half the population, and not everyone with one is tongue-tied. Two people can have frenula that look almost identical and yet function completely differently, one with significant restriction, the other with none. This is why appearance alone is not enough, and why assessment by an experienced clinician who evaluates height, elasticity, and function together, not just the attachment point, is essential to accurate diagnosis.
Attaches at the tongue tip. Visible and identified easily on inspection. Least likely to be missed.
Attaches just behind the tip. Usually visible on inspection. Commonly identified at newborn checks.
Attaches mid-tongue, beneath the mucosa or with only a small membrane visible. Requires palpation to identify. Not visible on inspection alone.
Attaches at the base of the tongue beneath the mucosa. The most posterior presentation. Palpation is essential for diagnosis.
The Coryllos classification describes attachment location. It does not capture the height of insertion on the tongue body or the elasticity of the frenular tissue, both of which significantly influence functional impact. These factors can only be assessed by an experienced clinician on palpation and functional examination. A Type 3 or 4 tie with very limited elasticity may be considerably more restricting than its classification alone suggests.
Why posterior tongue tie is so often overlooked
Routine newborn checks in Ireland and internationally are primarily visual. A midwife, GP, or public health nurse looking in a baby's mouth will identify an obvious anterior tie but may not identify a posterior tie without palpating the floor of the mouth. In the maternity hospital in particular, making this judgement in the first days of life is often not possible. It is only by observing how a baby feeds over time, and how feeding support measures such as latch, positioning, or an appropriate flow-rate teat, usually slower rather than faster, affect that feeding, that restriction can be reliably distinguished from a normal variant. This is not a failure of care. It reflects the training available for routine newborn assessment, which has historically not included palpation-based posterior tie assessment as standard.
The result is a significant group of infants, children, and adults whose tongue tie was missed, sometimes multiple times, because the diagnostic technique required was not applied. Many families seen at the National Tongue Tie Centre have previously been told their child has no tongue tie. In a meaningful proportion of these cases, a posterior tie is found on specialist assessment.
If your child has been assessed and cleared but continues to have feeding, speech, breathing, or sleep symptoms, a specialist assessment using palpation is warranted.
How posterior tongue tie presents by age
The functional consequences of a tongue tie are determined by how much it restricts tongue movement, not where the frenulum attaches. The presentation varies by age and by the specific demands placed on tongue function at each stage of development. The associations below are strongest for the infant feeding group, where the evidence is most robust, and are based on observed clinical patterns in older children and adults where the evidence base is more limited.
- Painful or ineffective latch despite positioning support
- Clicking or gulping during feeding
- Reflux, colic, and excessive wind
- Slow weight gain or feeding fatigue
- Feeding aversion developing over time
- Previously assessed and cleared for tongue tie
The association between ankyloglossia and breastfeeding difficulty is the most robustly evidenced area of tongue tie practice, supported by multiple randomised controlled trials.
- Articulation difficulties despite speech therapy
- Fussy eating and texture aversion
- Mouth breathing and open-mouth posture
- Snoring and disrupted sleep
- Dental crowding or high palatal vault
- History of tongue tie assessed and not found
Evidence for tongue tie contributing to these presentations is developing and not at the level of the infant feeding literature. A functional assessment determines whether restriction is present and likely to be contributing.
- Jaw pain and TMJ dysfunction
- Chronic headaches and neck tension
- Snoring or obstructive sleep apnoea
- Difficulty swallowing
- Symptoms that have never been fully explained
- Previous tongue tie assessment returned negative
Tongue tie as a contributing factor in adult jaw, sleep, and postural symptoms is the least-evidenced area of practice. Where these presentations are assessed, detailed functional evaluation is particularly important before any treatment recommendation is made.
Specialist assessment at the National Tongue Tie Centre
Every assessment at the National Tongue Tie Centre includes palpation of the floor of the mouth as standard. We do not rely on visual inspection alone. Our assessment incorporates validated clinical tools including the Hazelbaker Assessment Tool for Lingual Frenulum Function and the Martinelli protocol where indicated, alongside clinical observation, functional evaluation, and palpation.
We take a full history of feeding, speech, breathing, sleep, and jaw function before examining. The pattern of symptoms is clinically informative, and a thorough history shapes the examination that follows.
