Role of oral habits in dimensional changes /certified fixed orthodontic courses by Indian dental academy


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Role of oral habits in dimensional changes /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Role Of Oral Habits In Dimensional Changes Of Dental Arches During Growth & Development
  3. 3. Contents Introduction Maturation of oral functions Normal oral habits Abnormal oral habits and its role in malocclusion - Thumb sucking - Tongue thrusting - Mouth breathing - Bruxism - lip, cheek biting and others Conclusion
  4. 4. Introduction Oral habits may be a part of normal development; a symptom with a deep rooted psychological basis or may be a result of abnormal facial growth. These habits bring about harmful unbalanced pressures to bear on the immature, highly malleable dental arches, the potential changes in the position of the teeth, and occlusion, which may become decidedly abnormal if these habits are continued for a long time.
  5. 5. Definition: Boucher – a tendency towards an act or an act that has become a repeated performance, relatively fixed, consistent, easy to perform and almost automatic.
  6. 6. PRESSURE HABITS, ETIOLOGICAL FACTORS IN MALOCCLUSION AJO-DO Volume 1952 Aug (569 – 587 ERNEST T. KLEIN, D.D.S. 1. Living bone is an ever-changing tissue that constantly is being repaired and replaced from infancy to old age. 2. Living bone is extremely susceptible to the guidance and influence of pressure and stimulus. 3. The extent to which living bone can be changed with pressure or stimulus is controversial. However, even the most conservative group will agree that alveolar bone can be changed and the teeth in that bone regulated with orthodontic treatment (planned, intentional pressure).
  7. 7. 4. Abnormal pressure habits (unintentional pressures) also change alveolar bone and regulate teeth in that bone 5. Since changes take place in living bone whether the stimulating factor is intentional or unintentional, one cannot deny abnormal pressure habits as an etiological factor in malocclusion without denying the accepted principle of planned orthodontic treatment. 6. The face, with its cartilaginous bone, yields easily to stimulus and pressure, especially during growth spurts, and presents the most complicated growth problem in the entire skeleton. Since the greatest growth changes in the head are being made by the facial structures, it logically can be assumed, therefore, that all abnormal pressures should be kept from this most vulnerable target, the face.
  8. 8. 7. It is during the transition from the deciduous to the permanent arch that much damage takes place, and it is during this transition stage that the avoidance of all abnormal pressure habits is of the utmost importance. 9. Normal habits maintain normal structural form; abnormal habits maintain abnormal structural form (Johnson). 10. The orthodontist and the patient can suffer no possible detrimental effects by eliminating abnormal pressure habits. It is logical to eliminate everything that aggravates malocclusion, everything that nullifies the plan of orthodontic treatment, and everything that is a potential factor in causing treated orthodontic cases to relapse.
  9. 9. Etiology of oral habits- ruben ,karla :JODFC1996 The survival of the new born depends upon instinctive oral suckling, which allows nutritional satisfaction. Once the biological and psychological functions of the child undergo maturation, heshe can separate from mother without experiencing significant anxiety, spontaneously doing away with many oral habits. The persistence of suckling habits according to freud have been associated with an arrest of evolution (fixation), of a psychosexual oral phase, which repercuss in a short while in a distortion or prevention of oral psychophysiologic processes. The later may alter the somatognathical structures, depending on the duration, intensity and frequency. Some of the etiological factors consider responsible are conflict, jealousy, school pressure, lack of satisfaction through nourishment, irritations associated with tooth eruption, occlusal interferences, breathing obstructions etc.
  10. 10. Classification: Obsessive (Deep rooted) Intentional Masochistic Or Or Meaningful Self- inflicting Eg: nailbiting, digit suking, lipbiting Eg: gingival stripping
  11. 11. Non-obsessive (easily learned and dropped) Unintentional Functional habits Or Empty habits Eg:abnormal pillowing, chin propping Eg : mouth breathing, tongue thrusting, bruxism
  12. 12. Author Classification James (1923) Kingsley Morris Klein (1958) and (1971) Bohana (1969) Finn (1987) a) useful habits a) a) functional Pressure oral habits habits nonb) Pressure muscular habits habits b) biting c) habits combined ones .a) 1.compulsive habits 2. nonCompulsive habits b) harmful habits a) empty habits b) meaning ful habits b) 1. primary habits 2. secondary habits
  13. 13. Thumb sucking
  14. 14. 1-2yr Preschool 312 -4 yr No malocclusion malocclusion Thumb sucking Normal thumb Abnormal thumb sucking sucking Psychological Habitual
  15. 15. Sucking habits O’Brien 1996 Nutritive sucking habit Non-nutritive sucking habit Eg: breast feeding, bottle feeding Eg: Digit sucking, pacifier sucking
  16. 16. Theories: Classical Freudian theory (1905): The psychoanalytical theory holds that this orginal response arises from inherent psychosexual drive suggesting that digit sucking is a pleasurable erotic stimulation of the lips and mouth. One of the concepts of thumb sucking brought about by this theory is that humans possess a biological suckling drive. An infant associates sucking with pleasurable feelings such as hunger, satiety and being held. These events will be replaced in later life by transferring the sucking action to the most suitable object available, namely the thumb or finger The learning theory :(Davidson 1967) This theory advocates that non-nutritive sucking stems from an adaptive response. The infant associates sucking with such pleasurable feelings as hunger. These events are recalled by sucking a suitable object available mainly thumb or finger.
  17. 17. Oral drive theory :( Sears and wise 1982) They suggested that the strength of the oral drive is in part a function of how long the child continues to feed by suckling. Thus, thumb sucking is the result of prolonged nursing; and not the frustration of weaning. This theory agrees with Freud’s theory that sucking increases the erotogenesis of the mouth. Johnson and Larson 1993: They believed that combination of psychoanalytic and learning theories which explains that all children posses an inherent biological drive for suclking. The rooting and placing reflexes are merely a means of expression of the drive. Environmental factors may also contribute to this drive to nonnutritive sources such as thumb or finger.
