Role of oral habits in dimensional changes /certified fixed orthodontic courses by Indian dental academy

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Role Of Oral Habits In Dimensional
Changes Of
Dental Arches During Growth & Development


Contents
Introduction
Maturation of oral functions
Normal oral habits
Abnormal oral habits and its role in malocclusion
- Thumb sucking
- Tongue thrusting
- Mouth breathing
- Bruxism
- lip, cheek biting and others
Conclusion

Introduction
Oral habits may be a part of normal development; a
symptom with a deep rooted psychological basis or
may be a result of abnormal facial growth. These
habits bring about harmful unbalanced pressures to
bear on the immature, highly malleable dental
arches, the potential changes in the position of the
teeth, and occlusion, which may become decidedly
abnormal if these habits are continued for a long
time.

Definition:
Boucher – a tendency towards an act or
an act that has become a repeated
performance, relatively fixed, consistent,
easy to perform and almost automatic.


PRESSURE HABITS, ETIOLOGICAL FACTORS IN
MALOCCLUSION AJO-DO Volume 1952 Aug (569
– 587 ERNEST T. KLEIN, D.D.S.
1. Living bone is an ever-changing tissue that
constantly is being repaired and replaced from
infancy to old age.
2. Living bone is extremely susceptible to the
guidance and influence of pressure and stimulus.
3. The extent to which living bone can be changed
with pressure or stimulus is controversial. However,
even the most conservative group will agree that
alveolar bone can be changed and the teeth in that
bone regulated with orthodontic treatment (planned,
intentional pressure).

4. Abnormal pressure habits (unintentional
pressures) also change alveolar bone and regulate
teeth in that bone
5. Since changes take place in living bone whether
the stimulating factor is intentional or unintentional,
one cannot deny abnormal pressure habits as an
etiological factor in malocclusion without denying the
accepted principle of planned orthodontic treatment.
6. The face, with its cartilaginous bone, yields easily
to stimulus and pressure, especially during growth
spurts, and presents the most complicated growth
problem in the entire skeleton. Since the greatest
growth changes in the head are being made by the
facial structures, it logically can be assumed,
therefore, that all abnormal pressures should be kept
from this most vulnerable target, the face.

7. It is during the transition from the deciduous to the
permanent arch that much damage takes place, and it
is during this transition stage that the avoidance of all
abnormal pressure habits is of the utmost importance.
9. Normal habits maintain normal structural form;
abnormal habits maintain abnormal structural form
(Johnson).
10. The orthodontist and the patient can suffer no
possible detrimental effects by eliminating abnormal
pressure habits. It is logical to eliminate everything
that aggravates malocclusion, everything that nullifies
the plan of orthodontic treatment, and everything that
is a potential factor in causing treated orthodontic
cases to relapse. www.indiandentalacademy.com

Etiology of oral habits- ruben ,karla :JODFC1996
The survival of the new born depends upon instinctive oral
suckling, which allows nutritional satisfaction.
Once the biological and psychological functions of the child
undergo maturation, heshe can separate from mother without
experiencing significant anxiety, spontaneously doing away
with many oral habits.
The persistence of suckling habits according to freud have
been associated with an arrest of evolution (fixation), of a
psychosexual oral phase, which repercuss in a short while in a
distortion or prevention of oral psychophysiologic processes.
The later may alter the somatognathical structures, depending
on the duration, intensity and frequency.
Some of the etiological factors consider responsible are conflict,
jealousy, school pressure, lack of satisfaction through
nourishment, irritations associated with tooth eruption, occlusal
interferences, breathing obstructions etc.

Classification:

Obsessive
(Deep rooted)

Intentional

Masochistic

Or

Or

Meaningful

Self- inflicting

Eg: nailbiting,
digit suking,
lipbiting

Eg: gingival
stripping


Non-obsessive
(easily learned and
dropped)

Unintentional

Functional
habits

Or

Empty habits
Eg:abnormal
pillowing, chin
propping

Eg :
mouth breathing,
tongue thrusting,
bruxism


Author

Classification

James
(1923)

Kingsley Morris Klein
(1958)
and
(1971)
Bohana
(1969)

Finn
(1987)

a)
useful
habits

a)
a)
functional Pressure
oral habits habits
nonb)
Pressure
muscular habits
habits
b) biting
c)
habits
combined
ones

.a)
1.compulsive
habits
2. nonCompulsive
habits

b)
harmful
habits


a)
empty
habits
b)
meaning
ful habits

b)
1. primary
habits
2. secondary
habits

Thumb sucking


1-2yr

Preschool

312 -4 yr
No
malocclusion

malocclusion

Thumb sucking

Normal thumb

Abnormal thumb sucking

sucking

Psychological


Habitual

Sucking habits
O’Brien 1996

Nutritive sucking
habit

Non-nutritive
sucking habit

Eg: breast feeding,
bottle feeding

Eg: Digit sucking,
pacifier sucking


Theories:
Classical Freudian theory (1905):
The psychoanalytical theory holds that this orginal response
arises from inherent psychosexual drive suggesting that digit
sucking is a pleasurable erotic stimulation of the lips and
mouth. One of the concepts of thumb sucking brought about
by this theory is that humans possess a biological suckling
drive. An infant associates sucking with pleasurable feelings
such as hunger, satiety and being held. These events will be
replaced in later life by transferring the sucking action to the
most suitable object available, namely the thumb or finger
The learning theory :(Davidson 1967)
This theory advocates that non-nutritive sucking stems from
an adaptive response. The infant associates sucking with
such pleasurable feelings as hunger. These events are
recalled by sucking a suitable object available mainly thumb
or finger.

Oral drive theory :( Sears and wise 1982)
They suggested that the strength of the oral drive is in
part a function of how long the child continues to feed by
suckling. Thus, thumb sucking is the result of prolonged
nursing; and not the frustration of weaning. This theory
agrees with Freud’s theory that sucking increases the
erotogenesis of the mouth.
Johnson and Larson 1993:
They believed that combination of psychoanalytic and
learning theories which explains that all children posses
an inherent biological drive for suclking. The rooting and
placing reflexes are merely a means of expression of the
drive. Environmental factors may also contribute to this
drive to nonnutritive sources such as thumb or finger.


