this ppt desrcibes about how oral habits cause malocclusion and its management

1. ORAL
HABITS

2. Oral habits may be a part of normal development, a symptom
with a deep rooted psychological basis or may be the results of
abnormal facial growth
Digit sucking, lip biting, bruxism, mouth breathing, tongue
thrusting, etc are some of the oral habits
Persistence of these habits after a certain period of time affects
development of occlusion
INTRODUCTION:

3. Dorland(1957): habit can be defined as a fixed or constant
practice established by frequent repetition.
Buttersworth(1961): defined a habit as a frequent or constant
practice or acquired tendency, which has been fixed by
frequent repetition
Definitions

4. Obsessive(deep rooted)
- intentional or meaningful: nail biting, digit sucking, lip biting
- masochistic or selfinflicting injurious habit: gingival stripping
Non-obsessive(easily learned and dropped)
unintentional or empty: abnormal pillowing, chin propping
Functional habits: mouth breathing, tongue thrusting, bruxism
CLASSIFICATION OF HABITS

5. Useful and Harmful habits
Empty and Meaningful habits
Pressure, Non Pressure and biting habits
Compulsive and Non Compulsive habits
Normal and abnormal habits
Primary and secondary habits
Functional and muscular habits
Classification of Habits

6. Useful and Harmful habits
Useful habits: These include that are considered essential for
normal function
e.g: Proper positioning of tongue, respiration and deglutition
Harmful habits: These include habit that have deleterious effect
on the teeth and dental arches
e.g: tongue thrusting, mouth breathing

7. Empty habits: They are habit that are not associated with any
deep rooted psychological problems. This can be treated easily
by dentist using reminder therapy.
Meaningful habits: They are habits that have psychological
bearing.
Empty and Meaningful habits

8. Pressure habits: These include habits that apply direct force on teeth
and dental arches
Eg: sucking habits such as lip sucking
Non-Pressure habits: Habits do not apply a direct force on teeth
e.g: mouth breathing
Biting habits: These include habits such as nail biting, pencil biting etc.
Pressure , non pressure
and biting habits

9. THUMB SUCKING :
Definition:
Placement of thumb into various depths into the mouth

10. 1.Based on clinical
observation
normal abnormal
psychological habitual
Classification

11. Normal thumb sucking:
This habit is considered normal during the first one and half years of
life. Such habit disappears as the child matures. The habit at this age
doesnot generate any malocclusion
Abnormal thumb sucking:
When the habit persists beyond the preschool period then it could be
considered as an abnormal habit. If the habit is not controlled and
treated during this stage, it may cause deleterious effects on the dento-
facial structures.

12. May have deep rooted
emotional factors involved
Associated with insecurities,
neglect loneliness experienced
by the child
abnormal
psychological
•Child performs the act
out of habit.
habitual

13. Based on phases of development
Phase 1: normal & sub clinically significant
First 3 yrs of life
Phase 2: clinically significant
3-6 yrs of life
child is under anxiety
If not controlled, produces severe malocclusion
Phase 3 : intractable sucking
Sucking >5 yrs of life
Psychologist consultation is must

14. O.Brien’s(1996)
nutritive
e.g. breast feeding,
bottle feeding
Non nutritive
Sucking habits
(nns)
e.g. thumb or finger
Sucking,
Pacifier sucking

15. TYPE A TYPE B TYPE C TYPE D
•50% of children
•Whole digit is
placed inside the
mouth with pad
of the thumb
pressing over the
palate while at
the same time
maxillary &
mandibular
anteriors are in
contact
•13-24%
•Thumb is
placed into oral
cavity without
touching the
vault of the
palate, while at
the same time
maxillary &
mandibular
anteriors contact
is maintained
•18%
•Thumb is
placed into the
mouth just
beyond the first
joint & contact
the hard palate
& only max.
incisors , but
there is no
contact with
mand. Incisors.
•6%
•VERY LITTLE
portion of finger
is placed into
the mouth
Subtleny’s classification

17. Effects on
maxilla
• Increased proclination of the maxillary central
incisors.
• increased arch length
• increased SNA
• Decreased SN-PNS angle
• Decreased palatal arch width
• Increased trauma to maxillary central incisors
•Increased clinical crown length of the maxillary
central incisor
Clinical features

