oral habits

Oral habitsOral habits

Shrirang Anand Sevekar

ContentsContents

► Habit Habit DefinitionDefinition ClassificationClassification Trident of habitTrident of habit Dental response to pressure Dental response to pressure

habitshabits Treatment phylosophyTreatment phylosophy

► Breast feedingBreast feeding► Bottle feedingBottle feeding► Thumb Or digit suckingThumb Or digit sucking

► PacifiersPacifiers► Tongue thrustingTongue thrusting► Mouth breathingMouth breathing► Lip habitsLip habits► BruxismBruxism► Nail bitingNail biting► Cheek bitingCheek biting► Masochistic habitsMasochistic habits

HabitHabit

►William James- William James-

From psychological view, Is a Pathway of discharge From psychological view, Is a Pathway of discharge

formed in brain by which certain incoming currents formed in brain by which certain incoming currents

ever after tend to escape….ever after tend to escape….

Habit: DefinitionsHabit: Definitions

► Dorland – Dorland –

Fixed or constant practice established by Fixed or constant practice established by

frequent repetition frequent repetition

► Buttersworth –Buttersworth –

Frequent or constant practice or acquired Frequent or constant practice or acquired

tendency, which has been fixed by frequent tendency, which has been fixed by frequent

repetitionrepetition


►MoyerMoyer Habits are learnt pattern of muscle contraction Habits are learnt pattern of muscle contraction

of a very complex natureof a very complex nature

►Hogeboon and SalderHogeboon and Salder

It is a methodical way in which mind and body It is a methodical way in which mind and body act as a result of frequent repetition of a certain act as a result of frequent repetition of a certain definite sets of nervous impulsesdefinite sets of nervous impulses


►Mathewson – Mathewson –

Learned pattern of muscular contractionLearned pattern of muscular contraction

►Tandon –Tandon –

Settled tendency in response to a specific Settled tendency in response to a specific

cause resulting from repeated learningcause resulting from repeated learning

►BoucherBoucher As a tendency towards an act or an act that has As a tendency towards an act or an act that has

become a repeated performance, relatively fixed , become a repeated performance, relatively fixed , consistent, easy to perform and almost automaticconsistent, easy to perform and almost automatic

Development of habit Development of habit

► Unconscious mental patternUnconscious mental pattern InstinctInstinct

► Elementary reflex-Elementary reflex-► Pattern and orderPattern and order

Incorrect outlet of energyIncorrect outlet of energy Pain or discomfortPain or discomfort Abnormal physical sizeAbnormal physical size Imitation of othersImitation of others

► HabitHabit

Dental response to pressure exerting Dental response to pressure exerting oral habits : Foresteroral habits : Forester

► Functional matrix theory –Functional matrix theory –

Position of Dentition- skeletal growth pattern ,Position of Dentition- skeletal growth pattern ,

muscular forces and masticatory forcesmuscular forces and masticatory forces

► Orthopedic effect (Swine hart)Orthopedic effect (Swine hart)

2 types of forces acc. to site and duration2 types of forces acc. to site and duration► Ant. Force against palate (Sucking habit)Ant. Force against palate (Sucking habit)► Constriction force of buccal musculature (Mouth breathing) Constriction force of buccal musculature (Mouth breathing)

Habits: ClassificationHabits: Classification

► ObsessiveObsessive

(Deep rooted) (Deep rooted) Intentional OR Intentional OR

meaningfulmeaningful Masochistic or Self- Masochistic or Self-

inflicting injurious habitinflicting injurious habit

► Non- obsessiveNon- obsessive

(Easily learned)(Easily learned) Empty or UnintentionalEmpty or Unintentional

► Abnormal pillowing, chin Abnormal pillowing, chin proppingpropping

FunctionalFunctional► Tongue thrustingTongue thrusting

Tandon


► James (1923)/ GraberJames (1923)/ Graber UsefulUseful HarmfulHarmful

► KingsleyKingsley Functional oral habitFunctional oral habit Muscular habitMuscular habit combinedcombined

► Finn (1987)Finn (1987) Compulsive habitsCompulsive habits Non- compulsive habitNon- compulsive habit

Primary habitPrimary habit

Secondary habitSecondary habit

► Klein (1977)Klein (1977) EmptyEmpty meaningfulmeaningful


►Morris and Bohanna (1969)Morris and Bohanna (1969) Non pressure habit Non pressure habit Pressure habitPressure habit

►Sucking habitSucking habit Lip, Thumb sucking, Tongue thrustingLip, Thumb sucking, Tongue thrusting

►Biting habitBiting habit Nail biting, Needle, Thread holdingNail biting, Needle, Thread holding

►Posturing habitPosturing habit Pillow, Hand restPillow, Hand rest

►MiscellaneousMiscellaneous Bruxism, Cheek bitingBruxism, Cheek biting


► NormalNormal► AbnormalAbnormal

► Retained Retained ► CultivatedCultivated

► PhysiologicPhysiologic► PathologicPathologic

► Sucking habit Sucking habit JDC:1996:321JDC:1996:321

O Brian (1996)O Brian (1996)

Nutritive SuckingNutritive Sucking► Breast, Bottle feedingBreast, Bottle feeding

NonnutritiveNonnutritive► Thumb suckingThumb sucking► Tongue thrustingTongue thrusting

Trident of HabitTrident of Habit

► IntensityIntensity► FrequencyFrequency► DurationDuration

►Direction (Pinkham)Direction (Pinkham)Habit

IntensityIntensity

FrequencyFrequency DurationDuration

DirectionDirection

Treatment philosophy and Treatment philosophy and considerationsconsiderations

► Emotional significance of habit in relation to familyEmotional significance of habit in relation to family Excessive parental demand Excessive parental demand Psychological Psychological Prolonged separation Prolonged separation approachapproach Birth of siblingBirth of sibling

► AgeAge

► Existing or potential malocclusion asso. with a Existing or potential malocclusion asso. with a force exerting habitforce exerting habit

Nutritive habitsNutritive habits

Nutritive habits Nutritive habits JDC: 1996;321JDC: 1996;321

► Breastfeeding Breastfeeding Rooting reflex (Pinkham)Rooting reflex (Pinkham) Sucking reflexSucking reflex Psychological developmentPsychological development Effect on orofacial developmentEffect on orofacial development Malocclusion Malocclusion

Nutritive habitsNutritive habits JDC: 1996;321JDC: 1996;321

► Bottle feedingBottle feeding Artificial nipple Artificial nipple

► Size, length, flow rate, Size, length, flow rate, location of holeslocation of holes► Orthodontic or Orthodontic or physiologic physiologic

Effect on dentofacial Effect on dentofacial musculature developmentmusculature development

MalocclusionMalocclusion

Nonnutritive- Thumb Nonnutritive- Thumb suckingsucking

Thumb or Digit suckingThumb or Digit sucking

► Definition -Definition -

Placement of thumb or one or more fingers in various Placement of thumb or one or more fingers in various depths into the mouth or oral cavitydepths into the mouth or oral cavity

►SynonymsSynonyms Thumb sucking/ Digit sucking/ Finger suckingThumb sucking/ Digit sucking/ Finger sucking


► Prevalence Prevalence (DCNA:1978;608)(DCNA:1978;608)

16- 45 %16- 45 % Age and PrevalenceAge and Prevalence

►Damage (malocclusion) Damage (malocclusion) GraberGraber

Original morphologyOriginal morphology Suckle – swallow patternSuckle – swallow pattern Maturational cycle of deglutitionMaturational cycle of deglutition Intensity and duration of habitIntensity and duration of habit

Influence of different variables on incidence and Prevalence of Thumb Sucking Habit

Thumb sucking: ClassificationThumb sucking: Classification

► Normal thumb suckingNormal thumb sucking► Abnormal thumb suckingAbnormal thumb sucking

PsychologicalPsychological

HabitualHabitual

Thumb Sucking: ClassificationThumb Sucking: Classification

► Subtelny(1973)Subtelny(1973)

Type AType A Type BType B Type CType C Type DType D

50%50% 13-20%13-20% 18%18% 6%6%

Digit placementDigit placement Digit placementDigit placement Digit placementDigit placement Digit placementDigit placement

Max/ Mand Ant Max/ Mand Ant ContactContact




Nonnutritive habits Nonnutritive habits Johnson(1993)Johnson(1993)

Thumb or Digit sucking Thumb or Digit sucking Incidence Incidence ForesterForester

► Sucking reflexSucking reflex Starts at 29 week I.U.Starts at 29 week I.U. Disappear by 3 - 4 yr Disappear by 3 - 4 yr First coordinated muscular First coordinated muscular

activityactivity Psychological and nutritive needPsychological and nutritive need

► Rooting(Placing) reflexRooting(Placing) reflex Well defined sensory area Well defined sensory area

around moutharound mouth Head turning and opening of Head turning and opening of

mouth by stimulationmouth by stimulation


► Initiation of digit sucking (Infantile)Initiation of digit sucking (Infantile) Development of muscular Development of muscular

coordinationcoordination Ability to reach the face with handAbility to reach the face with hand Exploration of environment by Exploration of environment by

placing objects in mouthplacing objects in mouth Introjection and ProjectionIntrojection and Projection

