PRESENTED BY:-

Dr. Rahul Gote ,

post graduate student .
Department of orthodontics
and dentofacial
Orthopaedics
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 Introduction
Contents :
Definition
classification
common oral Habits in children
Thumb sucking
Tongue thrusting
Mouth Breathing
Other habits Bruxism
Lip Biting
Pillowing habit
Frenum Thrusting
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Bobby-pin opening
Introduction :

A wide variety of oral habits occur in the infants and young

children has been the center of much controversy for many
years.

Orthodontist, Parents, pediatricians, psychologist, speech

pathologist and dentists have discussed and argued the
significance of the oral habits, each from the view point of
their speciality.

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The orthodontist may place more importance on the
deep-seated behavioral problems of the child of which
the habits may be only a symptom.
The parent appears to be more concerned that a child
with an oral habit is exhibiting an act, which is socially
unacceptable.

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From the dental point of view, our concern for oral habits
falls into two basic areas.
1.What is the overall health and psychological significance of
the habits?
2. What are the dental manifestations and implications of the
habit?
So, we should understand why and how the habit had
developed, and what is psychology behind it?

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 Defination :

Habit as quoted by “Hogeboon” and attributed by Salder: is

the methodical way in which mind and body act as a result of
the frequent repetition of a certain definite sets of nervous
impulses.

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Habit may be defined as constant, settled practice or custom
established by repetition of the same act.

A repeated static or functional exercise is defined as a habit.

A habit may be defined as the tendency towards an act, that

has become a repeated performance, relatively fixed,
consistent and easy to perform by an individual.

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William James: an ancient psychologist defined habit from
psychological point – As habit is nothing but a new pathway of
discharge formed in the brain by which certain incoming
currents then tend to escape.

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 CLASSIFICATION :

1 According to Sigmund and Finn

a. Compulsive
Non-compulsive
a. Compulsive habits: These are deep-rooted habits that have
acquired a fixation in the child to the extent that the child retreat
to the habit whenever his security is threatened by events, which
occur around him. The child tends to suffer increased anxiety
when attempts are made to correct the habit
Non-compulsive habits: They are habits that are easily learned
and dropped as the child matures.
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B. Primary – it is the first habit that is
acquired e.g.: Thumb sucking

Secondary – is the habit that accompanying the primary habit.

E.g.: tongue thrusting along with thumb sucking

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2. Klein’s Classification :
a. Intentional habits: it functions as an important
psychological property for the child.
E.g.: thumb sucking
b. Un-intentional habit: pursued even though the child does
not support e.g.: mouth breathing

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3. Brash classification
1. Individual habits eg: lip sucking
2. Habits in which there is combined action of muscle of mouth
and jaw’s with of thumb/finger insertion
3.Muscular action and introduction of passive object in to mouth
eg. Pacifier
4.Habits in which muscles of the mouth and jaw take no active
part. The effect on position of dentition being extraneous. Eg:
pillowing habits
5. Functional disturbances eg. Mouth breathing

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4. Functional classification
a. Functional oral habit eg: mouth breathing
b. Muscular habits eg: lip and cheek biting
c.Combination of oral muscular action and other ways. E.g
thumb sucking.
d. Postural habits eg. Chin propping

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5. Anderson classification (1963)
I. a) Pressure habits: These include sucking habits such as
thumb sucking, lip sucking, finger sucking and also tongue
thrusting.

b) Non pressure habits: Habits, which do not apply a direct,

force on the teeth or its supporting structures. E.g. mouth
breathing

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II. a) Normal e.g.: Nutritive sucking
b) Abnormal. E.g. : Tongue thrusting and thumb sucking
III. a) Physiological e.g.: nutritive sucking
habit
b) Pathological e.g.mouth breathing
IV a) Functional e.g.: mouth breathing
b) Non functional e.g.: tongue
thrusting

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6.Useful and harmful habits

Useful habits should include all those habits of normal

function such as correct tongue position, proper respiration
and deglutition and normal use of lips in speaking, etc.

Harmful habits include all that exert prescribed stresses

against the teeth and dental arches, as well as those habits
such as mouth breathing, lip biting, lip sucking etc.