18. Effects on
mandible
• Increased proclination of mandibular incisors
• Increased mandibular intermolar distance
• Increased distal position of B point

19. Effects on the
interarch
relationship
• Decreased maxillary and
mandibular incisal angle
• Increased overjet
• Decreased overbite
• Increased posterior cross-bite
• Increased unilateral and bilateral
class II occlusion
Effects on lip
placement &
function
• Increased lip incompetence
• Increased lower-lip function
under the maxillary incisors

20. Effects of tongue
placement and
function
• Increased tongue thrust
• Increased lip to tongue resting
positions
• Increased lower tongue position
Other effects • Risk to psychological health
• Increased risk of poisoning
• Increased deformation of digits
• Increased risk of speech defects,
specially lisping
•Dish pan like appearance of the
nail.

21. Etiological factors associated
1. Socioeconomic status
2. Working mother
3. Number of siblings
4. Order of birth of child
5. Social adjustment and stress
6. Age of the child

22. History
Extra oral examination
Facial form analysis
Intra oral examination
Diagnosis

23. Determine the psychological component involved.
Ask about frequency, intensity and duration.
Presence of other habits should be evaluated.
HISTORY:

24. EXTRA ORAL EXAMINATION (DIGITS):
Will appear reddened, exceptionally clean,
chapped & with small finger nail.
i.e. a clean dish pan thumb.
Fibrous roughened callus also present.

25. Upper lip may be short hypotonic.
Note the position of the lip at rest whether they are held
together or apart.
Position of lips during swallowing should be observed.
Chronic thumb sucking are frequently characterized by
short hypotonic upper lip.
Lower lip is hyper active & this leads to a further increase in
the Proclination of upper ant. Due to its thrust on these
teeth.
EXTRA ORAL EXAMINATION
(LIPS):

26. Cheek form, mandibular retrusion, maxillary protrusion, high
mandibular plane angle & convex profile.
When swallowing patient is observed for presence of a facial
grimace of an excessive mentalis muscle contraction a normal
placement of the tongue against teeth & palate.
Check- The pattern of speech of child is essentially normal
Facial profile: straight or convex
FACIAL FORM ANALYSIS:

27. Tongue
Dento alveolar structure
Gingiva
INTRA ORAL EXAMINATION:

28. TONGUE:
• Compare position of tongue at rest and during
swallowing.

29. Individual with severe finger sucking habits where the digit
applied an ant. Sup. Vector to the upper dentition & palate will
have flared proclined max. with diatema and retroclined
mandibular anteriors.
Buccal crossbite
DENTO ALVEOLAR STRUCTURE:

30. Look for evidence of mouth breathing, gum line etching, excessive etching on
labial surface of upper central & lateral incisor.
GINGIVA

31. Higher incidence of middle ear infections
Enlarged tonsils
OTHER FEATURES

32. MANAGEMENT
Psychological
therapy
Dunlop Beta
Hypothesis
Parental concern
regarding the habit.
Love and affection
Chemical Therapy
Reminder
therapy
Bitter flavor
preparations
applied on tongue
like pepper,
quinine,etc.
Mechanotherapy
Fixed intraoral anti-
thumb sucking
appliances
Blue glass appliances
Quad helix

33. PSYCHOLOGICAL THERAPY:
With the age of 4-8 yrs, need only re-
assurance, +ve reinforcement & friendly
remainders.
Various aids are employed to bring habit
under the notice of child such as study
models.
During treatment, adequate emotional
support & concern should be provided to
the child by the parents.

34. DUNLOP’S BETA HYPOTHESIS:
It states that the best way to break a habit is by its
conscious, purposeful repetition
The child should be asked to sit in front of a large
mirror and asked to suck his thumb observing him as he
indulges in the habit

35. Extra oral
Intra oral
REMINDER THERAPY:

36. EXTRA ORAL:
It employs hot tasting, bitter
flavored preparation a distasteful
agent are applied to finger.
Eg. Quinine, asafoetida
Thermoplastic thumb post was
devised by Allen in 1991 where a
thermoplastic material was placed
on the offending digit

37. Increasing the arm length of the night suit or long
sleeve shirt
Hand puppets
Ace bandage –elbow
Thumb home concept

38. INTRA ORAL
Palatal cribs, hay rakes, oral
screens, palatal arch, lingual
spurs Hawley’s retainers with &
without spurs.