► Retained digit suckingRetained digit sucking Lack of oral gratificationLack of oral gratification Separation from motherSeparation from mother Social structure or cultureSocial structure or culture

► Eskimo studyEskimo study► Burlington studyBurlington study


►Theories (Etiology) Theories (Etiology) JDC:1993;385JDC:1993;385

Classical Freudian theory (1905)Classical Freudian theory (1905)►Biologic sucking drive (I.U.)Biologic sucking drive (I.U.)►Oral phase- Center of attraction (Oro -erotic zone)Oral phase- Center of attraction (Oro -erotic zone)►Deprivation of activity - InsecurityDeprivation of activity - Insecurity►Assoc. With pleasurable stimuli, but not discarded at Assoc. With pleasurable stimuli, but not discarded at

usual time due to psychological disturbanceusual time due to psychological disturbance►Substitution with less desirable habitSubstitution with less desirable habit

Counterview – Gesell and IlaCounterview – Gesell and Ila


►Benjamin theory (1962)Benjamin theory (1962)

Experimentation on monkeyExperimentation on monkey

Two theoriesTwo theories

Thumb sucking - Expression associated with sucking Thumb sucking - Expression associated with sucking along with primary reinforcing aspect of feedingalong with primary reinforcing aspect of feeding

Thumb sucking from Rooting and placing reflexThumb sucking from Rooting and placing reflex


► Learning theory: Davidson (1967)Learning theory: Davidson (1967)

Adaptive response to pleasurable feelingAdaptive response to pleasurable feeling No underlying causeNo underlying cause No emotional or psychological problemNo emotional or psychological problem No substituteNo substitute

Counterview – increased anxietyCounterview – increased anxiety


► Oral drive theory (Sears and Wise;1982)Oral drive theory (Sears and Wise;1982)

Duration of feeding Duration of feeding Oral driveOral drive

Prolonged nursing Prolonged nursing HabitHabit No correlation with frustration of weaningNo correlation with frustration of weaning Sucking - Erontogenic zone of mouth (Freud)Sucking - Erontogenic zone of mouth (Freud)


► Johnson and Larson (1993)Johnson and Larson (1993) JDC:1993:385JDC:1993:385

Combination of twoCombination of two Inherent biologic drive for suckingInherent biologic drive for sucking Rooting and Placing reflex- Expression of driveRooting and Placing reflex- Expression of drive Environmental factors for sucking driveEnvironmental factors for sucking drive


►Maintenance of habitMaintenance of habit

Normal upto 3 yrs (Psychoanalytic)Normal upto 3 yrs (Psychoanalytic)

Persistence - psychological disturbancePersistence - psychological disturbance

► Anxiety managementAnxiety management

Adaptation during development (Learning theory)Adaptation during development (Learning theory)


Causative factorsCausative factors

1.1. Parent’s occupation occupation1.1. Socioeconomic statusSocioeconomic status

2.2. Working motherWorking mother1.1. Absence - insecurityAbsence - insecurity

3.3. No. of siblingsNo. of siblings1.1. Compensation for Compensation for

neglectneglect

4.4. Order of birth of childOrder of birth of child1.1. ImitationImitation

5.5. Social adjustment and Social adjustment and stressstress1.1. Peer pressure, scolding Peer pressure, scolding

parentsparents

6.6. Feeding practicesFeeding practices1.1. Negative relation Negative relation

between breast feeding between breast feeding and habitand habit

Thumb or Digit sucking: Causative Thumb or Digit sucking: Causative factorsfactors

► Causative factorsCausative factors7 Age7 Age

1.1. In neonatesIn neonates1.1. Well developed suckling mechanismWell developed suckling mechanism

2.2. Primitive Demand for hungerPrimitive Demand for hunger

2.2. During eruption of primary molar- TeethingDuring eruption of primary molar- Teething

3.3. Still later (Active after 4 year)Still later (Active after 4 year)1.1. Emotional tensionsEmotional tensions

2.2. Stress outlet mechanismStress outlet mechanism


► DiagnosisDiagnosis Emotional statusEmotional status

►Meaningful or emptyMeaningful or empty

Case historyCase history► Active performanceActive performance► Information from motherInformation from mother

Feeding practiceFeeding practice Parental careParental care Presence of other habitsPresence of other habits


► Extra oral examinationExtra oral examination DigitDigit

► Reddened, clean, chapped, Reddened, clean, chapped, short fingernail (dishpan thumb) short fingernail (dishpan thumb) ► Chronic suckers - fibrous, Chronic suckers - fibrous, roughened callus on superior roughened callus on superior aspect of fingeraspect of finger► Deformation of fingerDeformation of finger

LipLip► Position at rest, During Position at rest, During swallowingswallowing► Hypotonic upper lipHypotonic upper lip► Hyperactive lower lipsHyperactive lower lips

Thumb or Digit sucking; Thumb or Digit sucking; Extra oral examinationExtra oral examination

►Facial form analysisFacial form analysis Maxillary protrusion Maxillary protrusion

Mandibular retrusionMandibular retrusion

High mandibular plane angleHigh mandibular plane angle

ProfileProfile

Mentalis muscle contractionMentalis muscle contraction


► Intraoral examinationIntraoral examination Tongue Tongue

► Position at rest , during Position at rest , during swallowingswallowing

GingivaGingiva► Evidence of mouth breathingEvidence of mouth breathing

ItchingItching Staining on max. labial Staining on max. labial

surfacesurface

Thumb or Digit sucking; Thumb or Digit sucking; Intra oral examinationIntra oral examination

► Dento alveolar structureDento alveolar structure Flared , proclined maxillary Flared , proclined maxillary

anteriors with diastemaanteriors with diastema

Retroclined mandibular Retroclined mandibular anteriorsanteriors

Deformed right or left sided Deformed right or left sided max. archmax. arch


► Dentofacial changes Dentofacial changes associated with prolonged associated with prolonged sucking habit sucking habit

JDC:1993:385JDC:1993:385 Effects on maxillaEffects on maxilla

► Maxillary arch lengthMaxillary arch length► Clinical crown length of incisorsClinical crown length of incisors► Counterclockwise rotation of Counterclockwise rotation of occlusal planeocclusal plane► Atypical root formationAtypical root formation► Trauma to incisorsTrauma to incisors► Palatal arch widthPalatal arch width

Thumb or Digit sucking: Cl/ FThumb or Digit sucking: Cl/ F

► Increased SNAIncreased SNA

SN

A

Thumb or Digit sucking: Cl /FThumb or Digit sucking: Cl /F

► Effect on mandibleEffect on mandible Proclination of incisors Proclination of incisors

(Finger sucking)(Finger sucking) Increased Intermolar Increased Intermolar

distancedistance

Increased Distal Increased Distal position of B pointposition of B point


► Effect on interarch Effect on interarch relationshiprelationship Anterior open biteAnterior open bite

Increased over jetIncreased over jet


Increased unilateral Increased unilateral and bilateral Cl II and bilateral Cl II malocclusionmalocclusion

Decreased U/ L incisal angleDecreased U/ L incisal angle


Decreased overbiteDecreased overbite

Increased posterior Increased posterior cross bitecross bite


► Effect on lip placement and Effect on lip placement and functionfunction Increased lip incompetenceIncreased lip incompetence Increased lower lip function Increased lower lip function

under max. incisorsunder max. incisors

► Effect on tongue placement Effect on tongue placement and functionand function Increase tongue thrustIncrease tongue thrust Increased lip to tongue Increased lip to tongue

resting positionresting position Increased lower tongue Increased lower tongue

positionposition


► Other effectsOther effects Risk to psychological Risk to psychological

healthhealth Increased risk of Increased risk of

poisoningpoisoning Increased risk of Increased risk of

speech defects, speech defects, especially lispingespecially lisping

Habitual mouth Habitual mouth breathingbreathing

Tongue thrustingTongue thrusting Middle ear infectionMiddle ear infection Enlarged tonsilsEnlarged tonsils


► Clinical aspect (Moyer: 1955)Clinical aspect (Moyer: 1955) Phase IPhase I

► Normal or sub clinically significant sucking (Pre school infant)Normal or sub clinically significant sucking (Pre school infant)► Birth to 3 yrBirth to 3 yr► Prophylactic approachProphylactic approach

Phase IIPhase II► Clinically significant sucking (Grade school)Clinically significant sucking (Grade school)► 3 – 7 yrs3 – 7 yrs

Related to anxietyRelated to anxiety Time for dental correctionTime for dental correction

► Firm and definitive programme of correctionFirm and definitive programme of correction


►Clinical aspectClinical aspect Phase IIIPhase III

►Intractable sucking (Teenage child)Intractable sucking (Teenage child)

►Beyond 4Beyond 4 th th yr yr

►PsychotherapyPsychotherapy

►Treatment for malocclusionTreatment for malocclusion

Psychological effects of Psychological effects of malocclusion resulting from habitsmalocclusion resulting from habits

