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

Shrirang Anand Sevekar
www.indiandentalacademy.com
Contents
►

Habit

►

Definition
Classification
Trident of habit
Dental response to pressure
habits
 Treatment phylosophy...
Habit
► William

James-

From psychological view, Is a Pathway of discharge
formed in brain by which certain incoming curr...
Habit: Definitions
► Dorland –

Fixed or constant practice established by
frequent repetition
► Buttersworth –

Frequent o...
Habit: Definitions
► Moyer

Habits are learnt pattern of muscle contraction
of a very complex nature
► Hogeboon and Salder...
Habit: Definitions
► Mathewson –

Learned pattern of muscular contraction
► Tandon –

Settled tendency in response to a sp...
Development of habit
► Unconscious mental pattern

 Instinct
► Elementary reflex► Pattern and order






Incorrect o...
Dental response to pressure exerting
oral habits : Forester
► Functional matrix theory –

Position of Dentition- skeletal ...
Habits: Classification
Tandon
►

► Non- obsessive

Obsessive
(Deep rooted)
 Intentional OR
meaningful
 Masochistic or Se...
Habits: Classification
► James (1923)/ Graber

 Useful
 Harmful

Finn (1987)
 Compulsive habits
 Non- compulsive habit...
Habits: Classification
► Morris and Bohanna (1969)

 Non pressure habit
 Pressure habit
►Sucking habit
 Lip, Thumb suck...
Habits: Classification
► Normal
► Abnormal
► Retained
► Cultivated

► Sucking habit JDC:1996:321
O Brian (1996)

 Nutriti...
Trident of Habit
Intensity
► Frequency
► Duration
►

Intensity

► Direction (Pinkham)

Frequency

Habit
Direction

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Treatment philosophy and
considerations
► Emotional significance of habit in relation to family




►

►

Excessive par...
Nutritive habits

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Nutritive habits
► Breastfeeding







Rooting reflex (Pinkham)
Sucking reflex
Psychological development
Effect on o...
Nutritive habits
► Bottle feeding
 Artificial nipple
► Size, length, flow rate,
location of holes
► Orthodontic or
physio...
Nonnutritive- Thumb
sucking

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Thumb or Digit sucking
►

Definition Placement of thumb or one or more fingers in various
depths into the mouth or oral ca...
Thumb or Digit sucking
►

Prevalence

(DCNA:1978;608)

 16- 45 %
 Age and Prevalence

► Damage (malocclusion)





O...
Influence of different variables on incidence and
Prevalence of Thumb Sucking Habit

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Influence of different variables on incidence and
Prevalence of Thumb Sucking Habit

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Thumb sucking: Classification
► Normal thumb sucking
►

Abnormal thumb sucking

Psychological
Habitual

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Thumb Sucking: Classification
►

Subtelny(1973)
Type A

Type B

Type C

Type D

50%

13-20%

18%

6%

Digit placement

Dig...
Nonnutritive habits
Johnson(1993)

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Thumb or Digit sucking
► Sucking reflex

Incidence

 Starts at 29 week I.U.
 Disappear by 3 - 4 yr
 First coordinated m...
Thumb or Digit sucking
►

Initiation of digit sucking
(Infantile)
 Development of muscular
coordination
 Ability to reac...
Thumb or Digit sucking
► Theories (Etiology)

JDC:1993;385

 Classical Freudian theory (1905)
►Biologic sucking drive (I....
Thumb or Digit sucking
► Benjamin theory (1962)

Experimentation on monkey
Two theories
 Thumb sucking - Expression assoc...
Thumb or Digit sucking
►

Learning theory: Davidson (1967)





Adaptive response to pleasurable feeling
No underlying...
Thumb or Digit sucking
► Oral drive theory (Sears and Wise;1982)

 Duration of feeding

Oral drive

 Prolonged nursing
H...
Thumb or Digit sucking
►

Johnson and Larson (1993)
JDC:1993:385






Combination of two
Inherent biologic drive for ...
Thumb or Digit sucking
► Maintenance of habit

 Normal upto 3 yrs (Psychoanalytic)
 Persistence - psychological disturba...
Thumb or Digit sucking


Causative factors
1. Parent’s occupation
1.

Socioeconomic status

2. Working mother
1.

4. Orde...
Thumb or Digit sucking: Causative
factors
►

Causative factors
7 Age
1.

In neonates
1. Well developed suckling mechanism
...
Thumb or Digit sucking
►

Diagnosis
 Emotional status
►Meaningful or empty

 Case history
Active performance
► Informati...
Thumb or Digit sucking
► Extra oral examination

 Digit
►
►

►

Reddened, clean, chapped,
short fingernail (dishpan thumb...
Thumb or Digit sucking;
Extra oral examination
► Facial form

analysis

 Maxillary protrusion
 Mandibular retrusion
 Hi...
Thumb or Digit sucking
► Intraoral examination

 Tongue
► Position at rest , during

swallowing

 Gingiva
► Evidence of ...
Thumb or Digit sucking;
Intra oral examination
► Dento alveolar structure

 Flared , proclined maxillary
anteriors with d...
Thumb or Digit sucking
► Dentofacial changes

associated with prolonged
sucking habit
JDC:1993:385

 Effects on maxilla
M...
Thumb or Digit sucking: Cl/ F
► Increased SNA

S

N

A

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Thumb or Digit sucking: Cl /F
► Effect on mandible

 Proclination of incisors
(Finger sucking)
 Increased Intermolar
dis...
Thumb or Digit sucking: Cl /F
► Effect on interarch

relationship
 Anterior open bite

 Increased over jet

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Thumb or Digit sucking: Cl /F

Increased unilateral
and bilateral Cl II
malocclusion

Decreased U/ L incisal angle
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Thumb or Digit sucking: Cl /F
 Decreased overbite

 Increased posterior
cross bite

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Thumb or Digit sucking: Cl /F
►

Effect on lip placement and
function
 Increased lip
incompetence
 Increased lower lip
f...
Thumb or Digit sucking: Cl /F
►

Other effects
 Risk to psychological
health
 Increased risk of
poisoning
 Increased ri...
Thumb or Digit sucking
► Clinical aspect (Moyer: 1955)

 Phase I
► Normal or sub clinically

significant sucking (Pre sch...
Thumb or Digit sucking
► Clinical aspect

 Phase III
►Intractable sucking (Teenage child)
►Beyond 4 th

yr

►Psychotherap...
Psychological effects of
malocclusion resulting from habits
► Exceedingly introvert
► Oversensitive
► Immature social beha...
Thumb or Digit sucking
► Treatment

Forester

 Treatment rationale
►

Emotional significance of habit
 Psychological sta...
Management
► Preventive treatment

 Littlefield
► Best when related to familial tendency

 Hughes (1949)
► Fulfillment o...
Management :Preventive treatment
► Psychological






Avoidance of scolding, frightening
Reassurance and positive rei...
Management :Preventive treatment
► β- Hypothesis or Dunlop’s hypothesis

 Forced purposeful repetition
 Abandonment of h...
Management: chemical treatment
► Least effective
► Bitter or sour chemical over the finger

 E.g. : Foul smelling Quinine...
Management: Mechanical or
reminder therapy
► Extra- oral approach

 Mechanical restraints to hand/ Digit
Adhesive bandage...
Management: Mechanical or
reminder therapy
► Intra- oral Approach

 Weiss and Eiser (1993)
► Upto 5 yr- No intervention

...
Management: Mechanical or
reminder therapy
► Removable and fixed

appliance
 Palatal crib
► Breaks the suction and force ...
Management: Mechanical or
reminder therapy
►

Oral screen
 Functional appliance
► Redirection of muscular and

soft tissu...
Management: Mechanical or
reminder therapy
► Triple loop corrector:

Barber (1960)

 Modified palatal arch
 Similar to t...
Thumb or Digit sucking: Treatment

According to Forester
► Younger than 3 yr

 No active intervention
 Class I openbite ...
Thumb or Digit sucking: Treatment:
Forester
►

3 – 7 yr
 Depending on type of habit
►Active puller
►Idle sucker

 Good m...
Thumb or Digit sucking: Treatment;
Forester
► Under 6 yr

 Class I
►Behavior conditioning








Openbite pictures...
Thumb or Digit sucking: Treatment;
Appliance; under 6 yr; Forester
►

Class II (Non self
correcting)
 With anterior pulle...
Thumb or Digit sucking: Treatment;
Appliance ;under 6 yr; Forester
► Class III

 Encouragement to suck

 Cl III activato...
Thumb or Digit sucking: Treatment;
Appliance ;older than 7 yr; Forester
► Class I

 With ant openbite and
spacing
► Hawle...
Thumb or Digit sucking: Treatment;
Appliance ;older than 7 yr; Forester
► Non crowding Buccal

cross bite
 fixed or remov...
Thumb or Digit sucking: Treatment;
Appliance ;older than 7 yr; Forester
►

Class II
 Non crowded Cl II Div-I with
low man...
Thumb or Digit sucking: Treatment:
Older than 7 yrs; Forester
 Openbite
► Removable

 Frankle IV
► Vestibular
configurat...
Thumb or Digit sucking: Treatment:
Older than 7 yrs; Forester
► Open bite

 Removable appliance
► Modified activator-

in...
Thumb or Digit sucking: Treatment:
Pinkham
►

Reminder therapy



►

Adhesive bandage
Unpleasant stimuli

Reward system
...
Thumb or Digit sucking: Treatment
Pinkham
►

Appliance therapy
 Attitude
► Self correcting

malocclusion
 Appliance as r...
Pacifier habit

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Pacifier habit

Ped.Dent:2002;552

Pacifier

► Natural sucking instinct or urge
► Restricted breast feeding and bottle fee...
Pacifier habit
► Clinical features
AJO;2002;347

 Oral Myofunctional
alteration
► Decrease muscular

tonicity of tongue a...
Pacifier habit: Cl / F
► Dental changes

 Posterior cross bite
► Increased mandibular

arch width
► Decreased max. arch
w...
Pacifier habit
► Controversies

associated with
pacifiers
 Protects against
SIDS

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.