  18. 18. Thumb sucking Disease or Restriction Suckling reflex Psychological + Nutritive
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  20. 20. Breast feeding
  21. 21. Non physiological nursing with a conventional artificial rubber nipple the mouth is propped open unduly and the lip seal is difficult. air intake with milk intake is likely. abnormal muscle pressures are exerted as a compensatory response to the excessive mouth opening required Nursing action of nuk sauger nipple closely stimulates natural activity. The perioral area is able to contact the warm nipple base which is flexible and adapts to the contour of the lips
  22. 22.
  23. 23. Thumb sucking (Subtelny1973) Type A Type B Type C Type D
  24. 24. Type A: This type is seen in almost 50% of the children; where in whole digit is placed inside the mouth with the pad of the thumb pressing against the palate, while at the same time maxillary and the Mandibular anteriors contact is present. Type B: This type is seen in almost 13- 24% of the children where in thumb is placed in the oral cavity without touching the vault of the palate, while at the same time the maxillary and mandibular anteriors contact is maintained. Type C: This type is seen in 18% of the children where in the thumb is placed into the mouth just beyond the first joint and contacts the hard palate and only the maxillary incisors, but there is no contact with the mandibular incisors. Type D: This type is seen in almost 6% of the children where in very little portion of the thumb is placed into the mouth.
  25. 25. level Description Classification of NNS habits by Johnson 1993 Level I (+/-) Boys and girls of any chronological age with a habit that occurs during sleep. Level II (+/-) Boys below the age of 8 with a habit that occurs at one setting during waking hours. Level III (+/-) Boys under the age of 8 with the habit that occurs at multiple settings during the waking hours Level IV (+/-) Girls below the age of 8 or boys above the age of 8 with a habit that occurs at one setting during waking hours. Level V (+/-) Girls below age of 8 or boys above the age of 8 with a habit that occurs across multiple settings during waking hours. Level VI (+/-) Girls over the age 8 with a habit during the waking hours.
  26. 26. Maturation of oral function With the eruption of the lower incisors the tongue starts retracting and muscular activity shifts from the anterior perioral region to the posterior region, of the tongue, pharynx and masticatory muscles, with the eruption of posterior teeth the tongue starts retracting laterally between the gum pads
  27. 27. Maintenance of the habit: Most children would stop digit sucking by the age of three to four years. But an acute increase in child’s level of stress and anxiety due to some underlying psychological or emotional disturbances can account for continuation of digit sucking habit, with conversion of an empty habit into a meaningful stress reducing response .
  28. 28. Causative factors: Parent’s occupation Working mother Number of siblings Order of birth of the child Social adjustment and stress Feeding practice Age of the child
  29. 29. Diagnosis of digital habits: 1) History 2) Extra oral examination a) The digits b) Lips c) Facial form d) Other features 3) Intra oral examination a) Tongue b) Dent alveolar structures c) Gingiva
  30. 30. The Effect of feeding methods on growth of the jaws in infants by Mario Legovic JODFC June 1991. Intent of the study was to suggest how infants to be fed and how physiologic and unphysiologic nipples and pacifiers might be used. To group the children according to the length of time they were breastfed. To examine the influence of breast feeding on the growth of alveolar process and jaws. The subjects were classified as Group A : Not breast fed Group B : Breast fed, three months or less Group C : Breast fed, more than three months.
  31. 31. There were no statistically significant relationship between prevalence of overjet and overbite and the way the child was fed. They suggest that there are numerous endogenous and exogenous factors that influence the occurrence of malocclusion Breast fed should be used for atleast nine months, many children were supplementally fed using unphysiological nipples. Although great number of children were using unphysiologic nipples and others who were breast fed did not used a pacifier they did not suck their finger, so they concluded that it is important to recognize the influence of unfavourable factors on growth and development of oral and facial structures, as well as the influence of favorable factors, such as breast-feeding should be considered.
  32. 32. Damage to primary dentition resulting from thumb and finger(digit) sucking by Osamu fukuta JODFC Nov.1996 The study was to investigate relationship between thumb or finger sucking in malocclusion, 930 subjects meet the following inclusion criteria were selected from the original 2180 children Those who only indulge in digit sucking, Those with no oral habits Subjects with complete primary dentition and no permanent teeth erupting.
  33. 33. This study investigated the effect of thumb and finger sucking on the antero posterior regions of the primary dentition of children 3-5 years of age. Around 19.8% of children were found to suck finger or thumb. At all ages the frequency of open bite and maxillary protrusion for the thumb sucking groups were higher than non oral habit group. In the five year old children the mesial step terminal plane type of thumb sucking group demonstrated significantly lower malocclusion frequencies and the distal step terminal plane type significantly higher frequencies than those of the non oral habit group. There was an increased tendency to a permanent malocclusion in distal step type in children who continued after 4 years of age. The results of this studies suggest that thumb and finger sucking should be eliminated before damage is done to the terminal plane. It would appear to be between 3-4 years of age.
  34. 34. Non-Nutritive suckling habits in brazilian children: Effects on deciduous dentition and relationship with facial morphology by cintia regina AJO 2004 The study was to assess the relationship between non nutritive suckling habits, facial morphology and malocclusion in all three planes of space, in four year old children attending state school. Conclusions drawn from these studies are prevalence of malocclusion the sample was high 49.7% and 28.5% of the children had association of 2-3 malocclusion factors(posterior crossbite, anterior open bite increased overjet). The assessed malocclusions were strongly associated with nonnutritive suckling habits. The results drawn attention to the magnitude of the problem of malocclusion in childhood and emphasize the need of longitudinal studies to provide scientific evidence.
