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Tongue by Dr. Analhaq Shaikh

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Tongue and Its Significance in Orthodontics

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Tongue by Dr. Analhaq Shaikh

  1. 1. BY SHAIKH ANALHAQ A. 1ST YEAR PG Dept. of Orthodontics 1
  2. 2. • INTRODUCTION • EMBRYOLOGY OF TONGUE • ANATOMY OF TONGUE oParts of tongue oMuscles of the tongue oBlood supply oLymphatic drainage oNerve supply • HISTOLOGY OF TONGUE 2
  3. 3. • FUNCTIONS OF NORMAL TONGUE • SIGNIFICANCE OF TONGUE IN ORTHODONTICS • CONCLUSION • REFERENCES 3
  4. 4. 4
  5. 5. • “TONGUE IS BARELY THREE INCHES LONG, BUT IT CAN KILL A PERSON SIX FEET TALL.” • The tongue is the large bundle of skeletal muscles on the floor of the mouth that manipulates food for chewing and swallowing (deglutition). • It is a mass of striated muscle covered with mucous membrane. • It is the primary organ of taste. 5 B. D. Chaurasia
  6. 6. • The tongue, with its wide variety of possible movements, assists in forming the sounds of speech. • It is sensitive and kept moist by saliva, and is richly supplied with nerves and blood vessels to help it move. • As for as animals are concern tongue is considered as SPOON. • In case of human beings it also considered as UNIVERSAL TOOTHBRUSH. 6
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  8. 8. Tongue, a soft muscular tissue is mainly made of mucosa, muscles and its vascular and nerve supply. First pharyngeal arch mucosa of body of tongue ( anterior 2/3rd ) Third pharyngeal arch mucosa of base of tongue (posterior 1/3rd) 8
  9. 9. From 1st arch mesenchyme From 3rd arch mesenchyme 9
  10. 10. • Development of tongue occurs in end of fourth week. • By the following arches . First arch. Third arch. Fourth arch. 10
  11. 11. Mesodermal thickening & migration of 3rd, 4th arches 11
  12. 12. First brachial arch Third brachial arch Fourth brachial arch Contribution of arches in the development of tongue 12
  13. 13. • Begins at 4th wk, 1st 3rd & 4th br arches • Pharyngeal arches meet in midline below the stomodeum • Local proliferation of the mesenchyme- 1st arch • Tuberculum impar-in midline • Lingual swellings-laterally • Lingual swelling enlarge merge with tuberculum impar- ant2/3 tongue 13
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  18. 18. • Hypobranchial eminence-large midline swelling- from mesenchyme of 3rd br arch-grows rapidly than 2nd arch • It gives-post 1/3 tongue/root • Post most part-4th arch • Tongue seperates from the FOM by downgrowth of the ectoderm around its periphery- degenerates to form lingual sulcus-mobility of tongue • Muscles-occipital myotomes 18
  19. 19. Another important developmental aspect of tongue is it’s contribution for normal development of palate. 19
  20. 20. • Proliferation of tongue muscle start at 9th day to till birth. • Under the influence of  HGF.  TGF-α.  Insulin like growth factors 20
  21. 21. • Development of skeletal muscle has following five phases. Phase I (commitent) Phase II (migration) Phase III (proliferation) Phase IV (differentiation) Phase V (maturation) 21
  22. 22. • Epithelium to study is the 14th day of fetus epithelium , • First have the thickness of 2 layers. • Then 4-8 layers 22
  23. 23. 23Human Anatomy Vol. 3, 4th Edition, B. D. Chaurasia
  24. 24. The Tongue has, • A root • A tip • body 24
  25. 25. • Attached to, Mandible and soft palate above Hyoid bone below • Because of these we are not able to swallow the tongue itself. 25
  26. 26. • Lies behind the upper incisor teeth. • Forms the anterior free end. 26
  27. 27. Dorsum Inferior 27
  28. 28. • It is a convex in all direction . • It is divided in to two parts by V Shaped groove, the sulcus terminalis.  oral part.  pharyngeal part. • The 2 limits of the V meet at the median pit named foramen caecum. 28
  29. 29. 29 Oriented in horizontal plane Orientedinverticalplane
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  32. 32. • A middle fibrous septum divides the tongue into right and left halves. • Each half contains four intrinsic and four extrinsic muscles. 32
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  34. 34. 34
