Oral Habits

By -
Sudeep Madhusudan Chaudhari
MDS 2nd Year
Dept of Paedodontics & Preventive Dentistry
Contents
●
Introduction
●
Definitions
●
Classification
●
Prevalence of habit
1) Thumb sucking
2) Pacifier habit
3) Tongue thrusting
4) Mouth breathing
5) Bruxism
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3)Tongue thrusting :-
Definitions :-
Tongue thrust is the forward most placement of tongue tip
between teeth to meet the lower lip during deglutition and in
sounds of speech, so the tongue becomes interdental.
-Tulley (1969)
It is the placement of the tongue tip forward between incisors
during swallowing.
-Profitt (1972)

3
Tongue thrust is the condition in which the tongue protrudes
between anterior and posterior teeth during swallowing with or
without affecting tooth position.
-Norton & Gellin (1978)

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Classifications of tongue thrusting-
1) Physiologic - This comprises of the normal tongue thrust
swallow of infancy
2) Habitual - The tongue thrust swallow is present as a habit even
after the correction of the malocclusion.
3) Functional - When the tongue thrust mechanism is an adaptive
behaviour developed to achieve an oral seal, it can be grouped
as functional.
4) Anatomic - Persons having enlarged tongue can have an
anterior tongue posture.
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James Braner and Holt classification (1965)
Type 1: Non-deforming tongue thrust
Type 2: Deforming anterior tongue thrust
Sub group 1: Anterior open bite
Sub group 2: Associated procumbency of anterior teeth
Sub group 3: Associated posterior cross bite

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Type 3: Deforming lateral tongue thrust
Sub group 1: Posterior open bite
Sub group 2: Posterior cross bite
Sub group 3: Deep overbite
Type 4: Deforming anterior and lateral tongue thrust
Sub group 1: Anterior and posterior open bite
Sub group 2: Proclination of anterior teeth
Sub group 3: Posterior cross bite
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Moyers classification-

Simple tongue Complex tongue Retained infantile

thrust thrust swallow
Here the tongue Here teeth are Persistence of
thrusting with apart infantile swallow
teeth are
together

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A)Infantile swallow

●
All infants thrust their tongue while
swallowing.
●
Tongue lies between the gumpads.
Mandible is stabilized by contraction of facial
●

muscle.
●
Disappears with eruption of teeth & growth
of mandible

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Mechanism of infantile swallow-

Infant lips closed around the areola of the

breast

Tongue protrudes to the lower lip &

forms a spoon like closure around nipple

relaxation of the elevator muscle of

mandible

mouth is open wide, milk directed to the

pharynx 10
B)Adult swallow

●
As a person swallows, tip of the tongue
contacts the palatal rugae area posterior to the
maxillary anterior teeth.
●
Midportion contacts the hard palate & posterior
aspect assumes a 45° angulation against the
posterior pharyngeal wall to permit the bolus of
food to move into the digestive tract.

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1)Simple tongue thrust -

Simple tongue thrust is usually associated with a history of digit

sucking that has led to open bite. According to Moyers, in
simple tongue thrust the teeth are in occlusion during
swallowing, some muscle contraction can be seen and
correction of malocclusion will correct the habit.

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2)Complex tongue thrust -

●
Complex tongue thrust is a more complicated type of
swallowing pattern associated with chronic nasorespiratory
issues such as mouth breathing, tonsillitis, or pharyngitis.
●
When the tonsil is inflamed and enlarged, the root of the tongue
exerts force on the tonsil and causes pain.
●
To avoid this force and resulting pain, the mandible will drop
reflexively, separating the maxillary and mandibular teeth,
enlarging the freeway space, and providing more room for the
tongue to move forward.
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●
This will create a more comfortable position during swallowing and
a more adequate airway. The forward position of the tongue exerts
continuous light force on the anterior teeth and alveoli, which will
result in dental or dentoalveolar protrusion, interdental spacing and
open bite.
●
Open bite might not be limited to anterior teeth. Treatment of
this type of tongue thrust is more complicated; myofunctional
therapy might also be required.

