The tongue is not merely an organ of taste. It is a powerful, constantly active muscle which, through its resting position and its movements during swallowing, exerts continuous pressure on the dental arches and the palate. In a growing child, this pressure literally shapes the form of the upper jaw, guides the eruption of the teeth and contributes to the harmonious development of the upper airways. A well-positioned tongue, resting against the palate, stimulates the transverse widening of the jaw and conditions a balanced occlusion in adulthood.
The received idea that “it will sort itself out” is a persistent one. Yet when the tongue adopts a low posture, when it pushes against the teeth during swallowing, or when its mobility is hampered by a frenulum that is too short, the consequences do not resolve spontaneously. On the contrary, they tend to become fixed with growth and to grow more complex. Identifying a tongue dysfunction early, understanding its causes and organising multidisciplinary management often makes the difference between a few months of early interceptive re-education and several years of later corrective treatment.
1. The tongue: a muscle that shapes the palate
The morphogenetic role of the tongue
The tongue is made up of seventeen muscles that interact constantly with the surrounding bony and dental structures. At rest, its physiological position lies against the hard palate, with the tip behind the upper incisors and the back of the tongue pressed against the palatal vault. This posture, known as the “high palatal” position, exerts a gentle but constant pressure that guides the transverse expansion of the upper jaw during the growth phases.
When this lingual pressure is lacking, either because the tongue adopts a low position or because its mobility is restricted, the palate no longer receives the mechanical stimulation it needs in order to widen. The upper jaw then develops in a narrow and deep manner, taking on a “high-arched” form reminiscent of a pointed Gothic vault.
The balance of muscular forces
The dental arch sits at the intersection of three muscular forces: the tongue on the inside, and the lips and cheeks on the outside. A dynamic balance between these forces conditions the alignment of the teeth and the morphology of the bony bases. Any disruption of this balance, whether it comes from a tongue that is too low, from prolonged sucking that interposes a finger or a dummy, or from an interposed lower lip, gradually translates into a deformation of the arches.
2. Normal swallowing versus atypical swallowing
Primary swallowing and secondary swallowing
The infant displays what is known as “primary” or “infantile” swallowing: the tongue thrusts forward between the gums to enable feeding. This pattern is physiological from birth until the appearance of the first primary molars, at around 12 to 18 months. With the establishment of the milk dentition and the move to solid food, the tongue must gradually adopt a new pattern: “secondary” or “adult” swallowing, characterised by a tongue tip that rests on the retro-incisive papilla, arches in contact and an absence of contraction of the perioral muscles.
When do we speak of atypical swallowing?
The transition to adult swallowing should be in place by around 5 to 6 years of age. Beyond this, the persistence of the infantile pattern, in which the tongue continues to interpose itself between the arches at each swallow, is considered atypical. Given that a child swallows between 1500 and 2000 times a day, the cumulative impact of a tongue that pushes against or between the teeth becomes considerable for the growth of the bony bases and the position of the teeth.
Atypical swallowing forms part of the wider category of orofacial myofunctional disorders (OMD), which bring together all the functional disturbances affecting the orofacial sphere: resting tongue posture, swallowing, breathing, chewing and speech.
3. Common causes of tongue malposition
Ankyloglossia, or short lingual frenulum
Ankyloglossia corresponds to an abnormally short or thick mucosal band linking the underside of the tongue to the floor of the mouth, restricting tongue mobility. Its anatomical prevalence is estimated at between 3 and 5% of newborns, with a male predominance. The Kotlow classification, drawn up by the American paediatric dentist Larry Kotlow, distinguishes four types according to the position at which the frenulum attaches:
- Type I: attachment at the tip of the tongue, with a visible anterior frenulum
- Type II: attachment behind the tip, on the first third
- Type III: attachment on the second third, with a thicker frenulum
- Type IV: posterior or submucosal ankyloglossia, barely visible but highly restrictive
Not every case of ankyloglossia is symptomatic. The clinical diagnosis rests less on pure anatomy than on functional assessment: can the child put the tongue out beyond the lips, lift it to the palate with the mouth open, and move it sideways without deviating the lower jaw? When these movements are hampered, the tongue compensates by staying in a low position, which deprives the palate of its morphogenetic stimulation.