  35. 35. • Superior longitudinal. • Inferior longitudinal. • Transverse. • Vertical. 35
  36. 36. 36  SUPERIOR LONGITIDINAL MUSCLE - lies beneath the mucous membrane - Shortens the tongue & makes the dorsum concave  INFERIOR LONGITIDINAL MUSCLE - narrow band, lies close to inferior surface between genioglossus & hyglossus - Shortens the tongue & makes the dorsum
  37. 37. 37
  38. 38.  TRANSVERSE MUSCLE - extends from median septum to margin - Makes the tongue narrow & elongated  VERTICAL MUSCLES - found at the border of anterior part of the tongue - Makes the tongue broad & flattened 38
  39. 39. 39
  40. 40. • Genioglossus. • Hyoglossus. • Styloglossus. • Palatoglossus. 40
  41. 41. • Origin: upper genial tubercle of the mandible • Insertion: fibres fan out runs backward; upper fibres – the tip, middle fibres – dorsum & lower fibres – into hyoid bone 41
  42. 42. 42
  43. 43. 43 • Origin: whole length of greater cornua & lateral part of body of hyoid • Insertion: side of tongue
  44. 44. 44 • Origin: medial surface of the base of styloid process • Insertion: passes downwards & forward and is inserted into the side of tongue
  45. 45. 45 • Origin: oral surface of palatine aponeurosis • Insertion: resend in the palatoglossal arch to the side of tongue at the junction of the oral & pharyngeal parts
  46. 46. 46
  47. 47. Lingual artery main Ascending pharyngeal 47
  48. 48. 48
  49. 49. • Deep lingual vein is the largest and principle vein of the tongue. 49
  50. 50. 50
  51. 51. • Tip - bilaterally to submental nodes. • R & L halves of Anterior 2/3rd - submandibular nodes. Few central lymphatics drain bilaterally to same nodes. • Posterior 1/3rd - bilaterally to jugulo-omohyoid nodes. 51
  52. 52. 52
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  55. 55. Hypoglossal N (XII) Cranial part of Accessory N (XI) • All intrinsic & extrinsic muscles except palatoglossus are supplied by Hypoglossal nerve. • Palatoglossus – cranial part of accessory nerve through pharyngeal plexus 55
  56. 56. 56
  57. 57. • Anterior 2/3rd : (except circumvallate papillae) • Lingual nerve (V3) is nerve of general sensation. • Chorda tympani is nerve of taste sensation. • Posterior 1/3rd : (including circumvallate papillae) • Glossopharyngeal nerve (IX) for both general sensation and taste sensation • Posteriormost part of the tongue : • Vagus nerve (X) through internal laryngeal branch 57
  58. 58. 58
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  62. 62. There are four types of papillae seen on the dorsal surface of tongue . Filliform papillae. Fungiform papillae. Circumvallate papillae. Foliate papillae. 62
  63. 63. 63
  64. 64. • Filliform: most numerous, cone-shaped and no taste buds, threadlike and scaly, gives characteristic velvety appearance • Fungiform: mushroom-shaped with few taste buds, distinguished bright red in appearance • Vallate: largest,1-2 mm in diameter, 8-12 in number, many taste buds on lateral walls • Foliate: small lateral folds of mucosa with few taste buds 64
  65. 65. 65
  66. 66. • Cover the presulcal area of the dorsum. • Characteristic velvety appearance. • Smallest & most numerous. • Pointed & covered with keratin. • Apex is often split into filamentous processes. 66
  67. 67. Magnified ,filliform papillaeHistology , filliform papillae 67
  68. 68. • Numerous near the tip & margins. • Also scattered over the dorsum. • Smaller than vallate papillae, but larger than filiform papillae. • Each papilla – Narrow pedicle + Large rounded head. • Distinguished by their bright red colour. 68
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  70. 70. • Large in size. • 1-2 mm in diameter. • Situated immediately in front of the sulcus terminalis. • Cylindrical projection surrounded by a circular sulcus. 70
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  74. 74. - Has several imp function of interest to the orthodontist - Mastication, deglutition, speech, breathing EQUILIBRIUM & DEVELOPMENT OF THE DENTAL OCCLUSION • Mastication : - Placing food in position (ant & lateral portions of body) - Pushes the food buccaly during Mastication 74
