Leader in oral habits and their classifications

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Contents
Introduction
Definition
classification
common oral Habits in children
Thumb sucking
Tongue thrusting
Mouth Breathing
Other habits
Bruxism
Lip Biting
Pillowing habit
Frenum Thrusting
Bobby-pin openingwww.indiandentalacademy.com

A wide variety of oral habits in the
infants and young children has been the
center of much controversy for many
years.
Orthodontist, Parents, pediatricians,
psychologist, speech pathologist and
dentists have discussed and argued the
significance of the oral habits, each
from the view point of his/her expertise
and/ or responsibility

The orthodontist may place more
importance on the deep-seated
behavioral problems of the child
of which the habits may be only a
symptom.
The parent appears to be more
concerned that a child with an
oral habit is exhibiting an act,
which is socially unacceptable.

From the dental point of view, our
concern for oral habits falls into two
basic areas.
1. What is the overall health,
psychological and cultural significance
of the habits?
2. What are the dental manifestations
and implications of the habit?
So, we should understand why and how
the habit had developed, and what is
psychology behind it?

Habit as quoted by “Hogeboon” and
attributed by Salder: is the methodical
way in which mind and body act s a result
of the frequent repetition of a certain
definite sets of nervous impulses

Habit may be defined as constant, settled
practice or custom established by
repetition of the same act.
A repeated static of functional exercise of
ritual is defined as a habit.
habit may be defined as the tendency
towards, an act that has become a
repeated performance, relatively fixed,
consistent and easy to perform by an
individual. www.indiandentalacademy.com

William James: an ancient psychologist
defined habit from psychological point –
As habit is nothing but a new pathway of
discharge formed in the brain by which
certain incoming currents then tend to
escape.

1 According to Sigmund and Finn
a. Compulsive
Non-compulsive
a. Compulsive habits: These are deep-rooted
habits that have acquired a fixation in the child to
the extent that the child retreat to the habit
whenever his security is threatened by events,
which occur around him. The child tends to suffer
increased anxiety when attempts are made to
correct the habit
Non-compulsive habits: They are habits that are
easily learned and dropped as the child matures.

B. Primary – it is the first habit that
acquired
e.g.: Thumb sucking
Secondary – is the habit that
accompanying the primary habit.
E.g.: tongue thrusting along with
thumb sucking

2. Klein’s Classification
a. Intentional habits: it functions
as an important psychological
prop for the child. E.g.: thumb
sucking
b. Un-intentional habit: pursued
even though the child does not
support e.g.: mouth breathing

3. Brash classification
1. Individual habits eg: lip; sucking
2. Habits in which there is combined action of
muscle of mouth and jaw’s and of thumb/finger
insertion
3.Muscular action and introduction of passive
object in to mouth eg. Pacifier
4.Habits in which muscles of the mouth and jaw
take no active part. The effect on position of
dentition being extraneous. Eg: pillow; habits
during sleeping
5. Functional disturbances eg. Mouth breathingwww.indiandentalacademy.com

4. Functional classification
a. Functional oral habit eg: mouth
breathing
b. Muscular habits eg: lip and cheek
biting
c.Combination of oral muscular
action and other ways. E.g thumb
sucking.
d. Postural habits eg. Chin propping

5. Anderson classification (1963)
I. a) Pressure habits: These include sucking
habits such as thumb sucking, lip sucking,
finger sucking and also tongue thrusting.
b) Non pressure habits: Habits, which do not
apply a direct, force on the teeth or its
supporting structures. E.g. mouth breathing

II. a) Normal e.g.: Nutritive sucking
b) Abnormal. E.g. : Tongue thrusting
and thumb sucking
III. a) Physiological e.g.: nutritive
sucking habit
b) Pathological e.g.mouth breathing
IV a) Functional e.g.: mouth breathing
b) Non functional e.g.: tongue
thrusting www.indiandentalacademy.com

6.Useful and harmful habits
Useful habits should include all those habits
of normal function such as correct tongue
position, proper respiration and deglutition
and normal use of lips in speaking, etc.
Harmful habits include all that exert
prescribed stresses against the teeth and
dental arches, as well as those habits such as
mouth breathing, lip biting, lip sucking etc.

7 Meaningful habits and empty
habits
Meaningful habits: is a habit with a
psychological problem deep rooted and
must be treated accordingly
Empty habits: is a meaningless habit,
and can be treated easily by a dentist
with parent help using a habit reminder
appliance

 Thumb-sucking
 Tongue thrusting
 Mouth breathing
 Bruxism
 Nail biting
 Finger biting
 Tongue sucking
 Self-mutilation

Sucking habit is a reflex occurring
in oral stage of development and
disappears during normal growth,
between the age 1 and 3 ½ years.
It is the first co-ordinate muscular
activity of the infant.

Sucking habits can be classified into
1. Nutritive – Nutritive sucking habits will
provide essential nutrient to the infant.
E.g. breast feeding and bottle feeding
2. Non-nutritive – It is the habit adopted by
infant in response to frustration and to
satisfy their urge and need for contact.
E.g. thumb sucking, finger sucking
and pacifier sucking

Classification of NNS (Non nutritive
Sucking)
1. Level I (+/-) boy or girl of any
chronological age with a habit that
occurs during sleep
2. Level II (+/-) – boy under the age of 8
years with a habit that occurs at one
setting during waking hours.
3. Level III (+/-) – boy under the age of
8years with a habit that occurs
across multiple setting during
waking hours.

4. Level IV (+/-)-girl under the age of 8
years or a boy over the age of
8years with a habit that occurs at
one setting during waking hours.
5. Level V (+/-)- girl under the age of 8
years or a boy over the age of 8
years with a habit that occurs
cross multiple settings
during waking hours.
6. Level VI (+5) – girl over the age of 8
years with a habit during
waking hours.www.indiandentalacademy.com

It is defined as the placement of thumb or
one or more fingers in varying depth into
the mouth.
Classification of thumb sucking
A. Group 1: Thumb placed into the mouth
beyond the first joint and occupies a
large portion of the vault of the hard
palate, pressing against the palatal
mucosa and alveolar treatment.

Group 2: The thumb did not go completely
into the vault area of the hard palate,
however it usually entered into the
mouth, upto and around the first joint
or just anterior to it.
Group 3: the thumb passed fully into the hard
palate as in group one.
Group 4: The thumb did not progress
appreciably into the mouth. The lower
incisors made contact at the
approximate level of the thumbnail.

b. Cook (1958) described three distinct pattern
of thumb sucking.
Group I - pushed the palate into a vertical
direction and displayed only little buccal wall
contraction.
Group II- registered strong buccal wall
contraction and a negative pressure in the
oral cavity. This group showed posterior
cross bite.
Group III- Altered positive and negative pressure
and showed the least amount of
malocclusion of any group.

A number of theories have been put forward to
explain why thumb sucking occurs.
Freudian theory: This theory was proposed by
Sigmund Freud. He suggested that a child
passes through various distinct phases of
psychological development of which the oral
and the anal phases are seen in the first
three-year of life. In the oral phase, the
mouth is believed to be an oro-erotic zone.
The child has the tendency to place his
fingers or any other object into the oral
cavity. Prevention of such an act is believed
to result in emotional insecurity and poses
the risk of the child diversifying into other
habits. www.indiandentalacademy.com

Oral drive theory of Sears and
Wise:
proposed that prolonged sucking can
lead to thumb sucking with no
underlying cause or psychological
bearing.