► Exceedingly introvertExceedingly introvert► OversensitiveOversensitive

► Immature social behaviorImmature social behavior► Speech defectSpeech defect

► Singled out in crowd Singled out in crowd


►Treatment Treatment ForesterForester

Treatment rationaleTreatment rationale► Emotional significance of habit Emotional significance of habit

Psychological status of childPsychological status of child

► Age of patientAge of patient

► Status of occlusionStatus of occlusion

ManagementManagement

► Preventive treatmentPreventive treatment LittlefieldLittlefield

► Best when related to familial tendencyBest when related to familial tendency

Hughes (1949)Hughes (1949)► Fulfillment of hungerFulfillment of hunger► Natural feeding practices- Brest feedingNatural feeding practices- Brest feeding

McBrideMcBride► For inhibition of sucking- Discontinuation at inceptionFor inhibition of sucking- Discontinuation at inception► Removal of finger from mouth as much as possibleRemoval of finger from mouth as much as possible► At sleep- Pinning the sleeves to stop the motion towards mouth At sleep- Pinning the sleeves to stop the motion towards mouth

Use of Dummy/ PacifierUse of Dummy/ Pacifier

Management :Preventive treatmentManagement :Preventive treatment

► PsychologicalPsychological Avoidance of scolding, frighteningAvoidance of scolding, frightening Reassurance and positive reinforcementReassurance and positive reinforcement Friendly remindersFriendly reminders Brauer (1965)Brauer (1965)

► Constructive parental educationConstructive parental education► Favorable contact with environmentFavorable contact with environment► Providence of age specific suitable play materialProvidence of age specific suitable play material► Avoidance of unnecessary regulationAvoidance of unnecessary regulation

Lewis (1930)Lewis (1930)► Immediate post weaning period- Most difficult time to handleImmediate post weaning period- Most difficult time to handle► Encouragement of chewing and bitingEncouragement of chewing and biting

Management :Preventive treatmentManagement :Preventive treatment

►- Hypothesis or Dunlop’s hypothesis- Hypothesis or Dunlop’s hypothesis

Forced purposeful repetitionForced purposeful repetition

Abandonment of habit following unpleasant Abandonment of habit following unpleasant reactionreaction

Management: chemical treatmentManagement: chemical treatment

►Least effectiveLeast effective

►Bitter or sour chemical over the fingerBitter or sour chemical over the finger E.g. : Foul smelling Quinine, Asofoctine, Pepper E.g. : Foul smelling Quinine, Asofoctine, Pepper

, Caster oil, Femite etc, Caster oil, Femite etc

Management: Mechanical or Management: Mechanical or reminder therapyreminder therapy

►Extra- oral approachExtra- oral approach Mechanical restraints to hand/ DigitMechanical restraints to hand/ Digit

► Adhesive bandageAdhesive bandage► Covering with clothsCovering with cloths► Heckman and Bready - Tubes attached around Heckman and Bready - Tubes attached around

elbow, Gloves around wristelbow, Gloves around wrist

Nail polishNail polish Thumb guardThumb guard


► Intra- oral ApproachIntra- oral Approach Weiss and Eiser (1993)Weiss and Eiser (1993)

► Upto 5 yr- No interventionUpto 5 yr- No intervention

Graber(1972)Graber(1972)► Appliance placement between 3- 4 yr.Appliance placement between 3- 4 yr.

Considerations before use of applianceConsiderations before use of appliance► Child’s understandingChild’s understanding► Parent cooperationParent cooperation► Friendly rapportFriendly rapport► Goal orientationGoal orientation► maturitymaturity


► Removable and fixed Removable and fixed applianceappliance Palatal cribPalatal crib

► Breaks the suction and force on Breaks the suction and force on anterior segmentanterior segment

► ReminderReminder► Makes the habit nonpleasurableMakes the habit nonpleasurable

Hay rakesHay rakes► Not much helpfulNot much helpful► Symptoms of irritability, night Symptoms of irritability, night

tremor, day wettingtremor, day wetting


► Oral screenOral screen Functional applianceFunctional appliance

► Redirection of muscular and Redirection of muscular and soft tissue pressure soft tissue pressure

Prevention of placement of Prevention of placement of thumb in mouththumb in mouth

► Quad helixQuad helix Expansion of constricted Expansion of constricted

maxillary archmaxillary arch Helixes as a reminderHelixes as a reminder Posterior cross bite Posterior cross bite

correctioncorrection


► Triple loop corrector: Triple loop corrector: Barber (1960)Barber (1960) Modified palatal archModified palatal arch Similar to transpalatal Similar to transpalatal

arch with 3 loopsarch with 3 loops► Blue grass appliance: Blue grass appliance:

Bruce Haskell (1991)Bruce Haskell (1991) Between 7 – 13 yrBetween 7 – 13 yr Teflon roller applianceTeflon roller appliance 3 – 6 month placement 3 – 6 month placement

timetime

Thumb or Digit sucking: TreatmentThumb or Digit sucking: Treatment

According to ForesterAccording to Forester

►Younger than 3 yrYounger than 3 yr No active interventionNo active intervention Class I openbite self correctingClass I openbite self correcting Reverse AttentionReverse Attention

Thumb or Digit sucking: Treatment: Thumb or Digit sucking: Treatment: ForesterForester

► 3 – 7 yr3 – 7 yr Depending on type of habitDepending on type of habit

►Active pullerActive puller►Idle suckerIdle sucker

Good molar intercuspation with little ant. Pull- Good molar intercuspation with little ant. Pull- behavior modificationbehavior modification

Permanent incisor eruption with openbite – Permanent incisor eruption with openbite – active interventionactive intervention

Thumb or Digit sucking: Treatment; Thumb or Digit sucking: Treatment; ForesterForester

►Under 6 yrUnder 6 yr Class IClass I

►Behavior conditioningBehavior conditioning Openbite picturesOpenbite pictures Reward systemReward system Intentional contralateral thumb suckingIntentional contralateral thumb sucking Advise for ignorance by parentsAdvise for ignorance by parents Band- aid, fingernail polishBand- aid, fingernail polish No need of applianceNo need of appliance

Thumb or Digit sucking: Treatment; Thumb or Digit sucking: Treatment; Appliance; under 6 yr; ForesterAppliance; under 6 yr; Forester

► Class II (Non self Class II (Non self correcting)correcting) With anterior puller – With anterior puller –

ApplianceAppliance

► With spaced primary With spaced primary dentition=Activator dentition=Activator

► High mandibular angle with High mandibular angle with

ant. openbite= High pull ant. openbite= High pull headgearheadgear

► Severe crowding in primary Severe crowding in primary dentition= Extractiondentition= Extraction

Thumb or Digit sucking: Treatment; Thumb or Digit sucking: Treatment; Appliance ;under 6 yr; ForesterAppliance ;under 6 yr; Forester

► Class IIIClass III Encouragement to suckEncouragement to suck

Cl III activator with Cl III activator with orthopedic chinorthopedic chin

Thumb or Digit sucking: Treatment; Thumb or Digit sucking: Treatment; Appliance ;older than 7 yr; ForesterAppliance ;older than 7 yr; Forester

► Class IClass I With ant openbite and With ant openbite and

spacingspacing► Hawley’s applianceHawley’s appliance► Palatal cribPalatal crib► Blue grass applianceBlue grass appliance


► Non crowding BuccalNon crowding Buccal

cross bitecross bite fixed or removable palatal fixed or removable palatal

expansion modified reminder expansion modified reminder (Quad helix)(Quad helix)

► Crowed dentitionCrowed dentition Serial extraction with digit Serial extraction with digit

sucking control apptsucking control appt


► Class IIClass II Non crowded Cl II Div-I with Non crowded Cl II Div-I with

low mandibular plane anglelow mandibular plane angle

► Activator and headgear that Activator and headgear that are habit breaking applianceare habit breaking appliance

► Class IIIClass III Simultaneous Cl III Simultaneous Cl III

correction with habit control correction with habit control Appt.Appt.