Thumb sucking

Disease
or
Restriction

Suckling reflex


Psychological
+
Nutritive

Breast feeding


Non physiological nursing with a conventional artificial rubber
nipple the mouth is propped open unduly and the lip seal is
difficult. air intake with milk intake is likely. abnormal muscle
pressures are exerted as a compensatory response to the
excessive mouth opening required
Nursing action of nuk sauger nipple closely stimulates natural
activity. The perioral area is able to contact the warm nipple base
which is flexible and adapts to the contour of the lips

Thumb sucking
(Subtelny1973)

Type A

Type B

Type C


Type D

Type A: This type is seen in almost 50% of the
children; where in whole digit is placed inside the
mouth with the pad of the thumb pressing against
the palate, while at the same time maxillary and
the Mandibular anteriors contact is present.
Type B: This type is seen in almost 13- 24% of the
children where in thumb is placed in the oral cavity
without touching the vault of the palate, while at
the same time the maxillary and mandibular
anteriors contact is maintained.
Type C: This type is seen in 18% of the children
where in the thumb is placed into the mouth just
beyond the first joint and contacts the hard palate
and only the maxillary incisors, but there is no
contact with the mandibular incisors.
Type D: This type is seen in almost 6% of the
children where in very little portion of the thumb is
placed into the mouth.

level

Description
Classification of NNS habits by Johnson 1993

Level I (+/-)

Boys and girls of any chronological age with a habit that occurs
during sleep.

Level II (+/-)

Boys below the age of 8 with a habit that occurs at one setting
during waking hours.

Level III (+/-)

Boys under the age of 8 with the habit that occurs at multiple
settings during the waking hours

Level IV (+/-)

Girls below the age of 8 or boys above the age of 8 with a habit
that occurs at one setting during waking hours.

Level V (+/-)

Girls below age of 8 or boys above the age of 8 with a habit that
occurs across multiple settings during waking hours.

Level VI (+/-)

Girls over the age 8 with a habit during the waking hours.


Maturation of oral function
With the eruption of the lower incisors the
tongue starts retracting and muscular
activity shifts from the anterior perioral
region to the posterior region, of the
tongue, pharynx and masticatory muscles,
with the eruption of posterior teeth the
tongue starts retracting laterally between
the gum pads

Maintenance of the habit:
Most children would stop digit sucking by the
age of three to four years.
But an acute increase in child’s level of stress
and anxiety due to some underlying
psychological or emotional disturbances can
account for continuation of digit sucking habit,
with conversion of an empty habit into a
meaningful stress reducing response .

Causative factors:
Parent’s occupation
Working mother
Number of siblings
Order of birth of the child
Social adjustment and stress
Feeding practice
Age of the child

Diagnosis of digital habits:
1) History
2) Extra oral examination
a) The digits
b) Lips
c) Facial form
d) Other features
3) Intra oral examination
a) Tongue
b) Dent alveolar structures
c) Gingiva

The Effect of feeding methods on growth of the jaws in
infants by Mario Legovic JODFC June 1991.
Intent of the study was to suggest how infants to be fed
and how physiologic and unphysiologic nipples and
pacifiers might be used.
To group the children according to the length of time
they were breastfed.
To examine the influence of breast feeding on the growth
of alveolar process and jaws.
The subjects were classified as
Group A : Not breast fed
Group B : Breast fed, three months or less
Group C : Breast fed, more than three months.

There were no statistically significant relationship
between prevalence of overjet and overbite and the way
the child was fed. They suggest that there are numerous
endogenous and exogenous factors that influence the
occurrence of malocclusion
Breast fed should be used for atleast nine months, many
children were supplementally fed using unphysiological
nipples. Although great number of children were using
unphysiologic nipples and others who were breast fed
did not used a pacifier they did not suck their finger, so
they concluded that it is important to recognize the
influence of unfavourable factors on growth and
development of oral and facial structures, as well as the
influence of favorable factors, such as breast-feeding
should be considered.

Damage to primary dentition resulting from thumb
and finger(digit) sucking by Osamu fukuta JODFC
Nov.1996
The study was to investigate relationship
between thumb or finger sucking in
malocclusion, 930 subjects meet the following
inclusion criteria were selected from the original
2180 children
Those who only indulge in digit sucking,
Those with no oral habits
Subjects with complete primary dentition and no
permanent teeth erupting.

This study investigated the effect of thumb and finger
sucking on the antero posterior regions of the primary
dentition of children 3-5 years of age. Around 19.8% of
children were found to suck finger or thumb.
At all ages the frequency of open bite and maxillary
protrusion for the thumb sucking groups were higher
than non oral habit group.
In the five year old children the mesial step terminal
plane type of thumb sucking group demonstrated
significantly lower malocclusion frequencies and the
distal step terminal plane type significantly higher
frequencies than those of the non oral habit group.
There was an increased tendency to a permanent
malocclusion in distal step type in children who
continued after 4 years of age.
The results of this studies suggest that thumb and finger
sucking should be eliminated before damage is done to
the terminal plane. It would appear to be between 3-4
years of age.

Non-Nutritive suckling habits in brazilian children: Effects
on deciduous dentition and relationship with facial
morphology by cintia regina AJO 2004
The study was to assess the relationship between non nutritive
suckling habits, facial morphology and malocclusion in all three
planes of space, in four year old children attending state school.
Conclusions drawn from these studies are prevalence of
malocclusion the sample was high 49.7% and 28.5% of the
children had association of 2-3 malocclusion factors(posterior
crossbite, anterior open bite increased overjet).
The assessed malocclusions were strongly associated with
nonnutritive suckling habits.
The results drawn attention to the magnitude of the problem of
malocclusion in childhood and emphasize the need of
longitudinal studies to provide scientific evidence.