Prolonged non-nutritive sucking
Thumb or dummy sucking is physiological and soothing in the infant. It becomes problematic when it continues beyond 3 to 4 years of age, the point at which the American Academy of Paediatric Dentistry recommends stopping non-nutritive sucking habits. The permanent presence of a finger or a dummy in the mouth produces several simultaneous effects:
- A tongue held in a low position, unable to fulfil its role of stimulating the palate
- Lateral pressure from the cheeks on the arches, which narrow in the transverse direction
- A forward movement of the upper incisors, under the effect of the repeated sucking
- The learning of a thrust swallowing pattern, which becomes ingrained over the months
The later sucking continues, the harder the orthodontic consequences become to correct spontaneously after it stops.
Mouth breathing and obstruction of the upper airways
Physiological nasal breathing requires the lips to close, which mechanically places the tongue in contact with the palate. Conversely, when the child breathes through the mouth, the tongue has to drop in order to free the passage of air, thereby losing its morphogenetic position. This mouth breathing is rarely a matter of choice: most often it reflects an obstruction of the upper airways linked to enlarged adenoids or tonsils, chronic rhinitis, a deviated nasal septum or uncontrolled allergies.
The impact goes beyond tongue posture. In children with obstructive sleep apnoea syndrome (OSAS), mouth breathing concerns roughly half of cases, snoring almost all of them, and around a third of children with apnoea present with a deep high-arched palate and a backward-positioned lower jaw. The link between ENT obstruction, mouth breathing, low tongue posture and deformation of the bony bases makes up a vicious circle that needs to be broken early.
Global orofacial myofunctional disorders
Beyond the individual causes, several dysfunctions frequently coexist in the same child: low tongue posture, mouth breathing, atypical swallowing, one-sided chewing and perioral hypotonia. This picture of OMD justifies a global assessment rather than an approach by isolated symptom, because correcting one element without treating the others exposes the child to relapses.
4. Dental and skeletal consequences
High-arched palate and maxillary endognathia
The most typical consequence of a tongue that does not stimulate the palate is maxillary endognathia, that is, an upper jaw that is too narrow in the transverse direction. The palate becomes deeper in height and narrower in width, giving this characteristic “high-arched” form. Clinically, one observes crowding of the upper teeth, which lack the space to align, and frequently a one-sided or two-sided posterior crossbite, in which the upper molars sit on the inside of the lower molars.
Anterior open bite
When the tongue interposes itself between the arches during swallowing or at rest, or when prolonged sucking maintains a gap between the incisors, an anterior open bite sets in: the upper and lower incisors no longer meet at occlusion, leaving an open, crescent-shaped space. This open bite complicates the cutting of food, disrupts speech and almost always signals an underlying tongue dysfunction.
Class II through mandibular shift
A narrow upper jaw with a crossbite can lead the child to move the lower jaw forward or sideways in order to find a comfortable occlusion, creating a false Class II or a mandibular asymmetry. In the long term, this positional shift can bring about an asymmetry of condylar growth and a more marked facial deviation.
Crowding and dental malpositions
The lack of expansion of the upper and lower jaws translates, when the permanent teeth arrive, into crowding that will often call for heavier orthodontic treatment, sometimes with extractions. Early detection of tongue dysfunctions makes it possible, in many cases, to create the necessary space by stimulating growth rather than by sacrificing healthy teeth.
5. Functional consequences
Speech: lisping and sigmatism
The tongue is the main organ for articulating consonants. A low tongue posture or a reduced mobility caused by a short frenulum alters the production of several speech sounds, in particular the sibilants (“s”, “z”) and the hushing sounds (“sh”, “j”). Interdental sigmatism, in which the tongue thrusts forward between the teeth during the production of the “s”, is typical of children with atypical swallowing. A lisp that persists after the age of 5 warrants a speech and language assessment.
