Tongue Thrusting Habit & Other Habits, Its Management 2

Tongue thrusting
Definition:
Placement of tongue tip forward
between incisors during
swallowing.
Tongue thrusting may be primary
cause of malocclusion or it may be
secondary adaptive factor as in
case in skeletal open bite.
It is generally associated with long
term thumb sucking children.
Classifications of tongue thrust:
Endogenous
Primary Anterior
lateral, Habitual
Secondary
complex Adaptive
(enlarged
tonsils,pharyngitis)
Effects of tongue thrusting
• Increase in overjet and overbite.
• Tongue no longer lie on the lingual cusps of the buccal
segment and posterior teeth erupt; thus eliminating
interocclusal clearence.
• May lead to bruxism.
• Narrowing of maxillary arch as the tongue drops lower in the
mouth. Clinically this may be seen as unilateral cross bite.
• In horizontal growth pattern, tongue dysfunction leads to
bimaxillary protusion.
• In vertical growth pattern, tongue dysfunction leads to lingual
inclination of lower incisors.
• Diastemas may be present.
• Deep bite in lateral tongue thrust.
Careful differentiation must be done
among simple, complex tongue
thrust and retained infantile
swallowing pattern and faulty
tongue posture.
• Prognosis is good for simple
tongue thrust.
Normal tongue
• Not very good for complex
tongue thrust.
• Poor for retained infantile
swallowing pattern.
Protracted tongue posture can be:
• Endogenous- no certain
treatment
• Acquired- can be corrected Tongue thrust
Management
• Simple tongue thrust: it is the tongue thrust with teeth
together swallow.
If there is excessive labioversion of maxillary incisors,treatment
of tongue thrust should be done after retraction of incisors.
Patient should be taught swallowing exercises with sugar less
mint and should be instructed to practice 40 times a day and
maintain the record.
On second appointment, patient should be able to swallow
correctly at will. Sugar less drops may be used to reinforce
the unconscious swallow.
If the problem continues, soldered lingual arch wire having short
and sharp spurs can be inserted.
To summarize;
Conscious learning of new reflex.
Transferal of control of the new swallow

Pattern to the subconscious level.
Reinforcement of the new

reflex.
• Complex tongue thrust:
It is the tongue thrust with teeth apart swallow.
Malocclusion present are:
 Poor occlusal fit.
 Generalized anterior open bite.
 Open bite may not be present if
the tongue is seated evenly atop
of all teeth.
Treatment:
Treat occlusion first.
When the treatment is in retentive phase- muscle
training is begun.
Maxillary lingual arch appliance is necessary for
these patients.
There may be chances of relapse and prognosis is
not very good
• Retained infantile swallow: It is
defined as the undue persistence of the
infantile swallow well past the normal time
for its departure. These patients occlude
only on one molar in each segment.
These patients do not have expressive faces.
They have difficulty in breathing.
Low gag threshold
It is a problem of neuromuscular
development.
Appliance used is tongue crib with 3-4 v-
shaped projections which extend
downward up to the cinguli of lower
incisors when the casts are occluded.
Prognosis is poor.
`
Mouth breathing
Respiratory needs are the primary determinant of the posture of jaws and
tongue. Therefore it is reasonable that an altered respiratory pattern,
such as breathing through mouth rather than nose, could alter the
equilibrium of pressure on jaws and teeth and affect both jaws growth
and tooth position.
Finn classified mouth breathing into 3 different categories:

• OBSTRUCTIVE
• HABITUAL
• ANATOMIC
• Obstructive mouth breathing:
These are the children who have complete obstruction of
normal air flow of air through the nasal passages. Due to
difficulty in breathing through nose child is forced to breath
through mouth.
• Habitual mouth breathing:

This is a child who continuously breath through mouth by
force of habit, even if abnormal obstruction is removed.
• Anatomic mouth breathing:

