Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation With Ankyloglossia

Laryngoscope. 2021 May;131(5):E1701-E1706. doi: 10.1002/lary.29140. Epub 2020 Oct 2.


Objectives: There is debate among otolaryngologists and other practitioners about whether upper lip tie contributes to difficulty with breastfeeding and whether upper lip tie and ankyloglossia are linked. Our objectives were to evaluate the anatomy of the upper lip (maxillary) frenulum, to determine if the visual anatomy of the upper lip has an effect on breastfeeding, and to determine whether the occurrence of lip tie and tongue tie are correlated.

Methods: A prospective cohort study of 100 healthy newborns was examined between day of life 3-7. Surveys were completed by the mother at the time of the initial exam and 2 weeks later. The maxillary frenulum was graded based on the Stanford and Kotlow classifications by two independent reviewers. Inter-rater reliability and relationships between tongue tie, lip tie, and the infant breastfeeding assessment tool (IBFAT) were calculated.

Results: Inter-rater reliability showed fair agreement (κ = 0.302) using the Kotlow scale and better agreement using the Stanford classification (κ = 0.458). There was no correlation between the upper lip tie classification and breastfeeding success score. Lastly, there was a modest inverse correlation in the degree of tethering for the tongue and lip.

Conclusions: There was no correlation between maxillary frenulum grade and comfort with breastfeeding, pain scores, or latch. There was also no relationship between tip to frenulum length (tongue tie) and visualized lip anatomy, suggesting that tongue tie and lip tie may not cluster together in infants.

Level of evidence: 2 Laryngoscope, 131:E1701-E1706, 2021.

Keywords: Maxillary frenulum; ankyloglossia; frenotomy; tongue-tie; upper lip-tie.

Publication types

  • Observational Study

MeSH terms

  • Ankyloglossia / complications
  • Ankyloglossia / diagnosis
  • Ankyloglossia / epidemiology*
  • Breast Feeding*
  • Female
  • Humans
  • Infant, Newborn
  • Labial Frenum / abnormalities*
  • Male
  • Observer Variation
  • Pain / diagnosis*
  • Pain / etiology
  • Pain Measurement
  • Prospective Studies
  • Reproducibility of Results