Oral habits 1 /certified fixed orthodontic courses by Indian dental academy

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Oral habits 1 /certified fixed orthodontic courses by Indian dental academy

  1. 1. www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. 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
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  5. 5. 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 www.indiandentalacademy.com
  6. 6. 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. www.indiandentalacademy.com
  7. 7. 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? www.indiandentalacademy.com
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  9. 9. 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 www.indiandentalacademy.com
  10. 10. 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
  11. 11. 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. www.indiandentalacademy.com
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  13. 13. 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. www.indiandentalacademy.com
  14. 14. 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 www.indiandentalacademy.com
  15. 15. 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 www.indiandentalacademy.com
  16. 16. 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
  17. 17. 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 www.indiandentalacademy.com
  18. 18. 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 www.indiandentalacademy.com
  19. 19. 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
  20. 20. 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. www.indiandentalacademy.com
  21. 21. 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 www.indiandentalacademy.com
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  23. 23.  Thumb-sucking  Tongue thrusting  Mouth breathing  Bruxism  Nail biting  Finger biting  Tongue sucking  Self-mutilation www.indiandentalacademy.com
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  25. 25. 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. www.indiandentalacademy.com
  26. 26. 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 www.indiandentalacademy.com
  27. 27. 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. www.indiandentalacademy.com
  28. 28. 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
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  30. 30. 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. www.indiandentalacademy.com
  31. 31. 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. www.indiandentalacademy.com
  32. 32. 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. www.indiandentalacademy.com
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  34. 34. 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
  35. 35. Oral drive theory of Sears and Wise: proposed that prolonged sucking can lead to thumb sucking with no underlying cause or psychological bearing. www.indiandentalacademy.com
  36. 36. 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
  37. 37. Psychological aspects: Children deprived of parental love, care and affection are believed to resort to this habit due to a feeling of insecurity. www.indiandentalacademy.com
  38. 38. 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. www.indiandentalacademy.com
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  40. 40. 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
  41. 41. 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 www.indiandentalacademy.com
  42. 42. 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
  43. 43. Dento facial changes associated with prolonged NNS Habits www.indiandentalacademy.com
  44. 44. 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
  45. 45. Effect on the mandible - Increased proclination of incisors - Increased inter molar distance - Increased distal position of B point www.indiandentalacademy.com
  46. 46. 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 www.indiandentalacademy.com
  47. 47. Effect on lip placement and function - Increased lip incompetence - Increased lower lip function under maxillary incisor www.indiandentalacademy.com
  48. 48. 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 www.indiandentalacademy.com
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  50. 50. 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.. www.indiandentalacademy.com
  51. 51. 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
  52. 52. 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
  53. 53. 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. www.indiandentalacademy.com
  54. 54. 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. www.indiandentalacademy.com
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  56. 56. Management may be divided into - Preventive - Interceptive - Corrective (a) early treatment (b) Late treatment - Post treatment or retention www.indiandentalacademy.com
  57. 57. 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 www.indiandentalacademy.com
  58. 58. 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. www.indiandentalacademy.com
  59. 59. 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. www.indiandentalacademy.com
  60. 60. 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
  61. 61. 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: www.indiandentalacademy.com
  62. 62. 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. www.indiandentalacademy.com
  63. 63. 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. www.indiandentalacademy.com
  64. 64. 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
  65. 65. 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. www.indiandentalacademy.com
  66. 66. 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. www.indiandentalacademy.com
  67. 67. 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 www.indiandentalacademy.com
  68. 68. . 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
  69. 69. 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
  70. 70. 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. www.indiandentalacademy.com
  71. 71. 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. www.indiandentalacademy.com
  72. 72. 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 www.indiandentalacademy.com
  73. 73. . 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
  74. 74. 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. www.indiandentalacademy.com
