Tongue thrustingDefinition: Placement of tongue tip forward

between incisors during swallowing.

Tongue thrusting may be primary cause of malocclusion or it may be secondary adaptive factor as in case in skeletal open bite.

It is generally associated with long term thumb sucking children.

Classifications of tongue thrust:

Endogenous

Habitual

Adaptive (enlarged tonsils,pharyngitis)

Anteriorlateral,complex

Primary Secondary

Effects of tongue thrusting• Increase in overjet and overbite.• Tongue no longer lie on the lingual cusps of the buccal

segment and posterior teeth erupt; thus eliminating interocclusal clearence.

• May lead to bruxism.• Narrowing of maxillary arch as the tongue drops lower in the

mouth. Clinically this may be seen as unilateral cross bite.• In horizontal growth pattern, tongue dysfunction leads to

bimaxillary protusion.• In vertical growth pattern, tongue dysfunction leads to lingual

inclination of lower incisors.• Diastemas may be present.• Deep bite in lateral tongue thrust.

Careful differentiation must be done among simple, complex tongue thrust and retained infantile swallowing pattern and faulty tongue posture.

• Prognosis is good for simple tongue thrust.

• Not very good for complex tongue thrust.

• Poor for retained infantile swallowing pattern.

Protracted tongue posture can be:• Endogenous- no certain

treatment• Acquired- can be corrected

Normal tongue

Tongue thrust

Management • Simple tongue thrust: it is the tongue thrust with teeth

together swallow.

If there is excessive labioversion of maxillary incisors,treatment of tongue thrust should be done after retraction of incisors.

Patient should be taught swallowing exercises with sugar less mint and should be instructed to practice 40 times a day and maintain the record.

On second appointment, patient should be able to swallow correctly at will. Sugar less drops may be used to reinforce the unconscious swallow.

If the problem continues, soldered lingual arch wire having short and sharp spurs can be inserted.

To summarize; Conscious learning of new reflex.

Transferal of control of the new swallowPattern to the subconscious level.

Reinforcement of the new reflex.

• Complex tongue thrust: It is the tongue thrust with teeth apart swallow. Malocclusion present are: Poor occlusal fit. Generalized anterior open bite. Open bite may not be present if the tongue is seated evenly atop of all teeth.

Treatment: Treat occlusion first. When the treatment is in retentive phase- muscle

training is begun. Maxillary lingual arch appliance is necessary for

these patients. There may be chances of relapse and prognosis is

not very good

• Retained infantile swallow: It is defined as the undue persistence of the infantile swallow well past the normal time for its departure. These patients occlude only on one molar in each segment.

These patients do not have expressive faces.They have difficulty in breathing.Low gag thresholdIt is a problem of neuromuscular

development.Appliance used is tongue crib with 3-4 v-

shaped projections which extend downward up to the cinguli of lower incisors when the casts are occluded.

Prognosis is poor.`

Mouth breathingRespiratory needs are the primary determinant of the posture of jaws and

tongue. Therefore it is reasonable that an altered respiratory pattern, such as breathing through mouth rather than nose, could alter the equilibrium of pressure on jaws and teeth and affect both jaws growth and tooth position.

Finn classified mouth breathing into 3 different categories:• OBSTRUCTIVE• HABITUAL• ANATOMIC

• Obstructive mouth breathing:These are the children who have complete obstruction of

normal air flow of air through the nasal passages. Due to difficulty in breathing through nose child is forced to breath through mouth.

• Habitual mouth breathing:This is a child who continuously breath through mouth by

force of habit, even if abnormal obstruction is removed.

• Anatomic mouth breathing:They are the one whose short upper lip does not permit

complete closure without undue effect.

Factors considered for mouth breathing

• For an average individual, when ventilation exchange rate of 40-45l/min. is reached, there is a transition to partial oral breathing.

• Heavy mental concentration could lead to increase air flow and a transition to partial mouth breathing.