  35. 35. Effects on maxilla Effects on mandible - proclination of maxillary incisors - increased maxillary arch length - anterior placement of apical base - increased SNA - increase in clinical crown length of anteriors - counter clock wise rotation of occl.plane - decreased SN to ANS-PNS angle - decreased palatal arch width - atypical root resorption in primary central incisors - trauma to maxillary central incisors - proclination or reteroclination of the mandibular incisors - increased intermolar distance - distal position of point B
  36. 36. Effects on interarch relationship -↓ maxillary and mandibular incisal angle - increased over jet - decreased over bite - posterior cross bite - uni-bilateral class-II occlusion Effect on lip - incompetence lips placement and - lower lip function under the maxillary function incisors - tongue thrust Effect on - lip to tongue resting position tongue placement and - lowered tongue position function Other effects - thumb deformity - speech defects, lisping
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  40. 40. AJO-DO Volume 1994 Aug (161 - 166): Effect of sucking habits on posterior crossbite Øgaard, Larsson, and Lindsten The upper and lower intercanine arch widths and the prevalence of posterior crossbite were registered for 445 3-year-old children with and without a continuing or previous dummysucking or finger-sucking habit in different areas in Sweden and Norway. Compared with the nonsuckers, an increased prevalence of posterior crossbite was observed for the finger suckers, especially the Swedish girls.
  41. 41. The probable mechanism is that the sucking activity in the cheeks combined with a reduced palatal support as the tongue takes as lower position, decreases the upper intercanine arch width. The transversal disharmony among the jaws becomes worse as the low tongue position widens the lower arch in the canine area, resulting in a forced lateral guidance of the mandible to a posterior crossbite. The study revealed that at least 2 years of dummy sucking is necessary to produce a significant effect in the upper jaw and 3 years in the lower jaw.
  42. 42. Sucking, Chewing, and Feeding Habits and the Development of Crossbite: A Longitudinal Study of Girls From Birth to 3 Years of Age Erik Larsson, (Angle Orthod 2001;71:116–119.) The aim of this investigation was to follow the development of crossbites in pacifier suckers and to determinate the possibility of reducing the prevalence of crossbite by informing and instructing the parents about sucking habits and reducing the time the child has the pacifier in the mouth. it was concluded that parents should be instructed to reduce the ‘‘in the mouth time’’ of the pacifier. The transverse occlusal relationship in pacifiersucking children should be evaluated between 2 and 3 years of age. If interfering contacts of the primary canines exist, the parents should be instructed to reduce the pacifier-sucking time.
  43. 43. Duration of nutritive and nonnutritive sucking behaviors and their effects on the dental arches in the primary dentition John J. Warren- ajo 2002;121:347-56) The purpose of this study was to assess the effects of the duration of breastfeeding and pacifier and digit sucking habits on the dental arch and the occlusal characteristics among a birth cohort of children in the primary dentition assessed at 5 years
  44. 44. conclusions drawn from the study are 1. Among children with minimal nonnutritive suckinghabits, those who breast-fed longer had similardental arch parameters and occlusal characteristicsas those with shorter duration of breastfeeding or no breast-feeding. 2. The durations of pacifier and digit habits were each positively related to the prevalence of certain malocclusions, but these malocclusions were different for pacifier and digit behaviors. Both behaviors were associated with increased prevalence of anterior open bite and reduced overbite; pacifier habits were associated with increased prevalence of posteriorcrossbite, while digit habits were associated with greater overjet, greater maxillary arch depths, and smaller maxillary arch widths.
  45. 45. 3. More importantly from a clinical perspective, some changes in dental arch parameters and changes in prevalence of certain occlusal traits persisted well beyond the cessation of pacifier or digit habits. 4. The results suggest that current recommendations for discontinuing nonnutritive sucking habits may not be optimal in preventing habit-related malocclusions at the end of the primary dentition stage.
  46. 46. Treatment Psychological therapy Reminder therapy Extra oral approaches Intra oral approaches Mechanotherapy Blue glass Quad helix
  47. 47. JCO 1984 Simultaneous Correction of Digital Sucking Habits and Posterior Crossbite with a Combo Appliance - PHILLIP M. CAMPBELL, DDS,
  48. 48. The Ace Bandage approach to digit-sucking habits The article describes an at-home program to assess children with nocturnal digit sucking habits. Children with such habits are candidates for this program, if they wish to discontinue their habits and have no psychological contra indications for the habits cessation. The program involves nightly use of an elastic bandage wrapped across the elbow. Pressure exerted by the bandage removes the digit from the mouth as the child tires and falls asleep. Careful patient selection and patient education can lead to success – pediatric dentistry 1999.
  49. 49. An aid to stop thumb sucking: the Bluegrass appliance Bruce S. Haskell, Pediatric dentistry 1991 The appliance indicated for those children who have continued a thumb sucking habit which is affecting the mixed or permanent dentition. Children also should indicate that they want to stop the habit and are willing to try for the appliance The patients believed that they had acquired a new toy with which to play with their tongues, as instructions were given to turn the roller instead of sucking digit.
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  51. 51. Tongue trusting:
  52. 52. Transition from infantile to mature swallow Infantile or visceral swallow : active contraction of the musculature of the lip, tongue tip brought forward in contact with the lower lip, and little activity of the posterior tongue or pharyngeal musculature. mandible is stabilized by the tongue interposed between the gum pads and the peri oral musculature with the involvement of 7th cranial nerve Adult or Mature swallow: this type of swallow is characterized by cessation of lip activity the placement of tongue tip against the alveolar process behind the upper incisors, more complex movements of the posterior part of the tongue. Posterior teeth come in contact for the stabilization of the mandible which is achived by the fifth cranial nerve
  53. 53. Normal swallow: Stage 1: the anterior third of the superior surface of the tongue is flat or retracted, the food bolus is collected on the flat anterior part of the tongue or in the sublingual area in front of the retracted tongue. The posterior arched part of the tongue is in contact with the soft palate. posterior seal is established. teeth and lips are not in contact.