Ped Den...
Pacifier habit

.

Ped Dent:2003;449

 Increases risk of otitis
media and other
infections

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Increases risk of otitis media and
other infections

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Pacifier habit
► Recommendations

 Should not use before breast feeding
established
 More restraints for use
 Cleaned
...
Tongue Thrusting

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Tongue thrusting
► Embryonic life

 Proportion of tongue to
developing mandible

 Spacing between Gum
pads

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Anatomy and Physiology of Sucking and swallowing
JDC:1996:321
► Sucking –

First Coordinated muscular
activity
► Infantile...
Anatomy and Physiology of Sucking
and swallowing
►

JDC:1996:321

Infantile swallow


Muscles involved
1.
2.
3.
4.
5.
6.
...
Anatomy and Physiology of Sucking
and swallowing
► Transitional swallow

 Inter mixing of normal infantile swallow and ma...
Anatomy and Physiology of Sucking and
swallowing
► Mature swallow

 Position of tongue (Stewart)
► Tongue tip
► Mid porti...
Phases Of Swallowing Or Deglutition
► Straub (1957)

 Preparatory phase/Oral phase
► Voluntary and conscious phase
► Bolu...
Phases of swallowing or deglutition
► Second phase
 Involuntary but conscious phase
 Bolus passes through pharyngeal
tub...
Phases of swallowing or deglutition
► Esophageal phase

Involuntary
Reflex mechanism
Bolus passes through cricopharyngeal ...
Anatomy and Physiology of
swallowing
►

Process of normal
swallowing
A. Resting posture
B. Initiation of deglutitionTongue...
Anatomy and Physiology of Sucking and
swallowing
► Abnormal swallow

(Stewart)
 Position of tongue
►
►
►

Tip
Mid portion...
Tongue Thrusting
► Definition

 Brauer Tongue thrust is said to be present if the tongue is
observed thrusting between an...
Tongue Thrusting: Definition
► Barber-

It is an oral habit pattern related to persistence of an
infantile swallow pattern...
Tongue Thrusting
► Prevalence






(DCNA:1978;603)

Newborn – 97%
5-6 yrs – 80%
By 12 yrs – 3%
Physiology (Stewart)
►...
Tongue Thrusting
► Significance (Forrester)

 Function governs form
►Adverse muscle forces – Abnormal form

► Occurrence ...
Tongue Thrusting
► Equilibrium

theory (Profit)

 Facial musculature vs. Tongue pressure
Light tongue forces – Against te...
Tongue Thrusting
► Classification

 Physiologic
►Infancy

 Habitual
►Present after correction of malocclusion

 Functio...
Tongue Thrusting: Classification
James S. Braner and Holt

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Tongue Thrusting: Etiology
► Retained infantile

swallow
 Retention of infantile
suckling mechanism
 Incisor eruption – ...
Tongue Thrusting: Etiology
► URTI





Obstruction of nasal passage
Mouth breathing
Forward tongue posture –
Physiologi...
Tongue Thrusting: Etiology
► Adenoids

 Location
 Complementary status:
Growth of Adenoid and
Upper face  Infection, Al...
Tongue Thrusting: Etiology
► Lymphoid tissue (Tonsils)

 Location
 Hypertrophy – Obstruction
of oropharyngeal area
 Ton...
Tongue Thrusting: Etiology
► Neurological disturbances





Hypo sensitive palate
Motor disability- brain injury
Disrup...
Tongue Thrusting: Etiology
► Functional adaptability

 Missing incisors
 Protrusion

ANTERIOR SEAL

 overjet
 openbite...
Tongue Thrusting: Etiology
► Feeding practices





Bottle feeding
Breast feeding
Consistency of infant’s foodDevelopme...
Tongue Thrusting: Etiology
► Induced due to other





habits

Digit sucking
Pacifier sucking
Sleeping habits

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Tongue Thrusting: Etiology
► Hereditary





Inherited hyperactive orbicularis oris
Anatomical configuration
Neuromuscu...
Tongue Thrusting: Etiology
►

Tongue size
 Macroglossia

►

Anesthetic throat
 Congenital physiologic
discrepancies- Abn...
Classification of etiological factors:
Fletcher (1975)
1.

Genetic factor
1.

Inherited variation in
orofacial form
►

2.
...
Tongue Thrusting: Diagnosis
History
►Sibling swallow, Parent
►Previous respiratory infections , sucking habits ,
►

neurom...
Tongue Thrusting: Diagnosis
►

Movements of tongue





►

Lateral
Protrusive
Retrusive
Restricted movement
(Ankyloglo...
Tongue Thrusting: Diagnosis
►

Gag reflex
 Palatal- Rare
 Pharyngeal

►

Abnormal tongue posture
 Retracted tongue
► Wi...
Tongue Thrusting: Diagnosis
►

Protracted tongue
 Result in openbite
 Types
► Endogenous

 Retention of infantile swall...
Tongue Thrusting: Diagnosis
 Tests
► Masseter activity test

► Temporalis activity test

► Lip apart swallow test

www.in...
Tongue Thrusting: Diagnosis
► Simple tongue thrust





Molar occlusion
Ant. Open bite
Contraction of lips,
Mentalis, m...
Tongue Thrusting: Diagnosis
► Complex tongue thrust

 Generalized open bite
 Absence of contraction of
lips, muscles
► L...
Tongue Thrusting
CLINICAL FEATURES
► Extra oral
 Lip posture
► Lip separation
 Mandibular movement
► Upward and backward...
Tongue Thrusting: Cl/F
► Intraoral

 Tongue posture
► Downward and forward
► At rest- lower

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Tongue Thrusting: Cl/F
► Malocclusion

 In relation to maxilla
► Increased overjet
► Generalized spacing

► Maxillary con...
Tongue Thrusting: Cl/F
 In relation to mandible
► Retroclination or

proclination of
mandibular teeth

 In relation to
I...
Tongue Thrusting
► Treatment considerations

 Age
►

Self correcting by 8-9 yr
 Improved muscular balance during swallow...
Tongue Thrusting:
Treatment considerations
 Malocclusion
►Correction of malocclusion

 Speech defect
►Speech therapy dur...
Tongue Thrusting :Treatment
► Myofunctional therapy
► Speech therapy
► Mechano therapy
► Correction of malocclusion
► Surg...
Tongue Thrusting :Treatment
► Myofunctional therapy

Am.J.Ortho:1972:499

► Phase I

 Tongue position during swallowing
►...
Tongue Thrusting :Treatment
Myofunctional therapy
Phase I
 Other activities for superoposterior tongue posture
► Retracti...
Tongue Thrusting :Treatment
Myofunctional therapy
► Phase III






Continuation of Phase I and II
Chewing and swallow...
Tongue Thrusting :Treatment
Myofunctional therapy
► Phase IV

 Carry- over
 Reminder appliance

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Treatment: Myofunctional therapy:
Garliner
► Guidance of correct posture of tongue during

swallowing by various exercises...
Treatment :Myofunctional therapy:
Garliner
► Lip exercise

 Tug of war and button pull exercise
► Lip massage

 Lower li...
Tongue Thrusting :Treatment
► Speech therapy




Training of correct position of tongue
Articulation of speech
Repetiti...
Tongue Thrusting :Treatment
► Mechano therapy

 Purpose
►Reeducation of tongue position
►Maintaining tongue in the confin...
Tongue Thrusting :Treatment
► Preorthodontic trainer for

myofunctional training
 Aids in correct positioning
of tongue w...
Tongue Thrusting :Treatment
►

Appliance therapy


Removable appliance

 Hawley’s appliance
►
1.
2.

