The “three M’s’: Muscles, malformation,

and malocclusion
T. M. GRABER, D.D.8., M.S8.D., Ph.D.
Kenilworth, Il.

It Lp be hard to convinee the neophyte that fashions flourish in ortho-

dontics even as they do in interior decorating and clothes design. A quick glance
at the programs of the various sectional components of the American Associa-
tion of Orthodontists and a summary perusal of the literature of the past 10
years would, indeed, indicate that there is a time-linked subject orientation.
Ten years ago editors were surfeited with papers on cephalometries. The ma-
jority of theses being written by graduate students were cephalometrically
oriented and, as one observer has put it, ‘‘the numbers racket was in high gear.’’
Most appliance articles 10 years ago were on the Angle edgewise appliance if
they dealt with mechanotherapy. The tenor of most of these articles was that
the problems were really quite simple if you had the proper mechanism and
observed the commandments emanating from above. For one group of disciples,
the most important commandments were the following:
1. Never take out teeth; to do so means compromise, and failure
is only a matter of degree.
2. You have been given an appliance that is capable of any movement
you choose. Use it properly and you shall not fail. Remember, you
are one of the ‘‘chosen people,’’ following in Fis footsteps.
3. The only true research is that being done by those who have inherited
His mantle; there is no other God but He.
4. Do not degrade thyself by commingling with disbelievers. You have
been given the divine message.
5. Obey and do not question.
6. If you put the teeth in their proper relationship to each other, nor-
mal function will result and stimulate the development of support-
ing bone.
7. Ignore the soft tissues; they will move out of your way.

From the Department of Orthodontics, University of Michigan School of Dentistry.

Presented at the thirty-third annual meeting of the Great Lakes Society of Ortho-
dontists, Detroit, Mich., Dee. 11, 1962.
418
Volume 49
Muscles, malformation, and malocclusion 419
Number 6

8. Don’t worry about the amount of foree you use. Teeth will move
one way or the other.
9. Read extensively in comparative anatomy, anthropology, and art,
for an erudite display of such knowledge will assist you in times of
travail,
10. Retain the orthodontie results indefinitely. This will allow function
to take over and stabilize the results.
If these commandments did not instill the fear of the deity in the eager
young orthodontist, he was somewhat perplexed when he ran into another set
of precepts, also emanating from an oracle on high. These commandments—from
a slightly different cult, of course—were as follows:

1. Thou shalt not expand.

2. Honor thy patient and practice and strive for perfection and a pleas-
ing profile.
3. Remember that the master has said that the lower incisors must be
90 degrees to the mandibular plane, or 65 degrees to the Frankfort
horizontal. Do not deviate!
4. Do not hesitate to extract first premolars. Only in this way ean you
achieve the objectives required by our master.
Band as many teeth as possible; to do less indicates sloth, inde-
cisions and lack of comprehension of the only road to orthodontie
salvation.
6. Ignore muscles, particularly those of the tongue, as you strive for
the magie mathematical formula.
7. Ignore morphogenetic pattern and growth gradients. Occlusion is
the be-all and the end-all of our existence,
8. Ignore root resorption, but do not show the roentgenograms to your
contréres because they might interpret this as a sign of weakness.
9. Take your ‘‘finished’’ records as soon as you remove applianees. If
you have not achieved the objectives as outlined by the master, the
case is not to be considered ‘‘finished.*’
10. Retain the case indefinitely. Never diseuss failures with nonbelievers,
for you may sow the seeds of ugly suspicion and mistrust.
It is obvious from looking at both sets of the ‘‘sacred ten’* that the ad-
herent to cither set of commandments had to have ‘‘religion.’’ Conflicting as
some of the admonitions seem, however, there were some common denominators.
In both cases, it was assumed that the appliances would automatically produce
the desired result if used properly. In both eases, one just did not think about
failure or the accomplishment of less than ideal results. In both eases, to use
something different meant to compromise, and compromise was a therapeutic
disgrace. Followers of both sets of rules paid lip service to functional forces
but ignored the role of museles.
In this wonderful world of fashion, museles were bound to have their dav.
The patient’s failure to wear his retainer could not be blamed for all the re-
lapses. Even the most zealous operator could see that his perfect. manipulations
420 Graber Am, J. Orthodontics
June 1968

at thes produced very Tinperfeet results Third tiolaes provided a road alli,
as did that nebulous entity known as ‘‘ growth and development,’’ but there
still must be something else.
There was a rude awakening as clinicians suddenly saw that the patient
had a tongue. From the pulpit came the sonorous declaration that ‘‘90 per cent
of all patients are reverse swallowers!’’ Disciples gulped a bit when they heard
this. Such a statement was, indeed, hard to swallow. Had not the master said
to ignore the tongue? At least, he had said this in effect when he said that for
every degree over 25 degrees for the Frankfort-mandibular plane angle, the
lower incisors should be tipped 1 degree lingually past the magie 90 degree
norm. In the spirit of the immortal Tennyson poem, ‘‘Theirs not to make reply,
theirs not to reason why, theirs but to do and die.’’ So now there was at least
the perfect scapegoat—the tongue!
The fine work of Gwynne-Evans,”* Ballard,’ Hovell,*” * and Tulley,* study-
ing the role of the musculature, was ‘‘discovered’’ and the numerous graphs
and curves associated with the cephalometric contribution to the literature gave
way to the curves and contours of the orofacial soft-tissue environment. Speech
therapists became tongue tamers. They soon found that lion taming was more
successful.® Improper nursing, poor design of artificial nipples, retention of in-
fantile mechanisms, and nonnutritive sucking were blamed for orthodontic
relapses. These tenuous connections are in much the same category as those
used by armchair psychologists who often attribute every adult neurosis to
imagined childhood frustrations. Many a physiologist has raised an eyebrow
as budding ‘‘musele-bound”’ orthodontists delve in fanciful flights of teleology
to explain their failures.
This facetious critique is exaggerated, but we cannot deny the basic fact
that, from a complete disregard of muscle activity and habit patterns, we have
jumped to aa belief that muscle plays a dominant role, affecting our manipulations
whether we like it or not. One almost senses a feeling of hopelessness or pessimism
in sharp contrast to the great optimism of the early 1950’s when orthodontists
could move teeth as they desired. Perhaps this reflects a belated recognition by
our orthodontic engineers that the results produced by the most precise tech-
niques and the most efficient armamentaria will not stand the test of time when
there is a conflict between the morphologic pattern attained and the physiologic
structure of the stonudegnathic system FPortumitely, the fundamental plie-
nomenon of homeostasis, or the organism's ability to adapt to change, does give
the orthodontist some leeway, reducing the air of gloom and pessimism that
pervades the lair of the muscle men tcday.
The orthodontic vernacular has been greatly expanded recently with the
inclusion of such terms as reverse swallowing, hereditary incompetence, endog-
enous pattern, visceral swallow, somatic pattern, retained imfantile swallow,
stntple fonyie-Thr ast, comples longue ff ust, fransitional swullawers, fe Where
do museles and malocclusion stand with respect to this mass of verdant verbiage?
Are the answers to be found in eurrent myometric and electromyographic
research and basic musele physiology? Is it not possible that there are many
facets to this problem?
Votume 49 Muscles, malformation, and malocclusion 421
Number6

The remainder of this study attempts to balance orthodontic therapy and

the museulature philosophically, just as the orthodontist must balance then
physically with his own appliance manipulations. The discussion deals with the
role of museles in the etiology and correetion of the various categories of mal-
occlusion, Some simple methods of controlling abnormal perioral muscle funetion
are illustrated.

