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2. CONTENTS :
Introduction
Anatomy
Development
Functions of normal tongue
Tongue in orthodontics
Swallowing
Examination of the tongue
• Morphological examination
• Functional examination
• D/D of abnormal tongue posturewww.indiandentalacademy.com
3. Role of tongue in malocclusion
Tongue thrust
Conclusion
References
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4. Introduction :
Muscular organ (mass of striated
muscle covered with MM) in FOM
Functions :
Taste
Speech
Mastication
Deglutition
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5. Anatomy
A root – attached to
mandible - above
Hyoid bone - below
A tip – free ant.
at rest lies behind
upper incisors
A body / dorsum-
convex,2parts
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6. ORAL PART (ant 2/3) PAPILLARY-in FOM
- Margins are free contact gums & teeth
- Sup surface-median furrow & papillae,rough
- Inf surface-smooth MM & median fold frenulum
lingue
PHARYNGEAL PART (Post 1/3)LYMPHOID-in
pharynx
- Post surface,MM,no papillae-lymphoids&
mucous glands
Seperated by V-shaped sulcus-sulcus terminalis
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8. Blood supply:
- Lingual art (br ECA) & Lingual vein
Nerve supply:
Motor- all muscles-hypogossal n.
Palatgossus-cr accessory n.
Sensory-
- ant 2/3-lingual (gen sensation)
- Chorda tympani (taste)
- Post 1/3-glossopharyngeal n
- Post most –vagus thro int laryngeal nwww.indiandentalacademy.com
9. Development
Begins at 4th
wk, 1st
3rd
& 4th
br arches
Pharyngeal arches meet in midline below the
stomodeum
Local proliferation of the mesenchyme- 1st
arch
Tuberculum impar-in midline
Lingual swellings-laterally
Lingual swelling enlarge merge with
tuberculum impar- ant2/3 tongue
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11. Hypobranchial eminence-large midline
swelling-from mesenchyme of 3rd
br arch-
grows rapidly than 2nd
arch
It gives-post 1/3 tongue/root
Post most part-4th
arch
Tongue seperates from the FOM by
downgrowth of the ectoderm around its
periphery-degenerates to form lingual
sulcus-mobility of tongue
Muscles-occipital myotomes
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12. Functions of normal tongue
- Has several imp function of intrest to the
orthodontist
- Mastication,deglutition,speech,breathing
- EQUILIBRIUM & DEVELOPMENT OF
THE DENTAL OCCLUSION
Mastication :
- placing food in position (ant & lateral
portions of body)
- Pushing food buccaly during Mastication
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13. Deglutition:
- Forming & propelling bolus in to
pharynx(1st
stg of swallowing)
- After swallowing tongue contact hard
palate while soft palate is pulled away
downward against the post portion of the
tongue
Speech:
- Formation of sounds - s,z,t,d,sh,e,g,is
- Elevation of tongue tip behind maxi
incisors as in ‘s’
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14. Breathing :
Nasal breathing-tongue in rest position
In forced mouth breathing-habit,exertion
- Mandible is depressed,lips are opened
- Tongue contacts laterally with lingual
surfaces of mandi teeth dropping away
from maxilla
- The ant portion is lowered lies on lingual
surfaces of mandi ant teeth
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15. EQUILIBRIUM & DEVELOPMENT
OF THE DENTAL OCCLUSION
EQUILIBRIUM THEORY:
As applied in engg “An object subjected
to unequal forces will be accelerated &
there by will move to a different position
in space”
It follows that if any object is subjected to
a set of forces but remains in the same
position, those forces must be in balance
or equilibrium
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16. From this
perspective,dentition is
in equilibrium as they
do not move to a new
location under usual
circumstances
(mastication,swallowin
g,speaking)
‘Tooth movement
occurs only when the
equilibrium against
dentition is
unbalanced’
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17. Contributors to the dental equilibrium:
Various factors-effect of
pressures,magnitude & its duration
Masticatory forces
Soft tissue pressures from the lips,cheeks
& TONGUE
External pressures- habits & orthodontic
forces
Intrinsic pressures-gingival & PDL fiberswww.indiandentalacademy.com
18. Soft tissue pressures from the lips,cheeks &
TONGUE:
Rest,swallowing,speaking