Modifications
Activ...
Tongue Thrusting :Treatment
►

Treatment with
myofunctional appliance
Promote lip closure
Enlarge oral cavity
Move incisor...
Tongue Thrusting :Treatment
 Fixed appliance
► Tongue crib

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Tongue Thrusting :Treatment
► Correction of malocclusion

 Openbite
► Removable

 Frankle IV
► Vestibular configuration
...
Tongue Thrusting: Treatment :
Malocclusion : Openbite
► Removable appliance

 Modified activatorintrusion of molars

► Fi...
Tongue Thrusting :Treatment
► Surgical treatment

 Removal of tonsils

 Correction of skeletal
malformation

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Mouth breathing

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Mouth breathing
► Nasal breathing Vs Mouth breathing

 Purification of air
 Development of muscles of chest ,back, neck
...
Mouth breathing
► Definition

 Sassouni (1971) - Habitual respiration through
the mouth instead of the nose

 Merle (198...
Mouth breathing: Incidence
► Common among 5 – 15 yr

► 85% nasal breathers suffer from

degree of obstruction

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Mouth breathing
► Classification

 Finn (1987)
►Anatomical

 Short upper lip
►Obstructive

 Obstruction in nasal passag...
Mouth breathing
► Etiology

 Developmental and morphologic anomalies
interfering nasal breathing
►Asymmetry of face
►Here...
Mouth breathing: Etiology
► Partial obstruction due to






Deviated nasal septum – Birth injury
Localized benign tum...
Mouth breathing; Etiology
► Infection and inflammation

 Ch. Inflammation of nasal
mucosa
 Ch. Allergic stomatitis
 Ch....
Mouth breathing
► Clinical features

 General features
►Pulmonary development

 Pigeon chest
►Lubrication of esophagus

...
Mouth breathing
►

Adenoid fancies












Debatable consequence
Long narrow face
Narrow nose and nasal
pas...
Mouth breathing: Cl / F
► Dental effect

 Protrusion with spacing
of upper incisors
 Decreased overbite
 Openbite
 Low...
Mouth breathing: Cl / F
 Increased overjet

 Constricted maxillary
arch

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Mouth breathing: Cl / F
 Narrow palate and
cranial vault
 Narrow long face

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Mouth breathing: Cl / F
►

Lips





►

Incompetent upper lip
Everted, heavy lower lips
Voluminous curled lower lips
G...
Mouth breathing: Cl / F
►

Gingiva
 Ch. Keratinized marginal
gingivitis
 Classic rolled margin and
enlarged interdental ...
Mouth breathing: Cl / F
► Other effects










Narrow maxillary sinus and nasal cavity
Turbinates- Swollen and ...
Mouth breathing
► Sleep apnea syndrome

 Increased enlargement of lingual tonsils
 Mechanism

Mouth breather lying on ba...
Sleep apnea syndrome
► Signs / Symptoms

 Snoring
 Loud pharyngeal snoring with interrupted
silences
 Abnormal behavior...
Mouth breathing
► Diagnosis

 History
►Lip apart posture
►Tonsillitis, allergic rhinitis, otitis media

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Mouth breathing: Diagnosis
►

Examination
 Observation of breathing
 Lip posture
 Nasal orifices

►

Clinical test


...
Mouth breathing
► Treatment consideration





Age
E.N.T. examination
Correction time
►Mix dentition

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Mouth breathing: Treatment
► Symptomatic relief




Gingival coating
Periodontal consideration
►Prophylaxis

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Mouth breathing: Treatment
► Elimination of cause

 Removal of nasal or pharyngeal obstruction
► Interception of habit

...
Mouth breathing: Treatment
► Maxillothorax

myotherapy
 Macaray activator
 Oral screen

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Mouth breathing: Treatment
► Correction of

malocclusion
 Cl I
► Oral screen

 Cl II Div-1
► Noncrowded dentition (5-

9...
Mouth breathing: Treatment
 Cl III
► Interceptive chin cap

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Lip habits
► Vary with imagination

of child

 Basic type
► Wetting of lip with tongue
► Pulling the lip into mouth

betw...
Lip habits
► Etiology

 Association with digit sucking
Increased overjet
Lip seal
Incompetent upper lip
Position of lower...
Lip habits: Etiology
► Malocclusion

 Cl II Div-1
►Large overjet and overbite

 Emotional stress
►Increases the intensit...
Lip habits: Cl / F
► Lip
 Reddened , irritated, chapped area below vermilion
border
 Vermilion border
► Relocation

outs...
Lip habits; Cl/ F
►
►

Accentuated mentolabial
sulcus
Malocclusion


1.

Winder--force equilibrium
Lip
tongue

Protrusion...
Lip habits: Treatment
►
►
►

Not self- correcting
Deleterious with age
Treating primary habit
 Correction of digit suckin...
Lip habits: Treatment
► Appliance therapy

 Oral shield
► Cl I malocclusion
► Lip exercise for

improvement of lip tonus
...
Bruxism
► Definitions

Ramfjord
►Habitual grinding of teeth when the individual is not

chewing or swallowing

Rubina
►Non...
Bruxism
► Classification
 Okinuora
► Bruxism associated with stressful event
► No such association (Hereditary)

► Types
...
Bruxism
► Occurrence

 Infants
►Eruption of first primary tooth

 More prevalent in mixed dentition
 Throughout life

...
Bruxism
► Etiology

 Local theory
► Reaction to an occlusal interference

 High restoration, irritating dental condition...
Bruxism: Etiology
► Systemic
 Intestinal parasites – GI disturbance





Nutritional deficiencies - Mg deficiency
Enz...
Bruxism: Etiology
► Psychological theory





Associated with feeling of anger, aggregation
Stress
Emotional status – i...
Bruxism
► Related

Factors

 Morphological malocclusion (Wigdoro)
► Cl I, II , III , over jet, over bite

www.indiandenta...
Bruxism: Related factors
► Functional malocclusion

 Intercuspation, lateral deviation, retruded position

www.indiandent...
Bruxism
► Causal hypothesis

Ped. Dent:1995;7-12

 Malocclusion can initiate and maintain forceful
grinding or clenching
...
Bruxism
► Counterview (Christensen)

 Removal of occlusal interference
►Continued bruxism

 Nocturnal bruxism
►Protectiv...
Bruxism
► Indicators

 Presence of dental
wear / Attrition
 Bruxofacet
 Grinding or clenching

www.indiandentalacademy....
Bruxism
► Clinical manifestation

 Occlusal trauma
► mobility

 Morning time

 Tooth structure
► Nonfunctional occlusal...
Bruxism: Cl / F

►

Muscular tenderness




►

Lateral pterygoid, masseter on palpation
Fatigue on waking
Hypertrophy o...
Bruxism: Cl / F
► Headache

 Muscular contraction type
► Other signs and symptoms





Sounds- Grinding and tapping
So...
Bruxism: Treatment
►

Occlusal adjustment
 Disappearance of habitual
grinding
► Coronoplasty
► High point correction

►

...
Bruxism: Treatment
► Restorative

 Severe abrasion
► Pulp therapy
► Stainless steel crown

► Psychotherapy

 Counseling
...
Bruxism: Treatment
►

Relaxing training
 Tensing and relaxing exercise
► Voluntary relaxation





Hypnosis
Behavior C...
Bruxism: Treatment
► Biofeedback

 Positive feedback for Learning of tension reduction
► Electrical method

 Electro gal...
Cheek biting
► Definition-

 keeping or biting the
cheek muscles in
between the upper and
lower posterior teeth
► Clinica...
Cheek biting
► Treatment




Vestibular screen
Reminders

www.indiandentalacademy.com
Nail biting
►
►

Sign of stressful condition
Age of occurrence
 Before 3 yr- absent
 4-6 yr- sharp rise in
incidence
 7...
Nail biting: Cl/ F
► Nail

 Inflammation of nail
beds and nail
 Irregular nail margins
► Dental effect





Crowding
...
Nail biting
► Management







Avoidance of punitive methods
Mild case- No treatment
Care for emotional condition
E...
Conclusion

www.indiandentalacademy.com
References
► Graber
► Profitt
► Moyer
► Tandon
► Forester
► Stewart
► Pinkham