Effects
on
maxilla

Effects
on
mandible

- proclination of maxillary incisors
- increased maxillary arch length
- anterior placement of apical base
- increased SNA
- increase in clinical crown length of anteriors
- counter clock wise rotation of occl.plane
- decreased SN to ANS-PNS angle
- decreased palatal arch width
- atypical root resorption in primary central
incisors
- trauma to maxillary central incisors
- proclination or reteroclination of the mandibular
incisors
- increased intermolar distance
- distal position of point B

Effects on
interarch
relationship

-↓ maxillary and mandibular incisal angle
- increased over jet
- decreased over bite
- posterior cross bite
- uni-bilateral class-II occlusion

Effect on lip - incompetence lips
placement and - lower lip function under the maxillary
function
incisors
- tongue thrust
Effect on
- lip to tongue resting position
tongue
placement and - lowered tongue position
function
Other effects

- thumb deformity
- speech defects, lisping

AJO-DO Volume 1994 Aug (161 - 166): Effect
of sucking habits on posterior crossbite Øgaard, Larsson, and Lindsten
The upper and lower intercanine arch widths
and the prevalence of posterior crossbite were
registered for 445 3-year-old children with and
without a continuing or previous dummysucking or finger-sucking habit in different
areas in Sweden and Norway.
Compared with the nonsuckers, an increased
prevalence of posterior crossbite was observed
for the finger suckers, especially the Swedish
girls.

The probable mechanism is that the sucking
activity in the cheeks combined with a reduced
palatal support as the tongue takes as lower
position, decreases the upper intercanine arch
width. The transversal disharmony among the
jaws becomes worse as the low tongue position
widens the lower arch in the canine area,
resulting in a forced lateral guidance of the
mandible to a posterior crossbite.
The study revealed that at least 2 years of
dummy sucking is necessary to produce a
significant effect in the upper jaw and 3 years in
the lower jaw.

Sucking, Chewing, and Feeding Habits and the Development of
Crossbite: A Longitudinal Study of Girls From
Birth to 3 Years of Age Erik Larsson, (Angle Orthod 2001;71:116–119.)

The aim of this investigation was to follow the
development of crossbites in pacifier suckers and
to determinate the possibility of reducing the
prevalence of crossbite by informing and
instructing the parents about sucking habits and
reducing the time the child has the pacifier in the
mouth.
it was concluded that parents should be instructed
to reduce the ‘‘in the mouth time’’ of the pacifier.
The transverse occlusal relationship in pacifiersucking children should be evaluated between 2
and 3 years of age. If interfering contacts of the
primary canines exist, the parents should be
instructed to reduce the pacifier-sucking time.

Duration of nutritive and nonnutritive sucking
behaviors and their effects on the dental arches in
the primary dentition John J. Warren- ajo
2002;121:347-56)

The purpose of this study was to assess
the effects of the duration of breastfeeding and pacifier and digit sucking
habits on the dental arch and the occlusal
characteristics among a birth cohort of
children in the primary dentition assessed
at 5 years


conclusions drawn from the study are
1. Among children with minimal nonnutritive
suckinghabits, those who breast-fed longer had
similardental arch parameters and occlusal
characteristicsas those with shorter duration of breastfeeding or no breast-feeding.
2. The durations of pacifier and digit habits were each
positively related to the prevalence of certain
malocclusions, but these malocclusions were different
for pacifier and digit behaviors. Both behaviors were
associated with increased prevalence of anterior open
bite and reduced overbite; pacifier habits were
associated with increased prevalence of
posteriorcrossbite, while digit habits were associated
with greater overjet, greater maxillary arch depths, and
smaller maxillary arch widths.

3. More importantly from a clinical perspective,
some changes in dental arch parameters and
changes in prevalence of certain occlusal traits
persisted well beyond the cessation of pacifier or
digit habits.
4. The results suggest that current
recommendations for discontinuing nonnutritive
sucking habits may not be optimal in preventing
habit-related malocclusions at the end of the
primary dentition stage.

Treatment
Psychological therapy
Reminder therapy
Extra oral approaches
Intra oral approaches
Mechanotherapy
Blue glass
Quad helix

JCO 1984 Simultaneous Correction of Digital
Sucking Habits and Posterior Crossbite with a
Combo Appliance - PHILLIP M. CAMPBELL, DDS,


The Ace Bandage approach to
digit-sucking habits
The article describes an at-home program to
assess children with nocturnal digit sucking
habits. Children with such habits are candidates
for this program, if they wish to discontinue their
habits and have no psychological contra
indications for the habits cessation. The
program involves nightly use of an elastic
bandage wrapped across the elbow. Pressure
exerted by the bandage removes the digit from
the mouth as the child tires and falls asleep.
Careful patient selection and patient education
can lead to success – pediatric dentistry 1999.

An aid to stop thumb sucking: the Bluegrass
appliance Bruce S. Haskell, Pediatric
dentistry 1991
The appliance indicated for those children who
have continued a thumb sucking habit which is
affecting the mixed or permanent dentition.
Children also should indicate that they want to
stop the habit and are willing to try for the
appliance
The patients believed that they had acquired a
new toy with which to play with their tongues, as
instructions were given to turn the roller instead
of sucking digit.

Tongue trusting:


Transition from infantile to mature
swallow
Infantile or visceral swallow : active contraction of the
musculature of the lip, tongue tip brought forward in
contact with the lower lip, and little activity of the
posterior tongue or pharyngeal musculature. mandible is
stabilized by the tongue interposed between the gum
pads and the peri oral musculature with the involvement
of 7th cranial nerve
Adult or Mature swallow: this type of swallow is
characterized by cessation of lip activity the placement of
tongue tip against the alveolar process behind the upper
incisors, more complex movements of the posterior part
of the tongue. Posterior teeth come in contact for the
stabilization of the mandible which is achived by the fifth
cranial nerve

Normal swallow:
Stage 1: the anterior third of
the superior surface of
the tongue is flat or
retracted, the food bolus
is collected on the flat
anterior part of the tongue
or in the sublingual area
in front of the retracted
tongue. The posterior
arched part of the tongue
is in contact with the soft
palate. posterior seal is
established. teeth and
lips are not in contact.