39. 1. Fixed intra oral anti thumb sucking appliances.
An intra oral appliances attached to upper teeth by means of
bands fitted to the primary II / I premolars
A lingual arch forms the base of an appliance to which are
added interlacing wires in the ant. Portion
It works by preventing the patient from putting the palmer
surface of the thumb in contact with the palatal gingiva,
thereby robbing the pleasure of sucking
MECHANOTHERAPY:

40. 2. Blue grass appliance
By Haskell (1991)
It consists of a modified six sided roller
machined from Teflon
It is slipped over a 0.045 stainless steel
wire soldered to molar orthodontic band
It is worn for 3-6 months

41. 3.QUAD HELIX
It prevents the thumb from being inserted and also corrects
the malocclusion

43. BARBER 1975: Tongue thrust is an oral habit pattern related to
the persistence of an infantile swallow pattern during childhood and
adolescence and thereby produces an open bite and protrusion of the
anterior tooth segments.
DEFINITION:

44. Infantile swallowing Mature swallowing

45. The characteristics of an infantile swallowing outlined by Moyers:
a. The jaws are apart and tongue is placed between the upper and
lower gum pads.
b. The mandible is stabilized by the contraction of muscles
c. The swallow is guided and to a large extent controlled by
sensory interchange between lip and tongue

46. Features of retained infantile swallowing Seen due to undue
persistence of the infantile swallow
•Usually occlude on one molar in each quadrant
•Strong contraction of facial muscles during swallow
•Tongue protrudes and is seen between all teeth during initial
stages
•Expressionless face

47. Fletcher has proposed the following factors
ETIOLOGICAL FACTORS:
1. Genetic factor
2. Learned behavior(habit)
3. Maturational
4. Mechanical restrictions
5. Neurological disturbance

48. GENETIC FACTORS:
Due to Anatomic or neuromuscular
variations in oro-facial junction
E.g. hypertonic orbicularis oris
muscle

49. LEARNED BEHAVIOR (HABIT):
Tongue thrust can be acquired as a habit
Predisposing factors are
Improper bottle feeding
Prolong thumb sucking
Prolonged tonsillar and URT infections
Prolonged duration of tenderness of the gums
or teeth

50. MATURATIONAL:
Infantile swallow changes to mature
swallow once the post deciduous teeth
start erupting
Sometimes the maturation is delayed and
thus infantile swallow persists for a
longer time which can result in the
tongue thrust habit

51. MECHANICAL RESTRICTIONS:
Macroglossia
Constricted dental arches
Enlarged adenoids

52. Causing tongue thrust are
Hypotensive palate &
Moderate motor disability
NEUROLOGICAL DISTURBANCES:

53. classification
physiologic
habitual
functional
antomic
Comprises of normal tongue thrust
swallow of infancy
Tongue thrust can be present as a
habit even after correction of
malocclusion
During early loss of deciduous
incisors the tongue is put forward
to achieve oral seal.
Persons with enlarged tongue
have anterior tongue posture

54. CLASSIFICATION OF TONGUE THRUST:
Simple tongue thrust
Complex tongue thrust

55. Extra oral
Intra oral
CLINICAL FEATURES:

56. Lip posture:
Greater lip separation both at rest and in function
Mandibular movement:
Movements during swallowing were more erratic
Speech:
Various speech disorders seen
Sibilant distortions,
Lisping,
problems in articulation of /s/, /n/, /t/, /d/, /l/, /th/, /z/, /v/ sounds
Facial form:
Increase in anterior height
EXTRA ORAL FINDINGS:

57. Tongue movements
Jerky and inconsistent
Movements are irregular from one swallow to
another
Tongue posture
Tongue tip at rest is lower due to ant open bite
Malocclusion
Maxilla
Proclination of the anteriors
Generalized spacing
Maxillary constriction
INTRA ORAL FINDINGS:
Mandible
Retroclination or proclination of
the teeth depending on type of
tongue thrust presesnt
If proclination it leads to
bimaxillary proclination
Intermaxillary relationship
Ant or post open bite
Post cross bite