www.indiandentalacademy.com
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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Oral habits /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
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Oral habits /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Oral habits Shrirang Anand Sevekar www.indiandentalacademy.com
  3. 3. Contents ► Habit ► Definition Classification Trident of habit Dental response to pressure habits  Treatment phylosophy     ► ► ► Breast feeding Bottle feeding Thumb Or digit sucking ► ► ► ► ► ► ► Pacifiers Tongue thrusting Mouth breathing Lip habits Bruxism Nail biting Cheek biting Masochistic habits www.indiandentalacademy.com
  4. 4. Habit ► William James- From psychological view, Is a Pathway of discharge formed in brain by which certain incoming currents ever after tend to escape…. www.indiandentalacademy.com
  5. 5. Habit: Definitions ► Dorland – Fixed or constant practice established by frequent repetition ► Buttersworth – Frequent or constant practice or acquired tendency, which has been fixed by frequent repetition www.indiandentalacademy.com
  6. 6. Habit: Definitions ► Moyer Habits are learnt pattern of muscle contraction of a very complex nature ► Hogeboon and Salder It is a methodical way in which mind and body act as a result of frequent repetition of a certain definite sets of nervous impulses www.indiandentalacademy.com
  7. 7. Habit: Definitions ► Mathewson – Learned pattern of muscular contraction ► Tandon – Settled tendency in response to a specific cause resulting from repeated learning ► Boucher As a tendency towards an act or an act that has become a repeated performance, relatively fixed , consistent, easy to perform and almost automatic www.indiandentalacademy.com
  8. 8. Development of habit ► Unconscious mental pattern  Instinct ► Elementary reflex► Pattern and order     Incorrect outlet of energy Pain or discomfort Abnormal physical size Imitation of others ► Habit www.indiandentalacademy.com
  9. 9. Dental response to pressure exerting oral habits : Forester ► Functional matrix theory – Position of Dentition- skeletal growth pattern , muscular forces and masticatory forces ► Orthopedic effect (Swine hart) 2 types of forces acc. to site and duration ► ► Ant. Force against palate (Sucking habit) Constriction force of buccal musculature (Mouth breathing) www.indiandentalacademy.com
  10. 10. Habits: Classification Tandon ► ► Non- obsessive Obsessive (Deep rooted)  Intentional OR meaningful  Masochistic or Selfinflicting injurious habit (Easily learned)  Empty or Unintentional ► Abnormal pillowing, chin propping  Functional www.indiandentalacademy.com ► Tongue thrusting
  11. 11. Habits: Classification ► James (1923)/ Graber  Useful  Harmful Finn (1987)  Compulsive habits  Non- compulsive habit Primary habit Secondary habit ► Kingsley    ► Functional oral habit Muscular habit combined ► Klein (1977)  Empty  meaningful www.indiandentalacademy.com
  12. 12. Habits: Classification ► Morris and Bohanna (1969)  Non pressure habit  Pressure habit ►Sucking habit  Lip, Thumb sucking, Tongue thrusting ►Biting habit  Nail biting, Needle, Thread holding ►Posturing habit  Pillow, Hand rest ►Miscellaneous  Bruxism, Cheek biting www.indiandentalacademy.com
  13. 13. Habits: Classification ► Normal ► Abnormal ► Retained ► Cultivated ► Sucking habit JDC:1996:321 O Brian (1996)  Nutritive Sucking ► Breast, Bottle feeding  Nonnutritive ► Thumb sucking ► Tongue thrusting ► Physiologic ► Pathologic www.indiandentalacademy.com
  14. 14. Trident of Habit Intensity ► Frequency ► Duration ► Intensity ► Direction (Pinkham) Frequency Habit Direction www.indiandentalacademy.com Duration
  15. 15. Treatment philosophy and considerations ► Emotional significance of habit in relation to family    ► ► Excessive parental demand Prolonged separation Birth of sibling Psychological approach Age Existing or potential malocclusion asso. with a force exerting habit www.indiandentalacademy.com
  16. 16. Nutritive habits www.indiandentalacademy.com
  17. 17. Nutritive habits ► Breastfeeding      Rooting reflex (Pinkham) Sucking reflex Psychological development Effect on orofacial development Malocclusion www.indiandentalacademy.com JDC: 1996;321
  18. 18. Nutritive habits ► Bottle feeding  Artificial nipple ► Size, length, flow rate, location of holes ► Orthodontic or physiologic  Effect on dentofacial musculature development  Malocclusion www.indiandentalacademy.com JDC: 1996;321
  19. 19. Nonnutritive- Thumb sucking www.indiandentalacademy.com
  20. 20. Thumb or Digit sucking ► Definition Placement of thumb or one or more fingers in various depths into the mouth or oral cavity ► Synonyms  Thumb sucking/ Digit sucking/ Finger sucking www.indiandentalacademy.com
  21. 21. Thumb or Digit sucking ► Prevalence (DCNA:1978;608)  16- 45 %  Age and Prevalence ► Damage (malocclusion)     Original morphology Suckle – swallow pattern Maturational cycle of deglutition Intensity and duration of habit www.indiandentalacademy.com Graber
  22. 22. Influence of different variables on incidence and Prevalence of Thumb Sucking Habit www.indiandentalacademy.com
  23. 23. Influence of different variables on incidence and Prevalence of Thumb Sucking Habit www.indiandentalacademy.com
  24. 24. Thumb sucking: Classification ► Normal thumb sucking ► Abnormal thumb sucking Psychological Habitual www.indiandentalacademy.com
  25. 25. Thumb Sucking: Classification ► Subtelny(1973) Type A Type B Type C Type D 50% 13-20% 18% 6% Digit placement Digit placement Digit placement Digit placement Max/ Mand Ant Contact Max/ Mand Ant Contact Max/ Mand Ant Contact Max/ Mand Ant Contact www.indiandentalacademy.com
  26. 26. Nonnutritive habits Johnson(1993) www.indiandentalacademy.com
  27. 27. Thumb or Digit sucking ► Sucking reflex Incidence  Starts at 29 week I.U.  Disappear by 3 - 4 yr  First coordinated muscular activity  Psychological and nutritive need ► Rooting(Placing) reflex  Well defined sensory area around mouth  Head turning and opening of mouth by stimulation www.indiandentalacademy.com Forester
  28. 28. Thumb or Digit sucking ► Initiation of digit sucking (Infantile)  Development of muscular coordination  Ability to reach the face with hand  Exploration of environment by placing objects in mouth  Introjection and Projection ► Retained digit sucking    Lack of oral gratification Separation from mother Social structure or culture ► Eskimo study ► Burlington study www.indiandentalacademy.com
  29. 29. Thumb or Digit sucking ► Theories (Etiology) JDC:1993;385  Classical Freudian theory (1905) ►Biologic sucking drive (I.U.) ►Oral phase- Center of attraction (Oro -erotic zone) ►Deprivation of activity - Insecurity ►Assoc. With pleasurable stimuli, but not discarded at usual time due to psychological disturbance ►Substitution with less desirable habit Counterview – Gesell and Ila www.indiandentalacademy.com
  30. 30. Thumb or Digit sucking ► Benjamin theory (1962) Experimentation on monkey Two theories  Thumb sucking - Expression associated with sucking along with primary reinforcing aspect of feeding  Thumb sucking from Rooting and placing reflex www.indiandentalacademy.com
  31. 31. Thumb or Digit sucking ► Learning theory: Davidson (1967)     Adaptive response to pleasurable feeling No underlying cause No emotional or psychological problem No substitute Counterview – increased anxiety www.indiandentalacademy.com
  32. 32. Thumb or Digit sucking ► Oral drive theory (Sears and Wise;1982)  Duration of feeding Oral drive  Prolonged nursing Habit  No correlation with frustration of weaning  Sucking - Erontogenic zone of mouth (Freud) www.indiandentalacademy.com
  33. 33. Thumb or Digit sucking ► Johnson and Larson (1993) JDC:1993:385     Combination of two Inherent biologic drive for sucking Rooting and Placing reflex- Expression of drive Environmental factors for sucking drive www.indiandentalacademy.com
  34. 34. Thumb or Digit sucking ► Maintenance of habit  Normal upto 3 yrs (Psychoanalytic)  Persistence - psychological disturbance ► Anxiety management  Adaptation during development (Learning theory) www.indiandentalacademy.com
  35. 35. Thumb or Digit sucking  Causative factors 1. Parent’s occupation 1. Socioeconomic status 2. Working mother 1. 4. Order of birth of child Absence - insecurity 1. 4. Social adjustment and stress 3. No. of siblings 1. 1. Compensation for neglect Imitation Peer pressure, scolding parents 4. Feeding practices 1. www.indiandentalacademy.com Negative relation between breast feeding and habit
  36. 36. Thumb or Digit sucking: Causative factors ► Causative factors 7 Age 1. In neonates 1. Well developed suckling mechanism 2. Primitive Demand for hunger 2. During eruption of primary molar- Teething 3. Still later (Active after 4 year) 1. Emotional tensions 2. Stress outlet mechanism www.indiandentalacademy.com
  37. 37. Thumb or Digit sucking ► Diagnosis  Emotional status ►Meaningful or empty  Case history Active performance ► Information from mother ►    Feeding practice Parental care Presence of other habits www.indiandentalacademy.com
  38. 38. Thumb or Digit sucking ► Extra oral examination  Digit ► ► ► Reddened, clean, chapped, short fingernail (dishpan thumb) Chronic suckers - fibrous, roughened callus on superior aspect of finger Deformation of finger  Lip ► ► ► Position at rest, During swallowing Hypotonic upper lip Hyperactive lower lips www.indiandentalacademy.com