Stage 2: the soft palate moves
cranially and posterior
direction. The platoglossal
and Plato pharyngeal seal
are now open. The tip of the
tongue moves up and the
dorsum drops down creating
a groove or depression in the
middle third and permitting
posterior transportation of
the bolus. Simultaneously a
slight contraction of the lips
and the lips are brought to
contact. The anterior teeth
approximate at the end of
this stage . Symptoms of the
tongue thrust swallow are
seen at this stage

Stage 3 : the superior
constrictor muscle ring in the
epipharyngeal wall starts to
constrict . The soft palate
assumes a triangular form;
both tissues together form
the platopharengeal seal.
with the closing of the
nasopharynx the posterior
part of the dorsum drops
further and allows the bolus
to go further back.
simultaneously the anterior
part of the tongue is pressed
against the hard palate,
which helps to manipulate
the bolus in posterior
direction. The teeth are in
contact and the lips are
together

Stage 4: the dorsum of
the tongue moves
posteriorly and
superiorly as the
platopharyngeal move
down ward and
forward . The tongue
presses aganst the
tensed soft palate ,
squeezing the residual
food bolus out of the
oropharyngeal area

Tongue trusting:
Definition:

Schneider 1982: tongue thrust is forward
placement of the tongue between the
anterior teeth and against the lower lip
during swallowing


Tongue thrust

Physiological

Habitual

Functional

Anatomic

Embryonic
life
Disproportionably large
Fills the nasal cavity

Infants
In between the gum pads
In contact with lower lip
Stabilizes the mandible

Childhood
Starts retracting with incisor eruption
7th to 5th cranial nerve
Volume of oral cavity increases

Fletcher (1971) listed the patterns
characteristic of tongue thrust.
- A thrusting movement of the tongue against or between
-

the anterior teeth
Slight or no contraction of the muscles of mastication
Strong contraction of the lip musculature
Movement of the hyoid bone in the oblique or forward
direction
Distortion of speech sounds.


TONGUE THRUSTING AND MALOCCLUSION
The differential growth changes that usually resolve the largeness of
the tongue size relative to skeletal jaw size is the reason why
orthodontists watch some open bite malocclusions close down with
no therapy.
Favourable growth of the craniofacial complex could substantially
increase space within the oral and pharyngeal cavities to reduce the
need for a tongue to be fronted and protrusive and permit a selfcorrection of some open bite malocclusions.
Worms et al 1971-80% spontaneous correction of anterior open
bite. Obviously, tongue thrust is more common than the
malocclusion it is supposed to cause. Also, the decreased
prevalence of open bite with increasing age,should indicate that if
myofunctional training techniques are to be employed to retrain
tongue position it would be best to defer treatment.
The best time to determine the need for therapy would be after
prepubertal growth spurt rather than during the period from 6-12 yrs
of age. Even then look out for fronted tongue posture( eg.,
unfavourable skeletal environment, specific respiratory problems or
thumb and finger sucking).

AJO-DO 1969 Jun (94 - 104): A critical appraisal of tongue
thrusting - Tulley
An attempt has been made here to place the problem of tongue
behavior in its true perspective by indicating that only a very
small percentage of orthodontic problems are ultimately
complicated by it.
In a limited number of cases with poor facial pattern associated
with forward tongue posture at rest, an anterior open-bite may
not be permanently reduced, whatever the method of
treatment. This clinical type is very unfavorable for treatment
but occurs in only about 0.6 per cent of the population. Early
treatment is undesirable, as the whole problem may look much
worse during the early mixed-dentition phase.
A classification of tongue-thrusting has been attempted. It is
better to place the emphasis on the morphology of the skeletal
and soft-tissue structures which demand abnormal posture and
activity, rather than on the more transient and rapid movements
of the tongue in speech and deglutition

A Cineradiographic Study of Deglutitive Tongue Movement and
Nasopharyngeal Closure in Patients with Anterior Open Bite
Tatsuya Fujiki, Angle Orthodontist 2000

The purpose of this study was to investigate the movement
of the tip and the dorsal surface of the tongue during deglutition
in patients with anterior open bite using cineradiography.
By cineradiography it was established 7 stages of tongue
movement and bolus position during deglutition and analyzed
the tongue position, tongue movement and the time.
The tongue-tip position was more protrusive during deglutition
in anterior open bite than in the controls. After the head of the
bolus arrived at the opening of the esophagus, the rear part of
the dorsal surface of the tongue demonstrated slower
movement in patients with anterior open bite than in controls.
The nasopharynx closed earlier in patients with anterior open
bite than in controls. It is suggested that anterior open bite
patients had compensatory coordination of tongue movement,
soft palate movement and pharyngeal constrictor muscle
activity during deglutition.

Open
spaces

Retained
infantile
swallow

Etiology
Tongue
size

Upper
Respiratory
tract
infections

Residuum Of
finger
Sucking habit

Anatomic

Tongue thrust

Heredity
Neurological
disturbances

Diagnosis
History >hereditary etiologic factor, speech problems , upper respiratory
infections, sucking habits and neuromuscular problems
Examination
1. Simple tongue thrust
- Normal tooth contact in posterior region
- Anterior open bite (defined)
- Contraction of the lips, mentalis muscle and mandibular elevators.
2. Complex tongue thrust
- Generalized open bite with the absence of contraction of lip and muscle and
teeth contact in occlusion. (undefined)
- Cusp to cusp occlusion
- Absence of gag reflex and streognosis
- Dysdiadokokinesis
3. Lateral tongue thrust -posterior open bite with tongue thrusting laterally.
 Functional methods

Maxilla

Mandible

Inter arch

- Tipping of the palatal plane
-Proclination of maxillary anteriors resulting
in increase in over jet
- Generalized spacing between the teeth
- Teeth may be mesially inclined
- or all parameters may be norm
-Retroclination or Proclination of mandibular
teeth depending on the type of growth
-Generalized spacing between the teeth
-Teeth may be mesially tilted
- or all parameters may be normal
- Anterior or posterior open bite depending on
the posture of the tongue
- Posterior cross bite
- lack of interdigitation of the posterior teeth
- Or all the parameters may be normal

Facial form
lips
Tongue

Speech

- Convex profile
- Increased LAFH

- Short upper lip/normal upper lip
- Hyperactive mentalis/ normal
- Enlarged
- Forwardly placed
- Normal position
-Tongue thrust children are more likely to have
various speech disorders, such as sibilant distortions,
lisping problems in articulation of s, n, i, d, l, th, z, v
sounds

Tongue thrust
habit

adaptive behavior

endogenous or innate
Pathologic and grossly abnormal.