Thumb or Digit sucking: Treatment: Thumb or Digit sucking: Treatment: Older than 7 yrs; ForesterOlder than 7 yrs; Forester

OpenbiteOpenbite

► RemovableRemovable Frankle IVFrankle IV

► Vestibular Vestibular configurationconfiguration

► protrusive bowsprotrusive bows

Thumb or Digit sucking: Treatment: Thumb or Digit sucking: Treatment: Older than 7 yrs; ForesterOlder than 7 yrs; Forester

► Open biteOpen bite Removable applianceRemovable appliance

► Modified activator- Modified activator- intrusion of molarsintrusion of molars

Fixed orthodontic Fixed orthodontic treatmenttreatment

Thumb or Digit sucking: Treatment: Thumb or Digit sucking: Treatment: PinkhamPinkham

► Reminder therapyReminder therapy Adhesive bandageAdhesive bandage Unpleasant stimuliUnpleasant stimuli

► Reward systemReward system Contract between child, Dentist, ParentContract between child, Dentist, Parent

Thumb or Digit sucking: TreatmentThumb or Digit sucking: TreatmentPinkhamPinkham

► Appliance therapy Appliance therapy AttitudeAttitude

► Self correcting Self correcting malocclusionmalocclusion

Appliance as reminderAppliance as reminder

Fixed reminderFixed reminder► Quad helixQuad helix► Palatal cribPalatal crib

Removable reminderRemovable reminder

Pacifier habit Pacifier habit

Pacifier habit Pacifier habit Ped.Dent:2002;552Ped.Dent:2002;552

► Natural sucking instinct or urgeNatural sucking instinct or urge► Restricted breast feeding and bottle feedingRestricted breast feeding and bottle feeding► Surplus sucking urge- frustration or satisfactionSurplus sucking urge- frustration or satisfaction► Pacifier – SatisfactionPacifier – Satisfaction

Pacifier

Pacifier habitPacifier habit

► Clinical featuresClinical features AJO;2002;347AJO;2002;347

Oral Myofunctional Oral Myofunctional alterationalteration

► Decrease muscular Decrease muscular tonicity of tongue and liptonicity of tongue and lip

► Lip entrapmentLip entrapment► Lip incompetenceLip incompetence► Narrow hard palateNarrow hard palate

Pacifier habit: Cl / FPacifier habit: Cl / F

► Dental changesDental changes Posterior cross bite Posterior cross bite

► Increased mandibular Increased mandibular arch widtharch width

► Decreased max. arch Decreased max. arch widthwidth

Anterior open biteAnterior open bite Cl II primary canine Cl II primary canine

relationshiprelationship Increased overjetIncreased overjet

Pacifier habit Pacifier habit PedPed..Dent:2003;449Dent:2003;449

► Controversies Controversies associated with associated with pacifierspacifiers Protects againstProtects against

SIDSSIDS

Pacifier habit Pacifier habit PedPed..Dent:2003;449Dent:2003;449

Increases risk of otitis Increases risk of otitis media and other media and other infectionsinfections

Increases risk of otitis media and Increases risk of otitis media and other infectionsother infections

Pacifier habitPacifier habit

►RecommendationsRecommendations Should not use before breast feeding Should not use before breast feeding

establishedestablished More restraints for useMore restraints for use Cleaned Cleaned Avoidance of sharing among siblingsAvoidance of sharing among siblings Use should be curtailed before 2 yr, Use should be curtailed before 2 yr,

discontinued by 4 yrsdiscontinued by 4 yrs

Tongue Thrusting Tongue Thrusting

Tongue thrustingTongue thrusting

► Embryonic life Embryonic life Proportion of tongue to Proportion of tongue to

developing mandibledeveloping mandible

Spacing between Gum Spacing between Gum padspads

Anatomy and Physiology of Sucking and swallowingAnatomy and Physiology of Sucking and swallowing

JDC:1996:321JDC:1996:321

► SuckingSucking ––

First Coordinated muscular First Coordinated muscular activityactivity

► Infantile swallow (Moyer)Infantile swallow (Moyer) Anterior tongue thrust between Anterior tongue thrust between

gum pads gum pads Mandibular thrust, and Mandibular thrust, and

stabilization by contraction of stabilization by contraction of facial musclesfacial muscles

Lip constriction Lip constriction

Anatomy and Physiology of Sucking Anatomy and Physiology of Sucking and swallowing and swallowing

JDC:1996:321JDC:1996:321► Infantile swallowInfantile swallow

Muscles involvedMuscles involved1.1. MasseterMasseter

2.2. Orbicularis orisOrbicularis oris

3.3. MentalisMentalis

4.4. BuccinatorBuccinator

5.5. Superior pharyngeal Superior pharyngeal constrictorconstrictor

6.6. Pterygomandibular Pterygomandibular rapheraphe

Anatomy and Physiology of Sucking Anatomy and Physiology of Sucking and swallowing and swallowing

►Transitional swallowTransitional swallow

Inter mixing of normal infantile swallow and mature Inter mixing of normal infantile swallow and mature swallowswallow

Diminishing Buccinator activityDiminishing Buccinator activity Contraction of mandibular elevator during swallow Contraction of mandibular elevator during swallow

to stabilize teeth in occlusionto stabilize teeth in occlusion

Anatomy and Physiology of Sucking and Anatomy and Physiology of Sucking and swallowingswallowing

► Mature swallowMature swallow Position of tonguePosition of tongue (Stewart) (Stewart)

► Tongue tipTongue tip► Mid portionMid portion► Posterior aspect- 45Posterior aspect- 45°angulation °angulation

against pharyngeal wall against pharyngeal wall

Lip sealLip seal

Function of masseter, Mentalis, Function of masseter, Mentalis, and facial musclesand facial muscles

Phases Of Swallowing Or DeglutitionPhases Of Swallowing Or Deglutition

► Straub (1957) Straub (1957) Preparatory phase/Oral phasePreparatory phase/Oral phase

► Voluntary and conscious phaseVoluntary and conscious phase► Bolus formation and transfer to Bolus formation and transfer to

isthmus of faucesisthmus of fauces Adjustments ofAdjustments of

► Soft palate, Soft palate, ► Tongue, Tongue, ► Larynx, Hyoid boneLarynx, Hyoid bone

► Role of muscles of mastication- ant Role of muscles of mastication- ant and lateral sealand lateral seal

Phases of swallowing or deglutitionPhases of swallowing or deglutition

► Second phaseSecond phase Involuntary but conscious phaseInvoluntary but conscious phase Bolus passes through pharyngeal Bolus passes through pharyngeal

tubetube Nasopharynx sealed off by closure Nasopharynx sealed off by closure

of soft palate against the posterior of soft palate against the posterior pharyngeal wall pharyngeal wall

Hyoid bone and tongue move Hyoid bone and tongue move forward to continue peristalsisforward to continue peristalsis

Phases of swallowing or deglutitionPhases of swallowing or deglutition

►Esophageal phaseEsophageal phase InvoluntaryInvoluntary Reflex mechanismReflex mechanism Bolus passes through cricopharyngeal sphincter Bolus passes through cricopharyngeal sphincter

continue through esophaguscontinue through esophagus Return to original position of hyoid bone, palate and Return to original position of hyoid bone, palate and

tonguetongue

Anatomy and Physiology of Anatomy and Physiology of swallowingswallowing

► Process of normal Process of normal swallowingswallowingA.A. Resting postureResting postureB.B. Initiation of deglutition- Tongue Initiation of deglutition- Tongue

tip movementtip movementC.C. First tongue- tip contactFirst tongue- tip contactD.D. Progression of deglutition: Progression of deglutition:

Tongue contacting palatal Tongue contacting palatal structurestructure

E.E. Completion of swallowing: Completion of swallowing: Total contact with posterior Total contact with posterior pharyngeal wallpharyngeal wall

Anatomy and Physiology of Sucking and Anatomy and Physiology of Sucking and swallowingswallowing

► Abnormal swallow Abnormal swallow (Stewart)(Stewart) Position of tonguePosition of tongue

► TipTip► Mid portionMid portion► Posterior aspectPosterior aspect

Faulty Masseter activityFaulty Masseter activity Mentalis activityMentalis activity

Tongue ThrustingTongue Thrusting

►DefinitionDefinition Brauer Brauer - -

Tongue thrust is said to be present if the tongue is Tongue thrust is said to be present if the tongue is observed thrusting between and the teeth did not close in observed thrusting between and the teeth did not close in centric occlusion during deglutitioncentric occlusion during deglutition

TulleyTulley - -

Forward movement of tongue tip between the teeth to Forward movement of tongue tip between the teeth to meet the lower lip during deglutition and in sounds of meet the lower lip during deglutition and in sounds of speech , so that the tongue becomes interdentalspeech , so that the tongue becomes interdental

Tongue Thrusting: DefinitionTongue Thrusting: Definition

► Barber- Barber- It is an oral habit pattern related to persistence of an It is an oral habit pattern related to persistence of an

infantile swallow pattern during childhood and adolescent infantile swallow pattern during childhood and adolescent and thereby produces an openbite and protrusion of and thereby produces an openbite and protrusion of anterior tooth segmentanterior tooth segment

► Shneider- Shneider- it is a forward placement of the tongue between it is a forward placement of the tongue between

the anterior teeth and against the lower lip during the anterior teeth and against the lower lip during swallowing swallowing


►Prevalence Prevalence (DCNA:1978;603)(DCNA:1978;603)

Newborn – 97%Newborn – 97% 5-6 yrs – 80%5-6 yrs – 80% By 12 yrs – 3%By 12 yrs – 3% Physiology (Stewart)Physiology (Stewart)

►At birth- soft structure confined in skeletal At birth- soft structure confined in skeletal environment- environment-

Large tongue – Forward movement Large tongue – Forward movement


►Significance (Forrester)Significance (Forrester) Function governs formFunction governs form

►Adverse muscle forces – Abnormal formAdverse muscle forces – Abnormal form

►Occurrence (Profit)Occurrence (Profit)Younger children with normal occlusionYounger children with normal occlusion

►Transitional stage in physiologic maturation Transitional stage in physiologic maturation

At any age with displaced incisors-At any age with displaced incisors- ► Adaptation for sealAdaptation for seal


►Equilibrium theory (Profit)Equilibrium theory (Profit) Facial musculature vs. Tongue pressureFacial musculature vs. Tongue pressure