Benjamin’s theory:
Benjamin has suggested that
thumb sucking arises from the
rooting or placing reflex seen in all
mammalian infants. Rooting reflex is
the movement of the infant’s head
and tongue towards an object
touching his cheek. The object is
usually the mother’s breast but may
also be a finger or a pacifier. This
rooting reflex disappears in normal
infants around 7-8 months of age.www.indiandentalacademy.com

Psychological aspects:
Children deprived of parental love,
care and affection are believed to
resort to this habit due to a feeling of
insecurity.

Learned pattern:
The behavioral theory states that the digit
sucking, is merely a learned pattern of
behaviour with no underlying causes and
no more emotional, or psychological
problems than are found among non-digit
suckers. When the habit is extinguished,
the child is not expected to experience an
emotional and psychological problem or to
substitute another more objectionable habit.
Advocates of this theory suggest that digit
sucking may even increase anxiety. Thus, if
a habit is eliminated there need be no
other habit begun as substitute.

Gender difference
Honzik and McKee found no gender difference
in the distribution of sucking habit during
infancy. Beginning with the second year of life
however the thumb sucking habit was found to
be stronger, more persistent and more wide
spread in girls than boys.
Breast-feeding Vs Bottle Feeding
Hanna in a study designed specifically to
investigate the effect of breast-feeding Vs
bottle feeding on NNS, found no correlation
between thumb sucking and the mode of
feeding www.indiandentalacademy.com

Traisman and Traisman found that out of
300 infants who were fully or partially
breast fed, 43.3% suck their thumb.
Comparing this with the 45.6% incidence
of thumb sucking in the total sample, the
authors concluded that breast-feeding was
not a significant factor in the incidence of
digit sucking.
Backlund also found no difference in the
incidence of digit sucking between breast-
fed and bottle fed children

The study by Infante also revealed a
significant difference in the incidence
of finger sucking between boys and
girls.
out Of the 680 children studied, 23.5% of
girls sucked a digit, but only 13.7% of
boys did.
It is also interesting to note that at age of
five, nine times more girls than boys
sucked their thumbswww.indiandentalacademy.com

Dento facial changes associated
with prolonged NNS Habits

Effects on maxilla
- Increased proclamation of incisors -
Increased maxillary arch length
- Increased anterior placement of apical
base of maxilla
- Increased SNA, Increased clinical crown
length of incisors, Increased counter clock
wise rotation of occlusion, Decreased SN to
ANS-PNS angle, Decreased palatal arch
width, Increased apical root resorption
of the primary central incisors, Increased
trauma to central incisorswww.indiandentalacademy.com

Effect on the mandible
- Increased proclination of incisors
- Increased inter molar distance
- Increased distal position of B point

Effect on inter arch relationship
1. Decreased maxillary and mandibular
incisor angle
2. Increased over jet
3. Decreased over bite
4. Increased posterior cross bite
5. Increased unilateral and bilateral
Class II occlusion

Effect on lip placement and
function
- Increased lip incompetence
- Increased lower lip function under
maxillary incisor

Effect of tongue placement and function
- Increased tongue thrust
- Increase lip to tongue resting position
- Increased lower tongue position
Other effects
- Risk to psychologic health
- Increased deformation to digit
- Increased risk of speech defect especially
lisping

The diagnosis of thumb sucking consists of
four diagnostic procedures.
1.History of digital sucking: Information on
whether the child has had an history of digital
sucking, obtained by parents. When there is a
positive answer, one should ask the question,
How frequently?, How long it lasted? And its
intensity and what remedies have been tried at
home?.
The clinical picture of malocclusion indicates
the intensity of the habit..

1. Emotional status: It is essential to determine
if the habit meaningful or empty. This requires an
insight into the emotional security and familial
well being of the child.
This differentiation allows us to identify the child
who wants to stop but needs some help.
In contrast there are instance in which the child
is emotionally not ready to accept any
interference during adverse situation like the
child failing in the school or at times of severe
family quarrelling centered around a child.
Success of treatment may well depend upon
organizing a meaningful sucking activity.www.indiandentalacademy.com

2. Extra-oral examination: The dentist
should check the patients digits. They should be
compared with the opposite finger of the other
hand. The finger engaged sucking with often
appear reddened or exceptionally cleaned,
chapped, with a short fingernail thumb.
Due to constant sucking the thumb or finger may
have thick callus formed or due to constant damp
environment may offer viral infection. The casual
sporadic thumb sucker will not usually have a
super clean finger. Chronic thumb-sucker have
short hypo tonic upper lip,active ones may also
have high chances of ear infection and enlarged
tonsils.Facial forms should also be noticed.www.indiandentalacademy.com

3. Intra-oral examination: examination. A
good and extended intra-oral examination
could be a key to diagnosis of the habit,
with its clear picture of clinical features.
The symptom and signs may have range
from any of the clinical features associated
with digital sucking i.e. from well-aligned
teeth and dental arches to severe
distortion of dental arches and maxillo-
mandibular relation.

These features are:
-Flared maxillary anteriors with diastema
-High probability of buccal cross-bite
-Children with vertical or anterior inclination of
condylar head and a skeleton tendency for
deep bite with a slightly retruded mandible,
may complicate malocclusion by trapping of
lower lip up by upper incisor and retrusive
force to the lower dentition. Here the adverse
lip actively may prolong and malocclusion may
be severe even after the halt of the habit.

Management may be divided into
- Preventive
- Interceptive
- Corrective (a) early treatment
(b) Late treatment
- Post treatment or retention

The treatment procedure could be introduced
during 3 phases of development of dentition.
Primary dentition between (3-5 yrs) prevention
Eruption of permanent incisors in progress (6-
8 yrs) interceptive
Erupting of permanent molars in progress (8
yrs-upto eruption of all permanent tooth)-
corrective.
And late corrective treatment in the adults

Preventive treatment
According to Little Field, because of hereditary
and its pre-disposition to digital sucking,
preventive treatment is best began whenever a
familial tendency to the habit is discovered.
Further, during the hand to mouth reaction
period, there is a danger of the passive mouthing
of thumb being converted into an active habit.
Consequently, if during this period the passive
action appears to be excessively indulged in,
preventive measure are indicated.

Hughes says- prevention of finger sucking
habit is very easy if the following simple
procedures are followed.
Firstly, feed the child whenever it is hungry, and
let him eat as much as he wants (treatment for
nutritive sucking). Dispense scheduling and
routine practice till 3 yrs of age when he has
considerable social learning and enough
maturity to understand their importance.
Secondly- feed the child in the natural way.
Importance of breast-feeding is primarily
psychological and secondarily nutritive.

McBride believes that if one wishes to prohibit
sucking, never let the habit get started, the
practice must be discontinued at its inception. In
the beginning, the finger is routinely removed
from the mouth and is kept out during sleeping-
hours by pinning sleeves of the sleeping
garments so that the child will not acquire the
motion.
The interceptive, corrective treatment
would also be considered as remedial
measures-which include chemical,
mechanical and psychological.www.indiandentalacademy.com

Psychological:
It is continues process. All authors are of the
opinion that ragging, scolding or frightening the
child should be avoided..
Brauer says that in the younger child, the
constructive education of the parent is the clue to
discontinue the habit.
He continues, to say, “intelligent attention must
be given to the following principles:

1. Promote favorable contact of the child to his
immediate environment.
2. Provide play materials suited to the Childs age.
3. See that the child has the opportunities and
space to be active, to experiment, to explore
and play.
4. Reduce unnecessary regulation for the child
and provide as much freedom as possible.
5. The home atmosphere should be one of
happiness, sympathy, patience and
understanding.

Lewis states thumb-sucking is not a disease to
be cured, but the symptoms of maladjustment, the
correction of which requires considerable
patience, skillful handling, self discipline, one of
the part of those whose responsibility is to handle
it.
Immediate post weaning period is probably the
most difficult time to handle the digit-suckers.
There is no convenient instrument for his re-
direction, he is not old enough for explanation and
reasoning and so the only way to handle them is to
encourage chewing and biting tendencies.