  54. 54. Stage 2: the soft palate moves cranially and posterior direction. The platoglossal and Plato pharyngeal seal are now open. The tip of the tongue moves up and the dorsum drops down creating a groove or depression in the middle third and permitting posterior transportation of the bolus. Simultaneously a slight contraction of the lips and the lips are brought to contact. The anterior teeth approximate at the end of this stage . Symptoms of the tongue thrust swallow are seen at this stage
  55. 55. Stage 3 : the superior constrictor muscle ring in the epipharyngeal wall starts to constrict . The soft palate assumes a triangular form; both tissues together form the platopharengeal seal. with the closing of the nasopharynx the posterior part of the dorsum drops further and allows the bolus to go further back. simultaneously the anterior part of the tongue is pressed against the hard palate, which helps to manipulate the bolus in posterior direction. The teeth are in contact and the lips are together
  56. 56. Stage 4: the dorsum of the tongue moves posteriorly and superiorly as the platopharyngeal move down ward and forward . The tongue presses aganst the tensed soft palate , squeezing the residual food bolus out of the oropharyngeal area
  57. 57. Tongue trusting: Definition: Schneider 1982: tongue thrust is forward placement of the tongue between the anterior teeth and against the lower lip during swallowing
  58. 58. Tongue thrust Physiological Habitual Functional Anatomic
  59. 59. Embryonic life Disproportionably large Fills the nasal cavity Infants In between the gum pads In contact with lower lip Stabilizes the mandible Childhood Starts retracting with incisor eruption 7th to 5th cranial nerve Volume of oral cavity increases
  60. 60. Fletcher (1971) listed the patterns characteristic of tongue thrust. - A thrusting movement of the tongue against or between - the anterior teeth Slight or no contraction of the muscles of mastication Strong contraction of the lip musculature Movement of the hyoid bone in the oblique or forward direction Distortion of speech sounds.
  61. 61. TONGUE THRUSTING AND MALOCCLUSION The differential growth changes that usually resolve the largeness of the tongue size relative to skeletal jaw size is the reason why orthodontists watch some open bite malocclusions close down with no therapy. Favourable growth of the craniofacial complex could substantially increase space within the oral and pharyngeal cavities to reduce the need for a tongue to be fronted and protrusive and permit a selfcorrection of some open bite malocclusions. Worms et al 1971-80% spontaneous correction of anterior open bite. Obviously, tongue thrust is more common than the malocclusion it is supposed to cause. Also, the decreased prevalence of open bite with increasing age,should indicate that if myofunctional training techniques are to be employed to retrain tongue position it would be best to defer treatment. The best time to determine the need for therapy would be after prepubertal growth spurt rather than during the period from 6-12 yrs of age. Even then look out for fronted tongue posture( eg., unfavourable skeletal environment, specific respiratory problems or thumb and finger sucking).
  62. 62. AJO-DO 1969 Jun (94 - 104): A critical appraisal of tongue thrusting - Tulley An attempt has been made here to place the problem of tongue behavior in its true perspective by indicating that only a very small percentage of orthodontic problems are ultimately complicated by it. In a limited number of cases with poor facial pattern associated with forward tongue posture at rest, an anterior open-bite may not be permanently reduced, whatever the method of treatment. This clinical type is very unfavorable for treatment but occurs in only about 0.6 per cent of the population. Early treatment is undesirable, as the whole problem may look much worse during the early mixed-dentition phase. A classification of tongue-thrusting has been attempted. It is better to place the emphasis on the morphology of the skeletal and soft-tissue structures which demand abnormal posture and activity, rather than on the more transient and rapid movements of the tongue in speech and deglutition
  63. 63. A Cineradiographic Study of Deglutitive Tongue Movement and Nasopharyngeal Closure in Patients with Anterior Open Bite Tatsuya Fujiki, Angle Orthodontist 2000 The purpose of this study was to investigate the movement of the tip and the dorsal surface of the tongue during deglutition in patients with anterior open bite using cineradiography. By cineradiography it was established 7 stages of tongue movement and bolus position during deglutition and analyzed the tongue position, tongue movement and the time. The tongue-tip position was more protrusive during deglutition in anterior open bite than in the controls. After the head of the bolus arrived at the opening of the esophagus, the rear part of the dorsal surface of the tongue demonstrated slower movement in patients with anterior open bite than in controls. The nasopharynx closed earlier in patients with anterior open bite than in controls. It is suggested that anterior open bite patients had compensatory coordination of tongue movement, soft palate movement and pharyngeal constrictor muscle activity during deglutition.
  64. 64. Open spaces Retained infantile swallow Etiology Tongue size Upper Respiratory tract infections Residuum Of finger Sucking habit Anatomic Tongue thrust Heredity Neurological disturbances
  65. 65. Diagnosis History >hereditary etiologic factor, speech problems , upper respiratory infections, sucking habits and neuromuscular problems Examination 1. Simple tongue thrust - Normal tooth contact in posterior region - Anterior open bite (defined) - Contraction of the lips, mentalis muscle and mandibular elevators. 2. Complex tongue thrust - Generalized open bite with the absence of contraction of lip and muscle and teeth contact in occlusion. (undefined) - Cusp to cusp occlusion - Absence of gag reflex and streognosis - Dysdiadokokinesis 3. Lateral tongue thrust -posterior open bite with tongue thrusting laterally.  Functional methods
  66. 66. Maxilla Mandible Inter arch - Tipping of the palatal plane -Proclination of maxillary anteriors resulting in increase in over jet - Generalized spacing between the teeth - Teeth may be mesially inclined - or all parameters may be norm -Retroclination or Proclination of mandibular teeth depending on the type of growth -Generalized spacing between the teeth -Teeth may be mesially tilted - or all parameters may be normal - Anterior or posterior open bite depending on the posture of the tongue - Posterior cross bite - lack of interdigitation of the posterior teeth - Or all the parameters may be normal
  67. 67. Facial form lips Tongue Speech - Convex profile - Increased LAFH - Short upper lip/normal upper lip - Hyperactive mentalis/ normal - Enlarged - Forwardly placed - Normal position -Tongue thrust children are more likely to have various speech disorders, such as sibilant distortions, lisping problems in articulation of s, n, i, d, l, th, z, v sounds
  68. 68.
  69. 69. Tongue thrust habit adaptive behavior endogenous or innate Pathologic and grossly abnormal.