Though pressure are much lighter than
masticatory but longer duration
Studies-very light forcs are succesful in
moving teeth if the force is longer duration
So light sustained pressures from the
lips,cheeks & TONGUE at rest are imp
determinants of tooth position
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19. Injury to soft
tissue of lips-
scarring
&contracture
Incisors moved
lingualy as lips
tightens against
them- altered
equilibrium
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20. No lip/cheeks
(tropical infection)
Teeth move
labially/buccaly in
rsponse to
unoposed pressure
from the tongue
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21. Pressure from the
tongue-
macroglossia/patho
/abnormal posture
labial displacement
of teeth though lips
& cheeks are
intact-altered
equilibrium
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22. From this equilibrium theory;light
sustained pressure by the tongue
against teeth has significant role in
development of OB (proffit)
If a pt has a forward resting posture
of the tongue the duration of the
pressure even light could affect tooth
position(vertical & H/Z)
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24. Normal swallowing
Teeth are in
contact,lips-closed
Dorsum of tongue
closely touch the
palate
Tip of the tongue-
interdental papillae
of maxi incisors
No tongue thrust
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25. Infantile(visceral) swallowing
Acc Moyers
The jaws are apart
with tongue b/w gum
pads
Mandible stabilized-
contraction of facial
muscles (buccinator)
& interposed tongue
Swallow guide -
sensory interchange
b/w lips & tongue
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26. Change to semi solid & solid food & the
eruption of teeth-mature swallow
(1yr/18mos)
The normal appearance of feature of both
the infantile & mature swallow-
TRANSITIONAL SWALLOW
- Diminishing of buccinator activity
- Appearance of contraction of mandi
elevators-stabilise occlusion
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27. Mature (somatic) swallowing
Teeth together
swallow
Mandible
stabilized-
contraction of
elevators
Tongue tip touch
palate lightly above
& behind incisors
Minimal contraction
of the lips
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28. RETAINED INFANTILE
SWALLOW
Def: ‘As predominant persistance of the
infantile swallowing reflex after the arrival
of perm teeth’
- Rare,may be assoc with craniofacial
developmental syndromes/neural defects
C/F:
Tongue thrust- ant & lateral
Contraction of buccinator muscle
Expression less face(facial muscles –used
for stabilising mandi)
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29. Difficulty in
mastication(as
occlusion only on
last molar of
quadrant)
Mastication-b/w
tongue tip &
palate(poor
occlusion)
Gag threshold is low
AFH - severe AOB
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30. Adaptive features to OB:
Tooth apart swallow with T.T
Infra eruption of incisors & alveolar
development
Hyperactive mentalis & lips
Mandible stabilized by facial muscles
Treatm :differentiate this with skeltal OB
- If require-orthodontic & surgery
- Poor prognosis
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31. TONGUE IN ORTHODONTICS
“ By examining the tongue of the
patient,physicians find out the diseases of
the body & philosophers the diseases of
the mind “ – St Justin
Examination of the tongue
Role of tongue in malocclusion
Tongue thrust
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32. Examination of the tongue
- From an orthodontic point of view
other than color,texture
Morphologic examination (size &
shape)
Functional examination (tongue
posture)-imp
D/D of abnormal tongue posture
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33. Morphologic examination
size & shape – subjective observation,related to
patient ,Position imp than size
Length-long tongue can touch tip of nose(not
confirmed method)
- Microglossia-rare
- Macroglossia –scalloping on lateral borders
Asymmetry-placing tongue out
- Functional asymmetry-change from one position to
other
- Morphological asymmetry-persists in drapped
position
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34. Clinical implications of asymmetry:
Tongue asymmetry is imp in
dental arch symmetry
dental midlines
Maintenance of treated incisal