Beta-Hypothesis-method of correction is
known as Dunlop-Hypothesis:
This theory holds that in practicing bad habit
with the intent to stop it, one learns not to
perform that undesirable act.
However, the child must know that the intention
in having him practice the habit is to break him
off the habit. Furthermore, the child is not
allowed to fall into daydreaming or derive
satisfaction from purposeful repetition of the
habit.
This is practiced only in older children in whom
co-operation can be obtained.www.indiandentalacademy.com

Mechanical treatment:
Mechanical restraints applied to the hand/ digit
like splints held by adhesives or two holes
drilled and stringed to the wrist.
Adhesive Bandages applied to the digit .
Levin described a method of altering the little
clothing (pyjamas), so that, the hand cannot be
moved to the mouth.
Daily records kept by the child, to use the
telephone to report how many times he/she has
sucked his thumb. Later if the frequency of
sucking reduces, the calls can be spaced apart.

If self-help programme is not successful, the
child asks for the help of the dentist and an
intraoral appliance or any other technique
advocated by the dentist can be employed.
Thumb guard: is a soft acrylic covering over
the thumb worn at night. Fabricated by the
dentist, made of soft acrylic has holes of
approximately 3/16” in diameter drilled into it,
to break the sucking seal. It is tied to the wrist
at night.

Chemical treatment:
Is a part of mechanical treatment, where
the use of bitter or sour chemicals are
used over the thumb or any digit used in
the practice of sucking to reduce or
remind the patient of the habit.
However, this should be done only when
the patient has a positive attitude, and
wants the treatment, to break the habit as
much as the dentist wants

.
The treatment advocated by the dentist
can be removal or fixed appliances as the
case may be.
Removable appliances: A removable
appliance is used for child who in our
clinical judgment in a meaningful sucking
activity. The removable appliance in the
choice, because the child can easily
remove it if his emotional status demands
it. www.indiandentalacademy.com

The removable appliances include
Palatal cribs: It may be a fixed or removable
appliance. The removable appliance is made of
acrylic, like a fence. The cribs are long vertical
cribs, made in the anterior palatal aspect, resting
lingually to the upper anterior, long enough not to
interfere with the mandibular movements.
The gauge of wire is 0.021” or 0.022”- lies 3-4mm
from the incisors, having a length of 6-12mm. The
cribs act 1}To break the suction and force of the
digit on the anterior segment.
2}To remind the patient of his habit.
3} To make the habit a non-pleasurable one.www.indiandentalacademy.com

Rakes: It has spur projecting from the acrylic
retainer into the palatal vault. The hay-rake
type appliance frequently are destroyed by
habitual sucking
There are also fixed types of rakes. Here the
palatal assembly is made of 0.040” inch from
(st. steel wire) wire. Crowns are made of steel.
The whole palate is either a loop type molar
band or the other is the steel crown.

It acts in a number
of ways.
1. Prevents the
habit.
2. Corrects the
open-bite.
3. Exercises the
hypo tonic lip and
the mentalis
muscle.
Oral screen: is made of acrylic. However,
the anterior position of the mouth rests
within the vestibule.

MYO appliance:
Called Munchee chewer Oral Prophylactic
device, has been extensively researched for the
past 12 years in Australia and Japan.
Researchers say MYO has excellent therapeutic
modality with treatment of open bite and anterior
protrusion of mandible. Dr. Mine and Dr.
Yoshihara have found MYO useful therapy
between 3-6 years children during the
stomatognathic system development.
Used for 30 mins. daily in severe cases
and 4 mins in no gross orthodontic problems

.
1.The MYO Provides necessary exercises to
oxygenate and empower the muscle of the
stomatognathic system.
2.To be used to increase blood supply to the
musculature.
3.Double the competency of 0. oris.
4.Chewing on the device produces a copious
salivary flow, to keep the oral cavity always
flushed.
MYO originally called chewing and oral
prophylactic because of its capacity to
physically remove plaque.www.indiandentalacademy.com

Fixed appliances:
Blue-grass appliance:
Is a non primitive fixed appliance using a
Teflon roller, together, with positive
reinforcement. It is used to manage digit
sucking in children between 7-13 years of age.
The roller appliance was cemented in place
and left in the mouth for a period of 3-6 months.
The initial reaction of the child was uniformly
positive, and enthusiastic, without the hostile
reaction frequently seen in hay-rake appliance.

The patient believes they have acquired a
new toy with which to play with their tongue, as
instructions have given him to roll the roller
instead of sucking the digit.
The first week was used for more
tolerance towards the appliance and 6 months
retention after the habit stopped.
Long-term familiarity with the roller
reduced the oral gratification and depending
upon appliance use. Thus, digit sucking was
eliminated and the dependency upon a positive
reinforcement was slowly removed.

Quad helix: The quad helix is fixed appliance
used to expand the constricted maxillary arch.
The helixes of the appliance serve to remind the
child not to place the finger in the mouth.
The quad helix is a versatile appliance because it
can correct a posterior cross-bite and
discourage a digit sucking habit at the same
time.
The palatal cribs is designed to interrupt a digit
sucking habit by interfering with finger
placement as sucking satisfaction. Used when
no posterior cross bite is present. This is the
fixed type. This can also be used as retainer
following maxillary expansion with quad helix.www.indiandentalacademy.com

Bands are fitted on the permanent first molars or
primary second molars. A heavy lingual archwire
(0.038) is bent to fit passively in the palate and is
soldered to the molar bands. Additional wire is
soldered into base wire to from crib as
mechanical obstruction for the digit.

Triple loop corrector:
By Antony D. Viazis,- is a new and simple thumb
sucking habit control appliance.
It can be very easily constructed by bending
three corrective loops on an 0.36” wire that is
designed to fit into the lingual sheaths of the
upper first molar bands, just like an regular
transpalatal ach this requires minimal chairside
time and can be adjusted to cover the whole
span of patient’s open bite to make insertion of
the thumb in mouth very difficult.

Instruction: it is the duty of the dentist
to tell the patient about the side effects
encountered during the various use of
the appliances.
The common side effects encountered
are:
During eating, there may be difficulty:
speech may be slurred or lisping with the
appliance in mouth

Sleeping patterns may be altered for a few
days following appliance delivery.
These difficulties usually subside within 3
days to 2 week, the major problem will be palatal
cribs and to lesser degree with the quad helix in
maintenance of oral hygiene.
Food trapped may cause halitosis and
tissue inflammation, as habit discouragement
appliances are left in place for 6 months or more.
Hayette et al have emphasized the period of
retention in a habit-braking scheme. A minimum
of 6 months retention for palatal cribs, quad helix
etc. is routine. www.indiandentalacademy.com

The abnormal positioning of tongue
(anteriorly) to varying degrees has been
termed as tongue thrust.
The tongue thrust habit is the most
controversial of all the oral habits. Some
consider a retained infantile swallow a
harmful habit, causing a malocclusion,
while other believe, its as normal and that
the soft tissue adjust to the dento skeletal
complex, rather than vice versa.
. www.indiandentalacademy.com

Classification of
tongue thrust

According to Moyers using EMG research has
classified the problem into
1.Simple tongue thrust: The malocclusion
usually associated with it is a well-
circumscribed open bite.
2.Complex tongue thrust: is defined as a
tongue thrust with a teeth apart swallow. The
malocclusion seen with a complex tongue
thrust has two distinguishing features.
a. A poor occlusal fit
b. generalized anterior open bite.www.indiandentalacademy.com

Retained infantile swallow:
Is defined as the under persistence of the
infantile swallow well past the normal time.
Very few people have a retained infantile
swallow, those who do ordinarily occlude on
just one molar on each quadrant.
They also demonstrate strong contraction of
the facial muscle during swallow.
The tongue protrudes markedly, and it is held
between all the teeth during the initial stages
of the swallow.

