TONGUE EXERCISES TO SUPPORT ORTHODONTIC

TREATMENT DURING THE GROWTH AND

DEVELOPMENT PERIOD: A SYSTEMATIC REVIEW
1
Arizal Fuad Alam, 2Eka Erwansyah, 3Zilal Islamy Paramma, 4Susilowati,
5
Harun Achmad.

1
Orthodontic Specialist Study Program, Faculty of Dentistry, Hasanuddin
University. Makassar, Indonesia.
2
Department of Orthodontic, Faculty of Dentistry, Hasanuddin University.
Makassar, Indonesia.
3
Department of Pediatric Dentistry, Faculty of Dentistry, Hasanuddin University.
Makassar, Indonesia.

Abstract
Introduction: Myofunctional Exercise is to provide an overview of the various exercises in
orofacial myofunctional therapy (OMT) as a treatment modality for tongue thrust habit. Tongue
thrust is the persistence ofan infantile swallow pattern during late childhood. During formative years,
most children successfully transition from an infantile to a mature swallowing pattern. Adverse
effects of these habits can be avoided by early detection and intervention in a growing child.
Objective: The purpose of this review is to understand how tongue exercises can support
malocclusion treatmentduring the growth and development period based on the existing literature.
Methods: This study uses a systematic review type of research. Data source searches were
performed using PubMed, EHASO, and available published literatures. Results: Based on this
systematic review, tongue exercises are expected to can be treated in different ways with early
diagnosis, removal of underlying causes, correcting tongue posture, and breaking of habit with the
use of orthodontic appliances. OMT has provided a dramatic and positive influence on patients
treated for tongue thrust.The joy of eating, speaking, and correct breathing can be regained along
with confidence, self-esteem, and improved quality of life. Conclusion: Tongue exercises can help
a child with tongue thrust habit, support orthodontic treatment particularly during the growth and
development period as well and achieve a perfect process of growth and development.

Keywords: Orthodontic treatment, tongue exercise, tongue thrusting.

Corresponding Author: Arizal Fuad Alam
Email: arizalfuadalam@gmail.com

INTRODUCTION

The functioning of stomatognathic system includes activities such as

breathing, chewing and swallowing.1,2 Due to changes during craniofacial growth

and development, orofacial function can be negatively influenced by the presence

of parafunctional habits, nasal obstruction, muscle tone of the tongue as well as

the lips, cheeks and masticatory muscles, which can lead to orofacial

dysfunction.3,4
 Characterized by changes in the normal pattern of stomatognathic functions

and muscle balance, orofacial dysfunction is found in some genetic and congenital

disorders and can also be the result of an injury, nerve disorder, problems with the

masticatory system or the practice of harmful oral habits.5,6

Tongue thrust is a term that describes a swallowing pattern in which an

individual pushes the tongue against or between the teeth.7,8

Tongue thrusting is normal in the neonate in which the tongue lies between

the gum pads and the mandible is stabilized by facial muscles during a swallow.
9,10
This gradually disappears with an eruption of primary dentition. Normal

mature swallow shows the positioning of the tongue high on the palate behind the

maxillary incisors and no lip and cheek activity during swallowing.11 A

transitional swallowing pattern is seen in mixed dentition, when some primary

teeth are lost and permanent are yet to erupt or are erupting. This type of swallow

is self-correcting.12 At rest or in action, the tongue plays an important part in

swallowing, chewing, breathing and speaking. When its posture is

dysfunctional, it perturbs

orofacial functions and tooth positioning.13

The mixed dentition phase is an important period of dentoskeletal changes, 14

during which children often practice harmful oral habits. 15 Thus, investigating

factors associated with malocclusion in the mixed dentition phase enables the

interception of inadequate oral habits and can help prevent functional and

psychological harm.16,17

Harmful oral habits can affect the neuromuscular orofacial balance and

contribute to the development of orofacial disorders,18,19 which compromise

functions such as breathing, chewing, and speech.20,21 The consequences of

orofacial disorders can affect orofacial growth and development and induce

malocclusion.17,22

In addition to surgery and medication, several other methods can be used to

alleviate or prevent swallowing dysfunction, including dietary modification and

muscle training.23,24 It comprises exercises for the tongue, salivary glands, and

muscles controlling facial expression and swallowing.25,26

According to the protocol described by Van Dyck et al. the supportive

myofunctional therapy was carried out during the orthodontic treatment. The

myofunctional therapy aimed at the coordination of tongue and lip muscles, the

removal of parafunctional habits, and the establishment of a physiological

swallowing pattern.27 Tongue exercises include strengthening and coordination of

tongue muscles (i.e., pushing the tongue tip upward against the anterior palatal

rugae, positioning the entire tongue against the hard and soft palate). Facial

exercises involve the recruitment of perioral muscles (i.e., increasing tone of the

orbicularis oris), buccinators (i.e., suction movements and application of intraoral

finger pressure against the buccinator muscles outward), and jaw muscles (i.e.,

gaining control of bilateral jaw movements).28

METHODS AND MATERIALS

Protocol and registration

The present review was based on a protocol developed, car ried out, and

reported following relevant methodological guidelines and registered

retrospectively in prospero. As the present study is a systematic review, ethical

approval was not necessary.