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3)Retained infantile swallow

●
Infant gum pads are not brought together in function, because
the mouth is designed for suckle feeding at this stage and the
space between the gum pads is occupied by the tongue.
●
At this age, the tongue is advanced in development and is
relatively larger than the surrounding jaws to facilitate suckling.
The transition from the infantile swallowing pattern to an adult
swallowing behavior occurs after 6 months, with tooth eruption.

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●
Moyers states that retained infantile swallow is an abnormal
swallowing pattern in which the infantile swallow remains and the
transition to an adult swallowing behavior has not occurred.
●
Open bite is more severe in patients with this type of swallowing
and may not be confined to the anterior segment. Treatment is
also more complicated and may include orthognathic surgery
and myofunctional therapy.

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Etiology -

●
Hereditary factors, such as a large tongue.
●
Vertical skeletal problems such as a steep mandible or wide
gonial angle.
●
Thumb or other finger sucking.
●
Short lingual frenum (tongue-tie).
●
Mouth breathing, which might be due to many factors that
cause nasal obstruction, such as allergies, nasal congestion,
deviated conchae or large adenoid.
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●
Sore throat, enlarged tonsils, or adenoids that cause difficulty in
swallowing.
●
Premature loss of primary teeth and abnormal tongue
adaptation.
●
Muscular, neurologic or other physiologic abnormalities, such as
loss of muscle coordination

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Different types of tongue thrust

i. Anterior tongue thrust-

●
Anterior tongue thrust is one of the
most common and typical types of
tongue thrust.
●
The resulting occlusal problem is
anterior open bite

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ii. Lateral tongue thrust
●
Lateral tongue thrust is not as
common as anterior tongue
thrust and depending on its
etiology, can cause unilateral or
bilateral open bite.
●
The anterior bite is usually closed; however, the posterior teeth
may be open on one or both sides, from the first premolar to the
distalmost molars. Correction of these anomalies is much more
difficult.

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Clinical features
1)Simple tongue thrust-
●
Intra oral findings:
→ Proclined & spaced upper incisor
→ Retroclined or proclined lower incisor
→ Anterior open bite

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→Posterior cross bite
→Normal tooth contact during swallowing
→ Tongue is thrust forward during swallowing to establish
anterior lip seal .

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●
Extra Oral Findings :
→Dolicocephalic face
→ Increase lower anterior facial height
→ Incompetent lips
→ Exression less face
→ Speech problems
→ Abnormal mentalis muscle activity
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2) Complex tongue thrust :
➔
Proclination of anterior teeth
➔
Generalized open bite
➔
Absence of temporalis muscle contriction
during swallowing
➔
Contraction of lip, facial & mentalis muscle

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●
Poor occlusion
●
Posterior cross bite

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3) Lateral tongue thrust
➔
May be unilateral or bilateral
➔
Lateral open bite is seen.

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Diagnosis:

●
Case history
●
Examination of the tongue thrusting :
– Check for size, shape & movement

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1) Functional examination -
●
Observe the tongue position, while the mandible is in the rest
position.
●
Observe the tongue during various swallows :
➢
Concious swallow
➢
Command swallow of saliva
➢
Command swallow of water
➢
Concious swallow during mastication
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2) Palpatory examination -
●
Place water beneath the patient’s tongue tip & ask him to
swallow
➔
Constriction of lips & facial muscles in tongue
thrusting.
●
Place hand over temporalis muscle & ask to swallow
➔
No temporalis contraction in tongue thrusting
●
Hold the lip & ask the patient to swallow
➔
Patient can not complete swallow. 29
Treatment

●
Age
Tongue thrust often self-corrects by 8 or 9 years of age by the
time the permanent anterior teeth completely erupt. The self-
correction occurs because of an improved muscular balance
during swallowing as the mature swallow is adopted.
However it is seen that orthodontic interception is usually more
successful than correction if initiated during the early mixed
dentition stage of dental development or between ages 9-11
years.
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Treatment is generally not recommended when tongue
thrust is present without malocclusion or a speech
problem. If the tongue thrust is present with
malocclusion but no speech problem orthodontic
correction of the malocclusion will usually eliminate
the tongue thrust.
If the tongue thrust is present along with malocclusion
and a speech problem, speech-and orthodontic
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1)Management of simple tongue thrust -
The management of tongue thrust involves interception of the
habit i.e., to remove the etiology followed by treatment to
correct the malocclusion. Once the habit is intercepted the
malocclusion associated with the tongue thrust is treated using
removable or fixed orthodontic appliances.