Persons with retained infantile
swallow do not have expressive faces,
since the muscle of the 7th cranial nerve
are being used for the massive effort of
stabilizing the mandible and not for the
delicate facial movements of facial
expression.
They also have serious difficulties in
mastication and may have low gag
threshold.

a. Abnormal tongue posture:
may produce more open bites than the more
obvious tongue thrust.
There are two forms of the protracted tongue
posture.
i. Endogenous and
ii) Acquired
This endogenous protracted tongue have the tip of
tongue, which persists in lying between the
incisors. The great majority of endogenous
protracted tongue are not unesthetic. And there is
stability of the incisors relationship, even though a
mild open bite exists.www.indiandentalacademy.com

The acquired protracted tongue is a
more simple matter, since it usually
results from chronic pharyngitis
tonsillitis or other naso respiratory
disturbances.
Thus, once the etiologic factor is
removed, the tongue posture is resumed
to its normal position.

According to Braucer and Townsend and
Holt
Type I: Non-deforming tongue thrust.
Means that the interdigitation of the teeth and
the profile were acceptable and within the
normal range.
The tongue pattern apparently is non-
deforming either because the thrust is mild in
nature or because there is sufficient tonus of
the lips and cheek to prevent deforming
changes. www.indiandentalacademy.com

Type II: Deforming anterior tongue
thrust
Subgroup
1. Anterior open bite
2. Associated procumberncy of anterior teeth
3. Associated posterior cross bite.
The deforming anterior tongue thrust is the
most prevalent type of pernicious swallowing
and may or may not result in an anterior open-
bite.

Sub group 1: The tongue thrust is the most
prevalent. The tongue is thrust and forced
between the anteriors during swallowing.
This leads to intrusive or lack of eruption of
those teeth and characteristic spacing
through which the tongue protrudes.
Sub group 2: Depending on the superior
interior level of the thrust and postural
position of the tongue, various type of
deformities are seen in this sub group.

When the tongue is thrust directly through
the anterior opening created by allowing the
mandible to open slightly during swallow, a
force is directed against these anterior teeth
approximately one or 2 times a minute. The
associated deformities observed may be
bimax protrusion, while these anterior teeth
may have a rather high degree of angular
protrusion towards the maxilla, the usual
results is procumbency of the maxillary If
however the tongue is thrust primarily
directly anteriors associated with class II Div
I malocclusion. www.indiandentalacademy.com

Another phenomenon associated with
this type of tongue thrust is the “Reverse
Curl” (preventing the mandibular incisors form
eruption to meet the palated tissue), is
produced when the tongue thrusts forward
against the upper teeth and upon withdrawal,
exerts a lingual fore on the lower anteriors.
When the anterior vector of force is
directed primarily towards the mandibular
arch, an abnormal low postural position of the
tongue thrust habit result in a wide mandibular
arch. Anterior posterior cross bite are
common in this pattern of swallowing and
tongue posture.

Type III: Deforming lateral tongue thrust
is limited to the posterior region. It is the
least common of the major types seen this
lateral thrust of the tongue during swallow is
found somewhat more often in conjunction
with an anterior type thrust which is separately
classified as type IV. In this type III tongue
thrust pattern, we see the tongue laterally
between the posterior teeth with the resultant
posterior open bite and often an associated
posterior cross bite.

Type IV: Deforming anterior and lateral
tongue thrust.
It can be mild or quite devastating in
nature the most usual situation is to find
that, during swallowing the tongue comes
up to cover the occlusal and incisal
surfaces of all the teeth except 2nd molars).
Usually this is associated with large
tongue, individual with a decreased degree
of control of their tongue such a sin
cerebral palsy and other neuromuscular
diseases etc. Patient fall into this category.

Fletcher has developed the following
outline to indicate proposed etiologic factor
for the tongue thrust syndrome
1. Genetic Factor:
Palmer, Subtenlny et al suggest that a type
of maxillary structure which favours
development of tongue thrust may be
hereditary.
Inherited variations in oro-facial forms that
precipitate in a tongue thrust pattern
.

Inherited variations in oro facial forms
that precipitate in a tongue thrust pattern.
Inherited 0. oris hypertrophy resulting
form specific anatomic configuration and
neuromuscular interplay and generating
a tongue thrust pattern.
Genetically predetermined pattern of
mouth behaviour.

2. Learned Behaviour
a. Improper bottle feeding
b. Protracted period off tenderness or
soreness of gum tissue and teeth,
keeping the teeth apart during
swallowing and thereby changing
the swallowing and thereby changing
the swallowing pattern.
c. Prolonged thumb sucking with the
habitual movements generalized to
tongue activitywww.indiandentalacademy.com

.
d. Tongue held in open spaces during mixed
dentition and extension and habituation
of such posture into other mobile
activities of the tongue.
e. Prolong tonsillar and other respiratory
infections which cause adaptive patterns
in tongue movements that are retained
after the infection subsides.

3. Maturational
a. Tongue thrust present as part of a normal
childhood oral behavioural pattern that
is gradually modified as the lingual
space and suspensory system change.
b. Tongue thrust patterns as evidence of late
maturation from infantile suckle
swallow
c. Late maturation from a retention of
immature pattern of general oral
behaviour. www.indiandentalacademy.com

4. Mechanical restriction
a. Constricted dental arches, which cause
the tongue to function in a lower than
usual position.
b. Microglosia, which limits space in the
oral cavity and forces a forward thrust
to manipulate the bolus.
c. Enlargement of the tonsil and adenoid,
which reduces the space available for
lingual movement.

5. Neurological disturbances
a. Hypersensitive palate, which precipitates
crude pattern of food manipulation and
swallowing.
b. Disruption in the tactile sensory control
and co-ordination of swallowing.
c. Moderate motor disability and loss of
precision in oral function.

6. Psychogenic Factors:
a. Substitution of tongue thrust for forcibly
discontinuing finger sucking without
evolving the cause
b. Exaggerated motor imaging of the
tongue.

Diagnosis

Consists of a detailed examination of the
tongue.
Morphologic examination
The tongue should be examined for size
and shape, though both are subjective
observations.

Asymmetry or symmetrical:
ask the patient to protrude the tongue and
note the symmetry of its position.
Then ask the patient to relax the tongue,
allowing it to drape over the lower lip.
Functional asymmetries of the tongue
change from one position to the other.
Morphologic asymmetries will persist in the
drapped position.

Size off tongue
The size and shape of tongue may show
many variations. The tongue can be bulky or
short, narrow and long or even wide and long.
There are various methods to check the size
of the tongue, the most common of which is to
ask the patient to touch his chin with his
tongue tip. A positive result indicates
macroglossia.

In macroglossia, the tongue fills the
entire oral cavity.
It is common to see creations, scalloping
or indentations on the lateral borders of the
tongue.
The tips of the scallop filling into the inner
proximal spaces between the teeth, which
may be proclined.
There may be associated open-bite.