  70. 70. Tongue-thrusting as a habit. The fact that this will not be seen very commonly past the age of 11 years is a reason for delaying treatment where the facial pattern is good and there is merely a slight open-bite and increased overjet with a Class I or Class II relationship These patients with a persistent tongue-thrust habit will be treated quickly when the labial segment is put into its correct position. It is quite unnecessary for these children to be sent for any form of re-educational therapy. Placement of the teeth in correct position and the very presence of the appliance will be sufficient. Although the psychologic aspects of this subject have been ignored, it is interesting to note that lisping speech has returned for a short time when the child is under stress.
  71. 71. Tongue-thrusting which is possibly endogenous or innate. In the epidemiologic investigation previously described, a familial pattern was evident in 30 per cent of the small group of children who had tongue-thrusting behavior . There is an obscure central variation. This kind of tongue-thrusting is particularly marked in the sibilant sounds of speech and may often be seen in siblings and in one of the parents. It can occur when there is a perfectly normal occlusion if there is a good facial skeletal pattern, and then it is of little significance to the orthodontist. If it occurs where there is an adverse facial pattern, it may be a dominant feature and may place severe limitations on the improvement of the incisor relationship . In contrast to the simple tonguethrusting habit, it will not respond to any kind of therapy.
  72. 72. Tongue-thrust as an adaptive behavior. The majority of problems which are of concern to the orthodontist fall into this category.. The resting posture of the tongue is more important than its functional movements. The type of deglutition in which there is a tongue-thrust and excessive circumoral contraction is due to the fact that there has to be excessive contraction of the labial musculature in cases where the lips are "incompetent" and the tongue comes forward to complete the anterior oral seal. This tongue-thrust swallow can change quite dramatically if orthodontic treatment can place the labial segments in good relationship so that the lower lip can come to seal on the labial surface of the upper incisor teeth
  73. 73. An adaptive tongue behavior, in which the tongue is not only forward in functional movement but postured forward over the lower incisors at rest to seal with the lower lip, is a very important problem. This posture is associated with an adverse skeletal pattern in which there is a high Frankfort-mandibular plane angle. In the epidemiologic survey, the type of facial pattern found in only 0.6 per cent of the child population has always been recognized by orthodontists as presenting a difficult problem It is the one in which tongue-thrust, and more especially tongue posture taken into conjunction with the adverse skeletal form, will produce an anterior open-bite which is very resistant to treatment. This may be associated with a Class I, II, or III malocclusion.
  74. 74. Pathologic and grossly abnormal tongue problems.. There is no doubt that tongue size plays some part, but true macroglossia is extremely rare.
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  76. 76.
  77. 77. The nature of arch width difference and palatal depth of the anterior open bite Am J Orthod Dentofacial Orthop 1998;113:344-50.) This study was designed to (1) explore the nature of the arch width difference for patients with anterior open bite, whether dental or skeletal in nature, and (2) clarify the general impression of “high” palatal vaults for anterior open bite cases, to make sure if there are “absolutely high” or “relatively high” palatal vaults. Measurements in male and female patients with open bite malocclusions were analyzed and compared with those in male and female patients with normal occlusions. Similar trends were found for both sexes.
  78. 78. Skeletally narrowed maxillary posterior width and dentally widened mandibular posterior widths were found. Palatal depth was in the normal range in the patients with anterioropen bite. Orthopedic widening of the maxillae and inclining of the mandibular posterior teeth lingually are recommended when orthodontic treatment is to be rendered to patients with anterior open bite.
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  82. 82. CONCLUSIONS Four conclusions can be drawn from this model study for the anterior open bite cases. 1. The posterior maxillary arch is narrowed skeletally. 2. The posterior mandibular arch is widened dentally. 3. Anterior open bite groups revealed an apparent posterior transverse discrepancy that was not present in the control groups. 4. The palatal depths of the subjects with anterior open bite were normal. Attention should be drawn to the skeletal narrowing of the maxillae and the buccally upright mandibular posteriors when posterior crossbite exists.
  83. 83. Oral perception in tongue thrust and other oral habits José S. Dahan, LDS, MD, PhD,a Odette Lelong, BA, LRL, PhD,b Sandrine Celant, BA,c and Valérie Leysen, BAc Brussels, Belgium Sensory feedback is important for muscle function. Stereognostic testing can be used to assess tactile perception. Oral recognition of shape is enhanced by repetition Stereognosis is sensitive to age, upper and lower anterior arch perimeter, and oral habits. test may be useful in differentiating light from to severe oral dysfunction. The possibility of an interaction between bolus location, stereognosis,and the swallowing act needs further investigation.
  84. 84. Treatment Age Presence or absence of associated manifestation Malocclusion Speech defects Associated with other habits
  85. 85. Treatment Traning of correct swallow and posture of the tongue a) myofunctional exercises b) using appliances as a giude in correct positioning of the tongue Speech therapy Mechanotherapy Removable appliance therapy Fixed habit breaking appliance Oral screen Correction of malocclusion Surgical treatment
  86. 86.
  87. 87. Mouth breathing
  88. 88. Mouth breathing Nasal resistance Mouth breathing Chest development +alteration of muscles of chest, back and neck Alteration of craniocervical angle + drop in mandible and tongue Increase in posterior dental height + increased mand. plane
  89. 89. Definition: Sassouni (1971) defined mouth breathing as habitual respiration through the mouth instead of the nose. Merle (1980) suggested the term oro-nasal breathing instead of mouth breathing. F.M. Chacker defined mouth breathing as the prolonged or continued exposure of the tissues of the anterior area of the mouth to the drying effects of the inspired air.