Search Strategy

This article was conducted according to the PRISMA (Preferred Reporting

Items for Systemic Review and Meta-Analysis) guidelines. Data were conducted

using the PICOS format. The data was collected by searching the literature on an

article search site, namely PubMed, EHASO, and available published literatures,

published from 2014 to 2022. The data search was carried out systematically

using the keywords tongue exercises, orthodontic treatment, tongue thrusting.

Research criteria

A. Inclusion Criteria

1. Articles Published between 2014 – 2022.

2. Articles in English

3. Articles that are published and available online

4. Articles which research about tongue exercises, orthodontic treatment, and

tongue thrusting

B. Exclusion Criteria

1. Articles that cannot be freely accessed

2. Articles which does not talk about tongue exercises, orthodontic treatment,

and tongue thrusting.

Data Extraction

The author using specific keywords and the article was selected by

screening the title and abstract, then analyzed based on the inclusion criteria that

have been
 determined to set the final list of articles. All selected articles were also screened

from the exclusion criteria. Data taken from the article include the author(s), year

of publication, clinical tongue exercises, orthodontic treatment, and tongue

thrusting.

Quality Evaluation

Selected articles that meet the requirements based on the title and abstract

according to the inclusion criteria. Then, screened the full articles from all the

collected studies and agreed on the most relevant articles to be included in this

study. Furthermore, an independent assessment of all aspects of the study,

including the quality of the study and the variables for the data sought.

Records identified through database searching: PubMed = 236,

Additional
EHASO literature
= 25 Google Scholar = 663
Identificati

Records Identified (n = 924)

Title and Abstract excluded (n = 770)

Screeni

Full Article obtained (n = 154)

Full text articles excluded (n = 148)

Full text articles evaluated (n = 6)

Eligibili

Not the result of research (n = 1)

Includ

Articles included for inclusion (n = 5)

Figure 1. PRISMA Flowchart

RESULT

The initial search database yielded 924 articles. After eliminating duplicated

articles, the titles and abstracts of each articles which resulted in the exclusion of

770 articles with some reasons such as were not relevant, duplicate, could not be

opened, and some other articles were literature review or systematic review and

meta analysis. The full-text articles in the remaining 154 articles were re-analyzed

and excluded 148 articles and produced 6 articles, of these 1 not the result of

research and produced 5 articles which were then entered into the analysis.

Table 1. Characteristics of the studies included in the systematic review.

No. Writer Year Title Conclusion

1. Homem MA., Raquel 2014 Effectiveness of Orofacial myofunctional therapy in

GVA., Saulo GMF., Maria orofacial myofunctional combination with orthodontic

LRJ., Leandro SM. therapy in orthodontic treatment to achieve better results in

patients: A systematic the correction of dentofacial

review disorders in individuals with

orofacial abnormalities.

2. Sardenberg F., Bianca LC., 2017 A population based The findings of the present study

Sara RBT., Fernanda MF., study on the impact of demonstrate an associ- ation

Nelson LBR., Fabian CF. orofacial dysfunction on between orofacial dysfunction and

oral health related impact on quality of life. This

quality of life among information could assist in the

Brazilian schoolchildren allocation of public resources and

the establishment of strategies aimed

prevention and education, as

orofacial dysfunction has a

multifactor aetiology and several

aspects associated with the

aggravation of this condition also

affect occlusal factors.

 3. Shah Sejal S., Meenakshi 2019 Orofacial Orofacial myofunctional therapy

YN., Vikas DB., Myofunctional Therapy definitely has a role in the

Bhagyashree RS. in Tongue Thrust Habit management of tongue thrust and

should be included as a part of the

comprehensive treatment plan for

the patient. It makes the patient

aware of the faulty rest position and

dynamic positions of the tongue and

helps to learn the physiological

myofunctional behavior.

4. Krekeler B., Jacqueline 2020 Effects of Tongue This is the first study of resistance

MW., Nadine PC. Exercise Frequency on and endurance exercise in the cranial

Tongue Muscle Biology muscle system to examine related

and Swallowing effects on muscle biology, and

Physiology in a Rat mitochondrial content and function.

Model We conclude that increasing

days/week of tongue exercise in the

rat leads to greater increases in

tongue force as measured by our

voluntary tongue press task.

\ Chen HH., Po-Yen L., 2022 Effects of oral exercise Oral exercise should be integrated

5. Ching-Kai L., Ping-Yi L., on tongue pressure in into comprehensive health

Lin-Yang C. Taiwanese older adults promotion programs to assist in the

in community day care improvement and maintenance of

centers. oral function among older adults.