The conditions where macroglossia
commonly occurs.
- Myxodema and cretinism
- Down’s syndrome
- Acromegaly
- Muscular hypertrophy
- Congenital
- Tumors

Functional examination
The tongue and lips are often intergrated and
synchronized in their activity. When the lips
are parted by the mouth mirror or the cheeks
are withdrawn by retractors, normal tongue
activity may inhibited and what is observed is
accommodation to the stretching of the lips
and cheeks.
The paradoxic problem of the tongue
examination is to study the tongues function
without displacing it or the lipswww.indiandentalacademy.com

[1] Observe the postural position of tongue
while the mandible it in its postural position.
This may be done in a Cephalogram.
Reference line is drawn from ISI – incisal
marginal or lower incisor, to a – the most
caudal point on the shadow of the soft
palate or its projection onto the reference
line. To Mc the tip of the disto buccal cusp
of the lower first molar ISI and Mc are
connected by a straight line extended to ‘v’
to form the reference line.

It has the following features:
1. A relatively large part of the tongue as
seen on the cephalogram normally
lies superior to it.
2. Skeletal relationship does not effect it.
3.Change in tongue position do not effect
it.
After the line is constructed, it is bisected
between SIRS and ‘V”. This point is
called “O” and a perpendicular
constructed from it to the palatal contour.www.indiandentalacademy.com

A transparent template is used to make
the necessary measurements. The base
line of the template coincides with the
constructed reference line, and the
vertical line intersects the reference line
at “O”.
From point “O” where 3 line now meet 4
more lines are constructed. Those 7 line
of 6 angles of 30 each. Lines are marked
in mm. placing the template over the
constructed lines permits reading of the
enact measurements.www.indiandentalacademy.com

[2] Observe the tongue during the various
swallows. The unconscious swallow, the
command swallow of water and the
unconscious swallow during mastication.
The tongue tip during the normal mature
swallow touches the curvature of the
palate just behind the maxillary incisors.
The low-lying flat tongue with a forward
posture is significant in development of
class III malocclusion. It can be seen as
hereditary.

The function may be attended also due to
nursing mode being a non physiological
design of nipple, thus a subsequent
adaptive response leads to altered
function and position of the tongue
leading to malocclusion.
Nasal and pharyngeal blockage, allergies,
alters tongue position and function. One
should be able to identify this etiology
before finding fault with the function or
position of the tongue.

Palatographic examination of
tongue using palatography
The technique permits tongue function to be
observed during swallowing and speaking
and also allows the influence of various
appliance.
Speech disorders were also studies by
palatography methods.

b. Indirect method was first used by
Kingsley. He prepared an upper plate
of black India rubber and covered the
tongue using a mixture of chalk, palate
were the transferred on the cast
a. Direct method: described by Oakley
Coles 1873, Gum Arabica and Flour were
mixed and painted on the tongue. After the
selected range of tongue exercises are
performed, the contacts on the palate and
teeth will be transferred to a cast

The current direct method entitles covering
the superior surface of the tongue with
precision impression material.
A thin even layer is applied to the tongue
with a spatula.
After functional exercise, a Polaroids print is
made of the palatal region with the help of
surface mirror.
The evaluation of the palathogram is
possible by direct measurement on the
picture. www.indiandentalacademy.com

The Payne technique
Dr. Evemt Payen and others developed a
technique to measure exactly where the
tongue hits the palate during the
swallowing act.
The revealing substance is orobase with a
1% sodium flourescien solution in water-
soluble base.
Utilizing the black light technique will
reveal exactly where the tongue is placed
during the swallowing act.www.indiandentalacademy.com

Cine flurographic analysis
The tip of tongue is quoted with barium
solution when the patient swallows.
The cine flurographic camera shorts at
the rate of nearly 240 frames per second.
The whole swallowing cycle takes a sec ,
which can be monitored on a TV. If the
tongue extended beyond the line
drawn,then the patient is considered to
have tongue thrust habit.

Differential diagnosis of abnormal
tongue posture
Tongue posture is related to skeletal
morphology
For example a sever class III skeletons, the
tongue tends to lie below the plane of
occlusion, and a class II facial skeletons
with a short mandible and steep
mandibular plane, the tongue may be
positioned forward.

Two significant variations from the normal
posture can be seen.
1. Retracted or locked tongue in which
the tongue tip is withdrawn from all
the anterior teeth.
2. Protracted tongue in which the resting
tongue is between the incisor.

.
The retracted tongue is seen in less than
10% of all children, but is often
associated with posterior open bite since
the tongue may spread laterally.
The retracted tongue is unsetting to
mandibular artificial dentures posture
(i) endogenous and (ii) acquired adaptive

The protracted tongue postures
may be i) endogenous and (ii) acquired
adaptive
The protracted tongue postures are
frequently adaptations to
excessive anterior facial height, a
condition which predisposes to
open bite, the tongue posture
necessarily adapting to enforce an
anterior seal during the swallow.

Clinical diagnosis of tongue
thrusting
-The patient is seated upright with the
vertebral column vertical and Frankfort
horizontal plane parallel to the floor.
- Try to observe, unnoticed several
unconscious swallow.

- Then place a small amount of water
beneath the patients tongue tip an
ask patient to swallow noting the
mandibular movement
- In the normal mature swallow, the
mandible rises as the teeth are
bought together during the swallow
and the lip touching. The facial
muscle ordinarily do not show
marked contraction in the normal
mature swallow.

A hand over the temporalis muscle,
pressing lightly with the finger tips against
the patients head with the hand in this
position.
The patient is given more water and ask
for a repeat swallow.
During the normal swallow, the temporalis
muscle can be felt to contract as the
mandible is elevated, and the teeth are
hold together, whereas in tooth apart
swallow, no contraction of the temporalis
muscle will be notedwww.indiandentalacademy.com

Clinical features

- Proclination of the upper anteriors
- Retroclination of the lower anteriors
- Typical diastema
- Open bite
- Complete collapse of the maxillary arch
- Open bite from first molar and second
molar forward.

Management

There are cases in which tongue thrust
therapy is not to be administered
1. When the malocclusion has been stable
for several month or years and is not
serious enough to warrant orthodontic
correction in case where patient and
parent are cautioned to watch carefully
for the sign of change in severity of
malocclusion.

2. When patient demonstrated either through
a history of failure speech therapy,
resistance to therapy, or unwillingness to
comply with practice requirements as they
are explained to him, a poor attitude towards
the remedy of his problem
3. In patients with severe mental retardation,
brain damage or behavioural disorders.

4. When parent and other responsible
person cannot or will not observe the
child and observe the child and
provide feed back to him and to the
therapist concerning his
performance.
The best stage to start treatment is the
mixed dentition, by interceptive
procedures called functional
compensation

Functional compensation should be
regarded as the ability of an organ or a
system to modify its behaviour.
The compensating appliance called “Bi
prax” because they allow a physiologic
display of two namely buccal “praxisms”
speech and deglutition. It is complied like
all the removal appliance, of an acrylic resin
base and metal elements. It is essential to
know the orientation and mode of action of
the muscle fibres of the different masticating
muscle before its usewww.indiandentalacademy.com

The other line of therapy is the use of
muscle forces by simple orthodontic
appliance may be fixed or active
removable plate use intrinsic or stored
forced to move teeth.
Functional or muscle motivating
appliance is broadly divided into 3 groups
All 3 groups may be considered as
interceptive appliances. Mixed dentition
being the most frequent and optimal time
for therapy www.indiandentalacademy.com

Oral screen
It is vestibular screen, to avoid the outward
thrust of the tongue and to control the
proclination of the anteriors.
Used together with breathing holes is used
also in the control of mouth breathing.