Tongue-thrusting as a habit. The fact that this will
not be seen very commonly past the age of 11
years is a reason for delaying treatment where the
facial pattern is good and there is merely a slight
open-bite and increased overjet with a Class I or
Class II relationship These patients with a
persistent tongue-thrust habit will be treated quickly
when the labial segment is put into its correct
position. It is quite unnecessary for these children
to be sent for any form of re-educational therapy.
Placement of the teeth in correct position and the
very presence of the appliance will be sufficient.
Although the psychologic aspects of this subject
have been ignored, it is interesting to note that
lisping speech has returned for a short time when
the child is under stress.

Tongue-thrusting which is possibly endogenous or
innate. In the epidemiologic investigation previously
described, a familial pattern was evident in 30 per cent of
the small group of children who had tongue-thrusting
behavior . There is an obscure central variation. This
kind of tongue-thrusting is particularly marked in the
sibilant sounds of speech and may often be seen in
siblings and in one of the parents. It can occur when
there is a perfectly normal occlusion if there is a good
facial skeletal pattern, and then it is of little significance
to the orthodontist. If it occurs where there is an adverse
facial pattern, it may be a dominant feature and may
place severe limitations on the improvement of the
incisor relationship . In contrast to the simple tonguethrusting habit, it will not respond to any kind of therapy.


Tongue-thrust as an adaptive behavior. The
majority of problems which are of concern to the
orthodontist fall into this category.. The resting
posture of the tongue is more important than its
functional movements.
The type of deglutition in which there is a
tongue-thrust and excessive circumoral
contraction is due to the fact that there has to be
excessive contraction of the labial musculature
in cases where the lips are "incompetent" and
the tongue comes forward to complete the
anterior oral seal. This tongue-thrust swallow
can change quite dramatically if orthodontic
treatment can place the labial segments in good
relationship so that the lower lip can come to
seal on the labial surface of the upper incisor
teeth

An adaptive tongue behavior, in which the tongue is not
only forward in functional movement but postured
forward over the lower incisors at rest to seal with the
lower lip, is a very important problem. This posture is
associated with an adverse skeletal pattern in which
there is a high Frankfort-mandibular plane angle.
In the epidemiologic survey, the type of facial pattern
found in only 0.6 per cent of the child population has
always been recognized by orthodontists as presenting a
difficult problem It is the one in which tongue-thrust, and
more especially tongue posture taken into conjunction
with the adverse skeletal form, will produce an anterior
open-bite which is very resistant to treatment. This may
be associated with a Class I, II, or III malocclusion.


Pathologic and grossly abnormal tongue
problems..
There is no doubt that tongue size plays some
part, but true macroglossia is extremely rare.


The nature of arch width difference and palatal
depth of the anterior open bite Am J Orthod Dentofacial
Orthop 1998;113:344-50.)

This study was designed to
(1) explore the nature of the arch width difference for
patients with anterior open bite, whether dental or
skeletal in nature, and
(2) clarify the general impression of “high” palatal
vaults for anterior open bite cases, to make sure if
there are “absolutely high” or “relatively high” palatal
vaults.
Measurements in male and female patients with open
bite malocclusions were analyzed and compared with
those in male and female patients with normal
occlusions. Similar trends were found for both sexes.

Skeletally narrowed maxillary posterior width
and dentally widened mandibular posterior
widths were found.
Palatal depth was in the normal range in the
patients with anterioropen bite.
Orthopedic widening of the maxillae and
inclining of the mandibular posterior teeth
lingually are recommended when orthodontic
treatment is to be rendered to patients with
anterior open bite.

CONCLUSIONS
Four conclusions can be drawn from this model study for
the anterior open bite cases.
1. The posterior maxillary arch is narrowed skeletally.
2. The posterior mandibular arch is widened dentally.
3. Anterior open bite groups revealed an apparent
posterior transverse discrepancy that was not present in
the control groups.
4. The palatal depths of the subjects with anterior open
bite were normal.
Attention should be drawn to the skeletal narrowing of the
maxillae and the buccally upright mandibular posteriors
when posterior crossbite exists.


Oral perception in tongue thrust and other oral habits
José S. Dahan, LDS, MD, PhD,a Odette Lelong, BA, LRL,
PhD,b Sandrine Celant, BA,c and Valérie Leysen, BAc
Brussels, Belgium
Sensory feedback is important for muscle function.
Stereognostic testing can be used to assess tactile
perception.
Oral recognition of shape is enhanced by repetition
Stereognosis is sensitive to age, upper and lower
anterior arch perimeter, and oral habits.
test may be useful in differentiating light from to severe
oral dysfunction.
The possibility of an interaction between bolus location,
stereognosis,and the swallowing act needs further
investigation.

Treatment
Age
Presence or absence of associated
manifestation
Malocclusion
Speech defects
Associated with other habits


Treatment
Traning of correct swallow and posture of the tongue
a) myofunctional exercises
b) using appliances as a giude in correct positioning of
the tongue
Speech therapy
Mechanotherapy
Removable appliance therapy
Fixed habit breaking appliance
Oral screen
Correction of malocclusion
Surgical treatment www.indiandentalacademy.com

Mouth breathing


Mouth breathing
Nasal resistance
Mouth breathing
Chest development +alteration of muscles of chest, back and neck

Alteration of craniocervical angle + drop in mandible and tongue

Increase in posterior dental height + increased mand. plane

Definition:
Sassouni (1971) defined mouth breathing as
habitual respiration through the mouth instead of
the nose.
Merle (1980) suggested the term oro-nasal
breathing instead of mouth breathing.
F.M. Chacker defined mouth breathing as
the prolonged or continued exposure of the
tissues of the anterior area of the mouth to the
drying effects of the inspired air.