Breathing and sleep
Chronic mouth breathing leads to poorer oxygenation, a dryness of the mucous membranes that encourages repeated ENT infections, and poorer-quality sleep. Paediatric OSAS, long underdiagnosed, is associated with attention disorders, learning difficulties, daytime tiredness and sometimes bed-wetting. Habitual snoring in a child is never trivial and should prompt a joint ENT and orthodontic assessment.
Chewing
A poorly positioned tongue often goes hand in hand with inefficient chewing, sometimes one-sided, which overloads one side of the temporomandibular joint and unbalances the growth of the two halves of the arches. The child may avoid hard foods and prefer a soft diet, which in turn impoverishes the chewing stimulation that the jaws need in order to develop.
Cervical and overall posture
The muscular chains linking the tongue, the lower jaw, the hyoid complex and the cervical spine are interconnected. A low tongue posture and mouth breathing frequently go together with a forward position of the head, rounded shoulders and an altered overall posture. This dimension justifies, in certain cases, an approach combining physiotherapy or osteopathy with the dental and ENT assessment.
6. Warning signs for parents
Certain signs should attract attention and prompt a consultation, ideally before the age of 6 or 7, the period when interceptive treatments are most effective:
- Thumb or dummy sucking that continues beyond 3 to 4 years of age
- An open mouth at rest, with the lips rarely together
- Night-time snoring, noisy breathing, restless sleep, night sweats
- Persistent bed-wetting, daytime drowsiness or irritability
- Speech difficulties after the age of 5, lisping, sigmatism
- Slow chewing, refusal of hard foods, chewing on one side only
- A visible open bite between the incisors, with teeth that do not touch at the front
- A narrow and deep palate, noticed while brushing
- Difficulty putting the tongue out beyond the lips or lifting it to the palate with the mouth open (suggesting a short frenulum)
- A difficult start to breastfeeding, pain for the mother, poor weight gain in the infant (an early signal of ankyloglossia)
- Repeated ENT infections, chronic rhinitis, a nasal-sounding voice
None of these signs taken in isolation amounts to a diagnosis, but their combination or their persistence justifies a professional opinion.
7. Multidisciplinary assessment
Why several specialists?
Tongue dysfunctions lie at the crossroads of several disciplines: dentistry, orthodontics, ear, nose and throat (ENT) medicine, and speech and language therapy or orofacial myotherapy. An isolated assessment often misses the underlying cause. A child with a low tongue may be referred for speech and language therapy for sigmatism, but without an ENT diagnosis of a nasal obstruction the tongue re-education will fail. Conversely, removing an ENT obstacle without re-educating the function leaves the child with an ingrained oral habit.
Roles and responsibilities
- The paediatric dentist carries out the initial examination, screens for dental anomalies and directs the global assessment
- The orthodontist evaluates the bony bases, growth and occlusion and plans any interceptive management
- The ENT doctor looks for an obstruction of the upper airways and assesses the adenoids, the tonsils, nasal patency and tubal function
- The speech and language therapist or orofacial myofunctional therapist assesses tongue posture, swallowing, chewing and speech, and re-educates the functions
- Depending on the case, a physiotherapist, an osteopath and a paediatrician complete the approach
8. Therapeutic management
Orofacial myofunctional re-education
Re-education is the cornerstone of management. It takes place in weekly sessions over several months, with daily exercises at home. It aims to restore a high tongue posture at rest, to make adult swallowing without tongue thrust automatic, to strengthen the tone of the perioral muscles and to correct the breathing. The child’s active participation and the parents’ commitment largely condition the result. Depending on the school of thought, this is referred to as tongue re-education, myofunctional therapy or orofacial myofunctional re-education.
Frenectomy in cases of symptomatic ankyloglossia
Surgical division of the lingual frenulum, called frenotomy in the very young infant or frenectomy with frenuloplasty in the older child, is indicated when the ankyloglossia is genuinely functionally restrictive and symptomatic. The indications must be set with discernment: not every visible band is pathological, and the decision rests on a precise functional assessment. Surgery on its own is not enough: it forms part of a protocol with pre and post-operative re-education to allow the tongue to learn to use its new range of movement.