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7 Meaningful habits and empty habits
Meaningful habits: is a habit with a
psychological problem deep rooted and must be
treated accordingly
Empty habits: is a meaningless habit, and can be
treated easily by a dentist with parent help using a habit
reminder appliance

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COMMONORAL HABITS IN CHILDREN :

 Thumb-sucking
 Tongue thrusting
 Mouth breathing
 Bruxism
 Nail biting
 Finger biting
 Tongue sucking
 Self-mutilation
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 SUCKING HABITS :

Sucking habit is a reflex occurring in oral stage development

and disappears during normal growth between the age 1 and
3 ½ years it is the first co-ordinate muscular activity of the
infant.

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Sucking habits can be classified into
1. Nutritive – Nutritive sucking habits will
provide essential nutrient to the infant. E.g.
breast feeding and bottle feeding
2. Non-nutritive – It is the habit adopted by infant
in response to frustration and to satisfy their urge
and need for contact. E.g. thumb sucking, finger
sucking and pacifier sucking

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Classification of NNS (Non nutritive
Sucking)
1. Level I (+/-) – boy or girl of any
chronological age with a habit that
occurs during sleep
2. Level II (+/-) – boy under the age of 8
years with a habit that occurs at one
setting during waking hours.
3. Level III (+/-) – boy under the age of
8years with a habit that occurs across
multiple setting during waking hours.
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4. Level IV (+/-)-girl under the age of 8 years or a boy over the
age of 8years with a habit that occurs at one setting during
waking hours.
5. Level V (+/-)- girl under the age of 8 years or a boy over the
age of 8 years with a habit that occurs cross multiple settings
during waking hours.
6. Level VI (+5) – girl over the age of 8 years with habit during
waking hours.

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It is defined as the placement of thumb or one or
more fingers in varying depth into the mouth.

Classification of thumb sucking

A. Group 1: Thumb placed into the mouth

beyond the first joint and occupies a
large portion of the vault of the hard
palate, pressing against the palatal
and alveolar mucosa
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Group 2: The thumb did not go completely into the vault area
of the hard palate, however it usually entered into the
mouth, upto and around the first joint or just anterior to it.

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Group 3: the thumb passed fully into the hard palate as in
group one but doesn’t press the palatal vault.

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Group 4:

The thumb did not progress appreciably into the mouth. The
lower incisors made contact at the approximate level of the
thumbnail

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b. Cook (1958) described three distinct pattern of thumb
sucking.
Group I - pushes the palate in an vertical direction and displayed
only little buccal wall contraction.
Group II- registered strong buccal wall contraction and a
negative pressure in the oral cavity. This group showed posterior
cross bite.
Group III- Altered positive and negative pressure and showed the
least amount of malocclusion of any group.

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 Etiology :

A number of theories have been put forward to explain why

thumb sucking occurs.
Freudian theory: This theory was proposed by Sigmund Freud.
He suggested that a child passes through various distinct phases of
psychological development of which the oral and the anal
phases are seen in the first three-year of life. In the oral phase, the
mouth is believed to be an oro-erotic zone. The child has the
tendency to place his fingers or any other object into the oral
cavity. Prevention of such an act is believed to result in emotional
insecurity and poses the risk of the child indulging into other
habits.
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Oral drive theory of Sears and Wise:
proposed that prolonged sucking can lead to thumb sucking
with no underlying cause or psychological bearing.

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Benjamin’s theory:
Benjamin has suggested that thumb sucking arises from
the rooting reflex seen in all mammalian infants. Rooting reflex
is the movement of the infant’s head and tongue towards an
object touching his cheek. The object is usually the mother’s
breast but may also be a finger or a pacifier. This rooting reflex
disappears in normal infants around 7-8 months of age.

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Psychological aspects:
Children deprived of parental love, care and affection
are believed to resort to this habit due to a feeling of
insecurity.

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Learned pattern:
The behavioral theory states that the digit sucking, is merely
a learned pattern of behaviour with no underlying
causes and no more emotional, or psychological problems
than are found among non-digit suckers.
Advocates of this theory suggest that digit sucking
may even increase anxiety. Thus, if a habit is eliminated
there need be no other habit begun as substitute.