Mouth breathing
Finn (1987)

Habitual

Anatomic
Obstructive


M
O
U

E T IOLOGY
H

B
R
E
A
T
H
I
N
G

Warren et al , a nasal airway cross
sectional area of less than 0.4 cm2
may represent an inadequate airway
and some mouth breathing would be
expected.
Allergic rhinitis, nasal polyps,
enlarged adenoids or tonsils
Abnormally short upper lip preventing
proper lip seal
Obstruction in the bronchial tree or
larynx
Obstructive sleep apnoea syndrome
Genetically predisposed individuals.
Ectomorphic children having a
genetic type of tapering face and
nasopharynx are prone for nasal
obstruction.
Thumb sucking or similar oral habits
can be the instigting agent.
Traumatic injuries to the nasal cavity

Diagnosis

History
Examination
Clinical tests - mirror test
- butterfly test
- water holding test

Facial form

Large anterior facial height
Increased mandibular plane
Reterognathic maxilla and mandible with
dolicocephalic head form

Adenoid facies

Long , narrow face with narrow nose and
nasal passages
Short , flaccid upper lip
‘v’ shaped arch, buccal crossbite

Dental effects

Speech effects

lip

Upper and lower incisors are retroinclined
Excessive incisal show
Posterior cross bite
Tendency towards open bite
There may be flaring of incisiors
Nasal tone in voice is seen

Incompetent

gingiva

Gingivits-rolled margins and interdental
enlargement

Nasal cavity

Turbinales swollen and engorged
Nasal mucosa becomes atrophic


THE LONG FACE SYNDROME

In 1872, C.V. Tomes coined the term
“Adenoid Facies” or ‘Long Face
Syndrome’ to describe the dentofacial
changes associated with chronic nasal
airway obstruction.Any condition that
causes nasal obstruction could lead to
this typical facial morphology. This
syndrome is characterized by an
increased LAFH,increased dentoalveolar
height,gummy smile,high arched
palate ,steep mandibular plane,excess
incisal show,anterior marginal gingivitis
and long-standing nasal obstruction may
lead to "disuse atrophy" of the lower
lateral cartilages , resulting in as slit-like
external nose with a narrow nasal vault.

Nasal obstruction and facial growth: Katherine W. L. Vig,
BDS, MS, FDS, DOrth

The purpose of this article is to review some
of the available evidence in children,
adolescents, and adults that suggest that
there may or may not be an association
between respiratory mode and facial
morphology.


The classic work of Harvold cited earlier in the
text was based on total obstruction of the nasal
airway in monkeys; this resulted in a cause and
effect relationship. However, human studies
have indicated that total nasal obstruction is
rare, and the most common respiratory mode is
a simultaneous oral and nasal airflow.The
percentage of nasal versus oral airflow is
dependent on a number of variables


Fields et al.used contemporary respirometric
techniques to compare respiratory modes of normal
and long-faced adolescents.They concluded that the
long-faced subjects had a significantly smaller
component of nasal airflow,although the tidal volume
and minimum nasal cross sectional area were similar.
They suggest that significant differences in airway
impairment do not have a direct effect on the
breathing mode, which may be behaviorally
determined rather than being structurally
dependent. The form-function interaction that
conveniently should explain the causal association
between nasal obstruction and facial growth in
children appears to be of a multifactorial nature .

Relation between nasorespiratory function and
dentofacial morphology - O'Ryan, AJO-DO Volume
1982 Nov
It is commonly assumed that nasorespiratory function can
exert a dramatic effect upon the development of the
dentofacial complex. Specifically, it has been stated that
chronic nasal obstruction leads to mouth breathing, which
causes altered tongue and mandibular positions. If this
occurs during a period of active growth, the outcome is
development of the "adenoid facies" (dentofacial
morphology). Such patients characteristically manifest a
vertically long lower third facial height, narrow alar bases, lip
incompetence, a long and narrow maxillary arch, and a
greater than normal mandibular plane angle. These
dentofacial traits have repeatedly been attributed to restricted
nasorespiratory function. It is generally believed that
environmental factors can exert subtle or dramatic effects
upon dentofacial morphology, depending upon their
magnitude, duration, and time of occurrence.

RADIOGRAPHIC AND RHINOMANOMETRIC RESEARCH ON THE
RELATIONSHIP BETWEEN RESPIRATION AND CRANIOFACIAL
MORPHOLOGY
Subtleny-Airway space increased with greater soft palate and hard
palate growth. Airway space did not increase with growth if the adenoids
became sufficiently hypertrophied.
Ricketts- space necessary for nasal respiration was related to the
angulation of the cranial base, the position of the posterior nasal spine, size
and function of soft palate and the amount of adenoid tissue.
Solow- positive association between the size of the nasopharyngeal
space and depressed maxillary width. He also found a positive correlation
between the acuteness of the cranial base and the width and height of the
maxilla.
Solow and Kreiborg- suggested a causal link between airway
obstruction, postural change resulting in stretching of facial soft tissue and
changes in cranial morphology.
Hannuksela-no significant difference in the dimensions of the dental arches,
overjet, overbite when comparing the allergic with normal group. She also
found that mouth breathing was less common in the children with enlarged
adenoids.
Handelman and Osborne were not able to demonstrate posterior rotation of
the mandible due to nasopharyngeal obstruction.
Sosa et al- no relation could be found between the airway space or
lymphoid tissue bulk and the type of malocclusion.

Angle Orthodontist 1990 Myofunctional and
dentofacial relationships in second grade children
Alan M. Gross, Gloria D. Kellum, Sue T. Hale,
One hundred and thirty-three second graders in rural
public school were assessed on a number of dental,
skeletal, and oral muscle function measures.
Correlational analyses were conducted in order to
determine whether specific myofunctional variables were
associated with dentofacial development. Significant
relationships were observed between open mouth
posture and a narrow maxillary arch and long facial
height. Labial and lingual rest and swallow patterns were
also related to poor coordination of lip and tongue
movements.


Angle Orthodontist 1994 A longitudinal evaluation
of open mouth posture and maxillary arch width in
children Alan M. Gross, Gloria D. Kellum
Open mouth posture and maxillary arch width were
assessed annually for 4 years in a group of children.
While younger children exhibited high levels of open
mouth posture, this behavior decreased significantly over
time. Racial and sex differences, as well as a race-bytime interaction were also evident. The children
displayed a significantincrease in maxillary arch width
across time with sex and racial differences in this growth
pattern. Subjects were classified as exhibiting primarily
open mouth or closed mouth posture. Although both
groups showed increased maxillary arch widths over
time, the closed mouth subjects showed significantly
greater maxillary arch growth.