relationships
Open bite etc
Not easily corrected, as treatm involve
some compromise
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35. Functional examination
- imp than clinical,position imp than size
- Tongue & lips often integrated
- Examine normal tongue function w/o displacing it
or the lips
Posture of the tongue while mandi in its
postural position
- Clinically- upright position
- Cephalometry-METRIC EVALUATION
- normal -Dorsum of the tongue touches the palate
lightly,tip rest in the lingual fossae/crevices of
mandi incisors
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36. Proffit –”Tongue posture is far more adapt to
cause of an openbite than tongue
thrust,becoz the tongue is always there
exerting a mild continous force”
Tongue during mastication:
- Difficult test
- Assoc with neurological problems
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37. Tongue during swallow :
Normal -Tip touches interdental papillae just
behind the maxi incisors
The unconscious swallow – most imp
The command swallow of saliva
The command swallow of water
The unconscious swallow during mastication
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38. During speech :
-Is abnormal tongue activity
adaptive/etiologic/unrelated to
malocclusion
- Usually- adaptive
- Ask pt to count 1-10,check for tongue
adaptivity,consonants sound
- ‘s’-sound (lisping) most affected
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42. Measuring the
distance b/w sup
surfce of tongue &
roof mouth-size- but
it must be supported
by clinical
examination
Retracted & elevated
tongue
Downward & forward
tongue posture
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43. Palatography
Recording the contact areas of the tongue
with the palate & teeth during
speech/certain tongue functions
A thin layer of contrasting imp material is
applied on tongue
Tongue movements-speech/swallowing
Palatogram records photographically
eg:lisping-defect S sound,T.T
Evaluation of the influence of functional
orthodontic appliance therapy
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46. Speech assessment is also desirable
from an orthodontic point of view
In malocclusions with malposed teeth,
there can also be a malposition of the
tongue, which can impair normal speech
An important diagnostic tool as the
clinician establishes a treatment plan
and a probable prognosis for functional
appliance therapy.
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47. Cineflourography-tongue movements
using camera & film is made during
swallowing
Tracing-T.T is measured by drawing str line
thro labial surfaces of U/L incisors
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48. D/D of abnormal tongue posture
Abnormal tongue posture is more
frequent problem than abnormal size
Tongue posture is Related to skeletal
morphology
In class-II
Mandi short
Tongue positioned
forward
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49. In class-III
Tongue lie below
the plane of
occlusion
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50. 2 significant variations:
The retracted tongue posture
The protracted tongue posture
The retracted tongue posture/COCKED
TONGUE:
Tongue tip is withdrawn from all ant
teeth
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52. 2 significant variations:
The retracted tongue posture
The protracted tongue posture- retained infantile
The retracted tongue posture/COCKED TONGUE:
Tongue tip is withdrawn from all ant teeth
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53. Retracted posture seen-10% children
Assoc with lateral OB
Edentulous adults/pt with bilateral loss
of several post teeth
Due to positional sense it retract itself to
establish tactile contact laterally with
alveo mucosa for better seal during
swallowing
Complic:unsettling of mandi denture
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54. The protracted tongue posture:
Tongue b/w incisors
Serious ,results in AOB
Endogenous & acquired adaptive
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55. Endogenous protracted tongue posture:
Retention of the infantile postural pattern
Not unesthetic,stable incisor relationship
Mild AOB
Protracted tongue is adaptation to AFH
Is Endogenous protracted tongue posture
caused OB? Or AFH/skeletal dysplasias
predispose to tongue protraction?