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 Dentofacial changes associated with
prolonged Habits :

Effects on maxilla
- Increased proclination of incisors - Increased maxillary arch
length
- Increased anterior placement of apical base of maxilla
- Increased SNA, Increased clinical crown length of incisors,
Increased counter clock wise rotation of occlusion , Decreased
palatal arch width, Increased apical root resorption of the
primary central incisors, Increased trauma to central incisors

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Effect on the mandible
- Increased proclination of incisors
- Increased inter molar distance
- Increased distal position of point B

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Effect on inter arch relationship
1. Decreased maxillary and mandibular
incisor angle
2. Increased over jet
3. Decreased over bite
4. Increased posterior cross bite
5. Increased unilateral and bilateral
Class II occlusion

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Effect on lip placement and function
- Increased lip incompetence
- Increased lower lip function under
maxillary incisor
Effect of tongue placement and function
- Increased tongue thrust
- Increased lower tongue position
Other effects
- Increased deformation to digit
- Increased risk of speech defect especially
lisping

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Diagnosis :

The diagnosis of thumb sucking consists of four diagnostic

procedures.
1.History of digital sucking: Information on whether the
child has had an history of digital sucking, obtained by
parents. When there is a positive answer, one should ask the
question, How frequently?, How long it lasted? And its
intensity and what remedies have been tried at home?

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2. Emotional status:
The Childs emotional status should be assessed by asking
questions like
-Feeding habits
-Parental care of child
-Whether the parents are working

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3. Extra-oral examination:
The dentist should check the patients digits. They should be
compared with the opposite finger of the other hand. The finger
engaged sucking with often appear reddened or exceptionally
cleaned, chapped, with a short fingernail thumb.
Due to constant sucking the thumb or finger may have thick callus
formed

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 4. Intra-oral examination: A good intra-oral examination
could be a key to diagnosis of the habit, with its
clear picture of clinical features.

These features are:

-Flared maxillary anteriors with diastema
-High probability of buccal cross-bite
-Narrow maxillary arch
-Lingual tipping of the mandibular incisors
-Open bite

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Management : divided into
- Preventive
- Interceptive
- Corrective (a) early treatment

(b)Late treatment
- Post treatment or retention

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The treatment procedure could be introduced during 3
phases of development of dentition.
-PREVENTIVE- Primary dentition between (3-5 yrs)
-INTERCEPTIVE - Eruption of permanent incisors in
progress (6-8 yrs)
-CORRECTIVE - Eruption of permanent molars in progress
(8 yrs-upto eruption of all permanent tooth)
And LATE CORRECTIVE treatment in the adults

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Preventive treatment
According to LITTLE FIELD because of hereditary and
its pre-disposition to digital sucking preventive
treatment is best began whenever a familial tendency to
the habit is discovered.
Further, during the hand to mouth reaction period
there is a danger of the passive mouthing of thumb
being converted into a active habit.
Consequently if during this period the passive action
appears to be excessively indulged in, preventive
measure are indicated.
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Hughes says- prevention of finger sucking habit is
very easy if the following simple procedures are
followed.
Firstly, feed the child whenever it is hungry, and let
him to eat as much as he wants (treatment for
nutritive sucking). Dispense and scheduling and
routine practice till 3 yrs of age when he has
considerable social learning and enough maturity to
understand their importance.
Secondly- feed the child in the natural way.
Importance of breast-feeding is primarily
psychological and secondarily nutritive.
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McBride believes that if one wishes to prohibit sucking, never
let the habit get started, the practice must be discontinued at its
inception. In the beginning the finger is routinely removed from
the mouth and is kept out during sleeping-hours by pinning
sleeves of the sleeping garments so that the child will not
acquire the motion.
The interceptive, corrective treatment would also be considered
as remedial measures-which include chemical, mechanical and
psychological methods

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Psychological :
scolding or frightening the child should be avoided..
Brauer says that in the younger child, education of the parent is
the clue to discontinue the habit.
He continues, to say, “intelligent attention must be given to the
following principles:

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1. Promote favorable contact of the child to his immediate
environment.
2. Provide play materials suited to the Childs age.
3. See that the child has the opportunities and space to be
active, to experiment, to explore and play.
4. Reduce unnecessary regulation for the child and provide as
much freedom as possible.
5. The home atmosphere should be one of happiness, sympathy,
patience and understanding.