  39. 39. Thumb or Digit sucking; Extra oral examination ► Facial form analysis  Maxillary protrusion  Mandibular retrusion  High mandibular plane angle  Profile  Mentalis muscle contraction www.indiandentalacademy.com
  40. 40. Thumb or Digit sucking ► Intraoral examination  Tongue ► Position at rest , during swallowing  Gingiva ► Evidence of mouth breathing  Itching  Staining on max. labial surface www.indiandentalacademy.com
  41. 41. Thumb or Digit sucking; Intra oral examination ► Dento alveolar structure  Flared , proclined maxillary anteriors with diastema  Retroclined mandibular anteriors  Deformed right or left sided max. arch www.indiandentalacademy.com
  42. 42. Thumb or Digit sucking ► Dentofacial changes associated with prolonged sucking habit JDC:1993:385  Effects on maxilla Maxillary arch length ► Clinical crown length of incisors ► Counterclockwise rotation of occlusal plane ► Atypical root formation ► Trauma to incisors ► Palatal arch width ► www.indiandentalacademy.com
  43. 43. Thumb or Digit sucking: Cl/ F ► Increased SNA S N A www.indiandentalacademy.com
  44. 44. Thumb or Digit sucking: Cl /F ► Effect on mandible  Proclination of incisors (Finger sucking)  Increased Intermolar distance  Increased Distal position of B point www.indiandentalacademy.com
  45. 45. Thumb or Digit sucking: Cl /F ► Effect on interarch relationship  Anterior open bite  Increased over jet www.indiandentalacademy.com
  46. 46. Thumb or Digit sucking: Cl /F Increased unilateral and bilateral Cl II malocclusion Decreased U/ L incisal angle www.indiandentalacademy.com
  47. 47. Thumb or Digit sucking: Cl /F  Decreased overbite  Increased posterior cross bite www.indiandentalacademy.com
  48. 48. Thumb or Digit sucking: Cl /F ► Effect on lip placement and function  Increased lip incompetence  Increased lower lip function under max. incisors ► Effect on tongue placement and function  Increase tongue thrust  Increased lip to tongue resting position  Increased lower tongue www.indiandentalacademy.com position
  49. 49. Thumb or Digit sucking: Cl /F ► Other effects  Risk to psychological health  Increased risk of poisoning  Increased risk of speech defects, especially lisping www.indiandentalacademy.com  Habitual mouth breathing  Tongue thrusting  Middle ear infection  Enlarged tonsils
  50. 50. Thumb or Digit sucking ► Clinical aspect (Moyer: 1955)  Phase I ► Normal or sub clinically significant sucking (Pre school infant) ► Birth to 3 yr ► Prophylactic approach  Phase II ► Clinically significant sucking (Grade school) ► 3 – 7 yrs  Related to anxiety  Time for dental correction ► Firm and definitive programme of correction www.indiandentalacademy.com
  51. 51. Thumb or Digit sucking ► Clinical aspect  Phase III ►Intractable sucking (Teenage child) ►Beyond 4 th yr ►Psychotherapy ►Treatment for malocclusion www.indiandentalacademy.com
  52. 52. Psychological effects of malocclusion resulting from habits ► Exceedingly introvert ► Oversensitive ► Immature social behavior ► Speech defect ► Singled out in crowd www.indiandentalacademy.com
  53. 53. Thumb or Digit sucking ► Treatment Forester  Treatment rationale ► Emotional significance of habit  Psychological status of child ► ► Age of patient Status of occlusion www.indiandentalacademy.com
  54. 54. Management ► Preventive treatment  Littlefield ► Best when related to familial tendency  Hughes (1949) ► Fulfillment of hunger ► Natural feeding practices- Brest feeding  McBride ► For inhibition of sucking- Discontinuation at inception ► Removal of finger from mouth as much as possible ► At sleep- Pinning the sleeves to stop  Use of Dummy/ Pacifier www.indiandentalacademy.com the motion towards mouth
  55. 55. Management :Preventive treatment ► Psychological     Avoidance of scolding, frightening Reassurance and positive reinforcement Friendly reminders Brauer (1965) ► Constructive parental education ► Favorable contact with environment ► Providence of age specific suitable play material ► Avoidance of unnecessary regulation  Lewis (1930) ► Immediate post weaning period- Most difficult time to handle ► Encouragement of chewing and biting www.indiandentalacademy.com
  56. 56. Management :Preventive treatment ► β- Hypothesis or Dunlop’s hypothesis  Forced purposeful repetition  Abandonment of habit following unpleasant reaction www.indiandentalacademy.com
  57. 57. Management: chemical treatment ► Least effective ► Bitter or sour chemical over the finger  E.g. : Foul smelling Quinine, Asofoctine, Pepper , Caster oil, Femite etc www.indiandentalacademy.com
  58. 58. Management: Mechanical or reminder therapy ► Extra- oral approach  Mechanical restraints to hand/ Digit Adhesive bandage ► Covering with cloths ► Heckman and Bready - Tubes attached around elbow, Gloves around wrist ►  Nail polish  Thumb guard www.indiandentalacademy.com
  59. 59. Management: Mechanical or reminder therapy ► Intra- oral Approach  Weiss and Eiser (1993) ► Upto 5 yr- No intervention  Graber(1972) ► Appliance placement between 3- 4 yr.  Considerations before use of appliance ► Child’s understanding ► Parent cooperation ► Friendly rapport ► Goal orientation ► maturity www.indiandentalacademy.com
  60. 60. Management: Mechanical or reminder therapy ► Removable and fixed appliance  Palatal crib ► Breaks the suction and force on anterior segment ► Reminder ► Makes the habit nonpleasurable  Hay rakes ► Not much helpful ► Symptoms of irritability, night tremor, day wetting www.indiandentalacademy.com
  61. 61. Management: Mechanical or reminder therapy ► Oral screen  Functional appliance ► Redirection of muscular and soft tissue pressure  Prevention of placement of thumb in mouth ► Quad helix  Expansion of constricted maxillary arch  Helixes as a reminder  Posterior cross bite correction www.indiandentalacademy.com
  62. 62. Management: Mechanical or reminder therapy ► Triple loop corrector: Barber (1960)  Modified palatal arch  Similar to transpalatal arch with 3 loops ► Blue grass appliance: Bruce Haskell (1991)  Between 7 – 13 yr  Teflon roller appliance  3 – 6 month placement time www.indiandentalacademy.com
  63. 63. Thumb or Digit sucking: Treatment According to Forester ► Younger than 3 yr  No active intervention  Class I openbite self correcting  Reverse Attention www.indiandentalacademy.com
  64. 64. Thumb or Digit sucking: Treatment: Forester ► 3 – 7 yr  Depending on type of habit ►Active puller ►Idle sucker  Good molar intercuspation with little ant. Pullbehavior modification  Permanent incisor eruption with openbite – active intervention www.indiandentalacademy.com
  65. 65. Thumb or Digit sucking: Treatment; Forester ► Under 6 yr  Class I ►Behavior conditioning       Openbite pictures Reward system Intentional contralateral thumb sucking Advise for ignorance by parents Band- aid, fingernail polish No need of appliance www.indiandentalacademy.com
  66. 66. Thumb or Digit sucking: Treatment; Appliance; under 6 yr; Forester ► Class II (Non self correcting)  With anterior puller – Appliance ► With spaced primary dentition=Activator ► High mandibular angle with ant. openbite= High pull headgear ► Severe crowding in primary dentition= Extraction www.indiandentalacademy.com
  67. 67. Thumb or Digit sucking: Treatment; Appliance ;under 6 yr; Forester ► Class III  Encouragement to suck  Cl III activator with orthopedic chin www.indiandentalacademy.com
  68. 68. Thumb or Digit sucking: Treatment; Appliance ;older than 7 yr; Forester ► Class I  With ant openbite and spacing ► Hawley’s appliance ► Palatal crib ► Blue grass appliance www.indiandentalacademy.com
  69. 69. Thumb or Digit sucking: Treatment; Appliance ;older than 7 yr; Forester ► Non crowding Buccal cross bite  fixed or removable palatal expansion modified reminder (Quad helix) ► Crowed dentition  Serial extraction with digit sucking control appt www.indiandentalacademy.com
  70. 70. Thumb or Digit sucking: Treatment; Appliance ;older than 7 yr; Forester ► Class II  Non crowded Cl II Div-I with low mandibular plane angle ► Activator and headgear that are habit breaking appliance ► Class III  Simultaneous Cl III correction with habit control Appt. www.indiandentalacademy.com
  71. 71. Thumb or Digit sucking: Treatment: Older than 7 yrs; Forester  Openbite ► Removable  Frankle IV ► Vestibular configuration ► protrusive bows www.indiandentalacademy.com
  72. 72. Thumb or Digit sucking: Treatment: Older than 7 yrs; Forester ► Open bite  Removable appliance ► Modified activator- intrusion of molars  Fixed orthodontic treatment www.indiandentalacademy.com
  73. 73. Thumb or Digit sucking: Treatment: Pinkham ► Reminder therapy   ► Adhesive bandage Unpleasant stimuli Reward system  Contract between child, Dentist, Parent www.indiandentalacademy.com
  74. 74. Thumb or Digit sucking: Treatment Pinkham ► Appliance therapy  Attitude ► Self correcting malocclusion  Appliance as reminder  Fixed reminder ► Quad helix ► Palatal crib  Removable reminder www.indiandentalacademy.com
  75. 75. Pacifier habit www.indiandentalacademy.com
  76. 76. Pacifier habit Ped.Dent:2002;552 Pacifier ► Natural sucking instinct or urge ► Restricted breast feeding and bottle feeding ► Surplus sucking urge- frustration or satisfaction ► Pacifier – Satisfaction www.indiandentalacademy.com
  77. 77. Pacifier habit ► Clinical features AJO;2002;347  Oral Myofunctional alteration ► Decrease muscular tonicity of tongue and lip ► Lip entrapment ► Lip incompetence ► Narrow hard palate www.indiandentalacademy.com
  78. 78. Pacifier habit: Cl / F ► Dental changes  Posterior cross bite ► Increased mandibular arch width ► Decreased max. arch width  Anterior open bite  Cl II primary canine relationship  Increased overjet www.indiandentalacademy.com