  75. 75. 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. www.indiandentalacademy.com
  76. 76. 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
  77. 77. 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. www.indiandentalacademy.com
  78. 78. 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. www.indiandentalacademy.com
  79. 79. 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 www.indiandentalacademy.com
  80. 80. 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
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  82. 82. 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
  83. 83. Classification of tongue thrust www.indiandentalacademy.com
  84. 84. 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
  85. 85. 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. www.indiandentalacademy.com
  86. 86. 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. www.indiandentalacademy.com
  87. 87. 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
  88. 88. 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. www.indiandentalacademy.com
  89. 89. Classification of tongue thrust www.indiandentalacademy.com
  90. 90. 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
  91. 91. 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. www.indiandentalacademy.com
  92. 92. 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. www.indiandentalacademy.com
  93. 93. 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
  94. 94. 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. www.indiandentalacademy.com
  95. 95. 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. www.indiandentalacademy.com
  96. 96. 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. www.indiandentalacademy.com
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  98. 98. 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 . www.indiandentalacademy.com
  99. 99. 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. www.indiandentalacademy.com
  100. 100. 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
  101. 101. . 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. www.indiandentalacademy.com
  102. 102. 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
  103. 103. 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. www.indiandentalacademy.com
  104. 104. 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. www.indiandentalacademy.com
  105. 105. 6. Psychogenic Factors: a. Substitution of tongue thrust for forcibly discontinuing finger sucking without evolving the cause b. Exaggerated motor imaging of the tongue. www.indiandentalacademy.com
  106. 106. Diagnosis www.indiandentalacademy.com
  107. 107. Consists of a detailed examination of the tongue. Morphologic examination The tongue should be examined for size and shape, though both are subjective observations. www.indiandentalacademy.com
  108. 108. 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. www.indiandentalacademy.com
  109. 109. 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. www.indiandentalacademy.com
  110. 110. 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. www.indiandentalacademy.com
  111. 111. The conditions where macroglossia commonly occurs. - Myxodema and cretinism - Down’s syndrome - Acromegaly - Muscular hypertrophy - Congenital - Tumors www.indiandentalacademy.com
  112. 112. 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
  113. 113. [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. www.indiandentalacademy.com
  114. 114. 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
  115. 115. 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
  116. 116. [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. www.indiandentalacademy.com
  117. 117. 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. www.indiandentalacademy.com
  118. 118. 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. www.indiandentalacademy.com
  119. 119. 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 www.indiandentalacademy.com
  120. 120. 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
  121. 121. 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
  122. 122. 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. www.indiandentalacademy.com
  123. 123. 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. www.indiandentalacademy.com
  124. 124. 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. www.indiandentalacademy.com
  125. 125. . 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 www.indiandentalacademy.com
  126. 126. 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. www.indiandentalacademy.com
  127. 127. 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. www.indiandentalacademy.com
  128. 128. - 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. www.indiandentalacademy.com
  129. 129. 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
  130. 130. Clinical features www.indiandentalacademy.com
  131. 131. - 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. www.indiandentalacademy.com
  132. 132. Management www.indiandentalacademy.com
  133. 133. 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. www.indiandentalacademy.com
  134. 134. 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. www.indiandentalacademy.com
  135. 135. 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 www.indiandentalacademy.com
  136. 136. 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
  137. 137. 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
  138. 138. 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. www.indiandentalacademy.com
  139. 139. 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
  140. 140. 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
  141. 141. 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. www.indiandentalacademy.com
  142. 142. 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. www.indiandentalacademy.com
  143. 143. 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. www.indiandentalacademy.com
  144. 144. 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
  145. 145. 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. www.indiandentalacademy.com
  146. 146. 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. www.indiandentalacademy.com
  147. 147. 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. www.indiandentalacademy.com
  148. 148. www.indiandentalacademy.com
  149. 149. Classification of mouth Breathers www.indiandentalacademy.com
  150. 150. 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. www.indiandentalacademy.com