► Light tongue forces – Against teeth (Normal state)Light tongue forces – Against teeth (Normal state)► Duration of swallowing 1 SecondDuration of swallowing 1 Second► 24 hr swallow – 1000/day24 hr swallow – 1000/day► Tongue thrust- Forward resting posture of tongue – Tongue thrust- Forward resting posture of tongue –

Obvious light forces Obvious light forces


►ClassificationClassification PhysiologicPhysiologic

►InfancyInfancy

HabitualHabitual►Present after correction of malocclusionPresent after correction of malocclusion

Functional (Profit)Functional (Profit)►Overjet, Open biteOverjet, Open bite

AnatomicalAnatomical►MacroglossiaMacroglossia

Tongue Thrusting: ClassificationTongue Thrusting: ClassificationJames S. Braner and Holt

Tongue Thrusting: EtiologyTongue Thrusting: Etiology

► Retained infantile Retained infantile swallowswallow Retention of infantile Retention of infantile

suckling mechanismsuckling mechanism Incisor eruption – No Incisor eruption – No

drop of tonguedrop of tongue Altered Tongue posture Altered Tongue posture

at restat rest


►URTIURTI Obstruction of nasal passageObstruction of nasal passage Mouth breathingMouth breathing Forward tongue posture –Forward tongue posture –

Physiologic need of adequate airwayPhysiologic need of adequate airway


► AdenoidsAdenoids LocationLocation Complementary status:Complementary status:

Growth of Adenoid and Growth of Adenoid and Upper face -Upper face -

Infection, Allergy – Infection, Allergy – Hypertrophy Hypertrophy - lost - lost equilibriumequilibrium – Mouth – Mouth breathing – Tongue breathing – Tongue postureposture


► Lymphoid tissue (Tonsils)Lymphoid tissue (Tonsils) LocationLocation Hypertrophy – Obstruction Hypertrophy – Obstruction

of oropharyngeal area of oropharyngeal area Tongue postureTongue posture


►Neurological disturbancesNeurological disturbances Hypo sensitive palateHypo sensitive palate Motor disability- brain injury Motor disability- brain injury Disrupted sensory control and coordination of Disrupted sensory control and coordination of

swallowingswallowing


►Functional adaptabilityFunctional adaptability Missing incisors Missing incisors

Protrusion Protrusion ANTERIOR SEALANTERIOR SEAL overjetoverjet openbite openbite


►Feeding practicesFeeding practices Bottle feedingBottle feeding Breast feedingBreast feeding Consistency of infant’s food- Consistency of infant’s food-

Development of adult swallow patternDevelopment of adult swallow pattern


► Induced due to other habitsInduced due to other habits Digit suckingDigit sucking Pacifier suckingPacifier sucking Sleeping habitsSleeping habits


►HereditaryHereditary Inherited hyperactive orbicularis oris Inherited hyperactive orbicularis oris Anatomical configurationAnatomical configuration Neuromuscular activityNeuromuscular activity


► Tongue sizeTongue size MacroglossiaMacroglossia

► Anesthetic throatAnesthetic throat Congenital physiologic Congenital physiologic

discrepancies- Abnormal discrepancies- Abnormal handling of bolus and Tongue handling of bolus and Tongue thrustthrust

► Soft diet- Soft diet-

Disuse atrophy of musculatureDisuse atrophy of musculature

► Trauma Trauma Persistent traumatic condition Persistent traumatic condition

leading to abnormal deglutitionleading to abnormal deglutition

Classification of etiological factors: Classification of etiological factors: Fletcher (1975) Fletcher (1975)

1.1. Genetic factorGenetic factor1.1. Inherited variation in Inherited variation in

orofacial formorofacial form► Constricted archConstricted arch

2.2. Learned behaviorLearned behavior1.1. Acquired habitsAcquired habits2.2. Prolonged Tonsillar Prolonged Tonsillar

hypertrophy, URTIhypertrophy, URTI

3.3. MaturationalMaturational1.1. Delayed progression from Delayed progression from

infantile to matureinfantile to mature

4.4. Mechanical restrictionMechanical restriction 1.1. Macroglossia, constricted Macroglossia, constricted

dental arches, Enlarged dental arches, Enlarged adenoidsadenoids

5.5. Neurological disturbancesNeurological disturbances1.1. Hyposensitive palate, motor Hyposensitive palate, motor

disabilitydisability

6.6. Psychological factorsPsychological factors1.1. Effect from forced Effect from forced

discontinuation of other discontinuation of other habithabit

Tongue Thrusting: DiagnosisTongue Thrusting: Diagnosis

HistoryHistory►Sibling swallow, ParentSibling swallow, Parent►Previous respiratory infections , sucking habits , Previous respiratory infections , sucking habits ,

neuromuscular problemneuromuscular problem► ExaminationExamination

TongueTongue► SizeSize

Macroglossia - Lateral scallopingMacroglossia - Lateral scalloping

► ShapeShape AsymmetryAsymmetry


► Movements of tongueMovements of tongue Lateral Lateral ProtrusiveProtrusive RetrusiveRetrusive Restricted movement Restricted movement

(Ankyloglossia)(Ankyloglossia)

► Functional examinationFunctional examination Observation of tongueObservation of tongue

► Mandibular rest positionMandibular rest position► Various swallowVarious swallow

Unconscious swallowUnconscious swallow Command swallow of salivaCommand swallow of saliva Command swallow of waterCommand swallow of water Unconscious swallow during Unconscious swallow during

masticationmastication


► Gag reflexGag reflex Palatal- RarePalatal- Rare PharyngealPharyngeal

► Abnormal tongue postureAbnormal tongue posture Retracted tongueRetracted tongue

►Withdrawn tongue tip Withdrawn tongue tip from anteriorfrom anterior

►Posterior openbite with Posterior openbite with lateral spreadlateral spread

►10 % 0f all children, 10 % 0f all children, Edentulous patientsEdentulous patients


► Protracted tongueProtracted tongue Result in openbiteResult in openbite TypesTypes

► EndogenousEndogenous Retention of infantile swallowRetention of infantile swallow Continuous presence of tongue Continuous presence of tongue

between teethbetween teeth Excessive vertical anterior face Excessive vertical anterior face

heightheight

► AcquiredAcquired Transitory adaptation due to Transitory adaptation due to

enlarged tonsils or pharyngitisenlarged tonsils or pharyngitis


TestsTests► Masseter activity testMasseter activity test

► Temporalis activity testTemporalis activity test

► Lip apart swallow testLip apart swallow test


► Simple tongue thrustSimple tongue thrust Molar occlusionMolar occlusion Ant. Open biteAnt. Open bite Contraction of lips, Contraction of lips,

Mentalis, mandibular Mentalis, mandibular elevatorselevators


► Complex tongue thrustComplex tongue thrust Generalized open biteGeneralized open bite Absence of contraction of Absence of contraction of

lips, muscleslips, muscles

► Lateral tongue thrustLateral tongue thrust Posterior open bitePosterior open bite Tongue thrusting laterallyTongue thrusting laterally

Tongue ThrustingTongue Thrusting CLINICAL FEATURESCLINICAL FEATURES►Extra oralExtra oral

Lip postureLip posture► Lip separationLip separation

Mandibular movementMandibular movement► Upward and backward with tongue moving forwardUpward and backward with tongue moving forward

SpeechSpeech► Speech disorder Speech disorder ► Sibilant distortion, lisping, problem in articulation of Sibilant distortion, lisping, problem in articulation of s, n, m, t, d, l, th, z, v s, n, m, t, d, l, th, z, v

Facial formFacial form► Increased Anterior face height Increased Anterior face height

Tongue Thrusting: Cl/FTongue Thrusting: Cl/F

► IntraoralIntraoral Tongue postureTongue posture

► Downward and forwardDownward and forward► At rest- lowerAt rest- lower


► MalocclusionMalocclusion In relation to maxillaIn relation to maxilla

► Increased overjetIncreased overjet

► Generalized spacingGeneralized spacing

► Maxillary constrictionMaxillary constriction


In relation to mandibleIn relation to mandible► Retroclination or Retroclination or

proclination of proclination of mandibular teethmandibular teeth

In relation to In relation to Intermaxillary Intermaxillary relationshiprelationship

► Ant. Or post. OpenbiteAnt. Or post. Openbite► Posterior crossbitePosterior crossbite


►Treatment considerationsTreatment considerations AgeAge

► Self correcting by 8-9 yrSelf correcting by 8-9 yr Improved muscular balance during swallowing Improved muscular balance during swallowing

► Orthodontic correction in early mixed dentition(9-11)Orthodontic correction in early mixed dentition(9-11)

Presence or absence of associated manifestationPresence or absence of associated manifestation► Not indicated without malocclusion or speech problemNot indicated without malocclusion or speech problem

Tongue Thrusting: Tongue Thrusting: Treatment considerationsTreatment considerations

MalocclusionMalocclusion►Correction of malocclusionCorrection of malocclusion

Speech defectSpeech defect►Speech therapy during elementary school yr.Speech therapy during elementary school yr.