  90. 90. Mouth breathing Finn (1987) Habitual Anatomic Obstructive
  91. 91. M O U E T IOLOGY H B R E A T H I N G Warren et al , a nasal airway cross sectional area of less than 0.4 cm2 may represent an inadequate airway and some mouth breathing would be expected. Allergic rhinitis, nasal polyps, enlarged adenoids or tonsils Abnormally short upper lip preventing proper lip seal Obstruction in the bronchial tree or larynx Obstructive sleep apnoea syndrome Genetically predisposed individuals. Ectomorphic children having a genetic type of tapering face and nasopharynx are prone for nasal obstruction. Thumb sucking or similar oral habits can be the instigting agent. Traumatic injuries to the nasal cavity
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  94. 94. Diagnosis History Examination Clinical tests - mirror test - butterfly test - water holding test
  95. 95. Facial form Large anterior facial height Increased mandibular plane Reterognathic maxilla and mandible with dolicocephalic head form Adenoid facies Long , narrow face with narrow nose and nasal passages Short , flaccid upper lip ‘v’ shaped arch, buccal crossbite Dental effects Speech effects lip Upper and lower incisors are retroinclined Excessive incisal show Posterior cross bite Tendency towards open bite There may be flaring of incisiors Nasal tone in voice is seen Incompetent
  96. 96. gingiva Gingivits-rolled margins and interdental enlargement Nasal cavity Turbinales swollen and engorged Nasal mucosa becomes atrophic
  97. 97.
  98. 98. THE LONG FACE SYNDROME In 1872, C.V. Tomes coined the term “Adenoid Facies” or ‘Long Face Syndrome’ to describe the dentofacial changes associated with chronic nasal airway obstruction.Any condition that causes nasal obstruction could lead to this typical facial morphology. This syndrome is characterized by an increased LAFH,increased dentoalveolar height,gummy smile,high arched palate ,steep mandibular plane,excess incisal show,anterior marginal gingivitis and long-standing nasal obstruction may lead to "disuse atrophy" of the lower lateral cartilages , resulting in as slit-like external nose with a narrow nasal vault.
  99. 99. Nasal obstruction and facial growth: Katherine W. L. Vig, BDS, MS, FDS, DOrth The purpose of this article is to review some of the available evidence in children, adolescents, and adults that suggest that there may or may not be an association between respiratory mode and facial morphology.
  100. 100. The classic work of Harvold cited earlier in the text was based on total obstruction of the nasal airway in monkeys; this resulted in a cause and effect relationship. However, human studies have indicated that total nasal obstruction is rare, and the most common respiratory mode is a simultaneous oral and nasal airflow.The percentage of nasal versus oral airflow is dependent on a number of variables
  101. 101. Fields et al.used contemporary respirometric techniques to compare respiratory modes of normal and long-faced adolescents.They concluded that the long-faced subjects had a significantly smaller component of nasal airflow,although the tidal volume and minimum nasal cross sectional area were similar. They suggest that significant differences in airway impairment do not have a direct effect on the breathing mode, which may be behaviorally determined rather than being structurally dependent. The form-function interaction that conveniently should explain the causal association between nasal obstruction and facial growth in children appears to be of a multifactorial nature .
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  103. 103. Relation between nasorespiratory function and dentofacial morphology - O'Ryan, AJO-DO Volume 1982 Nov It is commonly assumed that nasorespiratory function can exert a dramatic effect upon the development of the dentofacial complex. Specifically, it has been stated that chronic nasal obstruction leads to mouth breathing, which causes altered tongue and mandibular positions. If this occurs during a period of active growth, the outcome is development of the "adenoid facies" (dentofacial morphology). Such patients characteristically manifest a vertically long lower third facial height, narrow alar bases, lip incompetence, a long and narrow maxillary arch, and a greater than normal mandibular plane angle. These dentofacial traits have repeatedly been attributed to restricted nasorespiratory function. It is generally believed that environmental factors can exert subtle or dramatic effects upon dentofacial morphology, depending upon their magnitude, duration, and time of occurrence.
  104. 104. RADIOGRAPHIC AND RHINOMANOMETRIC RESEARCH ON THE RELATIONSHIP BETWEEN RESPIRATION AND CRANIOFACIAL MORPHOLOGY Subtleny-Airway space increased with greater soft palate and hard palate growth. Airway space did not increase with growth if the adenoids became sufficiently hypertrophied. Ricketts- space necessary for nasal respiration was related to the angulation of the cranial base, the position of the posterior nasal spine, size and function of soft palate and the amount of adenoid tissue. Solow- positive association between the size of the nasopharyngeal space and depressed maxillary width. He also found a positive correlation between the acuteness of the cranial base and the width and height of the maxilla. Solow and Kreiborg- suggested a causal link between airway obstruction, postural change resulting in stretching of facial soft tissue and changes in cranial morphology. Hannuksela-no significant difference in the dimensions of the dental arches, overjet, overbite when comparing the allergic with normal group. She also found that mouth breathing was less common in the children with enlarged adenoids. Handelman and Osborne were not able to demonstrate posterior rotation of the mandible due to nasopharyngeal obstruction. Sosa et al- no relation could be found between the airway space or lymphoid tissue bulk and the type of malocclusion.
  105. 105. Angle Orthodontist 1990 Myofunctional and dentofacial relationships in second grade children Alan M. Gross, Gloria D. Kellum, Sue T. Hale, One hundred and thirty-three second graders in rural public school were assessed on a number of dental, skeletal, and oral muscle function measures. Correlational analyses were conducted in order to determine whether specific myofunctional variables were associated with dentofacial development. Significant relationships were observed between open mouth posture and a narrow maxillary arch and long facial height. Labial and lingual rest and swallow patterns were also related to poor coordination of lip and tongue movements.
  106. 106. Angle Orthodontist 1994 A longitudinal evaluation of open mouth posture and maxillary arch width in children Alan M. Gross, Gloria D. Kellum Open mouth posture and maxillary arch width were assessed annually for 4 years in a group of children. While younger children exhibited high levels of open mouth posture, this behavior decreased significantly over time. Racial and sex differences, as well as a race-bytime interaction were also evident. The children displayed a significantincrease in maxillary arch width across time with sex and racial differences in this growth pattern. Subjects were classified as exhibiting primarily open mouth or closed mouth posture. Although both groups showed increased maxillary arch widths over time, the closed mouth subjects showed significantly greater maxillary arch growth.