Double screen
A small lingual screen is attached to the
vestibular screen with 0.036” wire.
Modified Bionator screened the adverse
tongue pressure promote mandibular
development with forward construction
bite and labial bow helps in retraction of
anterior teeth.
If the habit is noticed in its beginning stages
and the patient is willing for a treatment,
one can advocate self corrective treatment
procedure such as:www.indiandentalacademy.com

Acquaint the patient with the normal
swallow by placing the index finger on
the tip of the tongue and then on the
junction of the hard and soft palate and
instruct the patient to place the tongue
there while swallowing.
Instruct the patient to close the lips and
swallow while holding the tongue
position.
Use of tactile signals help the patient to
understand what to do. One is asked to
practice 40 minutes a day.www.indiandentalacademy.com

Single elastic swallow :
A small orthodontic elastic can be paced
in the tongue tip and patient asked to
swallow with the tip against the palate.
If the swallow is correct, the elastic will
retain ; in incorrect the elastic will be
swallowed.
practice 2-3 times/sessions each day.

When the new swallowing pattern is
being learnt on a conscious level, it is
necessary to reinforce it
subconsciously. Then sugarless fruit
drops can be used to reinforce it
subconsciously. Then sugarless fruit
drops can be used to reinforce the
unconscious swallow.

A removable or cribs appliance or a
spur appliance will help the tongue
to be reminded and redirected
towards the correct swallowing
pattern.
Psychologic aspects of disruption of
tongue thrust or tongue sucking by
means if a dental appliance.

Hay rake appliance: A device called Hay
rake is a non-removable appliance
cemented to the Childs teeth to prevent
tongue sucking and tongue thrust.
Having considered the interceptive
treatment, the corrective treatment include
appliance to correct the malocclusion as
well. These appliance include
Quad Helix described as an appliance
used in thumb sucking as well as tongue
thrust when tongue spurs are used to
inhibit the habit. www.indiandentalacademy.com

Treatment with bioactivator and
headgear: as it effects on dentition and
also on the skeletal structure. Effects were
increased in the sagittal than vertical plane
thus reducing the increased FMA angle
accompanied due to tongue thrust and lower
positioning of mandible.
Class II division I malocclusion with an
activator head gear showed that during
maximal bite the activity of the posterior
temporal muscle decreased in a group with
head gear and in activator.

The disease was considered to be an
effect of occlusal instability brought
bout by the treatment, although such
decrease has been described as a
sign of forward displacement of the
mandible during treatment with the
junctional appliance.

Active vertical corrector: A non-
surgical alternative for skeletal open bite
together with tongue thrust habit. It a
simple removable or fixed orthodontic
appliance that intrudes the posterior teeth
in both the maxilla and mandible by
reciprocal forces.
Frankles I, II, IV are also used depending
on the type of malocclusion present and
companying growth pattern existing in the
patient.

Classification of mouth Breathers

a. Obstructive
b. Habitual
c. Anatomic
Obstructive:
mouth breathers are children who have
an increased resistance to or complete
obstruction or the normal flow of air
through the nasal passage.

Because of the difficulty in inspiring the
expiring air to the nasal passage, the
child is forced by sheen necessity of
breath through his mouth.
Habitual:
these mouth breathers are children who
continually breath through the mouth by
force of habit. Although the abnormal
obstruction has been removed.

Anatomical:
The anatomic mouth breathers is are
whose short upper lip does not permit
complete closure without undue effort.
Anatomic mouth breathers are
frequently ectomorphic children, who
possess long, narrow faces and
nasopharyngeal space.
These children are more prone to nasal
obstruction.

Etiological factors

1. The nasal obstruction may be due
to
a. Deviated nasal septum.
b. Nasal polyps
c. Chronic inflamed nasal mucous,
hypersensitive nasal mucosa as in
chronic allergic rhinitis
d. Localized benign tumors.

e. Congenital enlargements of
tubrinates
f. Tonsillitis
g. Adenoid, which are enlarged.
The “adenoid facies” is the most often
ectopic factor of mouth breathing.
Adenoid are a mass of lymphoid tissue
situated at the roof of the nasopharynx in
the form of bee hive.

2. Mouth breathing related with thumb
sucking and lip biting
Thumb sucking and lip biting are often
accompanied by mouth breathing.
Thumb sucking lone does not produce
deformities beyond those of the dental arch
and teeth, while the accompanied mouth,
breathing does much more harm.

3] Hereditary
Some individuals are more
susceptible to this habit.
It occurs more frequently in long
faced (dolico facial) tall, slender
person (ectomorphic) in whom the
pharyngeal space is more long but
narrow.

1. Study the patient breathing unobserved.
Nasal breathing usually show the lip sucking
during relaxed breathing whereas mouth
breathers keep their lips apart
2. The patient is asked to take a deep
breath. Most respond by inspiring through
the nose with the lips lightly closed, but not
mouth breathers.

1. The patient is asked to take a deep breath
with lips closed, and breath through the nose.
nasal breathers normally demonstrated good
reflex control on the alar muscle, which control
the size and shape of the external nares,
therefore they dilate external nares, on
inspiration. Mouth breathers even though are
capable of breathing through the nose, do not
change the size and shape of the external
nares and occasionally actually contract the
nasal office while inspiring.

1. Placement of a double surfaced mirror
on the upper lip. If the patient is a nasal
breather, the upper surface will cloud, if
mouth breather, the lower surface will cloud.
2. Butterfly cotton wool test: Is a placement
of small cotton wisp in front of each nostril, if
it is pushed away during expirating, patient is
said to be a nasal breathers.
3. Patient asked to hold a piece of paper
between his lips. A mouth breather cannot
hold his lip together for too long.www.indiandentalacademy.com

Other diagnostic evaluation have thus been
formulated
Use of plethysmograph with a air flow
transducer is used to determine the total nasal
air flow and oral air flow. This is a quantitative
analysis stated by Warren.
The advent of lateral cephalograms have
enabled to identify the size the extent of
obstruction of the naso pharyngeal passage.
Adenoids in lateral cephalograms showed a y-
ray picture, and one could identify small,www.indiandentalacademy.com

Rhinomanometry and respirometry
Stedman’s medial dictionary defines
Rhinomanometry as study of nasal
obstruction and nasal airflow
characteristics. Since this term refers
only to nasal airflow measurements direct
oral respiratory measurements is termed
respirometry, and implies the study of
both nasal and oral respiratory function

The flow meter or prime mover is a tube
containing an electrically connected screen. As
air flowing through the tube passes the resistance
screen, a pressure drop occurs, the screen is
heated to prevent liner condensation of moisture,
which would distort the data. A given critical
value of nasal resistance constitutes nasal
obstruction to force a change from nasal to oral
breathing.
Sphygmomonometer spirometer measured the
total respiratory output while an attached nasal
mask coupled to a pneumotracheograph
recorded nasal airflow. Disadvantage is that a

Snort:
Simultaneous nasal and oral respirometric
technique for quantitative assessment of
respiratory mode by Gurley, Vig 82.
This system has an accuracy and
reproducibility of 97% and make it possible to
monitor, record and calibrate continuously
both oral and nasal inspiration and expiration.
The output is in the form of waves.

The recordings are 4:
- Oral inspiration
- Oral expiration
- Nasal inspiration
- Nasal expiration

The electrical signal can be converted to
digital form and stored.
Features of SNORT
1. Allows precise recording of respiratory
function
2. Capable of representing oral and nasal
inspiration and expiration in detail.
3. Able to record and measure airflow
simultaneously for oral, nasal inspiration and
expiration. www.indiandentalacademy.com

1. Provides a comparison between total
inspired air volume with expired air volume.
2. Inspirations can be compared with
expiration.
3. Generates numerical values for
variation in nasal respiratory functional and
oral breathing, thereby permitting the
objective determination of both normal and
pathologic state.

Plethysomography with airflow
transducer:
A quantitative technique for assessing nasal
airway impairment has been described by
Donald Warren.