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Lewis states thumb-sucking is not a disease be cured, but the
symptoms of maladjustment, the correction of which requires
considerable patience, skillful handling, self discipline, one of the
part of those whose responsibility is to handle it.
Immediate post weaning period is probably the most difficult time
to handle the digit-suckers. There is no convenient instrument for
his re-direction, he is not old enough for explanation and
reasoning and so the only way to handle them is to encourage
chewing and biting tendencies.

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B-Hypothesis-method of correction is known as
Dunlop-Hypothesis:
This theory holds that practicing bad habit with the intent to
stop it, one learns not to perform that undesirable act.
However, the child must know that the intention in having him
in practice the habit is to break him off the habit. Further, more
the child is not been allowed to fall into daydreaming or derive
satisfaction from purposeful repetition of the habit.
This is practiced only in older children co-operation can be
obtained.

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Mechanical treatment:
Mechanical restraints applied to the hand/ digit like splints held
by adhesives or two holes drilled and stringed to the wrist.
Adhesive Bandages applied to the digit .
Levin described a method of altering the little clothing
(pyjamas), so that, the hand cannot be moved to the mouth.
Daily records kept by the child, to use the telephone to report
how many times he/she has sucked his thumb. Later if the
frequency of sucking reduces, the calls can be spaced apart.

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If self-help programme is not successful, the child asks for the
help of the dentist and an intraoral appliance or any other
technique advocated by the dentist can be employed.
Thumb guard: is a soft acrylic covering over the thumb worn
at night. Fabricated by the dentist, made of soft acrylic has
holes of approximately 3/16” in diameter drilled into it, to
break the sucking seal. It is tied to the wrist at night.

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Chemical treatment:
Is a part of mechanical treatment, where the use of bitter or
sour chemicals are used over the thumb or any digit used in
the practice of sucking to reduce or remind the patient of the
habit.

However, this should be done only when the patient has a

positive attitude, and wants the treatment, to break the habit
as much as the dentist wants

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.
The treatment advocated by the dentist can be removal or
fixed appliances .
Removable appliances: A removable appliance is used for child,
who in our clinical judgment wants to stop and asks for help
,but who wants to be engaged in meaningful sucking. the
removable appliance is the choice, because the child can easily
remove it ,if his emotional status demands it.

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The removable appliances include
Palatal cribs: It may be a fixed or removable appliance.

The cribs act as

1}To break the suction
2}To remind the patient of his habit.
3} To make the habit a non-pleasurable one.

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Rakes: It has spur projecting from the acrylic retainer into
the palatal vault. The hay-rake type appliance frequently are
destroyed by habitual sucking

There are also fixed types of rakes. Here the palatal assembly
is made of 0.040” inch (st. steel wire) wire. Crowns are made
of steel.

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ORAL SCREEN:
is made of acrylic.

It acts in a number of ways.

1. Prevents the habit.
2. Corrects the open-bite.
3. Exercises the hypo tonic lip and the
mentalis muscle. 56
MYO appliance:
Called Munchee chewer, has been extensively
researched for the past few years in Australia and Japan.
Researchers say MYO has excellent therapeutic modality with
treatment of open bite and anterior protrusion of mandible. Dr.
Mine and Dr. Yoshihara have found MYO therapy useful
between 3-6 years children during the stomatognathic system
development

Used for 30 mins. daily in severe cases and 4 mins in

no gross orthodontic problems
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.
1. The MYO Provides necessary exercises to oxygenate and
enpower the muscle of the stomatognathic system.
2. used to increase blood supply to the musculature.
3. Double the competency of 0. oris.
4. Chewing on the device produces a copious salivary flow, to
keep the oral cavity always flushed.
MYO originally called chewing and oral prophylactic
because of its capacity to physically remove plague.

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Fixed appliances:
Blue-grass appliance:

Is a non primitive fixed appliance using a Teflon roller,

together, with positive reinforcement. It is used to manage
digit sucking in children between 7-13 years of age.
The roller appliance was cemented in place and left in
the mouth for a period of 3-6 months.