Associated with other habitsAssociated with other habits►Other habit correctionOther habit correction

Tongue Thrusting :TreatmentTongue Thrusting :Treatment

►Myofunctional therapyMyofunctional therapy►Speech therapySpeech therapy►Mechano therapyMechano therapy►Correction of malocclusionCorrection of malocclusion►Surgical treatmentSurgical treatment


►Myofunctional therapy Myofunctional therapy Am.J.Ortho:1972:499Am.J.Ortho:1972:499

►Phase IPhase I Tongue position during swallowingTongue position during swallowing

► Exercises for tongue StabilizationExercises for tongue Stabilization

Maintenance of tongue in bilateral contact with Maintenance of tongue in bilateral contact with max. teeth during swallowingmax. teeth during swallowing

►Sucking, holding, swallowing- Saliva, liquid, solidsSucking, holding, swallowing- Saliva, liquid, solids►Liquid trapping exercise- Liquid trapping exercise-

Between Tongue and roofBetween Tongue and roof Lip apart posture and approximation of teethLip apart posture and approximation of teeth Tilting of headTilting of head

Tongue Thrusting :Treatment Tongue Thrusting :Treatment Myofunctional therapyMyofunctional therapy

Phase IPhase I Other activities for superoposterior tongue postureOther activities for superoposterior tongue posture

► Retraction of tongue when held Retraction of tongue when held ► Clicking of tongueClicking of tongue► Back-of-the-mouth soundsBack-of-the-mouth sounds► Sucking and holding tongue to roof of mouthSucking and holding tongue to roof of mouth

► Phase IIPhase II Continuation of Phase IContinuation of Phase I Bite-and-swallow exercises- Bite-and-swallow exercises-

► Development Masseter , Temporalis strengthDevelopment Masseter , Temporalis strength Biting and relaxing exercisesBiting and relaxing exercises

► Pliable rubber, soft plastic tubing between teethPliable rubber, soft plastic tubing between teeth Teeth together swallowing test Teeth together swallowing test


►Phase IIIPhase III Continuation of Phase I and II Continuation of Phase I and II Chewing and swallowing with lips apartChewing and swallowing with lips apart Keeping lower lip immobileKeeping lower lip immobile Upper lip exercise-- Elevation, depression, Upper lip exercise-- Elevation, depression,

protrusion, retraction against resistanceprotrusion, retraction against resistance


► Phase IVPhase IV Carry- over Carry- over Reminder applianceReminder appliance

Treatment: Myofunctional therapy: Treatment: Myofunctional therapy: GarlinerGarliner

► Guidance of correct posture of tongue during Guidance of correct posture of tongue during swallowing by various exercisesswallowing by various exercises Placement of tongue tip in rugae area for 5 minPlacement of tongue tip in rugae area for 5 min Orthodontic elastics and sugarless fruit drops Orthodontic elastics and sugarless fruit drops 2 S ,4 S exercises2 S ,4 S exercises

Identification of SpotIdentification of Spot► SalivatingSalivating

Squeezing in spotSqueezing in spot► SwallowingSwallowing

Other exerciseOther exercise► WhistlingWhistling► Reciting from 60 To 90Reciting from 60 To 90► YawningYawning

Treatment :Myofunctional therapy: Treatment :Myofunctional therapy: GarlinerGarliner

► Lip exerciseLip exercise Tug of war and button pull exerciseTug of war and button pull exercise

► Lip massageLip massage Lower lip over upper massageLower lip over upper massage

► Subconscious therapySubconscious therapy Time- Special time for remindingTime- Special time for reminding Subliminal therapySubliminal therapy

► Placing reminder sign in sight during mealPlacing reminder sign in sight during meal

AutosuggestionAutosuggestion► 6 times swallow before sleeping 6 times swallow before sleeping


►Speech therapySpeech therapy Training of correct position of tongueTraining of correct position of tongue Articulation of speechArticulation of speech Repetition of words with ‘S’ soundRepetition of words with ‘S’ sound

Not indicated before 8 yrsNot indicated before 8 yrs

Tongue Thrusting :Treatment Tongue Thrusting :Treatment

►Mechano therapyMechano therapy PurposePurpose

►Reeducation of tongue positionReeducation of tongue position►Maintaining tongue in the confines of dentitionMaintaining tongue in the confines of dentition►Maintaining the interocclusal distanceMaintaining the interocclusal distance

Prevention of over eruption and narrowing of maxillary Prevention of over eruption and narrowing of maxillary buccal segmentbuccal segment


► Preorthodontic trainer for Preorthodontic trainer for myofunctional trainingmyofunctional training Aids in correct positioning Aids in correct positioning

of tongue with the help of of tongue with the help of tongue tagstongue tags

Tongue guardTongue guard


► Appliance therapyAppliance therapy Removable applianceRemovable appliance

Hawley’s applianceHawley’s appliance► ModificationsModifications

1.1. Active labial bowActive labial bow

2.2. Addition of palatal cribAddition of palatal crib

Oral screen and Oral screen and vestibular screenvestibular screen


► Treatment with Treatment with myofunctional appliancemyofunctional appliance Promote lip closurePromote lip closure Enlarge oral cavityEnlarge oral cavity Move incisorsMove incisors Improve relation among Improve relation among

jaws, tongue, Dentition and jaws, tongue, Dentition and soft tissuesoft tissue

E. gE. g► ActivatorActivator► BionatorBionator


Fixed applianceFixed appliance► Tongue cribTongue crib


► Correction of malocclusionCorrection of malocclusion OpenbiteOpenbite

► RemovableRemovable

Frankle IVFrankle IV► Vestibular configurationVestibular configuration

Tongue Thrusting: Treatment : Tongue Thrusting: Treatment : Malocclusion : OpenbiteMalocclusion : Openbite

► Removable applianceRemovable appliance Modified activator- Modified activator-

intrusion of molarsintrusion of molars

► Fixed orthodontic Fixed orthodontic treatmenttreatment


► Surgical treatmentSurgical treatment Removal of tonsilsRemoval of tonsils

Correction of skeletal Correction of skeletal malformationmalformation

Mouth breathingMouth breathing


► Nasal breathing Vs Mouth breathingNasal breathing Vs Mouth breathing Purification of airPurification of air Development of muscles of chest ,back, neckDevelopment of muscles of chest ,back, neck

► Postural defectPostural defect

► Functional adaptation for mouth breathingFunctional adaptation for mouth breathing MandibleMandible Tongue postureTongue posture HeadHead

► ManifestationsManifestations Facial height, Openbite, CrossbiteFacial height, Openbite, Crossbite


►DefinitionDefinition Sassouni (1971)Sassouni (1971) - Habitual respiration through - Habitual respiration through

the mouth instead of the nosethe mouth instead of the nose

Merle (1980) -Merle (1980) - Suggested the term oro - nasal Suggested the term oro - nasal breathing instead of mouth breathingbreathing instead of mouth breathing

Mouth breathing: IncidenceMouth breathing: Incidence

►Common among 5 – 15 yrCommon among 5 – 15 yr

►85% nasal breathers suffer from some 85% nasal breathers suffer from some degree of obstructiondegree of obstruction


►ClassificationClassification Finn (1987)Finn (1987)

►AnatomicalAnatomical Short upper lipShort upper lip

►ObstructiveObstructive Obstruction in nasal passageObstruction in nasal passage

►HabitualHabitual


►EtiologyEtiology Developmental and morphologic anomalies Developmental and morphologic anomalies

interfering nasal breathinginterfering nasal breathing►Asymmetry of face Asymmetry of face ►Hereditary Hereditary

Size of nasal passageSize of nasal passage Position of nasal septumPosition of nasal septum

►Abnormal development of nasal cavity, Nasal Abnormal development of nasal cavity, Nasal turbinatesturbinates

►Abnormally short upper lipAbnormally short upper lip►Under developed or abnormal facial musculatureUnder developed or abnormal facial musculature

Mouth breathing: EtiologyMouth breathing: Etiology

►Partial obstruction due toPartial obstruction due to Deviated nasal septum – Birth injuryDeviated nasal septum – Birth injury Localized benign tumorLocalized benign tumor Narrow maxillaNarrow maxilla Leontiasis osseaLeontiasis ossea

►Traumatic injuries to nasal cavityTraumatic injuries to nasal cavity

Mouth breathing; EtiologyMouth breathing; Etiology► Infection and inflammationInfection and inflammation

Ch. Inflammation of nasal Ch. Inflammation of nasal mucosamucosa

Ch. Allergic stomatitisCh. Allergic stomatitis Ch. Atrophic rhinitisCh. Atrophic rhinitis Enlarged adenoids, tonsilsEnlarged adenoids, tonsils Nasal polypsNasal polyps

► Genetic factorGenetic factor Ectomorphic childEctomorphic child


►Clinical featuresClinical features General featuresGeneral features

►Pulmonary developmentPulmonary development Pigeon chestPigeon chest

►Lubrication of esophagusLubrication of esophagus No mucous glandNo mucous gland Dry - EsophagitisDry - Esophagitis