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  108. 108. Angle Orthodontist 1988 Developmental Effects of Impaired Breathing in the Face of the Growing Child Man-Ching Cheng, Donald H. Enlow, .. Craniofacial morphology and occlusal pattern are evaluated in 71 subjects having impaired breathing as diagnosed by an otolaryngologist, and in an equal number of controls. The impaired group demonstrate characteristic combinations of craniofacial deformities and malocclusions, with the younger individuals demonstrating a lesser expression of malocclusion progression and morphologic deformities. This suggests that early recognition of such facial patterns may be utilized to identify those breathing compromised individuals who have a likely tendency to develop certain types of malocclusion.
  109. 109. Angle Orthodontist 1988 Developmental Effects of Impaired Breathing in the Face of the Growing Child Man-Ching Cheng, Donald H. Enlow, Micha... This study characterizes craniofacial morphology and occlusal patterns in breathing-impaired subjects and tests a hypothesis that specific types of malocclusions found in subjects with nasal obstruction relate to certain intrinsic morphologic combinations. The findings lead to the following conclusions: Craniofacial morphology and occlusal patterns in the breathing-impaired sample are significantly different from those in the control sample. The discrepancies relate to vertical components associated with a longer face and dentoalveolar and palatal heights.
  110. 110. •Transversely, the impaired subjects also show more narrow cranial and palatal widths. The mandibles in these subjects were characterized by greater whole mandibular length and more prominent antegonial notching. In the breathing-impaired group, Black subjects showed a larger mandibular length, wider dental arches and palates, a larger midcranial base angle, and a more backward alignment of the mandibular rami. • The younger a breathing-impaired subject, the less marked is the expression of these craniofacial morphologic and occlusal characteristics. • The results of multivariate analyses show high correlations of certain types of occlusal variables with specific combinations of craniofacial structures. High prediction rates for palate height and accurate groupings for posterior lingual crossbite, anterior crossbite, maxillary anterior crowding, and mandibular anterior crowding are achieved through utilization of certain combinations of craniofacial morphologic variables. • A multidisciplinary approach involving the otolaryngologist and the orthodontist is advantageous for curtailing or reducing continuing detrimental effects of breathing impairments on craniofacial morphology and occlusion.
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  112. 112. Harvold in 1973 simulated hypertrophied adenoids in primates with acrylic blocks and found that within 9-15 months the palatal vault increased in height creating an anterior open bite. He believed that an open clear airway is a prerequisite to normal facial form and function. Harvold further points out that there are two types of movement involved – rhythmic, such as respiration and tonic, which involves changes in posture. Changes in rhythmic movement cause few skeletal variations but tonic changes cause significant alterations in skeletal morphology. The muscles with which the dental clinician is primarily concerned, are those involved in tonic changes, such as the diagastrics, pterygoids, masseters and temporalis.
  113. 113. According to Paul and Nanda, there is much evidence that mouth breathing produces deformities of the jaws, inadequate position or shape of the alveolar process and malocclusion and results in the development of adenoid facies, or long face syndrome Adenoid enlargement leading to mouthbreathing results in a particular type of facial form and dentition. 3 mechanisms were found by which adenoid-mouth breathing relationship influences the etiology of facial form and dentition Compression Disuse atrophy – theory of inactivity Altered air pressure
  114. 114. In 1918, Norlund introduced the ‘compression theory’ which stated that constriction of the maxillary arch is related to the absence of the lateralizing pressure of the tongue against the palate. In response to nasal obstruction, the tongue drops and the medializing effects of the buccal musculature is left unopposed. The effect is further enhanced by a pressure differential across the hard palate in the absence of nasal airflow, leading to a narrow, high-arched palate.
  115. 115. Woodside in 1968 suggested that obstructed nasal ventilation, could, if present during a long period of time, act as an etiological factor in the development of a class II malocclusion.Recent study by Chang proposed that the degree of impact caused by nasal obstruction may vary with different facial types. A brachycephalic or broad faced pattern with strong facial musculature and a deep bite may be less affected by nasal obstruction, whereas dolicocephalic faces with narrow, more elongated pattern may be more susceptible.
  116. 116. Theories first proposing the existence of a relationship between mouth breathing and facial form stated that oral respiration alters normal air currents and pressures through the nasal and oral cavities, which causes impaired development of these structures. Several authors postulated this to be the result of the oral airstream in mouth-breathing individuals hindering normal downward palatal growth. Others believed that the raised negative air pressure difference between the oral and nasal passages in mouth breathers lead to development of a deep palatal vault.
  117. 117. A second theory held that oral respiration disrupts the muscle forces exerted by the tongue, cheeks, and lips upon the maxillary arch. The mouth breather was believed to position the tongue in a more downward and forward manner in the oral cavity, a position in which it could not exert adequate buccal pressure to counteract the inward forces from the lips and cheeks upon the maxilla. This theory exists in the current literature. A third school of thought denies a significant relationship between facial morphology and mode of breathing. Kingsley was among the first to consider the V-shaped maxillary arch and deep palate a congenital trait not related to mouth breathing.
  118. 118. Controversy over dentofacial morphology and mouth breathing The relationship between nasorespiratory function and dentofacial development remains controversial. The prevalent view among orthodontists is that nasal airway impairment and mouth breathing may lead to micro rhinodysplasia, adenoid facies long face syndrome, or open bite malocclusion. While many reports support this premise, almost as many deny it. Clinicians who believe that mouth breathing is orthodontically harmful have little problem justifying their position by citing supporting literature. Similarly, those who oppose this view also find ample support for their stance.
  119. 119. Sufficient proof for a causal relationship between mouth breathing and adenoid facies was also disclaimed by Moyers and by Tulley. The list of problems associated with mouth breathing has continued to grow. Quinn (1978) cited over 100 clinical symptoms and over 25 radiographic signs of mouth breathing. McNamara- individuals with enlarged adenoids or other forms of airway obstruction demonstrated the spectrum of craniofacial relationships with no specific pattern directly correlated to mouth breathing.