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 The patient believes they have acquired a new toy to
play with their tongue, as instructions have given him to roll
the roller instead of sucking the digit.
The first week was used for more tolerance towards the
appliance and 6 months retention after the habit stopped.
Long-term familiarity with the roller reduced the oral
gratification and depending upon appliance use. Thus, digit
sucking was eliminated and the dependency upon a positive
reinforcement was slowly removed.

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Quad helix: The quad helix is fixed appliance used to expand
the constricted maxillary arch. The helixes of the appliance
serve to remind the child not to place the finger in the mouth.
The quad helix is a versatile appliance because it can correct a
posterior cross-bite and discourage a digit sucking habit at the
same time.

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Triple loop corrector:
By Antony D. Viazis,- is a new and simple thumb sucking habit
control appliance.
It can be very easily constructed by bending three corrective
loops on an 0.36” wire that is designed to fit into the lingual
sheaths of the upper first molar bands, just like an regular
transpalatal ach this requires minimal chairside time and can
be adjusted to cover the whole span of patient’s open bite to
make insertion of the thumb in mouth very difficult.

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INSTRUCTION: it is the duty of the dentist to tell the patient
about the side effects encountered during the various use of
the appliances.
The common side effects encountered are:
During eating, there may be difficulty: speech may be slurred
or lisping with the appliance in mouth

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 Sleeping patterns may be altered for a few days following
appliance delivery.
These difficulties usually subside within 3 days to 2 week,
the major problem will be palatal cribs and to lesser degree with
the quad helix in maintenance of oral hygiene.
Food trapped may cause halitosis and tissue
inflammation, as habit discouragement appliances are left in
place for 6 months or more.
Hayette et al have emphasized the period off retention in a
habit-braking scheme. A minimum of 6 months retention for
palatal cribs, quad helix etc. is routine.

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Tounge thrust :

The abnormal positioning of tongue (anteriorly) to varying

degrees has been termed as tongue thrust.
The tongue thrust habit is the most controversial of all the oral
habits. Some consider a retained infantile swallow a harmful
habit, causing a malocclusion, while other believe, its as normal
and that the soft tissue adjust to the dento skeletal complex,
rather than vice versa.

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Classification :

According to Moyers using EMG research has classified the

problem into
1.Simple tongue thrust: defined as teeth to teeth contact during
swallowing. The malocclusion usually associated with it is a well-
circumscribed open bite.
2.Complex tongue thrust: is defined as a tongue thrust with a teeth
apart swallow. The malocclusion seen with a complex tongue
thrust has two distinguishing features.
a. poor occlussion
b. generalized anterior open bite.
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C. Retained infantile swallow:
Is defined as the under persistence of the infantile swallow well
past the normal time.
Very few people have a retained infantile swallow, those who do
ordinarily occlude on just one molar on each quadrant.
They also demonstrate strong contraction of the facial muscle
during swallow.

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Persons with retained infantile swallow do not have expressive
faces, since the muscles of 7th cranial nerve are being used for
the massive effort of stabilizing the mandible and not for the
delicate facial movements of facial expression.

They also have serious difficulties in mastication and

may have low gag threshold.

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d. Abnormal tongue posture:
There are two forms of the protracted tongue posture.
i. Endogenous and
ii . Acquired
This endogenous protracted tongue; have the tip of tongue, lying
between the incisors. The great majority of endogenous
protracted tongue are not unesthetic. And there is stability of the
incisors relationship, even though a mild open bite exists.

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 The acquired protracted tongue is a more simple
matter, since it usually results from chronic pharyngitis
tonsillitis or other naso respiratory disturbances.
Thus, once the etiologic factor is removed, the tongue
posture is resumed to its normal position.

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According to Braucer and townsend hott
There are 4 types
Type I: Non-deforming tongue thrust.
Means that the interdigitation of the teeth and the profile were
acceptable and within the normal range.
The tongue pattern apparently is non-deforming either because the thrust
is mild in nature or because there is sufficient tonus of the lips and cheek
to prevent deforming changes.