They are the one whose short upper lip does not permit
complete closure without undue effect.
Factors considered for mouth
breathing
• For an average individual, when ventilation exchange rate of
40-45l/min. is reached, there is a transition to partial oral
breathing.
• Heavy mental concentration could lead to increase air flow
and a transition to partial mouth breathing.
• If nose is partially obstructed, or there is a tortuous passage
an individual shifts to mouth breathing.
• Swelling of nasal mucosa accompanying common cold
converts one into mouth breathing.
• Chronic respiratory obstruction produced due to inflammation
within the nasorespiratory system can lead to mouth
breathing
• Pharyngeal tonsils and adenoids can cause mouth breathing.
Clinical features
• Associated with impeded maxillary growth.
• Narrow jaw with high palate, dental crowding as well as
retrognathism of maxilla.
• Prognathism of mandible.
• Tongue lies flat on th floor of mouth so it does not play its role
in development of maxilla.
• Hyperactivity of facial muscles especially buccinator, impedes
the development of maxilla.
• In class II malocclusion there is increase in overjet.
• Bilateral cross bite.
• Hyperplasia of gingiva.
• Extra oral appearance of these patients is often conspicuous
and is termed ‘adenoid facies’.
• There is downward and backward rotation of mandible to
maintain postural changes leading to open bite anteriorly.
• Two different tongue posture are possible:
type I -in class III malocclusion tongue is flat and protruding.
type II- in class II malocclusion tongue has a flat and
retracted position.
Examination of breathing mode:
Cotton pledget test: A cotton butterfly is placed below the
nostrils and observed. The nasal breather will displace the
cotton pledget on expiration where as the mouth breather will
not.
Mirror test: mirror is held in front of both the nostrils, in nasal
breather the mirror will cloud with condensed moisture during
expiration.
Observation of nostrils: Alar muscles are inactive in mouth
breathers i.e do not change their size on inhalation or
expiration where as nasal breathers do.
Management
• If mouth breathing is due to nasal
obstruction, then operation by an E.N.T
surgeon is indicated i.e in case of allergic
rhinopathy.
• If patient has habitual mouth breathing

then pre-orthodontic therapy should be
carried out by: breathing exercises,
incorporation of oral or vestibular screen.
In case in which vestibular screen is
used holes can be slowly closed as the
patient starts breathing through nose.
• Myofunctional exercises like to hold a

piece of card board to improve lip seal.
Bruxism
Definition : it is the habitual grinding of teeth, during sleep.
this term is applied to clenching of teeth and also to repeated tapping of teeth.
Incidence: 5- 20 %
Etiology (Nadler
and Meklas):
• Local
• Systemic
• Psychological
• occupational
;
Management
• If the underlying cause of the bruxism is an
emotional one, the nervous factor must be corrected
if the disease is to be cured.
• Removable rubber splints can be worn at night to

immobilize the jaws.
• A vinyl plastic bite guard that covers the occlusal

surfaces of all teeth plus 2mm of the buccal and
lingual surfaces can be worn at night to prevent
abrasion.
Lip sucking and lip biting
Lip sucking is a compensatory
activity which results from an
excessive overjet and relative
difficulty of closing the lips during
deglutation. In most cases it is the
mandibular lip that is involved in
sucking, although biting habits of
maxillary lip is also seen.
The deformity reaches maximum
when the discrepancy between the
maxillary incisors and mandibular
incisors becomes equal to the
thickness of the lip. (B.J.Johnson).
Common features:
• Labioversion of maxillary teeth and lingual
displacement of mandibular teeth.
• Vermillion border is hypertrophic and redundant
during rest.
• Flaccid lip due to lengthening.
• Chronic herpes with areas of irritation and
cracking of lips.
• If a patient has lip sucking habit during sleep
then telltale
• Redness and irritation extending from mucosa
to skin of lower lip is seen.
• If patient is class II div1 malocclusion then the
lip suking habit is only adaptive.
Management :
If the patient is having class II div 1 malocclusion then the
treatment should be done orthodontically. The lip sucking
habit generally ceases after the treatment.
If the habit continues then, the lip appliance i.e lip plumper is
given.
The appliance can be modified by adding acrylic between base
wire and auxillary wire.
Removal of appliance is done in parts i.e first the auxillary wire
then the base wire is removed.
A period of 8-9 months is required to cease the habit
completely.

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Tongue thrusting

Transferal of control of the new swallow

Reinforcement of the new

Finn classified mouth breathing into 3 different categories:

• Habitual mouth breathing:

• Anatomic mouth breathing:

• If patient has habitual mouth breathing

• Myofunctional exercises like to hold a

• Removable rubber splints can be worn at night to

• A vinyl plastic bite guard that covers the occlusal

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