JOURNAL CLUB

PRESENTED BY:
DR ESHAN AWASTHI
TONGUE & MALOCCLUSION

A Review…..
LEARNING OBJECTIVES:

• The normal physiology of tongue.

• The transitional changes in tongue with

age.

• Role of tongue in development of

malocclusion & relapse.
INTRODUCTION:

The morphology of the craniofacial complex, the dynamics

of the stomatognathic system & the arrangement of the
dentition is an integrated functioning unit.

Muscles are a potent force, whether they are in active

function or at rest.

The teeth & supporting structure are constantly under the

influence of the contiguous musculature.
TONGUE:
Muscular organ
Situated in the floor of the mouth
Associated with the functions of
Speech
Mastication
Deglutition
Essential in maintaining the arch
form & position of teeth.
Since long time, role of tongue in
malocclusion has remained
controversial.
Le Foulon (1839) was the first
to propose role of tongue in
malocclusion. “When tongue strikes
against the upper front teeth, it
pushes teeth forward”.
Breitner (1942) was Sweet (1948) Proffit, based on his Acc to this theory,
the first to highlight pointed out that in equilibrium theory, concept of tongue
the importance of improper proposed that hitting and moving
functional swallowing, tongue duration of force is the anterior teeth
equilibrium among thrusts forward much more forward is not valid
the forces of against the anterior important than but, abnormal
tongue and those teeth and hard magnitude of any posture and
produced from palate in order to force acting on position of tongue
action of lips and push bolus of food dental or skeletal can definitely cause
cheek musculature. into the pharynx. units. malocclusion
MUSCLES OF TONGUE:
• INTRINSIC EXTRINSIC
 Superior longitudinal Genioglossus
 Inferior longitudinal Hyoglossus
 Transverse Styloglossus
 Vertical Palatoglossus
• SUPERIOR LONGITUDINAL MUSCLE

Shortens the tongue & makes the dorsum

concave
• INFERIOR LONGITUDINAL MUSCLE
Shortens the tongue & makes
the dorsum convex
• TRANSVERSE MUSCLE:

Makes the tongue narrow & elongated.

• VERTICAL MUSCLE:

Makes the broad & flattened.

• Genioglossus – Protrudes the tongue out of the
mouth by pulling the posterior part forward

• Palatoglossus – brings the palatoglossal arches

together, thus shutting the oral cavity from the
oropharynx.
• Hyoglossus –
depresses the
tongue
• Styloglossus -
pulls it upward &
backward
DEGLUTITION

Infantile swallow ( visceral swallow)

Mature swallow ( somatic swallow)

INFANTILE (VISCERAL)
SWALLOW
• The jaws are apart, with the tongue
between the gum pads
• The mandible is stabilized by
contraction of the muscles of the 7th
cranial nerve & the interposed
tongue.
CHARACTERISTICS OF
INFANTILE SWALLOW
• The swallow is guided, & to a great
extent controlled by sensory
interchange between the lips & the
tongue.
TRANSITION PERIOD

At about the 5 to 6th month of age, as the

incisors begin to erupt, certain
proprioceptive impulses come into play &
the peripheral portions of the tongue starts
to spread laterally.

An average infant would show a dominant &

exclusive thrusting swallow for the first 6
months of life,a transitional thrusting &
lateral spread of tongue during the next year
& a dominant somatic swallow thereafter.
MATURE ( SOMATIC)
SWALLOW
• The teeth are together
• The mandible is stabilized by contraction
of the mandibular elevators,which are
primarily 5th cranial nerve muscles
CHARACTERISTICS OF
MATURE SWALLOW

The tongue tip is held against the palate,

above & behind the incisors
There are minimal contractions of the lips
during the mature swallow.
TONGUE POSTURE
NEONATES
 Tongue is postured forward & touches
the lips while the gum pads are held
slightly apart
• INFANTILE TO MATURE TONGUE
POSTURE

1. Eruption of incisors

2. Downward & forward growth of the

mandible – increases the intraoral
volume

3. Growth of the alveolar process in vertical

direction
MATURE TONGUE POSTURE
• During mandibular closure, the
dorsum touches the palate slightly
and the tongue tip normally is at rest
in the lingual fossa or at the crevices
of the mandibular incisors.
Basis for possible involvement
of tongue in malocclusion
Tongue alone counteracts various
buccal forces exerted by cheek and
lip musculature.

Any disturbance in this delicate

equilibrium will lead to instability of
dentoalveolar complex.
BUCCINATOR
MECHANISM
• The teeth and supporting structures are
constantly under the influence of
contiguous musculature.