  75. 75. - Forming & propelling bolus in to pharynx(1st stage of swallowing) - After swallowing tongue contacts hard palate while soft palate is pulled away downward against the post portion of the tongue • Speech: - Formation of sounds - s, z, t, d, sh, e, g, is - Elevation of tongue tip behind maxillary incisors as in ‘s’ • Deglutition 75
  76. 76. • Breathing :  Nasal breathing-tongue in rest position  Forced mouth breathing- - Mandible is depressed, lips are opened - Tongue contacts laterally with lingual surfaces of mandibular teeth dropping away from maxilla - The anterior portion is lowered lies on lingual surfaces of mandibular anterior teeth 76
  77. 77. Basic tastes: • Salt • Sour (acidic) • Sweet (sugar) • Bitter (vallate papillae) • Umami- new taste to a.a like gluatamate,aspatate 77
  78. 78. • Taste sensation –taste buds (4600),in papillae • Taste buds-sensory, neuroepithelial cells • Seen in tongue, soft palate & pharynx • Circumvallate - large, numerous taste buds- sour/bitter • Foliate - numerous taste buds – sour • Fungiform - anterior part • Filliform - mechanical, NO TASTE BUDS 78
  79. 79. EQUILIBRIUM THEORY: • As applied in engineering “An object subjected to unequal forces will be accelerated & there by will move to a different position in space” It follows that if any object is subjected to a set of forces but remains in the same position, those forces must be in balance or equilibrium 79 Contemporary Orthodontics, 5th Edition, William R. Proffit
  80. 80. • From this perspective, dentition is in equilibrium as they do not move to a new location under usual circumstances (mastication, swallowing, speaking) • ‘Tooth movement occurs only when the equilibrium against dentition is unbalanced’ 80
  81. 81. Contributors to the dental equilibrium: Various factors-effect of pressures, magnitude & its duration • Masticatory forces • Soft tissue pressures from the lips, cheeks & TONGUE • External pressures- habits & orthodontic forces • Intrinsic pressures-gingival & PDL fibers 81
  82. 82. According to T.M Graber 1200-2000/day, 4 pounds of pressure/swallow (in class-II div1,openbite - more) • Normal swallowing • Abnormal swallowing • Infantile (visceral) swallowing • Mature (somatic) swallowing • Simple -tongue thrust swallowing • Complex-tongue thrust swallowing • RETAINED INFANTILE SWALLOW 82
  83. 83. Teeth are in contact,lips-closed Dorsum of tongue closely touch the palate Tip of the tongue- interdental papillae of maxi incisors No tongue thrust 83
  84. 84. Teeth are separated; lips open close forcibly Dorsum of tongue drops away from the palate Contraction of the lips & mandible Tongue thrust b/w teeth 84
  85. 85. Acc Moyers The jaws are apart with tongue b/w gum pads Mandible stabilized- contraction of facial muscles (buccinator) & interposed tongue Swallow guide - sensory interchange b/w lips & tongue 85
  86. 86. Change to semi solid & solid food & the eruption of teeth-mature swallow (1yr/18mos) The normal appearance of feature of both the infantile & mature swallow- TRANSITIONAL SWALLOW - Diminishing of buccinators activity - Appearance of contraction of mandibular elevators- stabilize occlusion 86
  87. 87. Teeth together swallow Mandible stabilized- contraction of elevators Tongue tip touch palate lightly above & behind incisors Minimal contraction of the lips 87
  88. 88. Def: ‘As predominant persistence of the infantile swallowing reflex after the arrival of permanent teeth’ - Rare, may be associated with craniofacial developmental syndromes/neural defects C/F: • Tongue thrust- ant & lateral • Contraction of buccinator muscle • Expression less face(facial muscles – used for stabilizing mandible) 88
  89. 89. • Difficulty in mastication (as occlusion only on last molar of quadrant) • Mastication- b/w tongue tip & palate (poor occlusion) • Gag threshold is low • AFH - severe AOB 89
  90. 90. Adaptive features to OB: • Tooth apart swallow with T.T • Infra eruption of incisors & alveolar development • Hyperactive mentalis & lips • Mandible stabilized by facial muscles Treatment : differentiate this with skeletal OB - If require - orthodontic & surgery - Poor prognosis 90
  91. 91. 91