CLASS I MALOCCLUSION
Musele funetion is usually normal in cases of Class I malocclusion. The
teeth are in a state of balance with environmental forces (Fig. 1). While actual
measurements of tongue and lip forees show that they are not equal in any one
area during a particular function, a state of equilibrium has been reached if we
consider morphogenetic pattern, tooth size, available basal bone, character of
contiguous tissue, postural forees, and the various functional forees. Weinstein
and associates*’ indicate that there is probably more than one position of
equilibrium, all factors considered.

= ~ ed
x Ys
orbicularis oris axis
<A" [ah

genioglossus OL. aa, soft palate

Ba
geniohyoid

hyoid bone
VAN
| dorsum of tongue
epiglottis
ts

Fig. 1. Normal structural relationship. Note proximity of tongue and

palate; gentle, un-
strained lip contact; normal overbite and overjet. (After Lischer, B, E., in Graber, T. M.:
Orthodonties, Principles and Practice, Philadelphia, 1961, W. B. Saunders Company. }

Mastication is the primary consideration for us, as dentists, when we think

of the teeth, jaws, and motivating musculature. This is onlv part of the picture.
Posture, deglutition, respiration, and speech make use of the same structures,
and these functions are no less important.22 The head is balanced preeariously
on a bony column and is held ereet by the chain of postvertebral, prevertebral,
mastieatory, facial, suprahyoid, and infrahyoid muscles?’ (Fig. 2).
As we know, the primary position, or the point of initiation of the manifold
funetions of the stomatognathie system, is the postural resting position? This
position has been determined by the morphogenetic pattern and by the complex
functional demands that are constantly made on it from birth to senescence.
The orthodontist finds that as the point of return, as well as the point of initia-
tion for the functions of mastication, deglutition, respiration, and speech, this
 422) Graber Am. J. Orthodontics
Tune 1963

CcCRANIUM:

MANDIBLE
VERTEBR AL COLUMN’...
rag)

HYO
7

BONE
at
i

SHOULDER GIRDLE*=

Fig. 2, Vertical dimension, diagrammed to demonstrate role of muscles in

maintaining the
balance of the head on the vertebral column. Post- and prevertebral muscles and
masticatory,
facial, and hyoid group muscles all contribute to the establishment of the relatively constant
postural resting position, It is from here that the dynamie functions of respiration, deglu-
tition, mastication, and speech begin. (After Brodie, A. G., in Graber, T. M.:
Orthodontics,
Principles and Practice, Philadelphia, 1961, W. B. Saunders Company. )
 Muscles, malformation, and malocclusion 423
Volume “9
Numober
6

relationship is constant (Fig. 3). As Posselt*® has shown, streteh-reflex contro!

‘an be traced to the meseneephalon and the pons (Fig. 4).
However, in our eagerness to establish a ‘‘base of operation,’” we must not
forget that even postural resting position is amenable to alteration. There may

Fig. 3. Lateral cephalograms showing postural resting and habitual occlusion positions.
Patient has a Class IT, Division 2 malocelusion. Mandible moves upward and forward to point
of initial contact and is then foreed upward and backward until posterior-segment occlusion
is established,

Warea 0 tee
a@

Fig. 4, Postural reflex of temporalis muscle. Drawing is mainly of anterior fibers (1), in-
cluding stretch receptors (2), the sensory nucleus in the mesencephalon (3), the motor nu-
cleus in the pons (4), terminating in the muscle fiber end plates (5). (From Posselt, UH:
Physiology of Occlusion and Rehabilitation, Philadelphia 1962, F. A. Davis Company. }
 Am. Orthodontics
424 Graber Jd.
June 1963

be a measurable change from morning to night. Nervous tension, premature

contacts, temporomandibular joint disturbances, and homeostasis may all pro-
duce variation, and these possibilities should be checked whenever a postural rest
registration is made.** Usually such variations as are produced are minor and
do not mitigate any more against the concept of postural resting position than
does inherent variability in other areas of the body. Constant peripheral re-
cruitment of muscle fibers and tonus maintains the head in the position of best
advantage, from which the active functions may be initiated with minimum
effort.** Thus, postural resting position is hardly a system at rest in the truest
sense. When we measure the total forces acting on the dental arches, a significant
amount must be credited to these subelinieal, relatively minimal and yet potent

We AREA OF GREATEST MUSCLE STRENGTH

\\

NJ
rest-
Vig. 5, Lateral cephalometric tracings of mandible in open-mouth (1) and postural
of mandible on
ing (2) positions, occlusion (3), and overclosure (4). Positional influence
strength of muscle contraction is shown by the fact
that between 4 and ? the greatest force
is created. Magnitude falls off rapidly between 3 and 4.
Volume 49 Muscles, malformation, and malocclusion 425
Number 6

Tneteendis These darees are fron ome fourth: fenth these reeommcneded
as minimum for tooth movement, according to Weinstein."
Oye any period of tine, kinesthetic nenraiiusentar Tirputses. ty the Sarre
of propricception, maintain a constant maxillomandibular position, with the
teeth separated by a V-shaped space® (Fig. +). This interocclusal clearance is
wider anteriorly than in the posterior region. The prudent orthodontist has
learned to build his orthodontic objectives around this museularly determined
position, oxen as the prosthodontist tas leaned that he canta igtote restine.
position limitations unless he wants to see the alveolar process melt away as
Nature re-establishes an oeclusat position in harnieny with postural rest Phos
musele physiology teaches us that there are two vertieal dimensions—(1} o«-
clusal vertical dimension (OVD) as determined by the teeth when relaied In
habitual oeclusion and (2) postural vertical dimension(PVD) as determined
by the draping and motivating musculature. Lack of harmony of treated mal-
oerlasions with postural resting vertical dimension deterloration of post
treatment morphology. Even from the point of view of functional efficiency. it
is obvious that the correct establishment of OVD is essential.#? The area af
greatest muscle strength is in the 4 mm. range from postural resting position to
4

