Tongue thrusting is defined as the forward movement of the tongue between the teeth during swallowing or speech instead of the mature swallow pattern. It can be classified based on its effects and may cause malocclusions like an open bite. Diagnosis involves examining swallow patterns and tongue posture. Treatment depends on the age of the patient and involves myofunctional exercises, appliances to reposition the tongue, and orthodontics or surgery if malocclusion is present. Speech therapy may also be used if a speech defect is associated with the tongue thrusting.

1. Tongue Thrusting Habit

2. TOPIC INCLUDES : Definitions Classification Etiology Clinical manifestations Diagnosis Treatment considerations Treatment

3. DEFINITIONS : Tongue thrusting is defined as a condition in which the tongue makes contact with any teeth anterior to the molars during swallowing. A tongue thrust is said to be present if the tongue is observed thrusting between & the teeth do not close in centric occlusion during deglutition .- Brauer (1965)

4. Tongue thrust is the forward movement of the tongue tip between the teeth to meet the lower lip during deglutition & in sounds of speech, so that the tongue becomes interdental. - Tulley (1969) Tongue thrust is an oral habit pattern related to the persistence of an infantile swallow pattern during childhood & adolescence & thereby produces an open bite & protrusion of the anterior tooth segments. - Barber (1975)

5. Tongue thrust is a forward placement of the tongue between the anterior teeth & against the lower lip during swallowing. - Schneider (1982)

6. CLASSIFICATION OF TONGUE THRUSTING HABITS

7. Classification I (S. Braner & Hort) : Type I : Non deforming tongue thrust Type II : Deforming anterior tongue thrust Sub Group 1 : Anterior open bite Sub Group 2 : Anterior proclination Sub Group 3 : Posterior cross bite Type III: Deforming lateral tongue thrust Sub Group 1 : Posterior open bite Sub Group 2 : Posterior cross bite Sub Group 3 : Deep bite

8. Type IV: Deforming anterior & lateral tongue thrust Sub Group 1 : Anterior & Posterior open bite Sub Group 2 : Proclination of anterior teeth Sub Group 3 : Posterior cross bite

9. 2. Classification II: A. Simple tongue thrust Features : Normal tooth contact in posterior region Anterior open bite Contraction of lips, mentalis muscle & mandibular elevators

10. B. Lateral Tongue thrust Features : Posterior open bite with tongue thrusting laterally

11. C. Complex tongue thrust Features : a) Generalized open bite b) Absence of contraction of lip & muscle c) Teeth contact in occlusion

12. 3. Classification III 1. Physiologic Tongue Thrust : During infantile swallow the tongue is placed between the gum pads. After six months of life, several maturational events occur that alter the functioning of the orofacial musculature. With the arrival of incisors the tongue assumes a retracted posture. If the transition of infantile to mature swallow does not take place with the eruption of teeth, then it leads to tongue thrust swallow.

13. 2. Habitual Tongue Thrust : It is present as a habit after the correction of the malocclusion. 3. Functional Tongue Thrust : It develops to achieve an oral seal. 4. Anatomic Tongue Thrust : It occurs due to macroglossia.

14. Etiology of tongue thrust: Retained infantile swallow Upper respiratory tract infection Mouth breathing Chronic tonsillitis

15. 5. Neurological disturbances * Hyposensitive palate * Moderate motor disability * Disruption of sensory control * Coordination of swallowing 6. Due to transient change in anatomy * Tongue can protrude when the incisors are missing

16. Bottle feeding Thumb& finger sucking 9. Hypertonic orbicularis oris

17. 10. Macroglossia

18. Clinical Manifestations of tongue thrust : Clinical manifestations depend on Intensity Duration Frequency & Type of tongue thrust

19. Extra oral Findings Lip separation More erratic mandibular movements Speech disorders such as : * Sibilant distortions * Lisping distortions * Problem in articulation of s/n/t//d/l/th/z/v/sounds Increase in anterior face height

20. Intraoral findings Jerky and irregular tongue movements Lowered tongue tip because of : a) anterior open bite b) longer period of time required for tongue tip elevation

21. Malocclusion a) Proclination of maxillary anterior results in overjet b) Generalized spacing between teeth c) Retroclination or proclination of mandibular teeth d) Anterior & posterior open bite (depends on posture of tongue) e) Posterior teeth crossbite

22. Diagnosis Of Tongue Thrust Take History Ask about swallow pattern of siblings & parents to check for etiologic factor. Get information about upper respiratory tract infection, sucking habits & neuromuscular problems.

23. B. Examine : Detect perverted swallowing habit and correct it to facilitate normal development of the palate and dentitions. Study the tongue posture. Observe tongue movements during swallow.

24. Treatment considerations of tongue thrust Age : Tongue thrust often corrects itself by 8 or 9 years of age. Self-correction is due to improved musculature balance during swallowing. Presence/absence of associated manifestation : Treatment is not recommended when tongue thrust is present without malocclusion or a speech problem.

25. Tongue thrust with malocclusion & without speech defect: Orthodontic treatment may be carried out. Speech defect with tongue thrust : * Speech therapy is indicated. * Surgery may be done to reduce the size of pharyngeal lymphoid masses. Treatment of associated habit first : If an associated habit like thumb sucking is present, it must be treated first.

26. Treatment of tongue thrust I. Training the tongue for correct swallow & posture Myofunctional exercise : 1. The child is asked to place the tip of the tongue in the rugae area for 5 minutes. 2. Orthodontic elastic & sugarless fruit drop exercise. 3. 4s exercise.

27. Includes : * Identifying the spot * Salivating * Squeezing the spot * Swallowing 4. Ask the child to perform a series of exercises like * w histling * reciting the count from 60 to 69 * gargling or * yawning, to tone the respective muscles

28. b) Use of appliances to correct position of tongue : 1. Pre-orthodontic trainer for myofunctional training . Nance palatal arch appliance

29. II. Speech therapy * Not indicated before the age of 8 years III. Mechanotherapy * Fixed & removable appliances: can be fabricated to restrain the anterior tongue movements during swallowing * force the tongue downward & backward during swallowing * re-educates tongue position

30. Removable appliance therapy : Hawley’s appliance is used Fixed habit breaking appliance.

31. For posterior open bite modified habit crib is used. Oral screen * modified acrylic plate * used to control muscle forces both inside & outside the dental arches * reduces development of malocclusion

32. IV. Correction of Malocclusion Surgical Treatment For retained infantile swallow tongue thrust. For reduction of lymphoid tissue size improves abnormality to tongue thrust.