  92. 92. Orofacial musculature has strong influence on dental and skeletal units which makes it necessary for proper understanding of these structures. Dental arches are enveloped on both the sides (lingual and buccal) by muscular tissues and precise balance between these forces is utmost important for normal inter and intra-arch relations. Since long time, role of tongue in malocclusion has been remained controversial. 92
  93. 93. Le Foulon (1839) was the first to propose role of tongue in malocclusion. “When tongue strikes against the upper front teeth, it pushes teeth forward”. Breitner (1942) was the first to highlight the importance of functional equilibrium among the forces of tongue and those produced from action of lips and cheek musculature. Sweet (1948) pointed out that in improper swallowing, tongue thrusts forward against the anterior teeth and hard palate in order to push bolus of food into the pharynx. This thrusting force cause proclination of anterior teeth. 93
  94. 94. Proffit, based on his equilibrium theory, proposed that duration of force is much more important than magnitude of any force acting on dental or skeletal units. According to this theory, concept of tongue hitting and moving the anterior teeth forward is not valid but, abnormal posture and position of tongue can definitely cause malocclusion. 94
  95. 95. • “By examining the tongue of the patient, physicians find out the diseases of the body & philosophers the diseases of the mind” – St Justin 95  Examination of the tongue  Role of tongue in malocclusion  Tongue thrust
  96. 96. • Size & shape – subjective observation, related to patient, Position imp than size • Length - long tongue can touch tip of nose(not confirmed method) - Microglossia-rare - Macroglossia –scalloping on lateral borders 96
  97. 97. • Color –The normal color of a healthy tongue is a nice, robust, sanguine pink - a perfectly balanced blend of red and white • Any deviation from this denotes a deviation from this ideal state of health and balance; the greater the deviation, the more severe the imbalance. • White, Pale: Generally indicates coldness and deficiency, as well as an excess of cold phlegmatic humors in the bloodstream. This may also indicate anaemia or blood deficiency, if supported by other signs and symptoms. • Red: Generally indicates an excess of heat in the body - systemic if the whole tongue body is affected, or localized in a particular organ or part if only certain reflex zones are affected. If the tongue is bright red, it indicates more acute or excessive heat. A dark red tongue is often a sign of chronic consumptive or deficiency heat, or a consumptive fever or dyscrasia of the blood. A red, sore, swollen tongue generally indicates an excess of blood. 97
  98. 98. • Brown: Indicates an excess of black bile or melancholic residues in the bloodstream. • Purple: Indicates either blood stagnation or cyanosis due to a deficiency of vital principles - Vital Force and/or Innate Heat - in the blood. • Yellow: Generally indicates jaundice, or an excess of bilious, choleric residues backed up into the blood. Other characteristics a) Central cyanosis- bluish discoloration b) Jaundice- Yellowish discoloration c) Advanced uremia- Brown colour d) Ketosis- Brown discoloration e) Riboflavin deficiency- Meganta colour f) Niacin and some other B complex deficiency- Bright scarlet or beefy red tongue g) Severe anaemia- pallor 98 Kagan, Jerome (1998). Galen's Prophecy: Temperament In Human Nature. New York: Basic Books. ISBN 0465084052
  99. 99. • Asymmetry-placing tongue out, allow it to drape over lower lip - Functional asymmetry-change from one position to other - Morphological asymmetry-persists in drapped position 99
  100. 100. Clinical implications of asymmetry: Tongue asymmetry is imp in • dental arch symmetry • dental midlines • Maintenance of treated incisal relationships • Open bite etc Not easily corrected, as treatment involve some sort of compromise. 100
  101. 101. - imp than clinical, position imp than size - Tongue & lips often integrated - Examine normal tongue function w/o displacing it or the lips Posture of the tongue while mandible in its postural position - Clinically- upright position - Cephalometry- METRIC EVALUATION - normal -Dorsum of the tongue touches the palate lightly, the tongue tip rest in the lingual fossae/crevices of mandibular incisors 101