• Winders has shown during mastication

and deglutition, the tongue may exert two
to three times as much force on the
dentition as the lips and cheeks at one
time.
• But the net effect is one of the balance
as tonal contraction, peripheral fibre
recruitment of the buccal and labial
muscles and atmospheric pressure team
up to offset the momentarily greater
functional force of the tongue.
• The decussating fibres
of the orbicularis
muscle, joining right
and left fibres of the
lip,the buccinator
mechanism runs
laterally and
posteriorly around the
corner of the mouth,
joining other fibres of
the buccinator muscle
which inserts into the
pterygomandibular
raphae just behind the
dentition
• At this point it intermingles with the
fibres of the superior constrictor
muscle and continues posteriorly and
medially to anchor at the origin of the
superior constrictor muscles, at the
pharyngeal tubercle of the occipital
bone.
• Opposing the buccinator mechanism is a
very powerful muscle- the tongue.

• The tongue begins its manfold activities

even before birth, when it functions in
swallowing of the amniotic fluid.
TONGUE THRUST
• DEFINITION
• The forward movement of the tongue
tip between the teeth to meet the lower lip
in deglutition and in sounds of speech so
that the tongue becomes interdental.
• According to Moyers,
 Simple tongue thrust swallow
 Complex tongue thrust swallow
 Retained infantile swallow / tongue
sucking
SIMPLE TONGUE THRUST
SWALLOW
 Tongue thrust with a teeth together swallow
 Malocclusion:
Well circumscribed anterior open bite
Posterior teeth in perfect occlusion
 Open bite has definite beginning & an ending
 Usually associated with digit sucking, since it is
necessary for the tongue to thrust forward into
the open bite to maintain the anterior seal during
swallow.
Complex tongue thrust
swallow
 Tongue thrust with teeth apart swallow
 Malocclusion:
Poor occlusal fit – prompts a slide into occlusion
Generalized anterior open bite
 Mandibular elevators don't contract during swallowing, &
mandible is stabilized by tongue & inframandibular muscle
contractions
 Usually associated with chronic resp. distress, mouth
breathing, tonsillitis & pharyngitis.
Retained infantile swallow /
tongue sucking
 Undue persistence of the infantile swallow well past the
normal time for its departure
 Teeth occlude on only one molar in each quadrant
 Strong contractions of the facial muscles during swallowing
 Patients will have expressionless faces, since the muscles
of the 7th cranial nerve are being used for stabilization of
the mandible
 Difficulties in mastication & low gag threshold
• Tongue size abnormalities also influences
the dentition and leads to malocclusion like
aglossia leads to crowded teeth and
macroglossia leads to open bite.
 Abnormal tongue posture

Abnormal tongue posture produces

more obvious malocclusion than
tongue thrust because abnormal
posture is maintained almost all the
time unlike thrust which occur only
during swallow.
Normal structural relationship.
Lowered tongue posture associated with
certain habits (e.g digit sucking habit)
may lead to dental cross-bite due to
palatal tipping of maxillary molars under
the influence of unopposed cheek
pressure

tongue
Facial morphology and
tongue dysfunction
Morphology of facial skeleton
and effects of tongue dysfunction
are related to some extent.

A horizontal growth pattern in

conjunction with tongue thrust
results in bimaxillary
dentoalveolar protrusion.

But in vertical growth pattern with

tongue thrust, lower incisors are
inclined lingually while upper
incisors are proclined.
Class I malocclusion:
Most common type of tongue abnormality
seen in class I cases is tongue thrust
habit causing anterior openbite.
Occasionally bimaxillary protrusion is
partly attributed to tongue abnormality
being large or posture forward causing
forward positioning of both arches
Class II Div 1
Lowered tongue posture, elongated
functional position, narrowed buccal
dental segments in maxillary arch.
Lip and tongue team up to accentuate
deformity.
Class II, Division 2 malocclusion
Since most of class II div 2 cases have
horizontal growth pattern, deep bite and
large free way space, tongue tends to
accentuate the excessive curve of Spee
by interfering with the eruption of the
posterior teeth. (lateral tongue thrust).
Class III malocclusion
In most of the class III malocclusions, lower
jaw is protruded which makes more
space available for tongue in floor of
mouth favoring lower posture of tongue.

But cause and effect relationship is not

clear about this low posture.