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●
The treatment of tongue thrust can be divided into various
steps:
I. Training of correct swallow and posture of the tongue
II. Appliances to guide the correct positioning of tongue
III.Mechano therapy

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I. Training of correct swallow and posture of the tongue
a. Myofunctional exercises -
Educate the patient about normal swallowing by asking the patient
to keep the tongue tip against the junction of soft and hard
palate. Various muscle exercise of the tongue can help in
training it to adapt to the new swallowing pattern.

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i. The child is asked to place the tip of the tongue in the rugae
area for 5 minutes and is asked to swallow.
ii. The tongue tip against the palate can hold small orthodontic
elastics during swallowing. If the swallow is correct the elastic
will be retained in position.
iii. 4S exercises - This includes identifying the spot by tongue,
salivating, squeezing the spot and swallowing.

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II. Appliances to guide the correct positioning of tongue-
Once the patient is familiar with the new tongue position an
appliance is given for training the correct positioning of the
tongue.

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Pre orthodontic trainer/ Tongue trainer-
This appliance aids in the correct positioning
of the tongue with the help of tongue tags.
The tongue guards prevent the tongue
thrusting when in place. It can also used to
correct mouth breathing habit

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III. Mechano therapy -
Both fixed and removable appliances (cribs or rakes ) can be
fabricated to restrain anterior tongue movement during
swallowing with the objective of retraining the tongue to a more
posterior superior position in the oral cavity. Both fixed and
removable are valuable aids in breaking the habit.

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a. Removable appliance therapy -
●
A variety of modifications of
Hawley's appliance can be used
to treat tongue thrust. It has an
active labial bow, retentive
clasps, a crib or rake or spikes
present posteriorly to the upper
anterior teeth. The crib can
serve as a reminder.
●
The spikes should be bent in such a way that when it is worn it
should not impinge on lower anteriors or anterior lingual alveoli.
Usually the open bite is closed down by activating the labial
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●
Activation of labial bow reduces the proclination of the upper
anterior teeth. The acrylic should be trimmed off from the gingival
marginal area of the lingual surfaces of the maxillary anteriors to
allow the incisors to be move palatally.
●
The loops of the tongue crib are removed one by one as the
patient is weaned from the habit appliance over a 6 month
period.

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b. Fixed Habit breaking appliance-
●
Bands are adopted on the first permanent molar and a 0.040
inch stainless steel 'U'– shaped wire is adopted from one molar
to another molar of the opposite side. After the base bar is
fabricated the crib can be formed and soldered to the base.
Depending on the severity of the open bite, 6-12 months may
be required for the autonomous correction of the malocclusion.

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●
The cribs acts by walling off the tongue
from the dentoalveolar structures. They
acts as remainders to the tongue when
ever it tries to thrust forwards. A new
engram is created by the nervous system
so that the tongue learns proper position in
long term. Thus this appliances create a
new neuromuscular behavior.
●
The cribs can be fabricated along with expansion devices like
quadhelix and expansion screw if the arch is constricted.
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C.Oral screen
●
Another effective means of controlling
abnormal muscle habits like tongue
thrusting and at the same time utilizing
the musculature to effect a correction of
the developing malocclusion, is the
vestibular or oral screen or a
combination.
●
These appliances have been used mostly to intercept mouth
breathing ,tongue thrusting, lip biting and cheek biting. They
also correct mild proclination of anterior teeth.

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2)Management of complex tongue thrust
●
The prognosis of complex tongue thrust will not be that much
good when compared to simple tongue thrust if it is of
neuromuscular origin.
●
The two reflexes involved are
1. Abnormal occlusal reflex
2. Abnormal swallow

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●
TREATMENT PROTOCOL
1. Treat the occlusion first with contemporary fixed orthodontic
appliance followed by careful equilibration.
2. The muscle training then begun is similar to that for a simple
tongue thrust with minor modification.
3. Great emphasis must be placed on keeping the teeth together
during swallowing.
4. A maxillary lingual archwire with short, sharp spurs may be
used as retainer.
5. It is important to do meticulous teeth positioning and careful
equilibration followed by persistent myotherapy.
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