Tongue thrust and mouth breathing habits.

Presented by – Pratiksha N. Ahire

HabitA habit can be defined as the tendency towards an act that has become a repeated performance, relatively fixed, consistent and easy to perform by an individual.

Classification of habits•Useful and harmful habits.

▫ Useful habits: These include habits that are essential for normal function such as proper positioning of the tongue, respiration and normal deglutition.

▫ Harmful habits: These include habits that have a deleterious effect on the teeth and their supporting structures such as thumb sucking, tongue thrusting etc..

•Empty and Meaningful habits▫ Empty habits: These are the habits that are not associated

with any deep rooted psychological problems.▫ Meaningful habits: These are the habits that have a

psychological bearing

•Pressure, non pressure and biting habits.▫Pressure habits: These including sucking

habits like thumb sucking, lip sucking, finger sucking and also tongue thrusting.

▫Non-pressure habits: Habits which do not apply direct force on the teeth or its supporting structure are termed as non pressure habits. Example- Mouth breathing.

▫Biting habits: These include habits such as nail biting, pencil biting and lip biting.

•Compulsive and non compulsive habits.▫Compulsive habits: These are deep rooted

habits that have acquired a fixation in the child to the extent that the child retreats to the habit whenever his security threatened by events that occur around him. The child tend to suffer increased anxiety when attempts are made to correct the habit.

▫Non-compulsive habits: These are habits that are easily learnt and dropped as the child matures.

Tongue thrust habit

Tongue thrust is defined as a condition in which the tongue makes contact with any teeth anterior to the molars during swallowing

Etiology of tongue thrust• Genetic factors: They are specific anatomic or

neuromuscular variations in the oro-facial region that can precipitate tongue thrust e.g. Hypertonic orbicularis oris activity.

• Learned behaviour (habit): ▫Improper bottle feeding.▫Prolonged thumb sucking.▫Prolonged tonsillar and upper respiratory tract

infections ▫Prolonged duration of tenderness of gum or

teeth can result in change is swallowing pattern to avoid pressure on the tender zone

• Maturational: Tongue thrust can present as part of a normal childhood behaviour that is gradually modified as the age advances. The infantile swallow changes to a mature swallow once the posterior deciduous teeth starts erupting. Sometimes the maturation is delayed and thus infantile swallow persists for a longer duration of time.

• Mechanical restriction: The presence of certain conditions such as macroglossia, constricted dental arches and enlarged adenoids predispose to tongue thrust habit

• Neurological disturbance: Neurological disturbances affecting the oro-facial region such as hyposensitive palate and moderal ate motor disability can cause tongue thrust habit.

• Psychogenic factors:Tongue thrust can sometimes occur as a result of forced discontinuation of other habits like thumb sucking. It often seen that children who are forced to leave thumb sucking habit often take up tongue thrusting.

Classification of tongue thrust•Simple Tongue thrust

▫The simple tongue thrust is characterized by a normal tooth contact during the swallowing act.

▫Presence of an anterior open bite.▫They exhibit good intercuspation of teeth.▫The tongue is thrust forward during

swallowing to help establish an anterior lip seal.

▫Abnormal mentalis muscle activity is seen.

•Complex Tongue Thrust▫This kind of tongue thrust is characterized

by a teeth apart swallow.▫The anterior open bite can be diffuse or

absent .▫Absence of temporal muscle constriction

during swallowing.▫Contraction of the circumoral muscles

during swallowing.▫The occlusion of teeth may be poor.

Clinical Features•Proclination of anterior teeth.•Anterior open bite.•Bimaxillary protrusion.•Posterior open bite in case of lateral

tongue thrust.•Posterior crossbite.

Management of tongue thrust•Habit Interception

▫The tongue thrust can be intercepted by use of habit breakers as for thumb sucking. Both fixed and removable cribs or rakes are valuable aids in breaking the habit.

▫The child is taught the correct method of swallowing.

▫Various muscle exercise of the tongue can help in training it to adapt to the new swallowing pattern.