Since the maxillary arch does not have the

balancing effect of tongue, the maxillary
arch is usually narrow and the
interocclusal space is either very small or
entirely absent.
Tongue position is
further Low, but with
no anterior thrust on
deglutition.
Normal relationship Class II div 1
relationship

Class III relationship

ROLE OF TONGUE IN
SPEECH
SPEECH DIFFICULTIES
RELATED TO MALOCCLUSION
• s,z (sibilants) - Ant. Open bite, large gap b/w

incisors

• t,d (Linguoalveolar stops) - Irregular incisors

• f,v(Labiodental fricatives) - Skeletal class III

• th,sh,ch(lin.dental fricatives) - Anterior open bite

STUDIES
Postural & dimensional changes in
the Tongue from rest position to
occlusion
Leonard S Fishman

Aim : To ascertain if differences

exist between individuals with
normal occlusions & those with
abnormalities in tooth position with
respect to abnormal posture &
function of tongue.

The differences were also

investigated between individuals
with speech defect & those without
it.
Material & Methods:
• Three series of lateral cephalograms were used .

• Control group– 29 children with no speech defect

• Second group- 27 children ;

a) Class II division 1- 19
b) Class I – 5
c) Pseudo Class III – 2
d) Class II division 2 – 1

• Third group/speech group- 27 children who

underwent speech evaluations.
 A thin coating of A coordinate system
tantalum powder was devised using
Both rest &
mixed with gum reference planes
occlusion
acacia & water was the palatal plane &
radiographs were
painted on the a line dropped from
traced.
median sulcus & tip palatal plane (Ptm
of the dorsum. plane) from Ptm.
• Point A- tongue tip
• Point H- highest point on
the dorsum.
• Point AH- point on dorsal
surface of tongue joining
points A & H
• Point P- posterior point on
the dorsum of tongue
constructed by drawing a
line from point A parallel
with palatal plane.
• Point PH- point on dorsal
surface constructed from
line H-P
• Changes in the above points from rest position to
occlusion were measured from both palatal &
Ptm planes in horizontal & vertical components.

RESULTS:
• The posterior portion of the dorsum moved
anterosuperiorly from rest to occlusion mostly.

• The tip of the tongue moved posterosuperiorly

rather than anterosuperiorly in all three groups.

• The posterior aspect of the tongue seemed to

move more than the anterior.
In all three groups tongue usually decrease in its length.

In normal & malocclusion groups the tongue usually

decreased in height whereas increased in height in speech
group equally as it decreased.

In the rest position the speech & normal group tongue tips
usually were contacting lingual surface of lower incisor .

No postural change existed in malocclusion group

In occlusal position the tip did not elevate into more superior
postural position as mandible moved superiorly from rest to
closure ( control & malocclusion group)
Discussion & Conclusion

Tongue posture
When mandible
In general the tip Anterior tongue for posterior
moved from rest
contacted lingual movement was aspect was more
to occlusion the
surfaces of lower more posteriorly anteriorly related
posterior tongue
incisors in rest & directed for for speech group
moved upwards
occlusion. speech group. when compared
& backwards
with normals.
 In speech group tongue increased in
height from rest position to occlusion.

This was associated with the tendency

toward posterior movement of anterior
area of tongue & more forward posture
of posterior area of tongue

The malocclusion group demonstrated

no predominant tongue tip posture.

The fact that Class I malocclusions

demonstrated more dimensional
changes than other form of
malocclusion may indicate that
structural environment plays an
important role in tongue activity.
Resting Tongue Pressures
Richard Christiansen , Carla Evans , Steven Sue
AIM: to measure the magnitude of forces exerted by relaxed tongue in the
region of mandibular canines by specially designed strain gauge transducer.

Material & Methods: with the help of this transducer device force exerted on
the teeth were recorded.

Total of 23 subjects ( 17-normal occlusion , 6 dental open bite) were

examined for lateral resting tongue pressure.

Three sensing tips with different contact areas were used to study
relationship between sensor area & measured force.

A correlation was found between resting tongue pressure & mandibular

intercanine width.
DISCUSSION & CONCLUSION :

The normal relaxed

tongue produces a
very low force against
lingual surfaces of
mandibular dentition.
The level of lingual force in
patients with a dental open bite
malocclusion was found similar to
that of normal subjects.

Resting lingual forces increase rapidly as

tongue width is decreased by the force
transducer.
• The lack of striking relationship between tongue
pressure & anterior open bite suggests that the
morphology & functional environment are in
balance.