occlusion (Fig. 5). The strength of muscle contraction falls off if’ the
As have ii rapidly
clefl
patient is petnatted to overclose we seen studies of pak te
children with markedly deficient occlusal vertical dimension, even with significant
adaptive changes, and with increased anterior temporalis and anterior masseter
fiber activity and greater suprahyoid and infrahyoid activity, the magnitude
of closing forces is greatly reduced.”*
One would think that while we have not been sufficiently aware of the
vertical dimension, we at least have been concerned about the other two ecom-
ponents that quake up the horizontal vector. the Tutemul und auteruposteries
musele forces. This is partly true. Case, Grieve, and Tweed strongly attacked
the expansion philosophy in orthodontic therapy.** With effective appliances
anda precise technique, Pweed and tis followers exerted a profound fiflienes on
American orthodontic thought. Acutely aware of the failures resulting from
maving etowded teeth ontawerd and off hasal hone, they heat af thei efforts
toward maintaining existing arch form and size through the medium of tooth
sacrifice and space closure. Expansion as a rationale in Class I therapy has been
severely curtailed. There are those, however, who feel that the primarily mechani-
cal orientation of Tweed’s largely ignored the enveloping soft-
tisstie atid tousele forees With
has consideration
the qnaajar
pintosophy belnu hash hore ard
available space, Tweed literally built his cases around the mandibular incisor
and 2 90 deeres iInelination to the mandiindar plane {Fig 6° a the arit ar
neni
plane was steeperthan the arbittary 29 dewrées chosen as “nord Tweed
advised his disciples to tip the mandibular incisors lingually past the so-called
norm, or 90 degree inelination,1 degree for each degree over the 25 degree
mandibular inclination. Thus, if a patient has a Frankfort-mandibulay
plane
plane anele of 3A deerees, the Tayer dueisor qait tie at SA dearer. ty

compensate for the steepness and to provide the necessary profile improvement.
In their zeal to prevent expansion, Tweed and his followers thus ignored an
426 Graber Am, J. Orthodontics
June 1963

Tweed Triangle

ney/y

<A

Fig. 6. Cephalometric analysis by Charles Tweed. The larger the angle at 4 (the greater the
Frankfort-mandibular plane angle), the smaller the angles formed at 1, 2 and ra must be to
compensate for the gonial obtuseness. The treatment objective is a 65 degree angle formed
by the long axis of the mandibular incisors and the Frankfort horizonta) plane at 5, 6, and 7.
Mandibular incisors must be moved lingually to compensate for steep mandibular plane.
The maxilla (shaded area) is ignored in this analysis, regardless of category of malocclusion.

equally important muscle foree and mass—the tongue. The 90 degree incisor
inclination by itself was a fiction, nonexistent as a ‘‘norm”’ in Nature; it was a
convenient clinical creation that was obtainable by appliance manipulation but
empiric and mathematical and unphysiologic. As Winders and others have
shown, the functional forces of the tongue can be three to four times as great
in some areas as the opposing lip and cheek inuseles aud ean hardly he ignored
(Fig. 7).
To expansion must be added contraction in Class I malocclusion, or in any
category of malocclusion in which the teeth are tipped to arbitrary inclinations
that ignore the contiguous functioning musele masses. For the extractionist
there is ample posttreatment evidence in the form of spaces in the extraction
site, deepened overbite, crowding mandibular incisors, soft-tissue proliferation
and all-too-frequent root resorption, and temporomandibular joint disturbances."
These sequelae are of no less concern than the untoward effects of injudicious
expansion. With expansion, we are at least moving the teeth in the direction in
 Muscles, malformation, and malocclusion 427
Volume 49
NwMNoer

whieh normal growth and development may take them as the stomatognathic
system develops its fullest potential through growth. Routine empiric tooth
sacrifice at times gives the opposite impression of a general shrinking p1ocess.
Those who favor differential light-force techniques spend a great deal of
time discussing the optimum foree for moving a tooth, but many of them have
been no less guilty than proponents of the edgewise techniques in ignoring the
balancing effect of contiguous muscle and the role of growth and development.
Teeth are often tipped to bizarre inclinations during one stage of treatment.
Excessive lingual tipping of incisors frequently remains to encroach on the
tongue space.
The three-dimensional nature of musele forees as they act on the dentition is
thus apparent. In the vertical plane the postural considerations are dominant.
and vet the orthodontist must also be coneerned with the functions of respira-
tion, deglutition, mastication, and speech—all of which use the same structures.
70. 12 6 30 50.70 90 110 130 150 400 B00 1200, 1600 2000
geem 71 13 5) 7 9 Wy 3 20 40 60] 80 100) 120) !40) 200
|
|
|
600 1000} 1400 1800
|
| |

LAS
if sf

No Increase
Buccal
ADEASORES
IRAN ei
Moailary [OAR
AIKELIA WERE |
:

Meise
Stond. Dev.
Lingua! a E-=--—-
5 Pe
As

No Increase
Buccal
Mandibular EXIUE.>
SER I RIND- SE RSLS LUSTY
Te=}ad
mas

Molar +t

Lingus! E

HENLE See
=

AE SS
tf

No Increase
Labiol
Moxillary gD ed na a ee oe
Centres
Inc ser

uinguet Depends om Overbite

Labral No increase
Mandibular
Central
EU AOR PETRA OO BT ATS SEAR.
ee:
CO SN
TORT
TREN
_
_
incisor
Lingual a
|

EP
TERESI ECR
ORS
SCM SANTI LL,
NAKEDAE ERB
q T
TT
213
.

tbs/.nt0 142 2133 2.844 28446

sResting Pressures
Swallowing Pressures
a Maximum Effort Pressures

Fig. 7. Magnitude of lip, cheek, and tongue pressures in molar and incisor areas, as measured
hy Winders with strain gauges and transducers. Pressures were obtained on subjects with
excellent dentition. Resting, swallowing, and maximal-cffort pressures are graphed for buccal
labial and lingual components. Lingual pressures are significantly greater during postural
rest and deglutition but little more during maximal effort. Resting pressure appears greater
only on the labial aspect of the mandibular incisors. (Adapted from Winders, R. V.: Angle
Orthodontist 32: 38-48, 1962.)
428 Gra ber Am, J. Orthodontics
June 1963

We have been more cognizant of the horizontal forces and no longer aecept
expansion as routine rationale in Class I treatment, but contraction can be
equally bad and will fail just as surely in the posttreatment adjustment.

are

OF Acta

wd

ry

if

Fig. 8. Anterior open-bite associated with a retained infantile swallowing habit and manifest
tongue-thrusting, The peripheral portions of the tongue do not overlie the posterior occlusal
surfaces during rest. Thus, postural resting position and habitual occlusion are the same,
with no demonstrable interocclusal clearance.
Volume 49 Muscles, malformation, and malocclusion 429
Number 6

It has been pointed out that muscle activity is normal in Class I maloeelu-
sions in general, that Nature has given us the mold, and that we must work
within this frame of reference. In other words, we start with normal muscle
activity and we must maintain it. Some important exeeptions, however, are seen
in the various types of open-bite (Mig. 8).
The greatest share of Class I open-bite problems may be attributed to
thumb- and finger-sucking, a retained visceral or infantile swallowing habit,
or a combination of both.* '*: * 31 This type of malocclusion provides an exeellent
example of applicd muscle physiology. The infant begins lite with a well-de-
veloped tongue-thrusting mechanism (Fig. 9}. This nursing instinet is one of
the best developed of all infantile movements and is quite a contrast to the
akimbo and apparently meaningless activities of the extremities.” It is an
efficient mechanism, too, as the tongue darts forward innumerable times to
obtain milk from the mother’s breast or from a reasonable facsimile thereof.+