58. History
Examination
DIAGNOSIS:

59. Determine swallow pattern of siblings and parents to check for hereditary
etiological factor.
Information regarding URT infections, sucking habits and neuromuscular
problems
1. HISTORY:

60. Study the posture of tongue while mandible is in postural position.
Observe tongue during:-
> Unconscious swallowing
> Command swallow of saliva
> Command swallow of water
> During chewing
Check for the clinical features
2. EXAMINATION:

61. Treatment:
Training of correct swallow and
posture of the tongue
Speech therapy
Mechano therapy
Correction of malocclusion
Surgical treatment

62. Myofunctional exercises:
1. Ask the child to place the tip of the tongue in rugae for 5
min
2. Orthodontic elastics and sugarless fruit drop: held by tongue
tip against the palate on the rugae area
3. 4s exercises: spot, salivating, squeezing the spot and
swallowing
Use pressure point on the papilla to show where the spot is
salivate squeeze the tongue tip vigorously against this
spot swallow
4. Other:
Whistling, reciting the count from 60-69
Gargling,
Yawning, etc.
1. TRAINING OF CORRECT SWALLOW & POSTURE
OF THE TONGUE:

63. USING APPLIANCES
Pre orthodontic trainer for
myofunctional training:
Aids in correct positioning of the
tongue
Nance palatal arch:
With acrylic button used as guide to
place the tongue in correct position

64. SPEECH THERAPY:
The child is asked to repeat simple multiplication
tables of sixes to pronounce words starting with
‘s’
s…

65. Removable appliances
Fixed appliances
MECHANO THERAPY:

66. REMOVABLE APPLIANCES:
Modifications of Hawley's
appliance can be used
Advantages:
Anchorage value gained from the
acrylic covering the entire palate &
contacting the entire maxilla
dentition & its lingual surface.
To close ant. Open bite using labial
bow.
The crib can serve as remainder.

67. FIXED APPLIANCES:
Crowns and bands are
given on first permanent
molar
Cribs extending
downwards just behind
the level of cingulum of
mand incisor are made
Duration: 4-9 months

68. ORAL SCREEN
The oral screen is modified
acrylic plate. Either acrylic or
wire loop barrier may be
constructed to prevent
tongue thrusting.
The abnormal muscle forces
can be intercepted and there
by reducing the development
of maloccluslion

69. If continuous ant placement of tongue is result of adaptation to previously
existing anterior open bite, correction of malocclusion is the solution
For the complex tongue thrust swallow, active orthodontic treatment is
required
CORRECTION OF
MALOCCLUSION:

70. SURGICAL TREATMENT:
Orthoganthic surgical
procedure to correct the
skeletal malformation as
well as myofunctional
therapy in retained
infantile swallow

72. By Sassouni(1971):
DEFINITION:
It is a habitual breathing
from mouth instead of
nose

73. Classification
obstructive habitual anatomic

74. CLASSIFICATION BY FINN(1987):
Obstructive:
Complete or partial
obstruction of nasal passage
due to:
DNS (deviated nasal septum)
Nasal polyps
Chronis inflammation of nasal
mucosa
Localized benign tumors
Allergic rhinitis
Obstructive adenoids

75. Deviated septum
Enlarged tonsils
Abnormally short upper lip
preventing proper lip seal
Obstruction in the larynx
Obstructive sleep apnoea syndrome
Obstruction in the bronchial tree

76. Habitual:
habitual mouth breather is one who continues breathing from mouth even after nasal
obstruction is removed
Anatomic:
Short upper lip cannot close the mouth

77. CLINICAL FEATURES:
Long and narrow face
Narrow nose and nasal passage
Short and flaccid upper lip
Contracted upper arch with posterior
cross bite
An expressionless or blank face
Increased overjet
Ant marginal gingivitis
Dryness of the mouth
Ant open bite

78. GENERAL EFFECTS
impaired purification of the inspired air
Impaired lubrication of esophagus
Poor pulmonary function
Blood gas constituents---- 20 % more CO2 and 20 %less oxygen.
CLINCAL FEATURES

79. EFFECTS ON DENTO FACIAL STRUCTURES
FACIAL FORM
large face height
increased mandibular plane angle
retrognathic jaw
Adenoid facies
SPEECH DEFECTS
nasal tone in voice