  151. 151. 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. www.indiandentalacademy.com
  152. 152. 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. www.indiandentalacademy.com
  153. 153. Etiological factors www.indiandentalacademy.com
  154. 154. 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. www.indiandentalacademy.com
  155. 155. 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. www.indiandentalacademy.com
  156. 156. 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. www.indiandentalacademy.com
  157. 157. 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. www.indiandentalacademy.com
  158. 158. Diagnosis www.indiandentalacademy.com
  159. 159. 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. www.indiandentalacademy.com
  160. 160. 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. www.indiandentalacademy.com
  161. 161. 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
  162. 162. 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
  163. 163. 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 www.indiandentalacademy.com
  164. 164. 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 www.indiandentalacademy.com
  165. 165. 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. www.indiandentalacademy.com
  166. 166. The recordings are 4: - Oral inspiration - Oral expiration - Nasal inspiration - Nasal expiration www.indiandentalacademy.com
  167. 167. 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
  168. 168. 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. www.indiandentalacademy.com
  169. 169. Plethysomography with airflow transducer: A quantitative technique for assessing nasal airway impairment has been described by Donald Warren. www.indiandentalacademy.com
  170. 170. 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. www.indiandentalacademy.com
  171. 171. The principle is based upon hydrokinetic principles using instruments capable of accurately measuring respiratory parameters. www.indiandentalacademy.com
  172. 172. Clinical effects and features of mouth breathing Can be enumerated as a. Local i. Soft tissue ii. Hard tissue iii. Esthet ic hygiene. www.indiandentalacademy.com
  173. 173. 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 www.indiandentalacademy.com
  174. 174. 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. www.indiandentalacademy.com
  175. 175. 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. www.indiandentalacademy.com
  176. 176. 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. www.indiandentalacademy.com
  177. 177. 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. www.indiandentalacademy.com
  178. 178. 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 www.indiandentalacademy.com
  179. 179. 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. www.indiandentalacademy.com
  180. 180. 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 www.indiandentalacademy.com
  181. 181. 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. www.indiandentalacademy.com
  182. 182. 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. www.indiandentalacademy.com
  183. 183. 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 www.indiandentalacademy.com
  184. 184. 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. www.indiandentalacademy.com
  185. 185. 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. www.indiandentalacademy.com
  186. 186. 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. www.indiandentalacademy.com
  187. 187. 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
  188. 188. 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. www.indiandentalacademy.com
  189. 189. 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. www.indiandentalacademy.com
  190. 190. 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. www.indiandentalacademy.com
  191. 191. 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 www.indiandentalacademy.com
  192. 192. 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. www.indiandentalacademy.com
  193. 193. 3 exercises are recommended 1. An exercise to develop the upper lip 2. Enunciations of the latter ‘p’ and whistling. www.indiandentalacademy.com
  194. 194. 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. www.indiandentalacademy.com
  195. 195. 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 www.indiandentalacademy.com
  196. 196. 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
  197. 197. 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
  198. 198. 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. www.indiandentalacademy.com
  199. 199. 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
  200. 200. 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. www.indiandentalacademy.com
  201. 201. 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
  202. 202. 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. www.indiandentalacademy.com
  203. 203. 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. www.indiandentalacademy.com
  204. 204. 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 www.indiandentalacademy.com
  205. 205. 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. www.indiandentalacademy.com
  206. 206. 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. www.indiandentalacademy.com
  207. 207. 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 www.indiandentalacademy.com
  208. 208. 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 www.indiandentalacademy.com
  209. 209. 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. www.indiandentalacademy.com
  210. 210. 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. www.indiandentalacademy.com
  211. 211. - Cut the nail short - Light cotton metten worn at night to act as remedies - That the nails are not to be bitten www.indiandentalacademy.com
  212. 212. 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 www.indiandentalacademy.com
  213. 213. 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
  214. 214. 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.. www.indiandentalacademy.com
  215. 215. 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. www.indiandentalacademy.com
  216. 216. 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 www.indiandentalacademy.com
  217. 217. 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. www.indiandentalacademy.com
  218. 218. www.indiandentalacademy.com Thank you For more details please visit www.indiandentalacademy.com

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