Angle Orthodontist 1988 Developmental Effects of Impaired
Breathing in the Face of the Growing Child Man-Ching
Cheng, Donald H. Enlow, ..
Craniofacial morphology and occlusal pattern are
evaluated in 71 subjects having impaired breathing as
diagnosed by an otolaryngologist, and in an equal
number of controls. The impaired group demonstrate
characteristic combinations of craniofacial deformities
and malocclusions, with the younger individuals
demonstrating a lesser expression of malocclusion
progression and morphologic deformities. This suggests
that early recognition of such facial patterns may be
utilized to identify those breathing compromised
individuals who have a likely tendency to develop certain
types of malocclusion.


Angle Orthodontist 1988 Developmental Effects of
Impaired Breathing in the Face of the Growing Child
Man-Ching Cheng, Donald H. Enlow, Micha...
This study characterizes craniofacial morphology and
occlusal patterns in breathing-impaired subjects and
tests a hypothesis that specific types of malocclusions
found in subjects with nasal obstruction relate to
certain intrinsic morphologic combinations.
The findings lead to the following conclusions:
Craniofacial morphology and occlusal patterns in the
breathing-impaired sample are significantly different
from those in the control sample. The discrepancies
relate to vertical components associated with a longer
face and dentoalveolar and palatal heights.

•Transversely, the impaired subjects also show more narrow
cranial and palatal widths. The mandibles in these subjects
were characterized by greater whole mandibular length and
more prominent antegonial notching.
In the breathing-impaired group, Black subjects showed a
larger mandibular length, wider dental arches and palates, a
larger midcranial base angle, and a more backward alignment
of the mandibular rami.
•
The younger a breathing-impaired subject, the less marked
is the expression of these craniofacial morphologic and occlusal
characteristics.
•
The results of multivariate analyses show high correlations
of certain types of occlusal variables with specific combinations
of craniofacial structures. High prediction rates for palate height
and accurate groupings for posterior lingual crossbite, anterior
crossbite, maxillary anterior crowding, and mandibular anterior
crowding are achieved through utilization of certain
combinations of craniofacial morphologic variables.
•
A multidisciplinary approach involving the otolaryngologist
and the orthodontist is advantageous for curtailing or reducing
continuing detrimental effects of breathing impairments on
craniofacial morphology and occlusion.

Harvold in 1973 simulated hypertrophied
adenoids in primates with acrylic blocks and
found that within 9-15 months the palatal vault
increased in height creating an anterior open
bite. He believed that an open clear airway is a
prerequisite to normal facial form and function.
Harvold further points out that there are two
types of movement involved – rhythmic, such as
respiration and tonic, which involves changes in
posture. Changes in rhythmic movement cause
few skeletal variations but tonic changes cause
significant alterations in skeletal morphology.
The muscles with which the dental clinician is
primarily concerned, are those involved in tonic
changes, such as the diagastrics, pterygoids,
masseters and temporalis.

According to Paul and Nanda, there is much evidence
that mouth breathing produces deformities of the jaws,
inadequate position or shape of the alveolar process and
malocclusion and results in the development of adenoid
facies, or long face syndrome
Adenoid enlargement leading to mouthbreathing results
in a particular type of facial form and dentition.
3 mechanisms were found by which adenoid-mouth
breathing relationship influences the etiology of facial
form and dentition
Compression
Disuse atrophy – theory of inactivity
Altered air pressure

In 1918, Norlund introduced the ‘compression
theory’ which stated that constriction of the
maxillary arch is related to the absence of the
lateralizing pressure of the tongue against the
palate. In response to nasal obstruction, the
tongue drops and the medializing effects of the
buccal musculature is left unopposed. The effect
is further enhanced by a pressure differential
across the hard palate in the absence of nasal
airflow, leading to a narrow, high-arched palate.

Woodside in 1968 suggested that obstructed
nasal ventilation, could, if present during a long
period of time, act as an etiological factor in the
development of a class II malocclusion.Recent
study by Chang proposed that the degree of
impact caused by nasal obstruction may vary
with different facial types. A brachycephalic or
broad faced pattern with strong facial
musculature and a deep bite may be less
affected by nasal obstruction, whereas
dolicocephalic faces with narrow, more
elongated pattern may be more susceptible.

Theories first proposing the existence of a
relationship between mouth breathing and facial
form stated that oral respiration alters normal air
currents and pressures through the nasal and
oral cavities, which causes impaired
development of these structures. Several
authors postulated this to be the result of the
oral airstream in mouth-breathing individuals
hindering normal downward palatal growth.
Others believed that the raised negative air
pressure difference between the oral and nasal
passages in mouth breathers lead to
development of a deep palatal vault.

A second theory held that oral respiration disrupts the
muscle forces exerted by the tongue, cheeks, and lips
upon the maxillary arch. The mouth breather was
believed to position the tongue in a more downward and
forward manner in the oral cavity, a position in which it
could not exert adequate buccal pressure to counteract
the inward forces from the lips and cheeks upon the
maxilla. This theory exists in the current literature.
A third school of thought denies a significant relationship
between facial morphology and mode of breathing.
Kingsley was among the first to consider the V-shaped
maxillary arch and deep palate a congenital trait not
related to mouth breathing.

Controversy over dentofacial morphology and mouth
breathing

The relationship between nasorespiratory
function and dentofacial development remains
controversial. The prevalent view among
orthodontists is that nasal airway impairment
and mouth breathing may lead to micro
rhinodysplasia, adenoid facies long face
syndrome, or open bite malocclusion. While
many reports support this premise, almost as
many deny it. Clinicians who believe that mouth
breathing is orthodontically harmful have little
problem justifying their position by citing
supporting literature. Similarly, those who
oppose this view also find ample support for
their stance.

Sufficient proof for a causal relationship between
mouth breathing and adenoid facies was also
disclaimed by Moyers and by Tulley.
The list of problems associated with mouth
breathing has continued to grow. Quinn (1978)
cited over 100 clinical symptoms and over 25
radiographic signs of mouth breathing.
McNamara- individuals with enlarged adenoids
or other forms of airway obstruction
demonstrated the spectrum of craniofacial
relationships with no specific pattern directly
correlated to mouth breathing.