Treatm:surgery relapse - poor prognosis
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56. Acquired adaptive protracted tongue
posture:
Transient-adaptation to
tonsilitis/pharyngitis
Treatm:removal of cause(tonsillectomy)
Correctable – good prognosis
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57. Role of tongue in malocclusion
SIZE
Microglossia: small tongue
Congenital,piere-robin syndrome
C/F: tongue tip lower level
FOM is elevated& visible
Dental arch-collapsed & reduced
Extreme crowding in premolar area
Severe class-II relation
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59. Wide,broad & flat tongue
OB
Mandi prognathism / Class III
Chronic positioning tongue b/w teeth at rest
Buccal tipping of post teeth
Incre T/S width of dental arch
Inability in ortho treatment
Difficult diagnosis-tongue some times adapt
to contracted narrower space after ortho
treatment
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60. POSTURE
In neonate more
forward
Abnomal posture-
Generalised
spacing,proclination
Prognosis-depends
on cause-good in
respiratory problems
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61. TONGUE REFLEXES
Most significant is posture –imp for the
maintenance of the phayrngeal airway
Base of the tongue forms ant wall of the
pharynx
Maintenance of phayrngeal airway cause
base of the tongue to not to intrude into
airway
Genioglossus muscle performs this reflex
function
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62. Genioglossus reflex (initiated by large
tongue/tonsils/mouthbreathing)
Sustained jaw opening
Sustained tongue posture (T.T)
MALOCCLUSION
(proclination /OB/ prevent tooth
eruption-post open bite/deep
overbite)
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63. Consequences of tongue posture
& functional abnormalities on
skeletal pattern:
In HGP:
- Forward position/T.T-Bimax dental
protrusion(as tongue pressing on
lingual surfaces of both U/L incisors)
- Spacing(incisors), AOB
In VGP:
- T.T- tip the upper incisors to labialy &
Lower incisors-lingually tipped
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65. In the mid line,a fold of MM-frenulum
of the tongue connects the ventral
surface of the tongue to FOM
ANKYLOGLOSSIA:
Complete ankyloglossia: fusion of
tongue & FOM
Partial ankyloglossia / tongue tie:
Short lingual frenum /attachment of
lingual frenum too near the tip of
tongue
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66. Tongue tie : is most common
Restricted tongue movements
Speech difficulties (consonants)
Some cases are self corrective
Majority : surgical (frenectomy)
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67. Mesurement of tongue volume
True FISP-true fast imaging with
steady precession
MRI
CT scan
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68. Measuring tongue vol :using true FISP
2D-study,in healthy & acromegaly pts
In healthy pts-M-140ml F-90ml
Acromegaly pts-M-180ml, F-145ml
After treatmnt of acromegaly –M-
154ml,F-125 ml
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69. MRI:
In 19 adults-coronal & sagittal sections
Series of images & multiplying the
thickness of each slice & the gap b/w
each slice in th series
Avg vol 72.1cc (coronal) 79.3cc
(sagittal)
Results-reproducible
-Well definable anatomy of tongue
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70. MRI experiment on rabbits:
MRI measured vol & actual vol after
removing tongue compared-closer to
actual vol but slightly underestimated
CT scan: reliable measuring vol
Used in measuring vol of tumours in
Ca of tongue
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72. TASTE :
Basic tastes:
Salt
Sour (acidic)
Sweet (sugar)
Bitter (vallate
papillae)
Umami- new taste
to a.a like
gluatamate,aspatate
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73. Taste sensation –taste buds (4600),in
papillae
Taste buds-sensory,neuro epi cells
Seen in tongue,soft palate & pharynx
Circum vallate-large, numerous taste
buds- sour/bitter
Foliate -numerous taste buds – sour
Fungiform-ant part
Filiform- mechanical, NO TASTE BUDS
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74. TONGUE THRUSTING
Defin:
Proffit- “placement of the tongue tip
forward b/w the incisors during
swallowing” (1950&60s)
OR
It is the habit of thrusting tongue forward
against teeth/in b/w swallowing
Misnomer-implies tongue is forcibly thr
ust forward
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75. T.T-an adaptive mechanism to maintain
OB caused by something else-
thumbsucking
T.T term-1958 force teeth out of
alignment
School age children-67-95%(5-8yrs)
Assoc with/contributing to an
orthodontic/speech problem