  120. 120. Treatment considerations Age of the child E.N.T examination Correction of mouth breathing -symptomatic treatment - elimination of the cause - interception of the habit exercises Physical exercises Lip exercises Oral screen - correction of the malocclusion
  121. 121. PREVENTION – MYOFUNCTIONAL APPLIANCES Oral myofunctional therapy has been shown to be effective in correcting oral myofunctional disorders such as tongue thrust swallow, improper tongue and mouth resting posture, improper use of muscles of the mouth, tongue, and lips for chewing and swallowing, and late thumb/finger sucking habits.
  122. 122. RAPID MAXILLARY EXPANSION Brown, a rhinologist, was a vigorous supporter of midpalatal suture opening for the purpose of overcoming nasal stenosis. Widening the upper jaw enlarges the nasal airway and at the same time corrects lower jaw development gives the tongue more space and enhances the flow of air in the throat.
  123. 123. Bruxism Definition: Ramfjord 1966: habitual grinding of teeth when individual is not chewing or swallowing Rubina 1986: it is a term used 6to indicate nonfunctional contact of teeth which may include clenching, gnashing and tapping of teeth Vanderas 1995: nonfunctional movement of the mandible with or without an audible sound occurring during the day or night
  124. 124. Types Diurnal Nocturnal
  125. 125. Etiology Cns Psychological Occluasal discrepancies Genetics Systemic factors Allergies Occupational factors
  126. 126. AJO-DO 1980 Jan (48 - 59): Bruxism in allergic children Marks Without deprecating other prominently mentioned causes of bruxism, such as psychological influences, occlusal defects, and genetic factors, allergic sensitization must be considered seriously. Intermittent allergic edema of the Eustachian tube causes changes to occur in the tympanic cavity, reflexly initiating bruxism as a means of obtaining a patent Eustachian tube. Bruxism in allergic persons may have its origin in infancy and early childhood.
  127. 127. The dentofacial morphology of bruxers versus nonbruxers Susan E. Menapace, DMD, MDS; The purpose of this investigation was to determine whether a relationship existed between bruxism and craniofacial morphology and dental occlusion Conclusions 1. There was no statistically significant difference in the craniofacial or dental morphology of bruxers versus nonbruxers. 2. The dolichocephalic headform and the euryprosopic facial type and Angle Class I occlusion predominated in both bruxers and non-bruxers. 3. There was no relationship between headform/facial type and dental occlusion.
  128. 128. Craniofacial morphology of bruxers verses nonbruxers-DavidAngle 1999 The purpose of this study was to test for the association between craniofacial morphologies of bruxers verses non bruxers This study found no difference in the craniofacial morphologies of bruxers and non bruxers, nor there was any difference With over bite . But however there was stastically significant difference between bi zygomatic width and cranial width
  129. 129. Frequency Duration intensity TM J -Pain -Crepitation & clicking -Restricted movement Teeth &P.D Muscles - Mobility - Gingivitis> periodontitis - Occlusal wear -Muscle tenderness - Fatigue - Hypertrophy Bruxism
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  131. 131. Orthodontic treatment Electrical method Occlusal splints Bruxism Biofeed back Treatment Occlusal Adjustment & Retorative treatment s psychothearpy drugs Physical thearpy
  132. 132. Relation ship among nocturnal jaw muscle activities, decreased esophageal PH, and sleep position AJO- 2004..Miyawaki In healthy adults , at 50% of the jaw muscle activities during sleep were closely associated with saliva swallowing, and most jaw muscle activities is associated in relation with GER in the supine position. There fore it has been proposed that preventing both GER and sleeping in the supine position might be effective in decreasing the frequency of sleep bruxism
  133. 133. JCO 1979 Oct(684 - 701): Occlusion with particular emphasis on the functional and parafunctional role of anterior teeth: Part 2 Good posterior tooth occlusion in centric closure assures support for the condylar components and protection for the anterior teeth components. Good condyle and anterior teeth disclusion assures protection for the posterior teeth in all eccentric positions. This mutually protected arrangement will allow the gnathic system to function without conflict of its parts and long be useful to man.
  134. 134. Lip habit It may involve either of the lips , with a higher predominance of lower lip Definition Habits involving manipulation of the lips and perioral structures are termed as lip habits. Classification Wetting the lips with the tongue Pulling the lips into the mouth between the teeth (schneider1982)
  135. 135. Etiology Malocclusion Class II div 1 Deep bite Habits Thumb or digit habit Emotional stress
  136. 136. Dentition - Proclination of reteroclination of incisors -Reddened irritated and chapped area below Lips Mentolabial sulcus Malocclusion the vermilion border. - Vermilion border may be located further outside the mouth. -vermilion border becomes redundant and hypertrophic at rest - Deepens -Maintains the existing malocclusion -May cause gingival recession and bone loss on lower teeth and proclination of the upper
  137. 137. Treatment Correction of malocclusion Treating the primary habit Appliance therapy Lip bumper
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  139. 139. Cheek biting This is a abnormal habit of keeping or biting the cheek muscle in between the upper and lower posterior teeth. It may injure the soft tissue and may cause posterior open bite or individual tooth malposition in the buccal segment where posterior cheek biting exists Clinical features Ulcer at the level of occlusion Open bite Tooth malposition of tooth in the buccal segment Treatment Removable crib may be constructed
  140. 140. Nail biting Nail biting is one of the most commonest habit in children and adults. It is a sign of internal tension Etiology Emotional problem Effects Dental Crowding, rotation, attrition of incisal edges Effects on the nails Inflammation of the nail beds
  141. 141. Self injurious habits Definition Repetitive acts that result in physical damage of the individual. These habits show increased incidence in mentally retarded population
  142. 142. Etiology a) Organic b) Functional - Type A - Type B - Type C
  143. 143. Treatment Psychotherapy Pallative treatment Mechanotherapy
  144. 144. A stitch in time saves nine Interception in right time saves thirty two
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