Treatment considerations
Age of the child
E.N.T examination
Correction of mouth breathing
-symptomatic treatment
- elimination of the cause
- interception of the habit
exercises
Physical exercises
Lip exercises
Oral screen
- correction of the malocclusion


PREVENTION – MYOFUNCTIONAL APPLIANCES

Oral myofunctional therapy has been shown to be
effective in correcting oral myofunctional disorders
such as tongue thrust swallow, improper tongue and
mouth resting posture, improper use of muscles of
the mouth, tongue, and lips for chewing and
swallowing, and late thumb/finger sucking habits.


RAPID MAXILLARY EXPANSION

Brown, a rhinologist, was a vigorous supporter of midpalatal suture opening for
the purpose of overcoming nasal stenosis. Widening the upper jaw enlarges
the nasal airway and at the same time corrects lower jaw development gives
the tongue more space and enhances the flow of air in the throat.


Bruxism
Definition:
Ramfjord 1966: habitual grinding of teeth when
individual is not chewing or swallowing
Rubina 1986: it is a term used 6to indicate
nonfunctional contact of teeth which may include
clenching, gnashing and tapping of teeth
Vanderas 1995: nonfunctional movement of the
mandible with or without an audible sound
occurring during the day or night

Types
Diurnal
Nocturnal


Etiology
Cns
Psychological
Occluasal discrepancies
Genetics
Systemic factors
Allergies
Occupational factors

AJO-DO 1980 Jan (48 - 59): Bruxism in allergic children Marks

Without deprecating other prominently
mentioned causes of bruxism, such as
psychological influences, occlusal defects, and
genetic factors, allergic sensitization must be
considered seriously. Intermittent allergic edema
of the Eustachian tube causes changes to occur
in the tympanic cavity, reflexly initiating bruxism
as a means of obtaining a patent Eustachian
tube. Bruxism in allergic persons may have its
origin in infancy and early childhood.

The dentofacial morphology of bruxers versus nonbruxers Susan E. Menapace, DMD, MDS;
The purpose of this investigation was to determine
whether a relationship existed between bruxism and
craniofacial morphology and dental occlusion
Conclusions
1. There was no statistically significant difference in the
craniofacial or dental morphology of bruxers versus nonbruxers.
2. The dolichocephalic headform and the euryprosopic
facial type and Angle Class I occlusion predominated in
both bruxers and non-bruxers.
3. There was no relationship between headform/facial type
and dental occlusion.

Craniofacial morphology of bruxers verses
nonbruxers-DavidAngle 1999
The purpose of this study was to test for the
association between craniofacial morphologies
of bruxers verses non bruxers
This study found no difference in the craniofacial
morphologies of bruxers and non bruxers, nor
there was any difference With over bite .
But however there was stastically significant
difference between bi zygomatic width and
cranial width

Frequency
Duration
intensity

TM
J
-Pain

-Crepitation & clicking
-Restricted movement

Teeth &P.D

Muscles

- Mobility
- Gingivitis>
periodontitis
- Occlusal wear

-Muscle
tenderness
- Fatigue
- Hypertrophy

Bruxism

Orthodontic
treatment
Electrical
method

Occlusal
splints

Bruxism
Biofeed
back

Treatment

Occlusal
Adjustment &
Retorative
treatment s

psychothearpy

drugs
Physical
thearpy

Relation ship among nocturnal jaw muscle
activities, decreased esophageal PH, and sleep
position AJO- 2004..Miyawaki
In healthy adults , at 50% of the jaw muscle
activities during sleep were closely associated
with saliva swallowing, and most jaw muscle
activities is associated in relation with GER in
the supine position.
There fore it has been proposed that preventing
both GER and sleeping in the supine position
might be effective in decreasing the frequency of
sleep bruxism


JCO 1979 Oct(684 - 701): Occlusion with particular
emphasis on the functional and parafunctional role of
anterior teeth: Part 2

Good posterior tooth occlusion in centric
closure assures support for the condylar
components and protection for the anterior teeth
components. Good condyle and anterior teeth
disclusion assures protection for the posterior
teeth in all eccentric positions. This mutually
protected arrangement will allow the gnathic
system to function without conflict of its parts
and long be useful to man.


Lip habit
It may involve either of the lips , with a higher
predominance of lower lip
Definition
Habits involving manipulation of the lips and
perioral structures are termed as lip habits.
Classification
Wetting the lips with the tongue
Pulling the lips into the mouth between the
teeth (schneider1982)

Etiology
Malocclusion
Class II div 1
Deep bite
Habits
Thumb or digit habit
Emotional stress

Dentition

- Proclination of reteroclination of incisors
-Reddened irritated and chapped area below

Lips

Mentolabial
sulcus

Malocclusion

the vermilion border.
- Vermilion border may be located further
outside the mouth.
-vermilion border becomes redundant and
hypertrophic at rest

- Deepens
-Maintains the existing malocclusion
-May cause gingival recession and bone loss
on lower teeth and proclination of the upper

Treatment
Correction of malocclusion
Treating the primary habit
Appliance therapy
Lip bumper


Cheek biting
This is a abnormal habit of keeping or biting the cheek
muscle in between the upper and lower posterior teeth. It
may injure the soft tissue and may cause posterior open bite
or individual tooth malposition in the buccal segment where
posterior cheek biting exists
Clinical features
Ulcer at the level of occlusion
Open bite
Tooth malposition of tooth in the buccal segment
Treatment
Removable crib may be constructed

Nail biting
Nail biting is one of the most commonest habit in
children and adults. It is a sign of internal tension
Etiology
Emotional problem
Effects
Dental
Crowding, rotation, attrition of incisal edges
Effects on the nails
Inflammation of the nail beds

Self injurious habits
Definition
Repetitive acts that result in physical
damage of the individual. These habits
show increased incidence in mentally
retarded population


Etiology
a) Organic
b) Functional
- Type A
- Type B
- Type C


Treatment
Psychotherapy
Pallative treatment
Mechanotherapy


A stitch in time saves nine

Interception in right
time saves thirty two

Thank you
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