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Type II: Deforming anterior tongue
thrust
Subgroup
1. Anterior open bite
2. Anterior proclination
3. Associated posterior cross bite.

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Sub group 1:. The tongue is thrust and forced between the
anteriors during swallowing. This leads to intrusive or lack of
eruption of those teeth and spacing through which the tongue
protrudes.

Sub group 2: Depending on the superior inferior level of the

thrust and postural position of the tongue, various type of
deformities are seen in this sub group.

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When the tongue is thrust directly through the anterior opening,
created by allowing the mandible to open slightly during swallow,
a force is directed against these anterior teeth approximately one
or 2 times a minute. The associated deformities observed may be
bimax protrusion, while these anterior teeth may have a rather
high degree of angular protrusion towards the maxilla, the usual
results is procumbency of the maxillary If however the tongue is
thrust primarily directly anteriors associated with class II Div I
malocclusion.

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 Another phenomenon associated with this type of tongue
thrust is the “Reverse Curl” (preventing the mandibular incisors
form eruption to meet the palatal tissue), is produced when the
tongue thrusts forward against the upper teeth and upon
withdrawal, exerts a lingual fore on the lower anteriors.
When the anterior vector of force is directed primarily
towards the mandibular arch, an abnormal low postural position
of the tongue result in a wide mandibular arch. Anterior
posterior cross bite are common in this pattern of swallowing and
tongue posture.

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Type III: Deforming lateral tongue thrust
is limited to the posterior region. In this type III tongue thrust
pattern, we see the tongue laterally between the posterior teeth with
resultant posterior open bite and often an associated posterior
cross bite.

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Type IV: Deforming anterior and lateral tongue thrust.

It can be mild or quite devastating in nature. during

swallowing the tongue comes up to cover the occlusal and
incisal surfaces of all the teeth except 2nd molars. Usually this
is associated with large tongue, decreased degree of control of
tongue such as in cerebral palsy and other neuromuscular
diseases.

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 Etiology od tounge thrust :

Fletcher has developed the following outline to indicate proposed

etiologic factor for the tongue thrust syndrome
.
1. Genetic Factor:
Palmer, Subtenlny et al suggest that there are specific anatomic
or neuro-muscular variations in the oro-facial region that can
precipitate tongue thrusting ex. Hypertonic orbicularis oris
activity

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2. Learned Behaviour
Tongue thrust can be acquired as a habit.
The following pre-disposing factors that can lead to
tongue thrusting are
a. Improper bottle feeding
b. Prolonged thumb sucking
c. Prolonged tonsilar and upper respiratory tract
infections
d. prolonged duration of tenderness of gums or teeth can
lead to change in swallowing pattern to avoid pressure
on the tender zone.
e. tongue held in open spaces during mixed79dention
period.
3. Maturational
Tongue thrust can be present as a part of normal childhood
behavior that is gradually modified as age advances.
The infantile swallow changes to a mature swallow once the
posterior deciduous teeth start erupting.
Some times the maturation is delayed and thus infantile
swallow persist for a longer duration of time.

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4. Mechanical restriction
the presence of certain conditions such as macroglossia,
constricted dental arches and enlarged adenoids pre-
dispose to tongue thrusting.

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5. Neurological disturbances
Neurological disturbances affecting the oro-facial region
such as hypersensitive palate and moderate disability can
lead to tongue thrusting

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6. Psychogenic Factors:
Tongue thrust can some times occur as a result of forced
discontinuation of other habits like thumb sucking

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 Dignosis :

Consists of a detailed examination of the tongue.

Morphologic examination
The tongue should be examined for size and shape.

84
Asymmetry or symmetrical:
ask the patient to protrude the tongue and note the
symmetry of its position.
Then ask the patient to relax the tongue, allowing it to
drape over the lower lip.
. Morphologic asymmetries will persist in the drapped
position.

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Size of tongue
The size and shape of tongue may show many variations. The
tongue can be bulky or short, narrow and long or even wide and
long.
There are various methods to check the size of the tongue, the
most common of which is to ask the patient to touch his chin
with his tongue tip. A positive result indicates macroglossia.