In US 20-80% ortho pts have some
form of T.T
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76. Etiology
- No one specific cause
- Acc to Fletcher
1.Genetic factors -anatomic/neruomuscular
eg:hypertonic orbicularis oris activity
2.Learned behavior (habit)-acquired as habit
- prolonged thumb sucking,tonsillitis &
URTI,improper bottle feeding
3.Maturational –infantile swallow persists in
adulthood
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77. 4.Mechanical restriction-
macroglossia,constricted dental
arches,enlarged adenoids
5.Neurological disturbances -hypersensitive
palate,motor disability of tongue
6.Psyhcogenic factors – forced discontinuation
of thumbsucking
7.Younger children with reasonably normal
occlusion-trasitional stage in physiologic
maturation
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78. Classification
According to Moyers (1970)
a. simple tongue thrust swallow
b. complex tongue thrust swallow
Backlund (1963)
a. Ant tongue thrust
b.Post tongue thrust
Pickett’s (1966)
a.Adaptive-missing teeth/thumb sucking
b.Trasitory
c.Habitual-postural problem,habit/OB
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79. James S.Braner and Holt
Type I: Non-deforming tongue thrust
Type II: Deforming ant tongue thrust
sub group 1- assoc with AOB
sub group 2- ant proclination
sub group 3- post cross bite
Type III: Deforming lateral tongue thrust
sub group 1- posterior open bite
sub group 2- posterior cross bite
sub group 3- deep overbite
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80. Type IV- Deforming ant & lateral tongue
thrust
sub group 1- ant & posterior open bite
sub group 2- ant proclination
sub group 3- post cross bite
Non-deforming: occlusion & profile within
normal range & acceptable
Deforming: dentoalveolar defect
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81. C/F
- Seen from birth
- School age children-67-95%(5-8yrs)
- If retained after 4yr-concerned&need
correction
Proclination of ant teeth
AOB
Bimax dental protrusion
Post cross bite
Post open bite in lateral T.T
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83. Simple T.T Complex T.T
Teeth together
swallow –T.T to
seal OB
Well circumscribed
OB
Precise occlusion
-reinforced by teeth
together swallow
Contraction of
lips,mentalis &
mandi elevators
Teeth apart
swallow –T.T
Diffuse OB/no OB
Poor occlusion-
no reinforcing
Contraction of
lips,mentalis &
facial muscles.NO
mandi elevators
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84. H/O thumb
sucking -T.T as
adaaptive
mechanism to OB
No respi problems
Diminishes with
age
Prognosis - good
H/O
breathing/chronic
URTI & allergies
Respi problems
Does not
Diminishes with
age
Prognosis - poor
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85. Diagnosis
Extra oral-facial profile ,OB,AFH
Examination of- tongue posture
- tongue function
Careful differentiation should be made of
Simple tongue thrust
Complex tongue thrust
Retention of infantile swallowing
pattern
Faulty tongue posture
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86. Tests for diagnosis
1. swallowing: jaw drops- lips,mentalis muscle
contracts strongly-tongue thrust
2.Seperate the lips while swallowing to watch
tongue thrust,and in doing so,strong muscle
contractions can be felt
Methods of examination tongue dysfunction:
Position & size- LATERAL CEPH
Tongue pressure- EMG,cineradiography
palatograpic,neurolophysiologic examin
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87. Treatment
Simple tongue thrust: 3 phases
1.Conscious learning of the new reflex
2.Transferal of control of the new swalow
pattern to the subconscious level
3.Reinforcement of the new reflex
- If proclination is severe- correct the
habit after retraction
- Simple T.T-correct by itself during ortho
treatment
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88. Conscious learning of the new
reflex:
Teaching correct tongue position by
tactile signals (index finger)
Tip of tongue & palate
Put tongue tip-close teeth & lips-swallow
40times/day
With little water/food
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89. Small ortho intraoral elastics-held by
tip of tongue aginst palate during
swallowing
If correct swallow- elastic will be
retained
Incorrect swallow- elastic will be
swallowed
2-3times /day
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90. Reinforcing the new swallow
subconsciously:
To avoid abnormal
unconscious
swallow-2nd
visit
Flat sugarless fruit
drops-citric
flavoured(lemon)
Fruit drop on Tip of
tongue-hold
against palate until
dissolves
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91. Record timing