Table 1 showed that all of the studies were in human, that was to patient.

The studies used were published in 2014 and 2022.

DISCUSSION

A habit is a repetitive action that is repeatedly performed and being done

automatically. 10 Our mouth is a primary location for expression of emotions. Also

it is a source of relief in passion and anxiety in both children and adults. It gives a
soothing feeling when the region is stimulated with tongue, finger or sometimes a

nail. 12

Tongue thrusting can be defined as a behavioral pattern in which the tongue

makes contact with any teeth anterior to the molars during swallowing. The most

important consideration for the correction of the tongue thrusting habit is to

redirect the tongue’s resting position.12

Management of tongue thrust includes: 29

 Habit-breaking appliances like tongue cribs act as reminders and restrict the

forward movement of the tongue.

 Correction of malocclusion.

 Myofunctional therapy to correct the position of the tongue at rest and

during swallow.

All these management strategies go hand in hand. A habit-breaking

appliance only attempts to block the heavy force of swallowing, which, even

when added up, only amounts to about 20 minutes a day.30 The light, constant

pressure of the tongue and lips have much more influence on oral equilibrium

than tongue thrust ever will. Only treating the intermittent heavy force created by

tongue thrusting is not treating the source of the problem and hence after removal

of the habit correction appliance and the reason of the tongue thrust is not

attended to, the forward tongue position and functions can return leading to

relapse.6

The oral exercise program included deep breathing, the neck, shoulder,

front- to-back and top-to-bottom upper limb region movements, tongue area

motion, lip opening and closing motions, cheek inflation and deflation, vocal

exercising,
salivary gland massage. The vocal exercise for the syllables “pa-ta-ka-la”, which

improves the functions of the tongue, lips, pharynx, and larynx, and also prevents

dysarthria and aspiration in older adults.31,32 During the 3month intervention

period, a weekly group activity of approximately 15 min was conducted for the

participants at lunch time.33

Orofacial myofunctional therapy includes exercises of the cervical and

facial muscles for the improvement of proprioception, tone, and mobility. 34

Orofacial myofunctional therapy is neuromuscular re-education of the muscle

function to improve the functions of swallow, tongue, oral breathing, and rest

posture of lips, tongue, and cheeks. 35

Orofacial myofunctional therapy ats as an adjunct to orthodontic treatment

and helps in harmonizing the orofacial function. 36 It includes exercises that help

with toning and resistance training of the oral musculature.37

Orofacial myofunctional therapy in tongue thrust habit acts as an adjunct to

speech therapy and orthodontic correction of malocclusion.38 It also helped

stabilize the treated malocclusion13 and improve the child’s oral awareness.39

Orofacial myofunctional exercises for tongue thrust:

• Tongue exercises : Tongue spot, tongue click, Swallowing thin liquid,

Swallowing thick liquid, 4S exercise, Touch-nose exercise, Touch chin exercise,

Tongue- sideways movement exercise, Tongue-rolling exercise, Orthodontic

elastics and swallow, Hold and pull exercise, Tongue-exercise using food

reinforcers, K sound and swallow, Hold of tongue blades and push the tongue,

Tongue exercise using a

spoon, Tongue retraction, Tongue-extension exercise, Tongue-pull exercise,

Tongue around the world, Tongue push-ups. 6,40,41

Orofacial myofunctional therapy is not indicated in tongue thrusters in absence of

speech/dental problems according to the authors Proffit and Mason. 38 There is no

common agreement in the published literature regarding the right age for starting

OMT in tongue thrust.42,43 Some pediatric dentists have successfully used

myotherapy in children <10 years of age.44,45 Whereas some prefer waiting till 10

years of age or more, as there could be spontaneous closure of the anterior open

bite.46,47 Before starting OMT for tongue thrust patients, it is important to make

sure that any anatomical variation like tongue-tie is corrected. 48,49 The need for

surgical reduction of excessive lymphoid tissue should also be evaluated before

initiating myotherapy.50,51

CONCLUSION

Tongue exercises can help a child with tongue thrust habit, support

orthodontic treatment particularly during the growth and development period as

well and achieve a perfect process of growth and development.

ACKNOWLEDGEMENT
None

CONFLICT OF INTEREST
The authors report no conflict of interest.

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LIMITATION
There are several limitations to this review. There were very few studies available
for review that looked at diaphragmatic breathing alone, without any other
intervention. The studies available were not always consistent in how they defined
diaphragmatic breathing and often used terms such as yogic breathing or used
breathing in conjunction with other alternative methods such as meditation or
deep muscle relaxation. Many studies had to be eliminated based on this criterion
alone. The studies selected for review lacked homogeneity due to the differences
in the populations, interventions and outcome measures between studies.
Additionally, the search strategy limited the results to English and therefore
limited the number of studies available for review. The dissimilarity between the
type of diaphragmatic breathing and populations used in the studies limited the
ability to synthesize results for a meta-analysis.