  79. 79. Pacifier habit ► Controversies associated with pacifiers  Protects against SIDS www.indiandentalacademy.com . Ped Dent:2003;449
  80. 80. Pacifier habit . Ped Dent:2003;449  Increases risk of otitis media and other infections www.indiandentalacademy.com
  81. 81. Increases risk of otitis media and other infections www.indiandentalacademy.com
  82. 82. Pacifier habit ► Recommendations  Should not use before breast feeding established  More restraints for use  Cleaned  Avoidance of sharing among siblings  Use should be curtailed before 2 yr, discontinued by 4 yrs www.indiandentalacademy.com
  83. 83. Tongue Thrusting www.indiandentalacademy.com
  84. 84. Tongue thrusting ► Embryonic life  Proportion of tongue to developing mandible  Spacing between Gum pads www.indiandentalacademy.com
  85. 85. Anatomy and Physiology of Sucking and swallowing JDC:1996:321 ► Sucking – First Coordinated muscular activity ► Infantile swallow (Moyer)  Anterior tongue thrust between gum pads  Mandibular thrust, and stabilization by contraction of facial muscles  Lip constriction www.indiandentalacademy.com
  86. 86. Anatomy and Physiology of Sucking and swallowing ► JDC:1996:321 Infantile swallow  Muscles involved 1. 2. 3. 4. 5. 6. Masseter Orbicularis oris Mentalis Buccinator Superior pharyngeal constrictor Pterygomandibular raphe www.indiandentalacademy.com
  87. 87. Anatomy and Physiology of Sucking and swallowing ► Transitional swallow  Inter mixing of normal infantile swallow and mature swallow  Diminishing Buccinator activity  Contraction of mandibular elevator during swallow to stabilize teeth in occlusion www.indiandentalacademy.com
  88. 88. Anatomy and Physiology of Sucking and swallowing ► Mature swallow  Position of tongue (Stewart) ► Tongue tip ► Mid portion ► Posterior aspect- 45°angulation against pharyngeal wall  Lip seal  Function of masseter, Mentalis, and facial muscles www.indiandentalacademy.com
  89. 89. Phases Of Swallowing Or Deglutition ► Straub (1957)  Preparatory phase/Oral phase ► Voluntary and conscious phase ► Bolus formation and transfer to  isthmus of fauces  Adjustments of ► Soft palate, ► Tongue, ► Larynx, Hyoid bone ► Role of muscles of mastication- ant and lateral seal www.indiandentalacademy.com
  90. 90. Phases of swallowing or deglutition ► Second phase  Involuntary but conscious phase  Bolus passes through pharyngeal tube  Nasopharynx sealed off by closure of soft palate against the posterior pharyngeal wall  Hyoid bone and tongue move forward to continue peristalsis www.indiandentalacademy.com
  91. 91. Phases of swallowing or deglutition ► Esophageal phase Involuntary Reflex mechanism Bolus passes through cricopharyngeal sphincter continue through esophagus  Return to original position of hyoid bone, palate and tongue    www.indiandentalacademy.com
  92. 92. Anatomy and Physiology of swallowing ► Process of normal swallowing A. Resting posture B. Initiation of deglutitionTongue tip movement C. First tongue- tip contact D. Progression of deglutition: Tongue contacting palatal structure E. Completion of swallowing: Total contact with posterior pharyngeal wall www.indiandentalacademy.com
  93. 93. Anatomy and Physiology of Sucking and swallowing ► Abnormal swallow (Stewart)  Position of tongue ► ► ► Tip Mid portion Posterior aspect  Faulty Masseter activity  Mentalis activity www.indiandentalacademy.com
  94. 94. Tongue Thrusting ► Definition  Brauer Tongue thrust is said to be present if the tongue is observed thrusting between and the teeth did not close in centric occlusion during deglutition  Tulley Forward movement of tongue tip between the teeth to meet the lower lip during deglutition and in sounds of speech , so that the tongue becomes interdental www.indiandentalacademy.com
  95. 95. Tongue Thrusting: Definition ► Barber- It is an oral habit pattern related to persistence of an infantile swallow pattern during childhood and adolescent and thereby produces an openbite and protrusion of anterior tooth segment ► Shneider- it is a forward placement of the tongue between the anterior teeth and against the lower lip during swallowing www.indiandentalacademy.com
  96. 96. Tongue Thrusting ► Prevalence     (DCNA:1978;603) Newborn – 97% 5-6 yrs – 80% By 12 yrs – 3% Physiology (Stewart) ►At birth- soft structure confined in skeletal environment Large tongue – Forward movement www.indiandentalacademy.com
  97. 97. Tongue Thrusting ► Significance (Forrester)  Function governs form ►Adverse muscle forces – Abnormal form ► Occurrence (Profit) Younger children with normal occlusion ►Transitional stage in physiologic maturation At any age with displaced incisors► Adaptation for seal www.indiandentalacademy.com
  98. 98. Tongue Thrusting ► Equilibrium theory (Profit)  Facial musculature vs. Tongue pressure Light tongue forces – Against teeth (Normal state) ► Duration of swallowing 1 Second ► 24 hr swallow – 1000/day ► Tongue thrust- Forward resting posture of tongue – Obvious light forces ► www.indiandentalacademy.com
  99. 99. Tongue Thrusting ► Classification  Physiologic ►Infancy  Habitual ►Present after correction of malocclusion  Functional (Profit) ►Overjet, Open bite  Anatomical ►Macroglossia www.indiandentalacademy.com
  100. 100. Tongue Thrusting: Classification James S. Braner and Holt www.indiandentalacademy.com
  101. 101. Tongue Thrusting: Etiology ► Retained infantile swallow  Retention of infantile suckling mechanism  Incisor eruption – No drop of tongue  Altered Tongue posture at rest www.indiandentalacademy.com
  102. 102. Tongue Thrusting: Etiology ► URTI    Obstruction of nasal passage Mouth breathing Forward tongue posture – Physiologic need of adequate airway www.indiandentalacademy.com
  103. 103. Tongue Thrusting: Etiology ► Adenoids  Location  Complementary status: Growth of Adenoid and Upper face  Infection, Allergy – Hypertrophy - lost equilibrium – Mouth breathing – Tongue posture www.indiandentalacademy.com
  104. 104. Tongue Thrusting: Etiology ► Lymphoid tissue (Tonsils)  Location  Hypertrophy – Obstruction of oropharyngeal area  Tongue posture www.indiandentalacademy.com
  105. 105. Tongue Thrusting: Etiology ► Neurological disturbances    Hypo sensitive palate Motor disability- brain injury Disrupted sensory control and coordination of swallowing www.indiandentalacademy.com
  106. 106. Tongue Thrusting: Etiology ► Functional adaptability  Missing incisors  Protrusion ANTERIOR SEAL  overjet  openbite www.indiandentalacademy.com
  107. 107. Tongue Thrusting: Etiology ► Feeding practices    Bottle feeding Breast feeding Consistency of infant’s foodDevelopment of adult swallow pattern www.indiandentalacademy.com
  108. 108. Tongue Thrusting: Etiology ► Induced due to other    habits Digit sucking Pacifier sucking Sleeping habits www.indiandentalacademy.com
  109. 109. Tongue Thrusting: Etiology ► Hereditary    Inherited hyperactive orbicularis oris Anatomical configuration Neuromuscular activity www.indiandentalacademy.com
  110. 110. Tongue Thrusting: Etiology ► Tongue size  Macroglossia ► Anesthetic throat  Congenital physiologic discrepancies- Abnormal handling of bolus and Tongue thrust ► Soft diet Disuse atrophy of musculature ► Trauma  Persistent traumatic condition leading to abnormal deglutition www.indiandentalacademy.com
  111. 111. Classification of etiological factors: Fletcher (1975) 1. Genetic factor 1. Inherited variation in orofacial form ► 2. 4. 1. Macroglossia, constricted dental arches, Enlarged adenoids Constricted arch Learned behavior 1. 2. 4. Maturational 1. Neurological disturbances 1. Hyposensitive palate, motor disability Acquired habits Prolonged Tonsillar hypertrophy, URTI 4. 3. Mechanical restriction Delayed progression from infantile to mature Psychological factors 1. Effect from forced discontinuation of other habit www.indiandentalacademy.com
  112. 112. Tongue Thrusting: Diagnosis History ►Sibling swallow, Parent ►Previous respiratory infections , sucking habits , ► neuromuscular problem Examination  Tongue ► Size  Macroglossia - Lateral scalloping ► Shape  Asymmetry www.indiandentalacademy.com
  113. 113. Tongue Thrusting: Diagnosis ► Movements of tongue     ► Lateral Protrusive Retrusive Restricted movement (Ankyloglossia) Functional examination  Observation of tongue ► Mandibular rest position ► Various swallow     Unconscious swallow Command swallow of saliva Command swallow of water Unconscious swallow during mastication www.indiandentalacademy.com
  114. 114. Tongue Thrusting: Diagnosis ► Gag reflex  Palatal- Rare  Pharyngeal ► Abnormal tongue posture  Retracted tongue ► Withdrawn tongue tip from anterior ► Posterior openbite with lateral spread ► 10 % 0f all children, Edentulous patients www.indiandentalacademy.com
  115. 115. Tongue Thrusting: Diagnosis ► Protracted tongue  Result in openbite  Types ► Endogenous  Retention of infantile swallow  Continuous presence of tongue between teeth  Excessive vertical anterior face height ► Acquired  Transitory adaptation due to enlarged tonsils or pharyngitis www.indiandentalacademy.com
  116. 116. Tongue Thrusting: Diagnosis  Tests ► Masseter activity test ► Temporalis activity test ► Lip apart swallow test www.indiandentalacademy.com
  117. 117. Tongue Thrusting: Diagnosis ► Simple tongue thrust    Molar occlusion Ant. Open bite Contraction of lips, Mentalis, mandibular elevators www.indiandentalacademy.com