Interceptive orthodontics
When the bony bases are already deformed, interceptive orthodontics makes it possible to act before the end of growth, ideally between the ages of 6 and 10 depending on the case. Several devices may be used:
- The expander, or palatal expansion appliance, widens the palate transversely by making use of the mid-palatal suture while it is still active. The expansion is carried out gradually, at a rate of a quarter to a half a millimetre a day, and corrects posterior crossbites within a few months
- Educational trainers and functional appliances guide tongue posture, close the open bite and correct swallowing through their mechanical effect
- Removable appliances or the first aligner trays complete the range according to age and objective
The major value of interceptive orthodontics lies in its timing: it makes use of the plasticity of growth to direct development, rather than later correcting bony bases that have become set.
ENT management
When an obstruction is documented, ENT treatment may involve an adenotonsillectomy, medical treatment of a chronic or allergic rhinitis or, more rarely, nasal surgery. Freeing the airways is often an essential prerequisite for the success of tongue re-education.
Coordination and follow-up
A coordinated timetable between the practitioners, with regular review points, conditions success. The child’s motivation and the parents’ day-to-day involvement remain the major levers.
9. When to seek a consultation
Several milestones should prompt a request for an opinion:
- From birth and during the first months in the event of persistent breastfeeding difficulties, to assess a possible restrictive lingual frenulum
- At around 3 to 4 years of age for a first paediatric dental examination, the point at which non-nutritive sucking should be tailing off
- At around 5 to 6 years of age for a screening orthodontic assessment, recommended even in the absence of any warning sign, because this is the age at which tongue dysfunctions and skeletal imbalances become identifiable before growth sets the structures
- At any age in the face of persistent snoring, an open mouth at rest, sigmatism, sucking that continues or a visible open bite
Interceptive orthodontics is all the more effective the earlier the management. Waiting for the permanent dentition exposes the child to longer, more demanding and sometimes mutilating treatments.
10. At Chantepoulet Dental Clinic
Chantepoulet Dental Clinic brings together in a single location all the skills needed to detect and manage tongue malpositions in children.
A multidisciplinary team
The clinic team brings together dentists trained in paediatric dentistry, welcoming children from the appearance of the first teeth, at around 6 months to 1 year. The practitioners have undertaken specific training in the care of the very young and arrange consultations in a suitable atmosphere: equipment designed for children, playful decoration and cartoons in the treatment rooms, to turn the dental appointment into a reassuring experience.
For orthodontic management, Dr Gaia Toson, the orthodontist on the team, assesses the bony bases, growth and occlusion and proposes the appropriate treatments, ranging from interceptive orthodontics and Invisalign solutions to more conventional devices according to age and indication.
Working as a network
Tongue dysfunctions require a multidisciplinary approach. The clinic works in liaison with ENT colleagues and with speech and language therapists or orofacial myofunctional therapists in Geneva, in order to offer families a coordinated pathway: screening at the clinic, an ENT examination if an obstruction is suspected, re-education with a qualified speech and language therapist, orthodontic follow-up in line with the growth timetable, and a frenectomy carried out when the indication is established.
Practical information
- Address: Rue de Chantepoulet 21, 1201 Geneva, 3rd floor, 300 metres from Cornavin station
- Telephone: +41 22 547 44 44
- Email: info@gedentiste.ch
- Opening hours: Monday to Friday 8am to 7pm, Saturday 8am to 5pm, closed on Sunday
- Booking an appointment: by telephone, online on the website or via the OneDoc platform
If you notice in your child persistent snoring, an open mouth at rest, sucking that continues, a lisp or any other sign mentioned in this article, do not wait for it to “sort itself out”. An early consultation makes it possible, in the great majority of cases, to put in place simple and effective management that will avoid more complex treatments in adolescence.