80. DENTAL EFFECTS
Retroclined incisor
Posterior cross bite
Anterior open bite
EFFECTS ON LIP
Gummy smile
Short thick incompetent upper lip

81. EFFECTS ON GINGIVA
inflammed and irritated gingival tissue
hyperplastic gingiva
enlarged interdental papilla
OTHER EFFECTS
dull sense of smell
loss of taste
otitis media

82. History
Clinical tests
Cephalometric
DIAGNOSIS:

83. Parents can be asked for frequency of child adopting lip apart posture.
Tonsillitis
Rhinitis
Otitis media
HISTORY:

84. CLINICAL TESTS:
Water test:
Patient is ask to hold water in his mouth for 4 min
Mouth breather will be unable to do so
Mirror test:
Double sided mirror is held between the nose and the mouth
Fogging of the nasal side of the mirror nasal breathing
Fogging of oral side mouth breathing

85. Cotton test/butterfly test :
A butterfly shaped piece of cotton is placed over the upper lip below the
nostrils
Fluttering of the cotton nasal breathing
Useful in detection of nasal blockade

86. Helps in establishing amount of nasopharyngeal space, size of adenoids, etc.
RHINOMANOMATRY
allows percentage of nasal or oral respiration to be calculated.
CEPAHOLMETRY:

87. MANAGEMENT:
Removal of nasal and pharyngeal obstruction by
E.N.T surgeon
Interception of the habit: by oral screen
Rapid maxillary expansion

89. DEFINITION RAMFJORD (1966):
It is habitual grinding of
the teeth when individual
is not swallowing or
chewing

90. Psychological and emotional stresses
Occlusal interference or discrepancy
Pericoronitis and periodontal pain
Allergies
ETIOLOGY:

91. CLINICAL FEATURES:
Occlusal wear facets can be
observed on teeth
Fractures of teeth and
restorations
Mobility of the teeth
Tenderness and hypertrophy
of masticatory muscles
Muscle pain when the patient
wakes up in the morning
TMJ pain and discomfort

92. History & clinical examination
Occlusal prematurities diagnosed using articulating paper
Electro mayo graphic examination for hyper active muscle
DIAGNOSIS:

93. Treat emotional and psychological disturbances if any
Hypnosis, relaxing exercises and massage can help
relieving muscle tension
Occlusal adjustments- bite raising crowns, splints and
elimination of occlusal interference
Bite plates
Occlusal reconstruction and prosthesis
Bite guard
TREATMENT:

95. DEFINITION:
Habits that involve
manipulation of the lips
and perioral structures
are termed as lip habits

96. Wetting the lips with tongue
Pulling the lips into the mouth between the teeth
CLASSIFICATION (SCHNEIDER
1982):

97. ETIOLOGY:
Malocclusion- class II div I malocclusion, deep bite
Habits- thumb or digit sucking
Emotional stresses

98. Proclined upper anteriors
Retroclined lower anteriors
Hypertrophic and redundant lower lip
Cracking of the lips
C/F:

99. TREATMENT:
Lip bumpers
Not only keep the lips away but also improve axial
inclination of the teeth
correct class II div I malocclusion
Treat the primary habit
Lip habit along with digit sucking should
be corrected
Oral shield in class I malocclusion

101. Nail biting is one of the most common habit in children
It is the sign of internal tension

102. Absent at 3 yrs of age
Incidence rises sharply from 4-6 yrs
Remains at constant level between 7-10 yrs
Rises to peak during adolescence
AGE OF OCCURRENCE:
Etiology:
• Indicative of emotional problems

103. C/F:
Crowding of teeth
Rotation of teeth
Attrition of incisal edges
Inflammation of nail beds and also of the nails

104. No treatment required in mild cases
Avoid scolding and threat
Treat the emotional factor
Encourage outdoor activities to ease tension
etc
MANAGEMENT:

106. It is an abnormal habit of keeping or biting cheek
muscles in upper and lower posterior teeth
DEFINITION:

107. C/F:
Ulcer at the level of occlusion
Open bite
Tooth malposition in the buccal segment

108. TREATMENT:
Vestibular screen

109. Also know as:
masochistic habits
self – mutilating habits
Habits are those in which patient enjoys inflicting damage to
himself.
SEEN IN,
Mentally retarded children
Psychologically abnormal children
SELF INJURIOUS HABITS