►Blood gas constituentBlood gas constituent 20 % more CO20 % more CO22

Mouth breathingMouth breathing► Adenoid fanciesAdenoid fancies

Debatable consequenceDebatable consequence Long narrow faceLong narrow face Narrow nose and nasal Narrow nose and nasal

passagepassage Nose tipped superiorlyNose tipped superiorly Flat nasal bridgeFlat nasal bridge Flaccid lipsFlaccid lips Short upper lipShort upper lip Collapsed buccal segment of Collapsed buccal segment of

maxilla maxilla High palatal vaultHigh palatal vault Dolicofacial patternDolicofacial pattern Expressionless faceExpressionless face

Mouth breathing: Cl / FMouth breathing: Cl / F

► Dental effectDental effect Protrusion with spacing Protrusion with spacing

of upper incisorsof upper incisors

Decreased overbiteDecreased overbite

OpenbiteOpenbite

Lower tongue positionLower tongue position

Posterior cross bitePosterior cross bite


Increased overjetIncreased overjet

Constricted maxillary Constricted maxillary archarch


Narrow palate and Narrow palate and cranial vaultcranial vault

Narrow long faceNarrow long face


► LipsLips Incompetent upper lipIncompetent upper lip Everted, heavy lower lipsEverted, heavy lower lips Voluminous curled lower lipsVoluminous curled lower lips Gummy smileGummy smile

► External naresExternal nares Slit like external nares with Slit like external nares with

narrow nosenarrow nose Atrophied nasal mucosaAtrophied nasal mucosa


► GingivaGingiva Ch. Keratinized marginal Ch. Keratinized marginal

gingivitisgingivitis Classic rolled margin and Classic rolled margin and

enlarged interdental papilla enlarged interdental papilla Heavy plaque depositionHeavy plaque deposition Salivary flow and bacterial Salivary flow and bacterial

overgrowthovergrowth

Periodontal disease Periodontal disease ► Pocket formation and Pocket formation and

interproximal bone lossinterproximal bone loss


►Other effectsOther effects Narrow maxillary sinus and nasal cavityNarrow maxillary sinus and nasal cavity Turbinates- Swollen and engorgedTurbinates- Swollen and engorged Atrophic nasal mucosaAtrophic nasal mucosa Speech- Nasal toneSpeech- Nasal tone Infection of Lymphoid tissueInfection of Lymphoid tissue Otitis mediaOtitis media Dull sense of smellDull sense of smell Loss of tasteLoss of taste


► Sleep apnea syndromeSleep apnea syndrome Increased enlargement of lingual tonsilsIncreased enlargement of lingual tonsils MechanismMechanism

Mouth breather lying on backMouth breather lying on back

Tongue fall posteriorlyTongue fall posteriorly

Touch post. Pharyngeal wallTouch post. Pharyngeal wall

Occlusion of oropharynxOcclusion of oropharynx

Sleep apnea syndromeSleep apnea syndrome

►Signs / SymptomsSigns / Symptoms SnoringSnoring Loud pharyngeal snoring with interrupted Loud pharyngeal snoring with interrupted

silencessilences Abnormal behaviorAbnormal behavior

►Movement of limbsMovement of limbs Altered state of consciousness during attempted Altered state of consciousness during attempted

arousalarousal►Unresponsive to painUnresponsive to pain

Morning headacheMorning headache


►DiagnosisDiagnosis HistoryHistory

►Lip apart postureLip apart posture►Tonsillitis, allergic rhinitis, otitis mediaTonsillitis, allergic rhinitis, otitis media

Mouth breathing: DiagnosisMouth breathing: Diagnosis

► ExaminationExamination Observation of breathingObservation of breathing Lip postureLip posture Nasal orificesNasal orifices

► Clinical testClinical test Mirror testMirror test Butterfly testButterfly test Water holding testWater holding test Inductive plethysmographyInductive plethysmography

► Airflow through nose and Airflow through nose and mouthmouth

cephalometricscephalometrics


►Treatment considerationTreatment consideration AgeAge E.N.T. examinationE.N.T. examination Correction timeCorrection time

►Mix dentitionMix dentition

Mouth breathing: TreatmentMouth breathing: Treatment

►Symptomatic reliefSymptomatic relief Gingival coatingGingival coating Periodontal considerationPeriodontal consideration

►ProphylaxisProphylaxis

Mouth breathing: Treatment Mouth breathing: Treatment

►Elimination of causeElimination of cause Removal of nasal or pharyngeal obstructionRemoval of nasal or pharyngeal obstruction

► Interception of habitInterception of habit ExercisesExercises

►Physical – deep inhalation exercisePhysical – deep inhalation exercise►Lip Lip

Upper lip extension exerciseUpper lip extension exercise Upper, lower lip combined exerciseUpper, lower lip combined exercise

►Playing wind pipePlaying wind pipe►Disc holding exerciseDisc holding exercise


► Maxillothorax Maxillothorax myotherapymyotherapy Macaray activatorMacaray activator Oral screenOral screen


► Correction of Correction of malocclusionmalocclusion Cl ICl I

► Oral screenOral screen

Cl II Div-1Cl II Div-1► Noncrowded dentition (5-Noncrowded dentition (5-

9 yr) – Monobloc 9 yr) – Monobloc


Cl IIICl III► Interceptive chin capInterceptive chin cap

Lip habitsLip habits

► Vary with imagination Vary with imagination of childof child Basic typeBasic type

► Wetting of lip with tongueWetting of lip with tongue► Pulling the lip into mouth Pulling the lip into mouth

between teethbetween teeth Lip sucking-Lip sucking-

► Entire lower lip with Entire lower lip with vermilion border pulled in vermilion border pulled in mouthmouth

Mentalis habit-Mentalis habit- ► Vermilion border everted Vermilion border everted

Lip habitsLip habits

► EtiologyEtiology Association with digit sucking Association with digit sucking (Graber)(Graber)

Increased overjetIncreased overjet

Lip sealLip seal

Incompetent upper lipIncompetent upper lip

Position of lower lip behind upper incisorsPosition of lower lip behind upper incisors negative pressure for swallowingnegative pressure for swallowing

Lip habits: EtiologyLip habits: Etiology

► MalocclusionMalocclusion Cl II Div-1Cl II Div-1

►Large overjet and overbiteLarge overjet and overbite

Emotional stressEmotional stress►Increases the intensity and durationIncreases the intensity and duration

Lip habits: Cl / FLip habits: Cl / F

►LipLip Reddened , irritated, chapped area below vermilion Reddened , irritated, chapped area below vermilion

borderborder

Vermilion border Vermilion border ► Relocation outside the mouth due to constant wettingRelocation outside the mouth due to constant wetting► Redundant and hypertrophiedRedundant and hypertrophied

Ch. Herpetic infectionCh. Herpetic infection

Cracking Cracking

Lip habits; Cl/ FLip habits; Cl/ F

► Accentuated mentolabial Accentuated mentolabial sulcussulcus

► MalocclusionMalocclusion Winder--force equilibriumWinder--force equilibrium

Lip tongue Lip tongue

1.1. Protrusion of upper incisorsProtrusion of upper incisors1.1. Flaring with interdental Flaring with interdental

spacing spacing

2.2. Retrusion of lower incisorsRetrusion of lower incisors1.1. Collapse with crowdingCollapse with crowding

3.3. openbiteopenbite

Lip habits: TreatmentLip habits: Treatment

► Not self- correctingNot self- correcting► Deleterious with ageDeleterious with age► Treating primary habitTreating primary habit

Correction of digit sucking Correction of digit sucking followed by habit reminder followed by habit reminder (Hawley’s appliance)(Hawley’s appliance)

► Chemical reminderChemical reminder► Correction of malocclusionCorrection of malocclusion

ClI Div-1-ClI Div-1-► Fixed or removable Fixed or removable

applianceappliance ActivatorActivator

Lip habits: TreatmentLip habits: Treatment

► Appliance therapyAppliance therapy Oral shieldOral shield

► Cl I malocclusionCl I malocclusion► Lip exercise for Lip exercise for

improvement of lip tonusimprovement of lip tonus

Lip bumperLip bumper► Prohibits excessive force Prohibits excessive force

on mandibular incisorson mandibular incisors► Reposition of lower lip Reposition of lower lip

away from upper incisorsaway from upper incisors

BruxismBruxism

►DefinitionsDefinitionsRamfjord Ramfjord

►Habitual grinding of teeth when the individual is not Habitual grinding of teeth when the individual is not chewing or swallowingchewing or swallowing

Rubina Rubina ►Nonfunctional contact of teeth which may include Nonfunctional contact of teeth which may include

clenching, gnashing and tapping of teethclenching, gnashing and tapping of teeth

Vanderas Vanderas ► Nonfunctional movement of mandible with or without Nonfunctional movement of mandible with or without

an audible sound occurring during the day or night an audible sound occurring during the day or night

BruxismBruxism

►ClassificationClassification OkinuoraOkinuora

► Bruxism associated with stressful eventBruxism associated with stressful event► No such association (Hereditary)No such association (Hereditary)

►TypesTypes Day time bruxism / DiurnalDay time bruxism / Diurnal

► Conscious or subconscious grindingConscious or subconscious grinding► Along with parafunctional habitsAlong with parafunctional habits► SilentSilent