INFANTILE (VISCERAL) SWALLOW

ELONGATED TONGUE _ meee

Cf
a
TONGUE THRUST
PURSED LIPS
(PER! ORAL SPHINCTER
ACTION)
MANDIBULAR THRUST

MAXILLARY GUM PAD

— DEPRESSED CENTRAL FURROW

MANDIBULAR GUM PAD pe LOWER TONGUE POSITION

NARROW TONGUE

Fig. Infantile swallowing mechanism. Plungerlike action is associated with nursing, Cheek
9.
pads flow between posterior gum pads during nursing, unopposed by peripheral portions of
tongue. Associated with the tongue-thrust is the anterior positioning of the mandible. The
condyle may be felt gliding rhythmically forward and backward in the nursing act. Note
concave midline contour of dorsum of tongue.
 ‘ Am. J, Orthodontics
430 raber
Gra c
June 1963

There are no teeth to get in the way, and the dominant posture of the tongue
is one in which the center is depressed, the peripheral portions are raised, and
the mass is elongated, ready for plungerlike action. The instinct is so powerful
that the infant usually engages in the suckling act even when there is no nipple
present. There is very little in the way of an articular eminence, so the mandible
moves forward readily to assist in the nursing act. Lips purse and move
rhythmically in unison."*
At about 5 to 6 months of age, as the incisors begin to erupt, certain
proprioceptive impulses come into play and the peripheral portion of the

MATURE (SOMATIC) SWALLOW

HUMPED UP
PERISTALTIC TONGUE PALATE
APPROXIMATION
--REDUCED PERI-ORAL SPHINCTER
MOMENTARY INCISOR CONTACT

NO MANDIBULAR THRUST

SHALLOW CENTRAL FURROW

HIGHER TONGUE POSITION
TONGUE...
PERIPHERY
BETWEEN
OCCLUSAL
SURFACES

Fig. 10. Somatic swallowing mechanism, The dorsum is less concave and approximates the
palate during deglutition. The tip of the tongue is contained behind the incisors; peripheral
portions flow between opposing posterior segments. Anterior mandibular thrust has dis-
appeared,
Volume 49
Muscles, malformation, and malocclusion 431
Number 6

tongue starts to spread laterally. This change in tongue function is a gradual

one, and it is called the transitional stage.*7 As the incisors erupt more fully,
the peripheral portions of the tongue occupy the space between the remaining
edentulous areas of the upper and lower gum pads, and the more mature
somatie swallow is the result (Fig. 10). The lips close, and the incisors come
together momentarily as the tip of the tongue lies behind the incisors during the
swallowing act. Actually, all postural muscles are brought into play during
this aetivity, as electromyographie studies have shown.* * 14 15 1B 29) 41. 38. 4
ts

As the deciduous canines and molars erupt, the peripheral portions of the tongue
still overlie the occlusal surfaces during rest, as the mandible is maintained at
postural resting position. Thus, the tongue assists in maintaining the interoc-
elusal space or clearance.
With any physiologic phenomenon there is a wide range of variations that
can be ealled ‘‘normal.’’ An average infant would show a dominant and ex-
clusive thrusting visceral swallow for the first 6 months of life, a transitional
thrusting and lateral spread of the tongue during the next year, and a dominant
somatic type of swallow, with the tongue contained within the dentition, there-
atter,
It is considered normal for children to engage in nonnutritive sucking during
infaney.*® The most common form is thumb- or finger-sucking (Fig. 11). Since
the mouth is the initial avenue of communication with the outside world, and
since the orofacial musculature is relatively well developed, this nonnutritive
sucking apparently gives the infant a fecling of warmth, a glow, a sense of satis-
faction or euphoria that is closely linked to the infantile or visceral swallowing
mechanism. As other avenues of communication with the outside world develop,
as other muscle svstems mature, and as visual and auditory stimuli become
meaningful, the euphoria indueed by the oral activity assumes less importance.
In the average child, the nonnutritive sucking habits spontaneously disappear
sometime between the sixth and cighteenth months of life. In some children
these habits may be normal for at least another year or so. That the thrusting
action of the tongue is a primary instinet is shown by a study of the child with
athetoid cerebral palsy who returns to primitive developmental activities and
exhibits the monotonous thrusting of the tongue through most of his waking
hours.
There is a considerable body of opinion linking the nonnutritive sucking
habits with inadequate nursing and with poor nipple substitutes and artificial
nursing techniques. T have reached this conclusion after a study of more than
600 children with thumb- and finger-sucking problems in the last 17 years.?*
Whatever the reason for the persistence of the finger-sucking habit (slow
phvsiologie maturation, inadequate or improper nursing methods, nipple designs
which enhanec the infantile thrusting and do not allow the development of
more mature somatic swallow during the transitional stage, or possibly a heredi-
tary Class II, Division 1 type of maloeelusion whieh seems to demand more
nonnutritive sucking because of the child’s inability to thrust the mandible
forward sufficiently), the infant begins with a finger habit of sufficient intensity,
frequency; and duration to deform the maxillary anterior segment, forcing the
432 Graber Aim. J. Orthodontics
June 1963

q
Nee
.

4.
|
—

t
f
a\ \t
|

Ja

Fig.
us
11. Maloeclusions associated with finger-sucking., Bilateral narrowing of maxillary arch
may be attributed to tongue-thrusting, lower resting tongue posture, and excessive buccal
pressures that are a part of the infantile swallowing mechanism. Unilateral cross-bites are
the result of a ‘‘convenience swing’’ of the mandible to one side, with tooth guidance from
point of initial contact to habitual occlusion.
onthe
Naum cer ” Muscles, malformation, and maloceluston 438

fi

Fig. 12. Hypertrophic tonsils and adenoids may cause an anterior adaptive displacement.
of the tongue, enhancing the thrusting mechanism and interfering with the normal matura-
tional cycle of deglutition. (After Moyers, R. E., in Graber, T. M.: Orthodonties, Principles
and Practice, Philadelphia, 1961, W. B. Saunders Company.)
teeth labially and allowing the tongue to move further in this direction. Instead
of graduating from the infantile visceral thrusting pattern in the transitional
stage to the more mature somatie swallow, the tongue continues to thrust forward
(Figs. 8 and 9). A large part of this activity may be a compensatory condition
or an adaptive and adjustive mechanism. This is a classic example of the funda-
mental phenomenon of homeostasis. To close off the oral cavity for normal
deglutition, either a lip seal or a tongue seal is needed to create the negative
atmospheric pressure associated with the swallowing phenomenon."
If the finger displaces the maxillary incisors labially, the lip seal beeomes
more diffieult and the tongue thrusts forward between the maxillary incisors
to ‘‘close off’’ the oral cavity. Such activity aecentuates the open-bite tendeney,
preventing the incisors from erupting adequately, and the incisors are usually
foreed further labially. Since, as Winders®* ** has shown, the tongue foree during
function is actually greater than the opposing lip force (Fig. 7), this response is
easy to understand. We swallow a total of 1,200 to 1,600 times every 24 hours,
so it is no wonder that the compensatory tongue-thrust habit enhances the
malocclusion as the lips become more hypotonie and no longer contact each
other during rest. Mouth breathing is aggravated and becomes a dominant
pattern. Tonsils and adenoids, which are normally larger at this stage, may
also be a faetor, as Moyers*® 37 has shown (Fig. 12).
If the maxillary incisors are brought far enough labially, the lower lip
enters the picture (Fig. 18). Lips no longer contain the denture, so to speak.
as the tongue thrusts forward during the innumerable swallowing eveles in the
course of the day.’* With each swallow, the lower lip cushions to the lingual of
the maxillary incisors and joins the tongue in Nature's adaptive or adjustive
attempt to create the oral seal during swallowing.? Mentalis musele ac-
tivity greatly increases, and a puckering of the chin can he seen with each
swallow as both the lower lip and the tongue thrust upward and forward into
the excessive overjet and open-bite configuration (Figs. 14 and 15).
434 Graber Am. TF, Orthodontics
Tune 1963