The methods involve a modification of the
theoretical hydraulic principle and unables
the clinical too:
1. Estimate the size of the airway during
breathing.
2. Distinguish between normal and
impaired nasal respiratory function and
3. Determine quantitatively, the effects of
surgical and on orthodontic treatment of
improving nasal respiration.

The principle is based upon hydrokinetic
principles using instruments capable of
accurately measuring respiratory parameters.

Clinical effects and features of mouth
breathing
Can be enumerated as
a. Local
i. Soft
tissue
ii. Hard
tissue
iii. Esthet
ic hygiene.

Local effects: Lip become black and stay
open, so that the upper lip is shortened and
elevated form over the upper incisor, while the
lower lip becomes heavy and everted and
usually lies beneath and behind the upper
incisor instead of over them. Thus modeling
action of lips on upper incisors is lost.
Resulting protrusion of those teeth.
Cheeks: As the mouth is habitually held open,
the cheeks are pulled downward and becomes
narrow and full values with each inspiration.
Chin : Is receded

Gingivae: Become hypertrophied and also
inflamed persistent marginal gingivitis limited to
the anterior cuspid to cuspid region. This
continuous impact of cold air irritated the oral
tissue caused drying of the lips, and may result
in cheltis. As the lips do not close, the anterior
teeth loose their natural cleaning with saliva
resulting in collection of food debris and tatar
formation around the teeth.

Mucous Membrane: Becomes prone to
inflammation due to drying and irritation.
Nasal mucosa: becomes atrophied due to
disuse. The bacteriostatic action of the nasal
secretion is lost and pathway is permitted
whereby disease, particularly viral infection,
may safely enter the lungs.
Speech: Acquires a “nasal” tone;. This is
because the paranasal sinuses are not fully
formed, whose function is to give resonance to
the voice.

Smell: the sense of smell is dulled and it
taste sensation and appetite.
Nasal turbinates: becomes hyperplastic
from venous stasis and impact of cold, dust
laden air.

B. Hard tissue
1. Inhibits the growth of pre maxilla
2. Upper dental arch is decreased in width
and becomes V shaped. The molar process of
the maxilla instead of taking cold upward
sweep, develop a download curve at its
functions with the molar bone this display a
general narrowing of the face when viewed from
the front.

To breath through the mouth, one must
open up and maintain an oral airway. 3
changes in posture are needed to
accomplish this
- Lower the mandible
- Positioning of tongue downward and
forward
- Extending the head

1. Some animals learned to posture their
mandible with a down and backward
opening.
Dramatic morphological changes were
seen as mentioned earlier at the gonial
angle and chin region. The distance from
the nasion to chin increased significantly,
as did the distance from the nasion to the
hard palate. This indicated that the
lowering of the mandible was follo3wed by
a downward displacement of the maxilla.

The severity of the deformities depends on
1. Age of the child
2. Degree of adenoids and subsequent
mouth breathing
3. Duration
4. Degree of disposing cause

Other effects:
1. Older children snore at night, difficulty in
swallowing
2. Mucous secreted by the adenoids is
swallowed in large quantities and produce
dearrangement of stomach and intestine with
failure of growth and general health.

Psychic effects:
The general appearance and accompanying
malocclusion leads to an introvert personality.
The child fails to command respect from
others. The child is victim of mockery by his
fellowmates. The child develops inferiority
complex, becomes different and fail to
succeed in the normal way of life. The child
always remain backward and shows mental
deficiency.

Management
The first step is look for any obvious and
definite cause of nasal obstruction and to
treat them if any.
After ENT specialist has eliminated all air
passage obstruction, the first problem is to
divide if the child should have immediate
orthodontic treatment. Ballard is of the
opinion that there is seldom any need to
embard any treatment in young child, as he
believes than orthodontic treatment need not
be necessary as adenoids regress by age of

Prevention and interception of the habit
The habit ceases automatically around and
after puberty. This is because of the fact
that the nasal and pharyngeal passages
increase in size during the period of rapid
growth of the child it is during this period
when one can advocate self corrective
treatment and muscle exercise. These
include – self-reminding scheme to keep the
lip closed and breath through the nose at all
the times.

Reminder: A silent signal arranged between
parent and child serves as constant
reminder to the child. The signals eliminate
the nagging effect sometimes produced by
the spoken word.
Gard: A piece of card 11 ½ held between
the lip while reading listening to radio, home
work and at other odd times during the day
is helpful in keeping the lip closed for a
certain number of times each day.

Exercises:
Lip exercise: Blow under the upper lip and
hold under tension to a slow count of four.
Repeat 25 times each day.
Draw upper lip down over the upper incisor
and held it under tension for a count of 10.
Repeat 10 times, four times daily repeat with
altering the above two exercises.

Tape stick a tape to lip at night using 2 ½ - 3”
length about ½” wide cellulose tape in form of
an X. It is necessary that no mouth breathing
occurs during the 8 hours or so at night.
Webb’s exercise called 0. Oris exercise,
design to reestablish function and toxicity.
The exercise is carried out by using first two
fingers of the right hand.
Alternate contraction and relaxation until a
feeling of slight fatigue is experienced.
Repeat at least 20 times.www.indiandentalacademy.com

Wilson’s exercise: I useful when the
underdeveloped and hypotonic lips are due to
chronic breathing. The effects of this exercise
are to lengthen all the muscle of lateral nasal
wall. To increase the size and capacity of the
nasal cavity.
Patient routine: Close the teeth in correct
position, close lip tightly.
Contract the muscle at left corner of mouth
casing the corner to be pulled backward and
upwards.

While holding this position with fingers of left
hand placed on the right cheek tissue forward
and lift. The tissue t the left corner of the
mouth must continue the contraction all
through the muscle pulling.
While those tissue are left corner are still
contacted and right cheek is under pressure
by the finger breath deeply, 3 times through
the left nostril.

Relax the muscle an remove hand. Repeat
with right corner of the mouth using right
hand supplemental to these exercises all
patient should wear string at night.
This help in good lip seal and probably
reduces the overjet produced as a
consequence of mouth breathing habit.

Masseter temporal exercise
The patient is instructed to place the lip of the
tongue against the mucous membrane directly
behind the mandibular incisor teeth and with each
contraction of the alveolar process this exercise
trains the tongue to remain in its proper position
and has a tendency to prevent the narrowing of
the mandibular arch, facilitating the earlier
removal of the retentive appliance

The mentalis muscle exercises:
Myo functional therapy for the metnalis muscle
includes the development of the O. Oris and the
associated muscle. The lips must be trained to
function normally so that when they are closed,
the upper lip will do its hare of the work. The
exercises should be started as soon as the
protrusion has been reduced to the extent that it
is possible for the patient to close the lips without
stretching them.

3 exercises are recommended
1. An exercise to develop the upper lip
2. Enunciations of the latter ‘p’ and
whistling.

The exercise to develop the upper lip was
devised by LSI Lousie 57.
1. Grasp the chin firmly between the thumb
and the index finger with the lips relaxed.
2. Hold the lower lip down
3. Close the lips.