  102. 102. Variations in normal tongue posture 102
  103. 103. Proffit – “Tongue posture is far more adapt to cause of an openbite than tongue thrust, because the tongue is always there exerting a mild continuous force.” Tongue during mastication: - Difficult test - except for abnormalities associated with neurological problems. 103
  104. 104. Tongue during swallow : Normal –The tongue tip touches curvature of palate just behind the maxillary incisors • The unconscious swallow – most imp • The command swallow of saliva • The command swallow of water • The unconscious swallow during mastication 104
  105. 105. During speech : -Is abnormal tongue activity adaptive/etiologic/unrelated to malocclusion? - Usually- adaptive - Ask patient to count 1-10, check for tongue adaptivity, consonants sound - ‘s’-sound (lisping) most affected 105
  106. 106. • Metric evaluation- lateral ceph • Palatography • Cineflourography 106 Colour Atlas of Dental Medicine; Orthodontic-Diagnosis; Thomas Rakosi, Irmtrud Jonas & Thomas M. Graber
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  108. 108. • Measuring the distance b/w sup surfce of tongue & roof mouth-size- but it must be supported by clinical examination • Retracted & elevated tongue • Downward & forward tongue posture 108
  109. 109. • Recording the contact areas of the tongue with the palate & teeth during speech/certain tongue functions • A thin layer of contrasting impression material is applied on tongue • Tongue movements-speech/swallowing • Palatogram records photographically eg:lisping-defect S sound,T.T • Evaluation of the influence of functional orthodontic appliance therapy 109
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  113. 113. • Cineflourography- Tongue movements using camera & film is made during swallowing. Tracing- T.T is measured by drawing straight line through labial surfaces of U/L incisors. 113
  114. 114. Definition: Proffit- “placement of the tongue tip forward b/w the incisors during swallowing” (1950&60s) OR It is the habit of thrusting tongue forward against teeth/in b/w swallowing • Misnomer-implies tongue is forcibly thrust forward 114
  115. 115. - No one specific cause - Acc to Fletcher 1.Genetic factors -anatomic/neruomuscular eg: hypertonic orbicularis oris activity 2.Learned behavior (habit)-acquired as habit - prolonged thumb sucking, tonsillitis & URTI, improper bottle feeding 3.Maturational –infantile swallow persists in adulthood 115
  116. 116. 4.Mechanical restriction - macroglossia, constricted dental arches, enlarged adenoids 5.Neurological disturbances - hypersensitive palate, motor disability of tongue 6.Psyhcogenic factors – forced discontinuation of thumb sucking 7.Younger children with reasonably normal occlusion-transitional stage in physiologic maturation 116
  117. 117. • According to Moyers (1970) a. simple tongue thrust swallow b. complex tongue thrust swallow • Backlund (1963) a. Ant tongue thrust b. Post tongue thrust • Pickett’s (1966) a. Adaptive - missing teeth/thumb sucking b. Transitory c. Habitual-postural problem, habit/OB 117
  118. 118. • James S. Brauer and Townsend V. Holt (Angle Ortho., 35: 106-12; April, 1965)(University of North Carolina) • This classification is based on deformity observed rather than on etiology.  Type I: Non-deforming tongue thrust  Type II: Deforming anterior tongue thrust sub group 1- associated with AOB sub group 2- anterior proclination sub group 3- posterior cross bite  Type III: Deforming lateral tongue thrust sub group 1- posterior open bite sub group 2- posterior cross bite 118
  119. 119. Type IV- Deforming anterior & lateral tongue thrust sub group 1- anterior & posterior open bite sub group 2- anterior proclination sub group 3- post cross bite Non-deforming: occlusion & profile within normal range & acceptable Deforming: dent alveolar defect 119
  120. 120. - Seen from birth - School age children-67-95%(5-8yrs) - If retained after 4yr- concerned & need correction • Proclination of ant teeth • AOB • Bimax dental protrusion • Post cross bite • Post open bite in lateral T.T 120
  121. 121. Simple T.T Complex T.T 121