We observe the tongue in function: feeding for infants, speech and oral motor tasks for children and adults. This includes trialling feeding support, such as latch and positioning changes or an appropriate flow-rate teat, as part of determining whether a restriction is actually causing the difficulty rather than assuming it from structure alone. Function tells us as much as structure in many cases, and in some presentations more.
Visual inspection of the tongue and frenulum is followed by palpation of the floor of the mouth. Palpation allows us to assess the height of the frenular insertion, the elasticity of the tissue, and the degree of restriction under functional loading. This is the step that identifies posterior ties that visual inspection misses, and it is the step that requires the most experience to interpret accurately.
Every patient receives a written report of findings and a clear clinical recommendation, including an honest opinion on whether treatment is indicated. We will tell you clearly what we find, and clearly when we do not find a significant restriction.
Posterior tongue tie: common questions
My baby was checked by a midwife and GP who both said there is no tongue tie. Could a posterior tie still be present?
Yes. If the assessment was visual only, a posterior tongue tie would not reliably be detected. This is the most common clinical scenario we see. It is not a criticism of the practitioners involved; routine newborn assessment is not designed to include palpation-based posterior tie evaluation. A specialist assessment using palpation is the appropriate next step if feeding difficulties persist despite a clear routine assessment.
Is posterior tongue tie as significant as anterior tongue tie?
It can be. The functional impact of a tongue tie is not determined by where the frenulum attaches alone. The height of the insertion on the underside of the tongue and the elasticity of the frenular tissue are equally important factors. A posterior tie with very limited tissue elasticity may restrict tongue movement more significantly than an anteriorly attached tie with compliant, flexible tissue. The type classification tells you about location; palpation and functional assessment tell you about clinical significance. This is why a classification alone does not determine treatment and why assessment by an experienced clinician is necessary.
Does posterior tongue tie require a different surgical approach?
No. The surgical approach is not determined by whether a tie is anterior or posterior. At the National Tongue Tie Centre we offer two treatment options: frenectomy, performed for infants up to 12 weeks, and frenuloplasty, performed from 12 weeks onward for infants, children and adults where clinically indicated. Which procedure is used depends on age, not on how far back the frenulum attaches.
Can posterior tongue tie be hereditary?
Yes, based on clinical observation. All forms of tongue tie appear to have a hereditary component. We have treated three generations of the same family for tongue tie on a number of occasions, including within Dr. Roche's own family. If a parent has a posterior tongue tie, whether diagnosed or undiagnosed, their children have a higher likelihood of having it. This is one reason we ask about family history at every assessment appointment.
My child has had speech therapy for two years with limited progress. Could posterior tongue tie be involved?
Possibly, particularly where the difficulty is with sounds such as R and L, which require the tongue to elevate at the mid-tongue or reach the tip forward with precision. There is evidence from prospective cohort and observational studies that some children with confirmed functional tongue restriction and articulation difficulties show improvement following frenuloplasty, particularly those with moderate to severe presentation. Good, active engagement with speech therapy without the expected progress is itself worth investigating structurally. The challenge is that not all articulation difficulties are caused or maintained by structural restriction, and speech therapy alone may produce the same improvement over time in some children. The appropriate next step is a specialist functional assessment, including palpation, to determine whether restriction is present and whether it is plausibly contributing to the specific articulation errors your child has. We would expect a speech and language therapist assessment to be part of this process.
My child was told they had their tongue tie divided as a newborn, but problems have continued. Could a posterior tie have been missed or have reattached?
Both are possible. Sometimes the initial release only divides the anterior web of tissue and leaves the posterior component, the deeper, V-shaped band sometimes described as the bow of the tongue, untouched. If that remaining tissue is still short and inelastic, you may see some improvement in feeding at first, with difficulties reappearing or persisting later. The other possibility is reattachment: the diamond-shaped wound created by releasing the posterior component heals back onto itself, reforming the restriction. Posterior ties have a significantly higher reattachment rate than anterior ties: revision rates of approximately 21% have been reported in the literature compared to around 4% for anterior ties. A specialist reassessment is warranted where symptoms have persisted or returned after a previous release.
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Relevant services at NTTC
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Talk to a NTTC clinician. Every assessment at NTTC includes palpation of the floor of the mouth, not visual inspection alone, so posterior ties are not missed.
Frenuloplasty and frenectomy are surgical procedures. Risks, benefits, and individual expectations are discussed in full at assessment before any decision to proceed.