Relax and repeat 10-50 times, at a specified
time, as before meals.
Note: The lower lip is held down as the lips
are closed, the upper lip must come down to
meet the lower lip

The enunciating of sound ‘p’ is given by B.
Johnson
- Sound should be forcible
- Should be made before the mirror
- The patient should be instructed how to
make the sound
- The exercises period 5-10 minute each
day.
The muscular actively involved a (laying a wing
instrument is valuable in training andwww.indiandentalacademy.com

Orthodontic appliances used
Oral screen: Introduced by Newell 1912 and
since then many modifications have taken
place.
However, one has to be carefully use this
appliance for mouth breathing where nasal
passage is clear.
It can also be fabricated of self curing resin
breathing holes are included initially during
treatment to get adapted to the appliance.
The appliance fills the vestibular cavity thuswww.indiandentalacademy.com

A ring can be attached on the front of the oral
screen to exercise the lips
Alternative for a ring is string and button
attachment. An exercises of 30 minutes daily is
necessary for beneficial results.
Further, as the oral screen is resulting on the
protruded maxillary incisors, with the check held
away from the canine and premolar areas, arch
from csn improved by reduction of Overjet due to
pressure of lips translated onto the incisor
thereby decreasing the overjet. The buccal
clearance on each side is 2-3 mm, this keeps the
pressure of the posterior teeth.

Modification combined oral screen, describe din
tongue thrust.
Posterior bite block:
Has spring loaded posterior occlusal bite
blocks. (a) spring (b) Adamp Clarp 0.028”
The acrylic plastic on the mandibular base plate
should contact the lingual surface of the
mandibular incisors to prevent their eruption
and lingual movement, which is associated with
an open posture of mouth while appliance is
worn. www.indiandentalacademy.com

The helical spring may be activated
progressively to maintain continuous
tension in the neuromuscular system
supporting the mandible produces rapid
bone remodeling.
Sutural arches edgewise mechanotherpy
helps to assist vertical control of buccal
segment, while incisors teeth are being
aligned or intrude.

Frankle regulator: showed a greater downward
shift of mean frequency of massetter and
temporalis muscle. It was seen none in Frankle
I and Bionator, than in Frankle III. Then
downward shift might have been associated
with change in muscle fiber length and or
recruitment pattern as a result of both treatment
and normal growth.
Slow maxillary expansion can be applied to
mandibular arch, while rapid maxillary
expansion can be used for the narrow maxillary
arch, however the benefit of expansion inwww.indiandentalacademy.com

As the nasal cavity is high and narrow even
a small increase in width will produce a
great increase in cross sectional area and
permit the passage of increase volume of
air.
Surgical intervention is the last resort, to
wide the nasal passage. A Le-fort-I surgical
procedure is the surgical procedure often
carried out.

Other habit
Occlusal mannerisms may be defined as
position of the teeth and surrounding
structures assumed by the patient
involuntarily when they experience stress
anxiety and total etc. according Salzmann,
these mannerisms or tick occlusion are an
important cause of relapse.

Bruxism (Slider Dentium): Occlusion neurosis,
Karoli effect etc. refers to the involuntary
mandibular excursions which produce inaudible
or audible clenching, gnashing cusp tipping and
other traumatic effects. Rarely is the patient
aware of such a habit. The titanic contractions of
the masticatory muscles and rhythmic grinding
cause malocclusion or the result of malocclusion.
E.g. Unfavorable sequellae of deep bite may be
bruxism and clenching

Bruxism is an estomeric contraction of
masticatory muscles accompanies by
augmentation of tension and increase active
stimuli. This habit may be caused by
physical discomfort or may be an expression
of mental unrest, kinesthetic and
neuromuscular overplay. Nervous tensions
tends a most gratifying release in clenching
and bruxism.

High strung people are more prone to rent
great, crack and wear down their teeth with a
bruxing motion. Nocturnal bruxism cannot
even be duplicated during the waking hours
by most of them. The magnitude of
contraction is anonymous and the deleterious
effect on occlusion are obvious.
Discovering the habit by the patient of his
own unconscious biting or clenching during
waking hours is of diagnostic value and is
often first step towards correction.

Variation of bruxism
1. Clenching habit in which pressure is
brought upon the periodontal structured by
repeated clamping of teeth.
2. Clicking habit, which is rapid, repeated,
rhythmic, clamping of teeth.
Treatment includes, to exploit the weak links of
the psychogenic demands, performed crowns
and bridges.
Nail biting: (Onychophagy) is a condensed

It is therefore necessary to study the Childs
physical, mental an social difficulties if the root
of the habit are to be removed.
Psycho analysts consider nail biting to
represent the molar activity by which person
attempts to integrate his various drives to
release oral sadistic impulses or aggressions
and at the same time the external object is
spaced dental and guilt is expiated, by
infliction of pain upon one self. Therefore,
fingernail biting is usually absent below age of
3 years and a rapid increase at 6 years.
There is a constant trend to 10 years in girls

Kanner and Bawkin found that biting of
toenails occurred exclusively in girls.
The habit is usually replaced after
adolescence by lip biting, gum hewing or
smoking. Nail biting usually of a severe type
is especially seen among people showing
personality disturbances.
The habit shows a high correlation with
slaughtering but is present among will
adjusted as well as poorly adjusted children.

Treatment
Punishment, scolding and restraints are of no
value and may as in the treatment of thumb
sucking lead to psychological difficulties.
Clinical examination of teeth or nail biters
may disclose induced crowding, rotation and
attrition of incisal edges of incisal teeth
especially mandibular incisors. These
malocclusions are due to upward pressures
induced during nail biting. Thus the
treatment would include probing deeper in
the psychological backward of the child.

- Cut the nail short
- Light cotton metten worn at night to act
as remedies
- That the nails are not to be bitten

Lip biting: has many variations lip sucking
may occur as a variant of a lip sucking or as a
substituted for thumb or finger sucking.
Clinical the lip is seen to be trapped between
the upper anteriors. The diagnostic features
could be proclined upper anteriors and or
swollen and cracked lips due to chronic
sucking and prone to infection due to moist
nature. The lips may be redundant. Mento
labial sulcus becomes accentuated.
Treatment consists of constant reminding if
the habit has a psychogenic factor involved
like an expression of stress or anxiety one has

Pillowing habit
Postural defects during sleep have been
considered an etiologic factors in
malocclusion. Children and adults do not lie
in one position during sleep, but move bout at
frequent intervals. Those movements are
largely involuntary and are produced by
nervous reflexes in order to obviate pressure
interferences, with circulation, before his
position during sleep. In the final analysis, in
order for pressure to influence jaw growth, the
force of the pressure exerted on the jawswww.indiandentalacademy.com

Posture during the Childs waking hours is
more important than position during sleep, in
the production of dental malocclusion.
Deformity, flattening of the skull and facial
asymmetry may occasionally developed
during the first year in infants who habitually
lie in the superior position with the hed turned
to right or left the constant position of the
child may be due to the act that the infant
habitually turns to the source of light..

Such changes in the Cephalia index as one
brought about by inducing infants to lie in
one position are not usually persistent.
There is a tendency for the inherent pattern
to manifest itself in later life.
Self multilation – is a repetitive acts that
result in physical damage to the individual
is extremely rare in the normal child.

However the incidence of self mutilation in the
mentally retarted population is between 10-20%
(Don Bosten and MC Iver 84). It has been
suggested that self multitation is a learned
behaviour, to gain attention.
A frequent manifestation of self-mutilation or
biting of lips tongue and oral mucosa.
Self-mutilation has also been associated with bio
chemical disorder such as Lesch Nyham and de
Lanje’s syndrome

Frenum thrusting: If the upper anterior
teeth are spaced, the child may lock his
labial frenum between them and resort to
frenum thrusting. It may develop into a
tooth displacing habit by keeping the central
incisors apart, just s in case of abnormal
frenum attachment.
Body-pin opening: the upper and lower
anteriors are commonly and teeth partially
denuded of labial enamel, seen commonly
in girls.

Thank you
For more details please visit

Leader in oral habits and their classifications

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Leader in oral habits and their classifications

Similar to Leader in oral habits and their classifications (20)

More from Indian dental academy

More from Indian dental academy (20)

Recently uploaded

Recently uploaded (20)

Leader in oral habits and their classifications