  122. 122. Simple T.T Complex T.T 122 • Teeth together swallow –T.T to seal OB • Well circumscribed OB • Precise occlusion - reinforced by teeth together swallow • Contraction of lips, mentalis & mandibular elevators • Teeth apart swallow –T.T • Diffuse OB/no OB • Poor occlusion- no reinforcing(instability of intercuspation) • Contraction of lips, mentalis & facial muscles.NO mandibular elevators
  123. 123. • H/O thumb sucking - T.T as adaptive mechanism to OB • No respi problems • Diminishes with age • Prognosis - good • H/O breathing/chronic URTI & allergies • Respi problems • Does not Diminishes with age • Prognosis - poor Simple T.T Complex T.T 123 Handbook of Orthodontics, Robert E. Moyers
  124. 124. • Extra oral-facial profile, OB, AFH • Examination of - tongue posture - tongue function • Careful differentiation should be made of • Simple tongue thrust • Complex tongue thrust • Retention of infantile swallowing pattern • Faulty tongue posture 124
  125. 125. Tests for diagnosis 1. Swallowing: when jaw drops- lips, mentalis muscle contracts strongly - tongue thrust 2. Separate the lips while swallowing to watch tongue thrust, and in doing so, strong muscle contractions can be felt Methods of examination tongue dysfunction: Position & size- LATERAL CEPH Tongue pressure- EMG, cineradiography palatograpic, neurolophysiologic examination 125
  126. 126. • {AJO (July 1982) vol.48, no.7, W. J. STRAUB} • Use of a water pistol (Dr. James P. Kerrigan of Washington D. C.) • 2 squirts of water used. • Either patient told to swallow the water or he will do it unconsciously and swallowing pattern – noted. 126
  127. 127. Simple tongue thrust: 3 phases 1.Conscious learning of the new reflex 2.Transferal of control of the new swallow pattern to the subconscious level 3.Reinforcement of the new reflex - If proclination is severe- correct the habit after retraction - Simple T.T-correct by itself during ortho treatment 127 Handbook of Orthodontics, Robert E. Moyers
  128. 128. • Teaching correct tongue position by tactile signals (index finger) • Tip of tongue & palate • Put tongue tip-close teeth & lips-swallow • 40times/day • With little water/food 128
  129. 129. • Small ortho intraoral elastics-held by tip of tongue aginst palate during swallowing • If correct swallow- elastic will be retained Incorrect swallow- elastic will be swallowed • 2-3times /day 129
  130. 130. • To avoid abnormal unconscious swallow- 2nd visit • Flat sugarless fruit drops-citric flavoured(lemon) • Fruit drop on Tip of tongue-hold against palate until dissolves 130
  131. 131. • Record timing • Initially- less time, later more time • Distraction & self competition • Ones/day • Timing distraction- Best technique 131
  132. 132. • Appliance therpy- Tongue crib • Should not as the 1st step of treatment • As it traumatic to pt/ do not wear properly 132 Greg.Haang, et al, AO-1990 Tongue crib therapy significantly reduced the post treatment relapse of open bite.
  133. 133. Complex tongue thrust : • Occlusion treatment – 1st • Muscle exercises similar to simple T.T with minor modification - Swallowing with teeth together - Prolonged appliance therapy • Prognosis – Poor • More relapses 133
  134. 134. 134
  135. 135. • Tongue plays a major role in the maintaining the normal occlusion as well as it influences the development of the dental arches • Position of tongue and its function plays an important role or a contributing factor in dental malocclusion. • Correction of an abnormal tongue behavior is a proper treatment goal for us only if it is directly related to the etiology of malocclusion and the ultimate treatment goals. • Tongue thrust troubled orthodontic treatment, discouraged orthodontists as there is more relapses due to continuous force by tongue. 135
  136. 136. 136 Tongue is a very vital organ in your body Tongue does many important functions Keep your tongue safe!
  137. 137. 137
  138. 138. • Human Anatomy Vol. 3, 4th Edition, B. D. Chaurasia • Embryology, I. B. Singh • Tencate’s Oral Histology, 6th Edition • Handbook of Orthodontics, Robert E. Moyers • Contemporary Orthodontics, 5th Edition, William R. Proffit • Colour Atlas of Dental Medicine; Orthodontic-Diagnosis; Thomas Rakosi, Irmtrud Jonas & Thomas M. Graber • Anatomy of the Human Body, Henry Gray 138
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