Tongue and malocclusion - by DR. GAURAV VARMA . MDS
1. Presented by: Gaurav Varma
GUIDED BY-
Dr.Sagar Mapare
Dr.Baswaraj
Dr.Arjun Karra
Dr.Ram Mundada
Dr.Vijay yennawar
Dr.
TONGUE AND MALOCCLUSION
2. Introduction
The tongue is the large bundle of skeletal
muscles on the floor of the mouth that
manipulates food for chewing and swallowing .
It is a mass of striated muscle covered with
mucous membrane.
It is the primary organ of taste.
3. 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.
5. Root of tongue
Attached to,
- Mandible and soft palate above and Hyoid bone
below
- Because of these we are not able to swallow the
tongue itself.
6. Tip of the tongue
Lies behind the upper incisor teeth.
Forms the anterior free end.
7. Body of tongue
A . Dorsum of tongue
It is a convex in all direction .
It is divided in to two parts by V Shaped groove, the
sulcus terminalis.
a. oral part.
b. pharyngeal part.
The 2 limits of the V meet at the median pit named
foramen caecum
12. INTRINSIC MUSCLES
SUPERIOR LONGITUDINAL MUSCLE
shortens the tongue and make dorsum
concave.
INFERIOR LONGITUDINAL MUSCLE
shortens the tongue and make dorsum
convex.
13. TRANSVERSE
makes the tongue narrow and elongated.
VERTICLE
makes the tongue broad and flattened.
20. Lymphatic drainage
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.
23. Motor nerve supply of tongue
Hypoglossul nerve ( XII) Cranial part of
Accessory N
(XI)
24. All intrinsic & extrinsic muscles except
palatoglossus are supplied by Hypoglossal nerve.
Palatoglossus – cranial part of accessory nerve
through pharyngeal plexus.
25. Sensory nerve supply of tongue
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
Posterior most part of the tongue :
•Vagus nerve (X) through internal laryngeal
branch
26.
27. Development of tongue
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)
28. Development of tongue occurs in end of fourth
week.
By the following arches .
First arch.
Third arch.
Fourth arch.
29. EPITHELIUM
Anterior 2/3-
i) from 2 lingual swelling and one tuberculam
impar i.e. from first branchial arch.
ii) supplied by lingual nerve ( post – trematic) and
chorda tympani ( pre – trematic).
30. Posterior 1/3 –
i) from the cranial half of the hypobranchial
eminence i.e. from third arch.
ii) Supplied by glossopharyngeal nerve.
31. Posterior most
i) from the fourth arch
ii) supplied by vagus nerve
Muscles develops from the occipital myotomes
which are supplied by hypoglossal nerve.
Connective tissue develops from local
mesenchyme.
32.
33. Functions of normal tongue
Has several imp function of interest to the
orthodontist.
Mastication, deglutition, speech, breathing.
Mastication :
- Placing food in position (ant & lateral portions of
body).
- Pushes the food buccaly during Mastication.
34. Deglutition
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.
35. Speech
Formation of sounds - s, z, t, d, sh, e, g, is
- Elevation of tongue tip behind maxillary incisors
as in ‘s’
36. 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.
37. Taste sensation
Basic tastes:
Salt
Sour (acidic)
Sweet (sugar)
Bitter (vallate papillae)
Umami- new taste like
gluatamate,aspatate
Taste buds-sensory, neuroepithelial cells.
Seen in tongue, soft palate & pharynx.
38. 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
Contemporary Orthodontics, 5th Edition, William R. Proffit
39. 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’
40. Swallowing
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
41. Normal swallowing
Teeth are inncontact,lips-closed
Dorsum of tongue-
closely touch the palate
Tip of the tongue- interdental
papillae of maxi incisors
No tongue thrust
42. Abnormal swallowing
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
43. Infantile (visceral) swallowing
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
44. Mature (somatic) swallowing
Teeth together swallow
Mandible stabilized contraction
of elevators
Tongue tip touch
palate lightly above & behind
incisors
Minimal contraction of the
lips
45. RETAINED INFANTILE SWALLOW
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)
47. Morphological examination
The tongue should be examine for size and shape
1.Macroglossia –
scalloping on the lateral borders.
2. Microglossia-
severe crowding and collapsed dental arches.
48. Color –The normal color of a healthy tongue is a nice,
robust, sanguine pink - a perfectly balanced blend of
red and white.
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
1. bright red indicates acute or excessive heat
2. dark red is the sign of chronic consumptive or
deficiency heat.
49. 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.
Kagan, Jerome (1998). Galen's Prophecy: Temperament In Human Nature. New York:
Basic Books. ISBN 0465084052
50. 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
51. Clinical implications of asymmetry:
Tongue asymmetry is imp in
• dental arch symmetry
• dental midlines
• Maintenance of treated incisal
relationships
• Open bite etc
52. Functional examination
imp than clinical, position imp than size
Tongue & lips often integrated
Examine normal tongue function w/o displacing it
or the lips
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.”