  118. 118. Tongue Thrusting: Diagnosis ► Complex tongue thrust  Generalized open bite  Absence of contraction of lips, muscles ► Lateral tongue thrust  Posterior open bite  Tongue thrusting laterally www.indiandentalacademy.com
  119. 119. Tongue Thrusting CLINICAL FEATURES ► Extra oral  Lip posture ► Lip separation  Mandibular movement ► Upward and backward with tongue moving forward  Speech ► Speech disorder ► Sibilant distortion, lisping, problem in articulation of s, n, m, t, d, l, th, z, v  Facial form www.indiandentalacademy.com ► Increased Anterior face height
  120. 120. Tongue Thrusting: Cl/F ► Intraoral  Tongue posture ► Downward and forward ► At rest- lower www.indiandentalacademy.com
  121. 121. Tongue Thrusting: Cl/F ► Malocclusion  In relation to maxilla ► Increased overjet ► Generalized spacing ► Maxillary constriction www.indiandentalacademy.com
  122. 122. Tongue Thrusting: Cl/F  In relation to mandible ► Retroclination or proclination of mandibular teeth  In relation to Intermaxillary relationship ► Ant. Or post. Openbite ► Posterior crossbite www.indiandentalacademy.com
  123. 123. Tongue Thrusting ► Treatment considerations  Age ► Self correcting by 8-9 yr  Improved muscular balance during swallowing ► Orthodontic correction in early mixed dentition(9-11)  Presence or absence of associated manifestation ► Not indicated without malocclusion or speech problem www.indiandentalacademy.com
  124. 124. Tongue Thrusting: Treatment considerations  Malocclusion ►Correction of malocclusion  Speech defect ►Speech therapy during elementary school yr.  Associated with other habits ►Other habit correction www.indiandentalacademy.com
  125. 125. Tongue Thrusting :Treatment ► Myofunctional therapy ► Speech therapy ► Mechano therapy ► Correction of malocclusion ► Surgical treatment www.indiandentalacademy.com
  126. 126. Tongue Thrusting :Treatment ► Myofunctional therapy Am.J.Ortho:1972:499 ► Phase I  Tongue position during swallowing ► Exercises for tongue Stabilization  Maintenance of tongue in bilateral contact with max. teeth during swallowing ►Sucking, holding, swallowing- Saliva, liquid, solids ►Liquid trapping exercise-    Between Tongue and roof Lip apart posture and approximation of teeth Tilting of head www.indiandentalacademy.com
  127. 127. Tongue Thrusting :Treatment Myofunctional therapy Phase I  Other activities for superoposterior tongue posture ► Retraction of tongue when held ► Clicking of tongue ► Back-of-the-mouth sounds ► Sucking and holding tongue to roof of mouth ► Phase II  Continuation of Phase I  Bite-and-swallow exercises► Development Masseter , Temporalis strength  Biting and relaxing exercises ► Pliable rubber, soft plastic tubing between teeth  Teeth together swallowing test www.indiandentalacademy.com
  128. 128. Tongue Thrusting :Treatment Myofunctional therapy ► Phase III     Continuation of Phase I and II Chewing and swallowing with lips apart Keeping lower lip immobile Upper lip exercise-- Elevation, depression, protrusion, retraction against resistance www.indiandentalacademy.com
  129. 129. Tongue Thrusting :Treatment Myofunctional therapy ► Phase IV  Carry- over  Reminder appliance www.indiandentalacademy.com
  130. 130. Treatment: Myofunctional therapy: Garliner ► Guidance of correct posture of tongue during swallowing by various exercises  Placement of tongue tip in rugae area for 5 min  Orthodontic elastics and sugarless fruit drops  2 S ,4 S exercises Identification of Spot ► Salivating Squeezing in spot ► Swallowing  Other exercise ► Whistling ► Reciting from 60 To 90 www.indiandentalacademy.com ► Yawning
  131. 131. Treatment :Myofunctional therapy: Garliner ► Lip exercise  Tug of war and button pull exercise ► Lip massage  Lower lip over upper massage ► Subconscious therapy  Time- Special time for reminding  Subliminal therapy ► Placing reminder sign in sight during meal  Autosuggestion ► 6 times swallow before sleeping www.indiandentalacademy.com
  132. 132. Tongue Thrusting :Treatment ► Speech therapy    Training of correct position of tongue Articulation of speech Repetition of words with ‘S’ sound Not indicated before 8 yrs www.indiandentalacademy.com
  133. 133. Tongue Thrusting :Treatment ► Mechano therapy  Purpose ►Reeducation of tongue position ►Maintaining tongue in the confines of dentition ►Maintaining the interocclusal distance  Prevention of over eruption and narrowing of maxillary buccal segment www.indiandentalacademy.com
  134. 134. Tongue Thrusting :Treatment ► Preorthodontic trainer for myofunctional training  Aids in correct positioning of tongue with the help of tongue tags  Tongue guard www.indiandentalacademy.com
  135. 135. Tongue Thrusting :Treatment ► Appliance therapy  Removable appliance  Hawley’s appliance ► 1. 2. Modifications Active labial bow Addition of palatal crib  Oral screen and vestibular screen www.indiandentalacademy.com
  136. 136. Tongue Thrusting :Treatment ► Treatment with myofunctional appliance Promote lip closure Enlarge oral cavity Move incisors Improve relation among jaws, tongue, Dentition and soft tissue  E. g     ► Activator ► Bionator www.indiandentalacademy.com
  137. 137. Tongue Thrusting :Treatment  Fixed appliance ► Tongue crib www.indiandentalacademy.com
  138. 138. Tongue Thrusting :Treatment ► Correction of malocclusion  Openbite ► Removable  Frankle IV ► Vestibular configuration www.indiandentalacademy.com
  139. 139. Tongue Thrusting: Treatment : Malocclusion : Openbite ► Removable appliance  Modified activatorintrusion of molars ► Fixed orthodontic treatment www.indiandentalacademy.com
  140. 140. Tongue Thrusting :Treatment ► Surgical treatment  Removal of tonsils  Correction of skeletal malformation www.indiandentalacademy.com
  141. 141. Mouth breathing www.indiandentalacademy.com
  142. 142. Mouth breathing ► Nasal breathing Vs Mouth breathing  Purification of air  Development of muscles of chest ,back, neck ► Postural defect ► Functional adaptation for mouth breathing  Mandible  Tongue posture  Head ► Manifestations  Facial height, Openbite, Crossbite www.indiandentalacademy.com
  143. 143. Mouth breathing ► Definition  Sassouni (1971) - Habitual respiration through the mouth instead of the nose  Merle (1980) - Suggested the term oro - nasal breathing instead of mouth breathing www.indiandentalacademy.com
  144. 144. Mouth breathing: Incidence ► Common among 5 – 15 yr ► 85% nasal breathers suffer from degree of obstruction www.indiandentalacademy.com some
  145. 145. Mouth breathing ► Classification  Finn (1987) ►Anatomical  Short upper lip ►Obstructive  Obstruction in nasal passage ►Habitual www.indiandentalacademy.com
  146. 146. Mouth breathing ► Etiology  Developmental and morphologic anomalies interfering nasal breathing ►Asymmetry of face ►Hereditary  Size of nasal passage  Position of nasal septum ►Abnormal development of nasal cavity, Nasal turbinates ►Abnormally short upper lip ►Under developed or abnormal facial musculature www.indiandentalacademy.com
  147. 147. Mouth breathing: Etiology ► Partial obstruction due to     Deviated nasal septum – Birth injury Localized benign tumor Narrow maxilla Leontiasis ossea ► Traumatic injuries to nasal cavity www.indiandentalacademy.com
  148. 148. Mouth breathing; Etiology ► Infection and inflammation  Ch. Inflammation of nasal mucosa  Ch. Allergic stomatitis  Ch. Atrophic rhinitis  Enlarged adenoids, tonsils  Nasal polyps ► Genetic factor  Ectomorphic child www.indiandentalacademy.com
  149. 149. Mouth breathing ► Clinical features  General features ►Pulmonary development  Pigeon chest ►Lubrication of esophagus  No mucous gland  Dry - Esophagitis ►Blood gas constituent  20 % more CO2 www.indiandentalacademy.com
  150. 150. Mouth breathing ► Adenoid fancies            Debatable consequence Long narrow face Narrow nose and nasal passage Nose tipped superiorly Flat nasal bridge Flaccid lips Short upper lip Collapsed buccal segment of maxilla High palatal vault Dolicofacial pattern Expressionless face www.indiandentalacademy.com
  151. 151. Mouth breathing: Cl / F ► Dental effect  Protrusion with spacing of upper incisors  Decreased overbite  Openbite  Lower tongue position  Posterior cross bite www.indiandentalacademy.com
  152. 152. Mouth breathing: Cl / F  Increased overjet  Constricted maxillary arch www.indiandentalacademy.com
  153. 153. Mouth breathing: Cl / F  Narrow palate and cranial vault  Narrow long face www.indiandentalacademy.com
  154. 154. Mouth breathing: Cl / F ► Lips     ► Incompetent upper lip Everted, heavy lower lips Voluminous curled lower lips Gummy smile External nares  Slit like external nares with narrow nose  Atrophied nasal mucosa www.indiandentalacademy.com
  155. 155. Mouth breathing: Cl / F ► Gingiva  Ch. Keratinized marginal gingivitis  Classic rolled margin and enlarged interdental papilla  Heavy plaque deposition  Salivary flow and bacterial overgrowth  Periodontal disease ► Pocket formation and interproximal bone loss www.indiandentalacademy.com
  156. 156. Mouth breathing: Cl / F ► Other effects         Narrow maxillary sinus and nasal cavity Turbinates- Swollen and engorged Atrophic nasal mucosa Speech- Nasal tone Infection of Lymphoid tissue Otitis media Dull sense of smell Loss of taste www.indiandentalacademy.com
  157. 157. Mouth breathing ► Sleep apnea syndrome  Increased enlargement of lingual tonsils  Mechanism Mouth breather lying on back Tongue fall posteriorly Touch post. Pharyngeal wall Occlusion of oropharynx www.indiandentalacademy.com
  158. 158. Sleep apnea syndrome ► Signs / Symptoms  Snoring  Loud pharyngeal snoring with interrupted silences  Abnormal behavior ►Movement of limbs  Altered state of consciousness during attempted arousal ►Unresponsive to pain  Morning headache www.indiandentalacademy.com