With constant tongue-thrust, the tongue drops lower in the mouth and no
longer approximates the palate most of the time.*? The tongue naturally elongates
in shape as it thrusts forward, decreasing its balancing effect on the buccal
segments. Equally important, the lateral peripheral portions no longer overlie

Fe
| |

Fig. 13. Lip-sucking, the cushioning of the lower lip to the lingual aspect of the maxillary
incisors during both rest and active function, and hyperactive mentalis muscle activity (lower
center) enhance malocclusion and prevent normal deglutition. (From Mayne, Warren, in Graber,
T, M.: Orthodontics, Principles and Practice, Philadelphia, 1961, W. B. Saunders Company.)
 Muscles, malformation, and malocclusion 435

Mental Muscle

BUHL
Lateral Pterygoid Muscle
Anterior Temporal Muscle Fibers
Middle Temporal Muscle Fibers
Posterior Temporal Muscle Fibers
Ant. & Post. Masseter Muscle Fibers

JUU
Medial Pterygoid Muscle Fibers
HEAVY Supra & Infra-hyoid Muscle Action
Labii Superioris & Inferioris

NORMAL DEGLUTITION
MODERATE =

SLIGHT

Fig. 14. Bar graph illustrating comparative musele pressures during the normal swallowing
act. Only lateral and medial pterygoid, middle tempovalis, und anterior and posterior masseter
fibers show moderate activity. The remainder demonstrate slight activity.

the occlusal surfaces of the posterior teeth during postural resting position.
Morphologic and functional changes go hand in hand, each augmenting the
other. With changes in the tongue, check, and lip musele functions, the net
effect is a significant narrowing of the maxillary arch and overeruption of the
posterior teeth. Oeclusal vertical dimension and postural vertical dimension
(OVD and PVD) become one and the same as the intcrocclusal space is elimi-
nated. A cross-bite condition is frequently ereated by the bilateral narrowing of
the maxillary areh, and the convenience swing or mandibular displacement
results in a deflection to one side or the other from the point of initial contact
(Fig. 11), The open-bite is accentuated by this vicious cirele’’ activity. Unless
normal activity can be restored and a mature somatic swallowing habit achieved,
the maloeclusion may well be perpetuated and aggravated until Nature has
established a condition of balance with hereditarv pattern, basal hone limits,
tooth size, contiguous tissue, the functions of mastication, respiration, speech,
and posture as well as deglutition, and other as vet unequated factors.>”
As we have drawn this picture of a developing malocclusion, it is easy to
say that the finger-sucking habit caused the malocclusion. This, of course, is
 436 Graber Am. J. Orthodontics
June 1963

Mental Muscle
Lateral Pterygoid Muscle
Anterior Temporal Muscle Fibers
ea Middle Temporal Muscle Fibers
Posterior Temporal Muscle Fibers
co Anterior Masseter Muscle Fibers
Posterior Masseter Muscle Fibers
Medial Pterygoid Muscle Fibers
co Supra & Infra-hyoid Muscle Action
Labii Superioris & Inferioris

HEAVY
ABNORMAL DEGLUTITION

MODERATE

SLIGHT

Fig. 15. Bar graph illustrating comparative muscle pressures associated with abnormal swal-
lowing. Note heavy mentalis and lip activity, dominance of posterior temporalis and masseter
fibers, and increased hyoid muscle action. (See Fig. 14.)
incorrect. It is entirely correct to say that the finger habit was the first assault
on the integrity of the dentition and that the adaptive and compensatory activi-
ties of the tongue and lip teamed up to provide a much more significant detorm-
ing mechanism. Without the original deforming activity by the finger, however,
the subsequent lip and tongue action might never have occurred. For this reason,
it is considered a good intereeptive orthodontie procedure to place an appliance
which eliminates the finger habit before the arch is deformed sufficiently to
require homeostatic muscle action during deglutition (Fig. 16).
The optimal time for appliance placement is between the ages of 344 and
414 years, preferably during the spring or summer when the child’s health is
at its peak and the sucking desires can be sublimated in outdoor play and social
activity. The appliance serves several purposes. First, it renders the finger
Volume 49 437
Number 6
Muscles, malformation, and malocclusion

SP

&

Fig. 16. Intereeptive finger-habit appliance. Spurs are bent toward palate; posterior loo}
extends upswend aud backward ot degiee auple Met patatal baa crosses palate at tesa
ot gingival margin. Appliance is removed gradually over a period of 4 to 6 months---spurs
first, loop next, and finally remaining bar and crowns.

habit meaningless the suction, The child may, of eourse, place his
fimget in Vs mouth by but
breakingpeal satisfaction frota df Thus, the finger
The gets ne

sucking becomes smalogous to coffee without caffeine or cigarettes without nico-

tine. GGreat care is exercised to inform both the child and the parents that the
appliance is not a restrictive measure, that it is used not to prevent anything
but merely to straighten the teeth, improve the appearance and provide a healthy
‘*chewing machine.’’ Second, by virtue of its construction, the applianee prevents
finger pressure from displacing the maxillary incisors further labially, from
creating more damage, and from causing a greater likelihood of abnormal tongue
and lip funetion. Third, the appliance forees the tongue backward, changing its
shape during postural resting position from an elongated mass to a wider, move
neatly novinal tongue As a result, Mie formene fends fu exert pressiipe oa
the maxillary buccal segments and the of the maxillary arch by the
abnor swallowing habit is reversed,narrowing the
periplerab portions aeain aver
the ocelusal surfaces of the posterior teeth, preventing the overeruption of these
teeth. If the patients are normal, healthy children, no unfavorable sequelae are
observed) except for a temporary sibilant speech defect which disappears tite
the appliance is being worn or immediately after it is removed,"
In more than 600 eases treated in this manner during the past 17 years, not
a single case of habit transference has been observed. Psychological aberrations
do not oecur, psychoanalysts’ predictions to the contrary The
appliance is wotn for 3 to G@ months aud is
gradually otweithstanding.
reduecd, spurs and
loop being removed first and finally the bar (Fig. 16).
 AAAS ~
N