53. Functional analysis
Metric evaluation- lateral ceph
Palatography
Cineflourography
Colour Atlas of Dental Medicine; Orthodontic-Diagnosis; Thomas Rakosi, Irmtrud Jonas
& Thomas M. Graber
55. Measuring the distance
b/w sup surfce of tongue
& roof mouth-size- but it
must be supported by
clinical examination
Retracted & elevated tongue
Downward & forwardtongue posture
56. Palatography
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
Evaluation of the influence of functional orthodontic
appliance therapy
58. 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.
59. Tongue thrusting
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
60. Etiology
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
61. 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
62. Classification
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
63. • James S. Brauer and Townsend V. Holt (AngleOrtho., 35:
106-12; April, 1965)(University of NorthCarolina)
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
sub group 3- deep overbite
64. 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
65. Clinical features
- Seen from birth
- School age children-67-95%(5-8yrs)
- If retained after 4yr- concerned &
needcorrection
Proclination of ant teeth
AOB
Bimax dental protrusion
Post cross bite
Post open bite in lateral T.T
66. Simple tongue thrust
Tongue thrust with a teeth together swallow.
Malocclusion
- Well circumscribed ant. Open bite.
- posterior teeth in perfect occlusion.
open bite has definite beginning and an ending.
Usually associate with digit sucking.
67. Complex tongue thrust
Tongue thrust with a teeth apart swallow
Malocclusion
-poor occlusal fit
-generalized ant. Open bite
mandibular elevators don’t contract during
swallowing
Usually associated with chronic resp. distress, mouth
breathing, tonsils and pharyngitis.
68. Diagnosis
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
69. 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:
1.Position & size- LATERAL CEPH
2. Tongue pressure- EMG, cineradiography
palatograpic, neurolophysiologic examination
70. {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.
71. Treatment
Simple tongue thrust
should be start before the correction of incisor
proclination.
STEP 1
- pt. is instructed to swallow by holding the tongue
tip against the junction of hard and soft palate.
- To practice correct swallowing at least 40 times /
day.
- Small elastic can be held by tongue tip against
the palate.
72. STEP 2
- Reinforce the new swallowing pattern
subconciously.
- Flat, sugarless fruit drop can be used.
- To place the drop on the tip of tongue and hold it
against the palate until candy dissolve completely.
- Have the patient time how long the candy is held
in place.
73. STEP 3
- Well adapt lingual arch wire with short 2 mm ,
sharp , strategically place spurs can be given
- Should not be placed as the first appliance.
74. Complex tongue thrust treatment
Occlusal treatment – 1st
Muscle exercise similar to simple T.T with minor
modification.
Swallowing with teeth together
Prolonged appliance therapy.
75. Tongue posture
NEONATES
- Tongue is postured forward and touch the lip while
the gum pads are held slightly apart.
76. INFANTILE TO MATURE TONGUE POSTURE
- Eruption of incisor
- Downward and forward growth of mandible –
increase the intraoral volume.
- Growth of alveolar process in vertical direction .
77. MATURE TONGUE POSTURE
- During mandibular posture , the dorsum touches
the palate slightly and the tongue tip normally is at
rest in lingual fossa or at the crevice of mandibular
incisor .
79. Malocclusion associate with retracted
tongue posture
Crowded mandibular incisors with lingual tipping
Excessive overclosure
Distoocclusion
Posterior open bite.
80. Protracted tongue posture
1.Endogenous
- Retention of infantile tongue posture
- Adaptation to excessive ant. Facial height
2. Acquired
- Transitory adaptation to enlarged tonsils,
pharyngitis.
81. Tongue posture in various
malocclusion
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.
82. 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.
83. Class II malocclusion
Retracted and low
Buccinator force is not balanced by the tongue
and this lead to narrow ‘V’ shaped maxillary arch
85. Role of tongue in speech
Speech production requires
1. Pulmonary bellow – which provides an air steam
that is under pressure during the phase of
exhalation
2. Larynx – where sound originate
3. Organs of speech ( articulators)
86. The articulators modify the shape , volume and
cross section of the opening in the oral resonating
cavity.
The tongue can divide the oral space into double
cavity , which multiplies the possible types of
resonance and create the range of words
87. Speech difficulties related to
malocclusion
1 .S,Z ( sibilants) anterior open bite , large
gap b/w
incisors
2. T,D ( linguoalveolar stops) irregular
incisors
3. F,V ( labiodental fricatives) skeletal
class III
4. Th ,sh, ch ( linguodental fricatives) ant.
Open bite
88.
89. 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.
90. Tongue is a very vital organ in your body
Tongue does many important functions
Keep your tongue safe!
91.
92. 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