• The low negative correlation between intercanine

distance & tongue pressure tends to support
Proffit`s observation that individuals with wider
dental arches have less lingual pressure but
further studies are required.
Tongue movements in patients with
skeletal Class II malocclusion evaluated
with real time balanced turbo echo cine
MRI
Yilmaz etal AJODO 2012
Aim – the aim of this study was to
evaluate the deglutitive tongue
movements in patients with
skeletal Class II malocclusion.

Material & Methods:Total of 81

patients ( 45 males , 36 females )
were included.

Controls- 22 skeletal Class I ( 10

males, 12 females)
• Skeletal Class II – 59 ( 26 Male , 33 Female)
a) Group 1 ( n=19) mandibular retrognathism
b) Group 2 ( n = 20) maxillary prognathism
c) Group 3 ( n=20) both .

• For each patient , images matching following

three stages were determined:
1. Stage 1- oral stage; loss of contact of dorsal
tongue with soft palate.

2. Stage 2- pharyngeal; passage of bolus across

posterior margin of ramus of mandible.

3. Stage 3- esophageal; passage of bolus through

opening of esophagus
Discussion & Conclusion:
In the mandibular retrusion group- posterior portion of
dorsal tongue moved downward at stage 2 & upward at
stage 3.

In patients involving both components , middle portion

of dorsum tongue was positioned superiorly at stage 3
relative to stage 1.

In control group middle portion of dorsal tongue was

positioned superior at stage 3.

The posterior portion of tongue moved upward at stage

2 & downward at stage 3
• Contact of anterior portion of the tongue with
rugae area decreased in Class II malocclusion
group compared with control group.

• The middle portion of dorsum tongue was

positioned superiorly in class II group compared
to controls.

• The tongue tip was more retruded in class II

groups compared to controls.

• The posterior portion of dorsum was more

inferiorly placed than the other two Class II
groups.
Dentofacial morphology affects the position of tongue & deglutitive
movements.

In patients with class II malocclusions , the middle portion of dorsal

tongue is positioned more superiorly & tongue tip is positioned
more posteriorly than those with skeletal Class I malocclusion.

The contact between anterior portion of tongue & rugae area

showed significant decrease in all Class II & III groups

So increase or decrease in overjet decreases the contact , as it is

difficult to maintain a seal during swallowing.

Lips make contact to provide seal in anterior region in normal

occlusion cases whereas this physiologic seal is usually provided
by tongue lip –maxillary incisor contact in Class II & III subjects..
Correction of anterior open bite with
spurs: Long term stability
Roberto Justus WJO 2001

Lopez-Gavito reported that more than 35% of

anterior open bite patients treated with
conventional orthodontic appliances relapsed
3mm or more 10 years post retention.

He concluded that neither the magnitude of pre t/t

open bite , mandibular plane angle nor any other
parameter was reliable predictor of post t/t stability
or relapse.

The author proposes anterior tongue posture as

an etiologic factor & failure of tongue posture
adaptation subsequent to t/t might be the primary
reason for relapse.
The teeth are together for only 60 to 90 minutes each 24
hour period so mandibular & tongue rest posture can
cause anterior open bite.

The risk factors such as innate growth problems ,

excessive epipharyngeal lymphoid tissue , respiration
problems, tooth eruption problems , compensatory tongue
thrust during swallowing should be identified.

Anterior tongue rest posture is significant due to its long

duration whereas tongue thrust is of short duration(1-
3seconds maximum during swallowing)

The objective of this study is to demonstrate the long term

clinical results of closing anterior open bite.
 The spurs force change in anterior tongue rest posture which
allows incisors to erupt

A study by Huang et al investigated the effect of spur therapy.

There was an increased long term stabilty 5 years post

retention.It showed that the anterior open bite correction stability
is apparently related a modification in anterior tongue posture
due to spurs in both growing & non growing patients.

Haryett etal concluded that there was no psycological problem

associated with spurs provided there was a good rapport
between patient & doctor.
A crib without spurs simply restrains & does not
retrain the tongue while the spurs discourage
the tongue from resting against them

The spur appliance recommended by author

was made from .045 “ stainless steel wire with
eight short sharpened spurs , 3mm long
positioned 3mm away from the cingulum.

Patient A- 9 years boy Class I anterior open

bite-6mm;
Patient B- 8yrs 1month girl with Class I anterior
open bite-3mm
Patient C- woman 34 years 7months Class II
div 1 anterior open bite 3mm
• In patient A – There was seen a closure of
anterior open bite probably due to establishment
of new tongue posture encouraged by spurs.