\ ‘2

ge
Y

«
Fig. 17.
taal demain
Tongue-thrust appliance, Full metal crowns are used as abutments on second de-
ciduous or first permanent molars, Lingual bar and loop assemblage of 0.040 inch stainless
steel. Palatal bar and y-shaped loops terminate immediately lingual to oceluding lower in-
cisors, Care must be exercised so that projections do not impinge on gingivae. Buccal tubes
may be added to crowns, anticipating possible need for extraoral force, Tongue crib may
De ruodified ty rebdition of
coc
pote’ Teer ty the first Whe teat Son palvedts

with severe finger-sucking habits. Intraoral views show bite closure over a 3 week, period.
Head plate illustrates crib relation to incisors and open-bite.
Volume 49 Muscles, malformation, and malocclusion 439
Number 6

vi oun

ae

a
~N

Fig. 18. Tongue and finger appliances incorporating extraoral force auxiliary. Tf incisors are
not banded (and this is usually the case), a 0,040 inch arch wire with vertical spring loops
at molars and soldered extraoral arm loops is fabricated. If incisors are banded, cervical
anchorage assists in elongating incisors and closing bite. Lingual crib is then eut off ans
hands are polished down tu pernct finishing af the cuse with extrac) fave,

If
the oeclusion has been sufficiently deformed by the finger habit, if a
morphogenetic pattern of incisor protrusion has heen aggravated by the finger
habit to a degree requiring abnormal lip and tongue function of an adaptive
nature, or if there is merely a retained infantile tongue-thrusting habit instead
of the more mature somatie swallow, a tongue-thrust appliance is used (Fig.
17). Its funetion and action are similar to those of the finger appliance just
deseribed. The main purpose is to prevent the tongue from being inserted into
the open-bite 1,200 to 1,600 times a day, as it would be if no appliance were
present. The child is encouraged to learn the somatic swallowing habit by crowd-
ing back of the tongue and by the change in resting shape. Peripheral portions
of the tongue occupy the interocelusal clearance and restore a normal interoc-
elusal space and occlusal vertical dimension in harmony with the postural vertical
dimension. The anterior open-bite closes down as the incisors erupt toward each
other and as the teeth are molded by the lip action.
The strong action of the tongue working against the applianee may cause
the overjet to be increased, and it is good practice to place a simple labial areh
440 Grader Am J.
Ortodontis

and to use cervical extraoral force to reduce the protrusion, thus offsetting the
potent tongue force (Fig. 18).
If the open-bite is combined with an excessive overjet and the lower lip has
already entered the picture, forcing the maxillary incisors further labially
because of hyperactivity of the mentalis musele, and if a flattening or crowding
of the mandibular anterior segment is in progress, a lip appliance is construeted

4
1
ae

Vv

Fig. 19. Lip-habit appliance. A 0.040 inch bar is soldered to full metal crowns on second
deciduous or first permanent molars. Bar may cross from lingual to labial either mesial or
distal to canine, depending on occlusion and anterior spacing. The operator should be sure
that labial assemblage is 2 to 3 mm. anterior to labial aspect of lower incisors. Model is foiled
first before endothermic acrylic is adapted to wire framework. Appliance is cemented in
place for a period of 3 to 6 months, depending on severity of lip habit and amount of overjet.
Volume
Number
49
Muscles, malformation, and. maloccluston 441
6

(Fig. 19). Usually this type of appliance is not necessary if extraoral force has
been employed with the tongue-thrusting appliance. The mere elimination of
the excessive overjet usually permits homeostatic changes in musele function.
The lip no longer cushions to the lingual of the upper incisors, and mentalis
muscle aetivity disappears. If the problem is primarily a lip or mentalis musele
condition or a lip-sucking habit,a lip appliance proves effective.
The lip appliance is constructed so that the labial wire and the aerylie mass
are sufficiently gingival to the mandibular incisal margin to permit the maxillary
incisors to erupt into a normal overbite. Care must be exercised to make sure
that the lingual surface of the appliance is at least 2 to 3 mm. labial to the
mandibular incisors so that the tongue may move these teeth forward into a
normal are and contact relationship. This is necessary to re-establish the integrity
of the lower anterior segment and reduce the horizontal overjet. The goal of
therapy is to permit the mandibular incisors to move far enough labially and
the maxillary incisors to drop far enough lingually to eliminate the excessive
overjet and the space provided for abnormal lip action. Hyperactive mentalis
muscle funetion will not disappear until excessive overjet is eliminated. The
lip appliance is worn for 6 to 12 months, depending on the severity of the
problem. Because of the obvious leverage problems and the forces working
against the wire framework, regular orthodontic bands are usually inadequate.
Full metal erowns serve as excellent abutments for these habit appliances, and
they are easy to place. There is no need to grind down the veclusal surfaces of
either the teeth or the crowns, since the open-hite created by the placement of
these crowns quickly closes down within a week.

CLASS II, DIVISION 1 MALOCCLUSION

In contrast to Class I maloeelusions, in which muscle function is usually
normal (Fig. 1), with the exeeption of open-bite, the majority of Class II,

of \
changed 7
Yk
hypo-functional
upper lip tongue position
Qs
hyper-functional
lower lip

hyperactive
mentalis muscle
SS ws

Fig. 20. Sagittal section illustrating Class LI, Division 1 relationship. Compare with Fig. 1.
Note lowered tongue posture, elongated functional position, narrowed buceal dental segments
in maxillary arch, and lower lip cushioning to lingual aspect of
maxillary ineisors during
rest and active fuse dior Tap and tongue team up to accentuate
Getormuty After Lascher,
B. E., in Graber, T. M.: Orthodontics, Principles and Practice, Philadelphia, 1961, W. B.
Saunders Company.)
 442 rabeer Am. J. Orthodontics
Gira June 1963