Night time / NocturnalNight time / Nocturnal► Subconscious grinding in rhythmic pattern of masseter Subconscious grinding in rhythmic pattern of masseter

BruxismBruxism

►OccurrenceOccurrence InfantsInfants

►Eruption of first primary toothEruption of first primary tooth More prevalent in mixed dentitionMore prevalent in mixed dentition Throughout lifeThroughout life

SleepSleep►Transition from deeper stages to lighterTransition from deeper stages to lighter►REM stageREM stage

7- 88% in children7- 88% in children

BruxismBruxism

► EtiologyEtiology Local theoryLocal theory

► Reaction to an occlusal interferenceReaction to an occlusal interference High restoration, irritating dental conditionHigh restoration, irritating dental condition

► Disturbed afferent impulses from PDDisturbed afferent impulses from PD

CNS CNS ► Cortical lesions, cerebral palsy, mental retardationCortical lesions, cerebral palsy, mental retardation

Bruxism: EtiologyBruxism: Etiology

►SystemicSystemic Intestinal parasites – GI disturbanceIntestinal parasites – GI disturbance

Ch. AbdCh. Abd Nutritional deficiencies - Mg deficiency Nutritional deficiencies - Mg deficiency distressdistress Enzymatic distress Enzymatic distress Allergies - FoodAllergies - Food Endocrine disorderEndocrine disorder

Bruxism: EtiologyBruxism: Etiology

► Psychological theoryPsychological theory Associated with feeling of anger, aggregationAssociated with feeling of anger, aggregation StressStress Emotional status – inability to express the emotionEmotional status – inability to express the emotion

► Other causesOther causes GeneticsGenetics Occupational factorsOccupational factors

► Enthusiastic student , compulsive overachieverEnthusiastic student , compulsive overachiever► Competition sportsCompetition sports

BruxismBruxism

► Related FactorsRelated Factors Morphological malocclusion (Wigdoro)Morphological malocclusion (Wigdoro)

► Cl I, II , III , over jet, over biteCl I, II , III , over jet, over bite

Bruxism: Related factorsBruxism: Related factors

► Functional malocclusionFunctional malocclusion Intercuspation, lateral deviation, retruded positionIntercuspation, lateral deviation, retruded position

BruxismBruxism

►Causal hypothesisCausal hypothesis Ped. Dent:1995;7-12Ped. Dent:1995;7-12

Malocclusion can initiate and maintain forceful Malocclusion can initiate and maintain forceful grinding or clenchinggrinding or clenching

MechanismMechanism Occlusal discrepanciesOcclusal discrepancies

PD mechanoreceptorsPD mechanoreceptors Sensory input Sensory input Activation of jaw closing musclesActivation of jaw closing muscles

Clenching or grindingClenching or grinding

BruxismBruxism

►Counterview (Christensen)Counterview (Christensen) Removal of occlusal interferenceRemoval of occlusal interference

►Continued bruxismContinued bruxism Nocturnal bruxismNocturnal bruxism

►Protective mechanoreceptor function cancelledProtective mechanoreceptor function cancelled►Continuation of clenchingContinuation of clenching

Correlation between malocclusion Correlation between malocclusion and bruxism is not consistentand bruxism is not consistent

BruxismBruxism

► Indicators Indicators Presence of dental Presence of dental

wear / Attritionwear / Attrition

BruxofacetBruxofacet

Grinding or clenchingGrinding or clenching

BruxismBruxism

► Clinical manifestationClinical manifestation Occlusal traumaOcclusal trauma

► mobilitymobility Morning timeMorning time

Tooth structureTooth structure► Nonfunctional occlusal Nonfunctional occlusal

wearwear► SensitivitySensitivity► Atypical shiny wear facet Atypical shiny wear facet

with sharp edgeswith sharp edges► Pulpal exposurePulpal exposure► # crown, restoration# crown, restoration

Bruxism: Cl / FBruxism: Cl / F

► Muscular tendernessMuscular tenderness Lateral pterygoid, masseter on palpationLateral pterygoid, masseter on palpation Fatigue on wakingFatigue on waking Hypertrophy of masseterHypertrophy of masseter

► TMJ disturbancesTMJ disturbances Crepitation , clicking , Crepitation , clicking , Restriction of mand. MovementRestriction of mand. Movement Deviation of chinDeviation of chin Pain – Dull , unilateral Pain – Dull , unilateral

Bruxism: Cl / FBruxism: Cl / F

►HeadacheHeadache Muscular contraction typeMuscular contraction type

►Other signs and symptomsOther signs and symptoms Sounds- Grinding and tappingSounds- Grinding and tapping Soft tissue traumaSoft tissue trauma Small ulceration or ridging on buccal mucosa Small ulceration or ridging on buccal mucosa

opposite the molar teethopposite the molar teeth

Bruxism: TreatmentBruxism: Treatment

► Occlusal adjustmentOcclusal adjustment Disappearance of habitual Disappearance of habitual

grindinggrinding► CoronoplastyCoronoplasty► High point correctionHigh point correction

► Occlusal splints (Night Occlusal splints (Night guard)guard) Vulcanite splint to cover Vulcanite splint to cover

occlusal surfaces occlusal surfaces ► Reduction of increased Reduction of increased

muscle tonemuscle tone TMJ applianceTMJ appliance

► Prefabricated intra oral Prefabricated intra oral appliance for TMJ disorderappliance for TMJ disorder


► Restorative Restorative Severe abrasionSevere abrasion

► Pulp therapyPulp therapy► Stainless steel crownStainless steel crown

► PsychotherapyPsychotherapy Counseling Counseling

► Tension reliefTension relief► Habit awareness -Habit awareness -

Increase voluntary Increase voluntary controlcontrol


► Relaxing trainingRelaxing training Tensing and relaxing exerciseTensing and relaxing exercise

► Voluntary relaxationVoluntary relaxation HypnosisHypnosis Behavior ConditioningBehavior Conditioning Physical therapyPhysical therapy

► Musculoskeletal pain and stiffnessMusculoskeletal pain and stiffness► DrugsDrugs

Placebo Placebo Vapocoolant – Ethyl chloride for pain -TMJVapocoolant – Ethyl chloride for pain -TMJ Local anesthetics - TMJLocal anesthetics - TMJ Tranquilizers, sedatives, muscle relaxantsTranquilizers, sedatives, muscle relaxants Diazepam – Anxiety and alteration of sleep arousalDiazepam – Anxiety and alteration of sleep arousal Tricyclic antidepressants- Reduce REMTricyclic antidepressants- Reduce REM


► BiofeedbackBiofeedback Positive feedback for Learning of tension reductionPositive feedback for Learning of tension reduction

► Electrical methodElectrical method Electro galvanic stimulationElectro galvanic stimulation

► Muscle relaxation Muscle relaxation

► AcupunctureAcupuncture

► Orthodontic correctionOrthodontic correction Cl II,III, Ant. Openbite, Crossbite Cl II,III, Ant. Openbite, Crossbite

Cheek bitingCheek biting

► Definition- Definition- keeping or biting the keeping or biting the

cheek muscles in cheek muscles in between the upper and between the upper and lower posterior teethlower posterior teeth

► Clinical featuresClinical features Ulcers at the level of Ulcers at the level of

occlusal lineocclusal line Open biteOpen bite Tooth malposition in Tooth malposition in

buccal segmentbuccal segment

Cheek bitingCheek biting

►TreatmentTreatment Vestibular screenVestibular screen RemindersReminders

Nail bitingNail biting

► Sign of stressful conditionSign of stressful condition► Age of occurrenceAge of occurrence

Before 3 yr- absentBefore 3 yr- absent 4-6 yr- sharp rise in 4-6 yr- sharp rise in

incidenceincidence 7-10 yr- constant level7-10 yr- constant level Adolescence- sharp riseAdolescence- sharp rise

► EtiologyEtiology Emotional problemEmotional problem Stressful conditionStressful condition

Nail biting: Cl/ FNail biting: Cl/ F

► NailNail Inflammation of nail Inflammation of nail

beds and nailbeds and nail Irregular nail marginsIrregular nail margins

► Dental effectDental effect CrowdingCrowding RotationRotation Attrition of incisal edges Attrition of incisal edges

of incisorsof incisors

Nail bitingNail biting

►ManagementManagement Avoidance of punitive methodsAvoidance of punitive methods Mild case- No treatmentMild case- No treatment Care for emotional conditionCare for emotional condition Encouragement of stress relieving activitiesEncouragement of stress relieving activities Nail polish, light cotton mittens as reminderNail polish, light cotton mittens as reminder Bitter or sour chemical over the fingerBitter or sour chemical over the finger

► E.g. : Foul smelling Quinine, Asofoctine, Pepper , Femite etcE.g. : Foul smelling Quinine, Asofoctine, Pepper , Femite etc

ConclusionConclusion

ReferencesReferences

► GraberGraber► ProfittProfitt► MoyerMoyer► TandonTandon► ForesterForester► StewartStewart► PinkhamPinkham

oral habits

Documents

definitionsmoyer habits

frequent repetitionhabit

result of frequent repetition

physiology of sucking

muscular forces

skeletal growth pattern

pattern of muscle contraction

constant practice