  159. 159. Mouth breathing ► Diagnosis  History ►Lip apart posture ►Tonsillitis, allergic rhinitis, otitis media www.indiandentalacademy.com
  160. 160. Mouth breathing: Diagnosis ► Examination  Observation of breathing  Lip posture  Nasal orifices ► Clinical test     Mirror test Butterfly test Water holding test Inductive plethysmography ► Airflow through nose and mouth  cephalometrics www.indiandentalacademy.com
  161. 161. Mouth breathing ► Treatment consideration    Age E.N.T. examination Correction time ►Mix dentition www.indiandentalacademy.com
  162. 162. Mouth breathing: Treatment ► Symptomatic relief   Gingival coating Periodontal consideration ►Prophylaxis www.indiandentalacademy.com
  163. 163. Mouth breathing: Treatment ► Elimination of cause  Removal of nasal or pharyngeal obstruction ► Interception of habit  Exercises ►Physical – deep inhalation exercise ►Lip  Upper lip extension exercise  Upper, lower lip combined exercise ►Playing wind pipe ►Disc holding exercise www.indiandentalacademy.com
  164. 164. Mouth breathing: Treatment ► Maxillothorax myotherapy  Macaray activator  Oral screen www.indiandentalacademy.com
  165. 165. Mouth breathing: Treatment ► Correction of malocclusion  Cl I ► Oral screen  Cl II Div-1 ► Noncrowded dentition (5- 9 yr) – Monobloc www.indiandentalacademy.com
  166. 166. Mouth breathing: Treatment  Cl III ► Interceptive chin cap www.indiandentalacademy.com
  167. 167. Lip habits ► Vary with imagination of child  Basic type ► Wetting of lip with tongue ► Pulling the lip into mouth between teeth  Lip sucking► Entire lower lip with vermilion border pulled in mouth  Mentalis habit► Vermilion border everted www.indiandentalacademy.com
  168. 168. Lip habits ► Etiology  Association with digit sucking Increased overjet Lip seal Incompetent upper lip Position of lower lip behind upper incisors negative pressure for swallowing www.indiandentalacademy.com (Graber)
  169. 169. Lip habits: Etiology ► Malocclusion  Cl II Div-1 ►Large overjet and overbite  Emotional stress ►Increases the intensity and duration www.indiandentalacademy.com
  170. 170. Lip habits: Cl / F ► Lip  Reddened , irritated, chapped area below vermilion border  Vermilion border ► Relocation outside the mouth due to constant wetting ► Redundant and hypertrophied  Ch. Herpetic infection  Cracking www.indiandentalacademy.com
  171. 171. Lip habits; Cl/ F ► ► Accentuated mentolabial sulcus Malocclusion  1. Winder--force equilibrium Lip tongue Protrusion of upper incisors 1. 2. Retrusion of lower incisors 1. 3. Flaring with interdental spacing Collapse with crowding openbite www.indiandentalacademy.com
  172. 172. Lip habits: Treatment ► ► ► Not self- correcting Deleterious with age Treating primary habit  Correction of digit sucking followed by habit reminder (Hawley’s appliance) ► ► Chemical reminder Correction of malocclusion  ClI Div-1► Fixed or removable appliance  Activator www.indiandentalacademy.com
  173. 173. Lip habits: Treatment ► Appliance therapy  Oral shield ► Cl I malocclusion ► Lip exercise for improvement of lip tonus  Lip bumper ► Prohibits excessive force on mandibular incisors ► Reposition of lower lip away from upper incisors www.indiandentalacademy.com
  174. 174. Bruxism ► Definitions Ramfjord ►Habitual grinding of teeth when the individual is not chewing or swallowing Rubina ►Nonfunctional contact of teeth which may include clenching, gnashing and tapping of teeth Vanderas ► Nonfunctional movement of mandible with or without an audible sound occurring during the day or night www.indiandentalacademy.com
  175. 175. Bruxism ► Classification  Okinuora ► Bruxism associated with stressful event ► No such association (Hereditary) ► Types  Day time bruxism / Diurnal ► Conscious or subconscious grinding ► Along with parafunctional habits ► Silent  Night time / Nocturnal ► Subconscious grinding in rhythmic pattern of masseter www.indiandentalacademy.com
  176. 176. Bruxism ► Occurrence  Infants ►Eruption of first primary tooth  More prevalent in mixed dentition  Throughout life  Sleep ►Transition from deeper stages to lighter ►REM stage  7- 88% in children www.indiandentalacademy.com
  177. 177. Bruxism ► Etiology  Local theory ► Reaction to an occlusal interference  High restoration, irritating dental condition ► Disturbed afferent impulses from PD  CNS ► Cortical lesions, cerebral palsy, mental retardation www.indiandentalacademy.com
  178. 178. Bruxism: Etiology ► Systemic  Intestinal parasites – GI disturbance     Nutritional deficiencies - Mg deficiency Enzymatic distress Allergies - Food Endocrine disorder www.indiandentalacademy.com Ch. Abd distress
  179. 179. Bruxism: Etiology ► Psychological theory    Associated with feeling of anger, aggregation Stress Emotional status – inability to express the emotion ► Other causes  Genetics  Occupational factors ► Enthusiastic student , compulsive overachiever ► Competition sports www.indiandentalacademy.com
  180. 180. Bruxism ► Related Factors  Morphological malocclusion (Wigdoro) ► Cl I, II , III , over jet, over bite www.indiandentalacademy.com
  181. 181. Bruxism: Related factors ► Functional malocclusion  Intercuspation, lateral deviation, retruded position www.indiandentalacademy.com
  182. 182. Bruxism ► Causal hypothesis Ped. Dent:1995;7-12  Malocclusion can initiate and maintain forceful grinding or clenching  Mechanism Occlusal discrepancies PD mechanoreceptors Sensory input Activation of jaw closing muscles Clenching or grinding www.indiandentalacademy.com
  183. 183. Bruxism ► Counterview (Christensen)  Removal of occlusal interference ►Continued bruxism  Nocturnal bruxism ►Protective mechanoreceptor function cancelled ►Continuation of clenching Correlation between malocclusion and bruxism is not consistent www.indiandentalacademy.com
  184. 184. Bruxism ► Indicators  Presence of dental wear / Attrition  Bruxofacet  Grinding or clenching www.indiandentalacademy.com
  185. 185. Bruxism ► Clinical manifestation  Occlusal trauma ► mobility  Morning time  Tooth structure ► Nonfunctional occlusal wear ► Sensitivity ► Atypical shiny wear facet with sharp edges ► Pulpal exposure ► # crown, restoration www.indiandentalacademy.com
  186. 186. Bruxism: Cl / F ► Muscular tenderness    ► Lateral pterygoid, masseter on palpation Fatigue on waking Hypertrophy of masseter TMJ disturbances     Crepitation , clicking , Restriction of mand. Movement Deviation of chin www.indiandentalacademy.com Pain – Dull , unilateral
  187. 187. Bruxism: Cl / F ► Headache  Muscular contraction type ► Other signs and symptoms    Sounds- Grinding and tapping Soft tissue trauma Small ulceration or ridging on buccal mucosa opposite the molar teeth www.indiandentalacademy.com
  188. 188. Bruxism: Treatment ► Occlusal adjustment  Disappearance of habitual grinding ► Coronoplasty ► High point correction ► Occlusal splints (Night guard)  Vulcanite splint to cover occlusal surfaces ► Reduction of increased muscle tone  TMJ appliance ► Prefabricated intra oral appliance for TMJ disorder www.indiandentalacademy.com
  189. 189. Bruxism: Treatment ► Restorative  Severe abrasion ► Pulp therapy ► Stainless steel crown ► Psychotherapy  Counseling ► Tension relief ► Habit awareness -Increase voluntary control www.indiandentalacademy.com
  190. 190. Bruxism: Treatment ► Relaxing training  Tensing and relaxing exercise ► Voluntary relaxation    Hypnosis Behavior Conditioning Physical therapy ► Musculoskeletal pain and stiffness ► Drugs       Placebo Vapocoolant – Ethyl chloride for pain -TMJ Local anesthetics - TMJ Tranquilizers, sedatives, muscle relaxants Diazepam – Anxiety and alteration of sleep arousal Tricyclic antidepressants- Reduce REM www.indiandentalacademy.com
  191. 191. Bruxism: Treatment ► Biofeedback  Positive feedback for Learning of tension reduction ► Electrical method  Electro galvanic stimulation ► Muscle relaxation ► Acupuncture ► Orthodontic correction www.indiandentalacademy.com  Cl II,III, Ant. Openbite, Crossbite
  192. 192. Cheek biting ► Definition-  keeping or biting the cheek muscles in between the upper and lower posterior teeth ► Clinical features  Ulcers at the level of occlusal line  Open bite  Tooth malposition in buccal segment www.indiandentalacademy.com
  193. 193. Cheek biting ► Treatment   Vestibular screen Reminders www.indiandentalacademy.com
  194. 194. Nail biting ► ► Sign of stressful condition Age of occurrence  Before 3 yr- absent  4-6 yr- sharp rise in incidence  7-10 yr- constant level  Adolescence- sharp rise ► Etiology  Emotional problem  Stressful condition www.indiandentalacademy.com
  195. 195. Nail biting: Cl/ F ► Nail  Inflammation of nail beds and nail  Irregular nail margins ► Dental effect    Crowding Rotation Attrition of incisal edges of incisors www.indiandentalacademy.com
  196. 196. Nail biting ► Management       Avoidance of punitive methods Mild case- No treatment Care for emotional condition Encouragement of stress relieving activities Nail polish, light cotton mittens as reminder Bitter or sour chemical over the finger ► E.g. : Foul smelling Quinine, Asofoctine, Pepper , Femite etc www.indiandentalacademy.com
  197. 197. Conclusion www.indiandentalacademy.com
  198. 198. References ► Graber ► Profitt ► Moyer ► Tandon ► Forester ► Stewart ► Pinkham www.indiandentalacademy.com
  199. 199. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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