Division 1 malocelusions do involve abnormal muscle activity in the beginning

(Fig. 20). In Class II, Division 1 therapy, a ehange in muscle function is a
requisite; expansion 7s a treatment objective. With a hereditary type of Class
II malocclusion, the teeth merely refleet the abnormal anteroposterior jaw re-
lationship, and the excessive overjet is a consequence. If we apply the same
logie and the lessons that we learned in our analysis of the development of open-
bites in Class I malocclusions, it is easy to see why compensatory and adaptive
muscle activity of an abnormal nature will enhance and perpetuate the Class 11
malocclusion.** The finger-sucking habit or the retained visceral swallowing
pattern is not a prerequisite to establishment of a favorable environment for
abnormal muscle activity.’* If a structural malrelationship exists, the muscle
function adapts to this pattern as best it ean in line with the requirements of
mastication, deglutition, respiration, and speech. The lower lip cushions to the
lingual of the maxillary incisors, both at postural rest and during active fune-
tion (Fig. 13). In some instances a lip-sueking habit develops, with the lower
lip mass almost constantly thrust into the excessive overjet. The lip itself may
become hypertrophic as a result. The maxillary incisors move further labially,
weakly resisted by a hypotonie and relatively functionless upper lip (Fig. 8).
The lower incisors buckle as the mandibular segment is flattened by continuously
abnormal mentalis muscle activity. The curve of Spee increases. With the eom-
pensatory tongue-thrust, lower tongue position, and increased buccinator muscle
activity, the maxillary arch narrows and assumes the V shape so often associated
with Class II, Division 1 problems, Thus, the picture is similar to the open-bite
problem just described in Class I malocclusions.* Open-bite occurs in Class II
malocelusions also, but it was deseribed previously to emphasize the faet that it
can occur despite a normal jaw relationship. Abnormal musele activity ean thus
create a pseudo Class II, Division 1 malocclusion, even with harmonious antero-
posterior jaw relations. A difference in true Class II, Division 1 problems is that
the morphology and jaw relationship arc abnormal to begin with and muscle
activity has only accentuated an existing pattern. In Class I open-bite and in
pseudo Class II, Division 1 malocclusions, abnormal finger, tongue, and lip
activity initiated the morphologie changes which, in turn, ealled on further
abnormal muscle activity to meet functional demands and to compensate for the
structural changes.
Orthodontic treatment of Class IJ, Division 1 malocclusions should be di-
rected first toward the creation of a normal basal bone relationship which permits
the muscles to function properly. The establishment of a normal anteroposterior
jaw relationship, climinating the excessive overjet and overbite conditions which
have fostered adaptive muscle function, permits normal muscle activity.*? No
longer is excessive buccal musele pressure exerted on the posterior segments.'
Expansion of the buccal segments and an increase in maxillary intereanine
width oceur autonomously or ean be accomplished by means of orthodontic
appliances. In line with our initial appraisal of the three-dimensional character
of the muscle problem, this type of expansion is essential and quite stable after
the removal of all appliances. Kleetromyographie research strongly substantiates
this analysis.”
Volume 49 Muscles, malformation, and malocelusion 443
Number 6

CLASS Il, DIVISION 2 MALOCCLUSION

The precise role of the musculature in Class II, Division 2 malocclusion is
more difficult to establish. A hereditary pattern for the specific malocelusion
characteristics seems the predominant consideration. Activity of the cheek and
Hpouseles ts tisuaity normal, contrary fe Division There is some evidence
to

to support the contention that the tongue at least tends to accentuate the exces-
sive curve of Spee and that it interferes with the eruption of the posterior teeth
by ocettpying the tnteroeelusal space (Pig, 21) Ti this is indeed true, the eon.
dition would tend to increase the interocclusal clearance—and it is a faet that
Moanest cases of Class TT, Division 2 anatoeelusion there is excessive inter:
ocelusal space. Because of the lingual inclination of the maxillary central in-
ecisors, combined with the excessive interocclusal clearanee and the infraclusion

AD

ma
Fig. 21. Atypical Class II, Division 2 malocclusion showing lateral tongue-thrust. To a lesser
degree, lateral tongue-thrust may be a factor in other Division 2 cases. (From Mayne, Warren.
in Graber, T. M.: Orthodonties, Principles and Practice, Philadelphia, 1961, W. B. Saunders
Company. }
of the posterior teeth, functional guidanee of the mandible is quite common
(Figs 3 and 22° The inandible closes frome posttial vesting postficn ta
point of initial eontact. The lingually inclined maxillary incisors then guide the
mandible into a retruded position during the halance of the closing movement
to full occlusal contact.*? Eleetromyographic research shows that there is a
compensatory muscle activity, with dominance of the posterior fibers of both
temporatis aud) tiassefer niuseles from: (he tttiah contact position fo Che postion
of habitual oeelusion (Fig. 23), The posterior-fiber dominance is eliminated by
propetcty eutded orthodontic theraps whieh restores ai oeeltisa? vertedh dimen.
sion that is in harmony with the postural vertical dimension, thus eliminating
the ‘forced retrusion’’? phenomenon.
tid Gra
raber
or Am, J, Orthodontics
June 1963

POSTERIOR SUPERIOR
DISPLACEMENT

ans
1

Fig. 22. Funetional mandibular retrusion seen most commonly with a Class IT, Division 2
malocclusion. Note overclosure and tooth guidance. 1, open-mouth position; 2, postural resting
position; 3, initial contact; 4, habitual (retruded) occlusal position. With overclosure, the
prospect is for reduced strength of muscle contraction and possibly reduced masticatory
efficiency. (See Fig. 5.)

It
is with tooth-guidance problems particularly, such as those encountered in
Class II, Division 2 malocclusions, that temporomandibular joint problems
arise,’ 2° with clicking, crepitus, pain, and other vague but disturbing com-
plaints. Posselt®® graphs the distribution (Fig. 24) and frequency (Fig. 25) of
symptoms in 731 patients by combining the studies of Sdderberg,** Staz,**
Lindblém,** Hankey,’ and himself.** In the truest sense, temporomandibular
joint disorders may also be considered musele problems. From such nonhomeo-
static phenomena as the inability of museles to adapt to morphologic variation
and ehanging functional demands, their selective activity as shown by electro-
myographie research, their occasional disregard for proprioceptive warnings of
 Muscles, malfarmation, and malocclusion 445
Numoer

tle seffex are, aud thelr vevasiunal (visuue uy uneoordinated: respotise: fa Thess

stimuli comes the temporomandibular joint symptomatology.

CLASS ILL MALOCCLUSION

In Class 1IT malocclusion, as in Class I], Division 1. we are dealing with a
dominant bone dysplasia, with adaptive muscle function and tooth irregularities
reflecting a severe basal dysplasia. All three systems—bone, teeth, and muscles
are Gnvolyed TTere again, there is a strome hereditary pattern The apper
lip is relatively short, though not necessarily hypotonic. The lower lip is hyper-
trophic and redundant and appears to be relatively passive during the degluti-
tion eyele (Fig. 26). During swallowing, there is actually a greater activity of
the upper lip. The tongue is a potent force, although it is not clear whether the
tongue mass or tongue function is the basis for the lingual “‘cupping out’ be-
neath the mandibular teeth. The tongue does appear to lie lower in the floor of
the mouth. Since the maxillary arch does not have the balancing effeet of tongue

=>)

—4

5
Fig. 23. Muscles primarily responsible for mandibular functional movements. 1, Anterior and
posterior fibers of temporalis; 2, lateral pterygoid; 3, anterior, middle, and posterior com-
ponents of masseter; 4, suprahyoid; 5, infrahyoid. Medial pterygoid not shown. In forced
retrusion, electromyographic records show a dominance of posterior temporalis, posterior
masseter, and posterior suprahyoid muscles, Resistance to posterior condylar displacement
by the lateral pterygoid muscles (2) is apparently insufficient, since primary function is
that of opening, not closing, and secondary stabilizing assignment on closure can result in
excessive forward movement of the articular dise on maximum contraction. (After Posselt, U.:
The Physiology of Occlusion and Rehabilitation, Philadelphia, 1962, F. A. Davis Company.)
 DISTRIBUTION OF SYMPTOMS
9FT

TENDERNESS ON PALPATION Bec

See
CLICKINGOF THE JOINTON
Graber

MOVEMENT
PAIN ON MOVEMENT

EXCESSIVE MOVEMENT

JOINT SYMPTOMS
LIMITED MOVEMENT
(INCL. LOCK JAW)
TINNITUS
STOPPING OF STUFFY SENSATION
IN THE EARS

VERTIGO

MILD CATARRHAL DEAFNESS

EAR SYMPTOMS
PAIN IN OR ABOUT THE EARS

HEADACHE
PAIN OVER VERTEX , OCCIPUT ,OR
POSTAURICULAR AREAS

HEAD
SYMPTOMS
NEURALGIA MAX.,MAND., &
NECK
BURNING,OR PRICKING SENSATION
IN THE TONGUE
Am.