Initialy-less
time,later more
time
Distraction & self
competition
Ones/day
Timing
distraction-Best
technique
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92. Reinforcing the new reflex:
Appliance therpy-
Tongue crib
Should not as the
1st
step of
treatment
As it traumatic to
pt/ do not wear
properly
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93. Tongue crib:
Ni-cr/S.S, 3-4 projections (spurs)
Follow the palatal contour
Forms barrier/picket fence just
behind cingulum of mandi incisors
Duration:depends on severity of
OB(4-9mos)
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94. MOA:
Eliminate the strong T.T & plunger like
action during swallowing
Reeducate the tongue posture -Dorsum-to
touch palate vault
Tip - palatal rugae
Effects: as tongue confines with in
dentition-rests on occlusal surfaces of
post teeth-maintains IOD-supra eruption
& narrowing of max post teeth prevented-
NO OB www.indiandentalacademy.com
95. After habit interception
Treat malocclusion assoc with T.T-
with removable / fixed ortho
appliances
By these above 3 sequential therapy
simple T.T is correctable
Prognosis - good
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96. Complex tongue thrust :
Occlusion treatm – 1st
Muscle exercises smilar to simple T.T
with minor modification
- Swallowing with teeth together
- Prolonged appliance therapy
Prognosis – Poor
More relapses
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97. Management of tongue thrust
Factors to be considered:
Diagnosis –
GDP,orthodontist,pedodontist/pediatri
cians
Majority –by Orthodontist - when
child displays dental/speech problem
1.Type of malocclusion: The common
types of malocclusion associated with
tongue thrust habits are
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98. a.Class I malocclusion with incr over jet.
b.Angle’s Class II division I malocclusion with
increased over jet.
c. Deep bite
d. Marked open bite.
2. Degree of malocclusion
3. Scope of the problem:
habitual,severe tongue thrusting-needs
immediate attention.
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99. 4. Maturity of the child.
5. Attitude and the degree of cooperation-from the
parents.
6. Progressive malocclusions should be considered
for immediate treatment.
7. Structural considerations to be eliminated are
a. Nasal air blockage.
b. Extremely narrow palatal arch.
c. Maxillary posterior teeth in extremely,
lingual position
d. Macroglossia.
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100. Probability of correction:
Sincere commitment & cooperation of pt
& parents
No neuromuscular problems- successful
70%- successful
25%- unsuccessful (poor cooperation of
pt & parents/both)
5%- unsuccessful (factore that make
treatm impossible
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101. Case reports
Tongue muscle activity after ortho treatm
of AOB-AJODO1999;115:660-66
Class I with AOB & bimax dental
protrusion-T.T,lisping
Prior to treat- EMG activity of GG & OI
(protrusion)
After treat – activity
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102. Severe dental OB with tongue reduction after
ortho treat AO2001;71:228-36
21yr,Class III with OB,macroglossia
Edgewise with crib & begg retainer
Relapse –mandi arch-spacing,flaring of ant
teeth,incre mobility
Partial glossectomy-1/3 middle dorsum
Improvement itself w/o further appliance
after surgery in 4months
Shows - EQUILIBRIUM
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103. A cineradiographic study of deglutive
tongue movement & nasopharyngeal
closure in pt with AOB
AO 2000;70:284-89
Results-tongue tip protrusion
Slow movement of ppost part of dorsum
Suggest – compensatory coordination of
tongue
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104. Conclusion
Hence position of tongue & its
function plays an important role or a
contributing factor in dental
malocclusion (T.T,macroglossia)
Tongue thrust troubled orthodontic
treatment, discouraged orthodontists
as there is more relapses due to
continuous force by tongue
(protrusion)
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105. Accomplishment of successful
orthodontic treatment is pssible
through proper diagnosis & treatment
plan taking into consideration of all
the surrounding oral structres
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106. References
Hand book of orthodontics,4th
edition,Robert E.Moyers
Contemporary orthodontics,3rd
edition,William R.Proffit
Color atlas of dental medicine-ortho
diagnosis,Thomas Rakosi
Human anatomy vol3 head &
neck,3rdedition, B.D Chaurasias
Tencate’s Oral histology,6th
edition
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