• In patient B- there was seen a closure of anterior

open bite & the stabilty of closure was retained
18 years post treatment( super imposition of
radiographic tracings)

• In patient C- there was seen a closure of anterior

open bite & stabilty was retained 12 years post
treatment( age- 45 years 10 months age)
Neurophysiology of spurs:
Spurs(maxillary lingual arch) Inhibit maxillary
molar eruption

Stop sucking habit

Encourage mature tongue Establish new N-M

rest posture pattern

Allow incisors to erupt Diminish the

closing the bite probability of relapse
Conclusion :

Since the anterior

The effectiveness of Although dental & tongue posture &
the spur appliance , skeletal malrelations musculature might play
both in closing anterior can be corrected , the primary roles , not just
open bite & achieving stability of anterior adaptive ones , they
long term stability has open bite will improve must be addressed in
been validated. with etiology removed. orthodontic therapy to
minimize the relapse.
Initial effects of the tongue crib on
tongue movements during deglutition
Sayin et al Angle Orthodontist-2006

• Aim: to investigate the initial effects of a tongue

crib on tongue movements during deglutition
using real time balanced turbo field echo
(B-TFE).
• Material & methods :
• Total patients- 21;
• Open bite group- 11 , (7 girls , 4 boys )
• Mean age- 11.09±2.02 years
• Over bite- -5.14±1.83mm
• Control group- 10 ( 5 boys , 5 girls )
• Mean age- 14.5±2.6 years
• Mean overbite- 1.6±0.5 mm.

• T1- before wearing crib.

• T2- time period while wearing crib.

• Tongue crib with a smooth spur & no metal

clasps was constructed.
 Result &Conclusion:
• The tongue`s tip positioned more posteriorly
when the crib was in place T2
• The anterior portion of tongue dorsum was at
lower position at T2.
• The midportion of tongue`s dorsum was at lower
position in T2.

• So to compensate for the posterior position of

the tongue`s tip ( caused by tongue crib)
adaptive changes occurred in the anterior &
midportions of the dorsum.
Relapse of anterior open bites with
orthodontic appliances with & without
myofunctional therapy
Smithpeter et al AJODO 2011

AIM: To compare the

subjects who were treated
with orthodontics alone vs
those treated with
orthodontics combined with
OMT.

The purpose was to

evaluate whether completion
of an OMT program before
removal of orthodontic
appliances decreases the
risk of relapse of closed
anterior open bites
Material & Methods :
• Control group- 49 patients after orthodontic
relapse ( 15 M, 34 F )
• Mean age- 17 years 8 months.
• At debanding- 90% had closed bites
• 2years after debanding- 84% showed opening of
bite.
• Experimental group- 27 subjects either before or
during ortho. t/t ( 5 M , 22 F )
• Mean age- 14 years 1 month.
• 4 subjects had relapsed after active ortho. t/t
• 23 subjects had no history of fixed ortho t/t.
Discussion & Conclusion:
OMT with orthodontic t/t was effective in closing & maintaining closure of
dental open bites in Angle`s Class I & II cases & reduced the relapse who
had forward tongue posture & tongue thrust.

Correcting low forward tongue posture & tongue thrust swallows minimized
the risk of orthodontic relapse.

Speech errors & oral habits were associated with relapse but were often
correctable with OMT.

Retention of speech errors did not necessarily preclude correction of tongue

rest posture & swallows.

In addition to dental anterior open bites , common denominators in both

groups at initial OMT examination were forward tongue rest posture & tongue
thrust swallows.
Summary:

Though it is not yet established cause and effect

relationship between tongue dysfunction and
malocclusion, it seems that tongue thrust and /
or particular posture and position of tongue may
be associated with particular type of
malocclusion.

Wherever possible, underlying cause should be

identified and eliminated for example anterior
tongue posture if not corrected is bound to
cause a relapse

Retaining the achieved results is a major

challenge faced by every orthodontist. Not only
esthetically pleasing arch form & occlusion but
positioning the teeth where muscular forces (
intra & extra oral ) are balanced should be aimed
at right from the day one of the treatment.
TAKE HOME MESSAGE
Tongue is a very powerful muscular
organ which if not kept an eye on &
over looked in long term is definitely
going to have its toll on the efforts &
results which have been achieved by the
orthodontist………………..
 Its high time now……….
Fasten your seat belts,
Work harder than u have ever before
Be stronger than u have been before
Show ur confidence than u have shown before
Coz in few days from now………………………………
U will fly higher than u have flew before…

Just one last go…………….

ALL D BEST SENIORS….
THANK YOU…..