• If nose is partially obstructed, or there is a tortuous passage an individual shifts to mouth breathing.

• Swelling of nasal mucosa accompanying common cold converts one into mouth breathing.

• Chronic respiratory obstruction produced due to inflammation within the nasorespiratory system can lead to mouth breathing

• Pharyngeal tonsils and adenoids can cause mouth breathing.

Clinical features• Associated with impeded maxillary growth.• Narrow jaw with high palate, dental crowding as well as

retrognathism of maxilla.• Prognathism of mandible.• Tongue lies flat on th floor of mouth so it does not play its role

in development of maxilla.• Hyperactivity of facial muscles especially buccinator, impedes

the development of maxilla.• In class II malocclusion there is increase in overjet.• Bilateral cross bite.• Hyperplasia of gingiva.• Extra oral appearance of these patients is often conspicuous

and is termed ‘adenoid facies’.

• There is downward and backward rotation of mandible to maintain postural changes leading to open bite anteriorly.

• Two different tongue posture are possible: type I -in class III malocclusion tongue is flat and protruding. type II- in class II malocclusion tongue has a flat and

retracted position.

Examination of breathing mode: Cotton pledget test: A cotton butterfly is placed below the

nostrils and observed. The nasal breather will displace the cotton pledget on expiration where as the mouth breather will not.

Mirror test: mirror is held in front of both the nostrils, in nasal breather the mirror will cloud with condensed moisture during expiration.

Observation of nostrils: Alar muscles are inactive in mouth breathers i.e do not change their size on inhalation or expiration where as nasal breathers do.

Management • If mouth breathing is due to nasal

obstruction, then operation by an E.N.T surgeon is indicated i.e in case of allergic rhinopathy.

• If patient has habitual mouth breathing then pre-orthodontic therapy should be carried out by: breathing exercises, incorporation of oral or vestibular screen. In case in which vestibular screen is used holes can be slowly closed as the patient starts breathing through nose.

• Myofunctional exercises like to hold a piece of card board to improve lip seal.

Bruxism Definition : it is the habitual grinding of teeth, during sleep.

this term is applied to clenching of teeth and also to repeated tapping of teeth.

Incidence: 5- 20 %

Etiology (Nadler

and Meklas):• Local• Systemic• Psychological• occupational

;

Management • If the underlying cause of the bruxism is an

emotional one, the nervous factor must be corrected if the disease is to be cured.

• Removable rubber splints can be worn at night to immobilize the jaws.

• A vinyl plastic bite guard that covers the occlusal surfaces of all teeth plus 2mm of the buccal and lingual surfaces can be worn at night to prevent abrasion.

Lip sucking and lip biting Lip sucking is a compensatory

activity which results from an excessive overjet and relative difficulty of closing the lips during deglutation. In most cases it is the mandibular lip that is involved in sucking, although biting habits of maxillary lip is also seen.

The deformity reaches maximum when the discrepancy between the maxillary incisors and mandibular incisors becomes equal to the thickness of the lip. (B.J.Johnson).

Common features: • Labioversion of maxillary teeth and lingual

displacement of mandibular teeth.• Vermillion border is hypertrophic and redundant

during rest.• Flaccid lip due to lengthening.• Chronic herpes with areas of irritation and

cracking of lips.• If a patient has lip sucking habit during sleep

then telltale• Redness and irritation extending from mucosa

to skin of lower lip is seen.• If patient is class II div1 malocclusion then the

lip suking habit is only adaptive.

Management :If the patient is having class II div 1 malocclusion then the

treatment should be done orthodontically. The lip sucking habit generally ceases after the treatment.

If the habit continues then, the lip appliance i.e lip plumper is given.

The appliance can be modified by adding acrylic between base wire and auxillary wire.

Removal of appliance is done in parts i.e first the auxillary wire then the base wire is removed.

A period of 8-9 months is required to cease the habit completely.