SIMILAR SENSATION IN THE

SYMPT.
15%

RYNGEAL
NASOPHA-
THROAT & THE NOSE é5%
&
June

Fig. 24. Distribution of temporomandibular joint symptoms based on a compilation of studies by Séderberg,4> Staz,5 Lindblém,t> Hankey,?*
and Posselt.28 The sample consists of 731 patients. Clicking is included only in conjunction with other complaints, not when it is the sole
1968
J. Orthodontics

symptom. (From Posselt, U.: The Physiology of Occlusion and Kehabilitation, Philadelphia, 1962, F. A, Davis Company.)
 Muscles, malformation, and malocclusion 447
6

mass, and since the peripheral portions of the tongue are less apparent between
the occlusal surfaces, the maxillary arch is usually narrow and the interocelusal
space is either very small or entirely absent. During the deglutition cycle, there
is greater mobility of the hyoid bone as the suprahvoid and infrahvoid museles
demonstrate greater activity.
Tt ois difficult ta assess low aaueho oof the muscle activity is hotmeostatie,

compensatory, or adaptive to the structural malrelationship and how much of it

CLICKING OF THE JOINT ON

MOVEMENT
LIMITED MOVEMENT.
(INCL, LOCK-JAW)
mm
PAIN IN OR ABOUT THE EARS
V/)
\S
PAIN ON MOVEMENT
3
HEADACHE

TENDERNESS ON PALPATION f°

TINNITUS

EXCESSIVE MOVEMENT

MILD CATARRHAL DEAFNESS

PAIN OVER VERTEX, OCCIPUT, OR

POSTAURICULAR AREAS
NEURALGIA MAX.,MAND.,@ NECK 15% 25%
Fig. 25. Frequency of symptoms listed in Fig. 24. (From Posselt, U.: The Physiology of
Occlusion and Rehabilitation, Philadelphia, 1962, F. A. Davis Company.)

]
A

lingually inclined
lower incisors /'s
Ni i low tongue
redundant é
position
lower lip

marked mento-
labial sulcus aie

\
Fig. 26. Tongue and lip adaptation to Class III malocclusion. Relatively functionless lower
lip is in marked contrast to excessive activity associated with Class II, Division 1 malocelusion.
Lower tongue position is similar, but with no anterior thrust on deglutition. Greater upper
lip activity is in evidence in the attempt to ‘‘close off’? during swallowing.
 448 Graber Am. J. Orthodontics
June 1963

is in itself due to morphogenetic pattern. Very probably, depending on the case,

the proportions vary, As in the Class I and Class II maloeclusions, the three-
dimensional character of the muscle problem is again emphasized. Muscle forees
are a significant factor of vertical, lateral, and anteroposterior dimensions.

SUMMARY
An analysis has been made of muscles and their relationship to structural
configuration in Class I, Class II, and Class III malocclusions. The effect of
muscle forces is three-dimensional, although most orthodontists have considered
it only in one vector—that of expansion. Whenever there is a struggle between
muscle and bone, bone yields. Musele function can be adaptive to morphogenetic
pattern. A change in muscle function ean initiate morphologic variation in the
normal configuration of the teeth and supporting bone, or it can enhance an
already existing malocclusion. In the latter instance, the inherent structural
malrelationship calls for compensatory or adaptive muscle activity to perform
the daily functions. The structural abnormality is increased by compensatory
muscle activity to the extent that a balance is reached between pattern, environ-
ment, and physiology. At times it is impossible to assign a specific cause-and-
effect role to any one factor. It is imperative that the orthodontist appraise
muscle activity and that he conduct his orthodontic therapy in such a manner
that the finished result reflects a balance between the structural changes obtained
and the functional forces acting on the teeth and investing tissues at that time.

REFERENCES
1. Alderisio, J. P., and Lahr, Roy: An Electronic Technique for Recording the Hypo-
dynamic Forces of Lip, Cheek, and Tongue, J. D. Res. 32: 548-553, 1953.
2. Andersen, W. S.: The Relationship of the Tongue-Thrust Syndrome to Maturation and
Other Factors, AM. J. ORTHODONTICS 49: 264-275, 1963.
3. Angelone, L., Clayton, J. A., and Brandhorst, W. 8.: An Approach to Quantitative
Electromyography of the Masseter Muscle, J. D. Res. 39: 17-23, 1960.
4, Ardran, G. M., Kemp, F. H., and Lind, J.: A Cineradiographic Study of Bottle Feeding,
Brit. J. Radiol. 31: 11-22, 1958,
5. Asling, C. W.: Recent Developments in Biologie Studies of the Osseous System, AM.
J. ORTHODONTICS 47: 830-843, 1961.
6. Baker, R. E.: Tongue and Dental Function, AM. J. OrTHODONTICS 40: 927-939, 1954.
7. Ballard, C. F.: The Aetiology of Malocclusion—An Assessment, D. Practitioner 3: 42-50,
1957.
8. Baril, C., and Moyers, R. E.: An Electromyographic Analysis of the Temporalis Muscles
and Certain Facial Museles in Thumb and Pingersucking Patients, J. D. Res. 39: 536-
553, 1960.
9, Barrett, R. H.: One Approach to Deviate Swallowing, AM. J. ORTHODONTICS 47: 726-736,
1961.
10. Bosma, J. F.: Maturation of Function of the Oral and Pharyngeal Region, AM. J. ORTHO-
DONTICS 49: 94-104, 1963.
11. Choukas, N. C., and Sicher, H.: The Structure of the Temporomandibular Joint, Oral
Surg., Oral Med. & Oral Path. 13; 1203-1213, 1960.
12. Di Salvo, N.: Neuromuscular Mechanisms Involved in Mandibular Movement and Pos-
ture, AM, J. ORTHODONTICS 47: 330-342, 1961.
13. Dixon, D, A.: An Investigation Into the Influence of Soft Tissues on Tooth Position,
D. Practitioner 10: 89-92, 1960.
Volume 49 Muscles, malformation, and malocclusion +45
Number 6

14, Doty, R. W., and Bosma, J. F.: An Eleetromyographic Analysis of Reflex Deglutition,
J. Neurophysiol. 19; 44-60, 1956.
.
Ekleberry, J. W., and Eggleston, W. B.: An Electromyographie and Functional Bvalua-
tion of Treated Orthodontic Cases, Master’s thesis, Horace H. Rackham School of
Graduate Studies, University of Michigan, Ann Arbor, Mich., 1961.
1€ . Eskew, H., and Shepard, E.: Congenital Aglossia, AM. J. ORTHODONTICS 35: 116-119, 1949.
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