Exercise for the tongue• One Elastic Swallow : This exercise is used for correction of

improper positioning of the tongue. A 5/16 inch intra oral elastic is placed on the tip of the tongue and the patient is asked to raise the tongue and hold the elastic against the rugae are and swallow.

• Tongue Hold exercise: A 5/16 inch elastic is positioned over the tongue in a designated spot for a prescribed period of time with the lops closed. The patient is then asked to swallow with elastic in place and lips apart.

• Two elastic swallow: Two 5/16 inch elastics are placed over the tongue, one in the midline and the other on the top and the patient is asked to swallow with the elastics in position.

• The hold pull exercise: The tip of the tongue and the midpoint are made to contact the palate and the mandible is gradually opened. This exercise helps in the stretching the lingual frenum.

Palatal crib

•Treatment of Malocclusion Once the habit is intercepted the

malocclusion associated with the tongue thrust is treated using removable or fixed orthodontic appliances.

MOUTH BREATHING HABITIt has been attributed as a possible

etiological factor for malocclusion.The mode of respiration influences the

posture of the jaw ,the tongue and to a lesser extent the head which could alter the oro-facial equilibrium leading to malocclusion.

Most normal people indulge in mouth breathing when they are under physical exertion such as during strenuous exercise or sports activity.

Classification of mouth breathing•It can be classified into three types:•a. Obstructive • b. Habitual• c. anatomicObstructive : complete or partial obstruction of nasal

passage can result in mouth breathing.Following are some of the causes of nasal obstruction:a. Deviated nasal septumb. Nasal polypsc. Chronic inflammation of nasal mucosad. Localised beingn tumourse. Congenital enlargement of nasal turbinatesf. Allergic reaction of thr nasal mucosag. Obstructive adenoids

•Habitual: habitual mouth breather is one who continues to breath through his mouth even though the nasal obstruction is removed. Thus mouth breathing becomes a deep rooted habit that is performed unconsciously.

•Anatomic : an anatomic mouth breather is one whose lip morphology does not permit complete closure of the mouth, such as a patient having short upper lip.

Pathophysiology: •During oral respiration,the changes in the

posture occur:a. Lowering of mandibleb. positioning the tongue downwards and

forwards.c. tipping back of the head. lowering of tongue and mandible upsets the

oro-facial equilibrium. There is unrestricted buccinator activity that influences the position of teeth and also the growth of jaws.

Clinical features:• The type of malocclusion often associated with mouth

breathing is called long face syndrome or a classic adenoid face.

• These patients exhibits the following features: a. long and narrow face b. narrow nose and nasal passage c. short and flaccid upper lip d. contracted upper arch with possibility of

posterior cross bite e. An expressionless or blank face f. increased overjet as a result of flaring of incisors g. anterior marginal gingivitis can occur due to drying of the

gingiva h. dryness of mouth leed to caries i. Anterior open bite can occur.

Diagnosis:History: a good history should be recorded

from the patient as well as parents.Clinical examination: number of simple

tests can be carried out to diagnose mouth breathing such as mirror test, water test etc.

Rhinomanometry: it is the study of nasal airflow characteristics using devices consisting of flow meters , and pressure gauges. These devices helps in estimation of airflow through the nasal passage and nasal resistance.

Management of mouth breathing•Removal of nasal and pharyngeal obstruction

by referring the patient to the E.N.T. surgeon.•Interception of habit by use of vestibular

screen. The screen should be fabricated with number of holes that are gradually closed in a spaced manner.

•Alternatively adhesive tapes can be used to establish lip seal.

•Rapid maxillary expansion in patients with narrow , constricted maxillary arches. It has been found to increase the nasal airflow and decrease the nasal air resistance.

Vestibular screen

References:•Textbook of pediatric dentistry- Nikhil

Marwah(third edition)•Orthodonics the art and science(sixth

edition)

References:•Textbook of pediatric dentistry- Nikhil

Marwah(third edition)•Orthodonics the art and science(sixth

edition)