86
In macroglossia, the tongue fills the entire oral cavity.
It is common to see scalloping or indentations on the
lateral borders of the tongue.
The tips of the scallop filling into the inter proximal spaces
between the teeth, which may be proclined.
There may be associated open-bite.

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The conditions where macroglossia commonly occurs
are.
- Myxodema and cretinism
- Down’s syndrome
- Acromegaly
- Muscular hypertrophy
- Congenital
- Tumors

88
Functional examination
The tongue and lips are often intergrated and synchronized in
their activity. When the lips are parted by the mouth mirror or
the cheeks are withdrawn by retractors, normal tongue activity
is inhibited and what is observed is accommodation to the
stretching of the lips and cheeks.
The problem of the tongue examination is to study the tongues
function without displacing it or the lips

89
[1] Observe the postural position of tongue while the mandible it
in its postural position. This may be done in a Cephalogram.

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91
Palatographic examination of tongue using palatography
The technique permits tongue function to be observed during
swallowing and speaking and also allows the influence of various
appliance.
Speech disorders were also studied by palatography methods.

92
 There are two methods

a. Direct method: described by Oakley Coles 1873. Gum

Arabica and Flour were mixed and painted on the tongue.
After the selected range of tongue exercises are performed,
the contacts on the palate and teeth were transferred to a cast

b. Indirect method was first used by Kingsley. He prepared an

upper plate of black India rubber and covered the tongue
using a mixture of chalk, plate were the transferred on the
cast

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The current direct method entitles covering the superior surface of
the tongue with precision impression material.
A thin even layer is applied to the tongue with a spatula.
After functional exercise, a Polaroids print is made of the palatal
region with the help of surface mirror.
The evaluation of the palathogram is possible by direct
measurement on the picture.

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The Payne technique
Dr. Evemt Payne and others developed a technique to measure
exactly where the tongue hits the palate during the swallowing
act.
The revealing substance is orobase with a 1% sodium
flourescien solution in water-soluble base.
Utilizing the black light technique, will reveal exactly where
the tongue is placed during the swallowing act.

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Cine flurographic analysis
The tip of tongue is quoted with barium solution when the
patient swallows.
The cine flurographic camera shots at the rate of nearly 240
frames per second.
The whole swallowing cycle takes a sec , which can be
monitored on a TV. If the tongue extended beyond the line
drawn,then the patient is considered to have tongue thrust habit.

96
Differential diagnosis of abnormal tongue posture
Tongue posture is related to skeletal morphology
For example a sever class III facial skeleton,
the tongue tends to lie below the plane of occlusion,
and a class II facial skeletons with a short mandible and steep
mandibular plane,
the tongue may be positioned forward.

97
Two significant variations from the normal posture can be seen.

1. Retracted or locked tongue in which the tongue tip is

withdrawn from all the anterior teeth.
2. Protracted tongue in which the resting tongue is between
the incisor.

The retracted tongue is seen in less than 10% of all children, but
is often associated with posterior open bite since the tongue may
spread laterally.
.

98
The protracted tongue postures may be

i) endogenous and
ii) acquired
The protracted tongue postures are frequently adaptations
to excessive anterior facial height, a condition which
predisposes to open bite, the tongue posture necessarily
adapting to enforce an anterior seal during the swallow.

99
Clinical diagnosis of tongue thrusting
-The patient is seated upright with Frankfort horizontal plane
parallel to the floor.
- Try to observe, unnoticed several unconscious swallow.

100
- Then place a small amount of water beneath the patients
tongue tip and ask patient to swallow note the mandibular
movement
- In the normal mature swallow, the mandible rises as the teeth
are bought together during the swallow with the lip touching.
The facial muscle ordinarily do not show marked contraction
in the normal mature swallow.

101
--A hand over the temporalis muscle, pressing lightly with the
finger tips against the patients head with the hand in this
position.
The patient is given more water and ask for a repeat swallow.
During the normal swallow, the temporalis muscle can be felt to
contract as the mandible is elevated, when the teeth are held
together, whereas in tooth apart swallow, no contraction of the
temporalis muscle will be noted

102
 Clinical feature :

- Proclination of the upper anteriors

- Retroclination of the lower anteriors
- Typical diastema
- Open bite
- Complete collapse of the maxillary arch

103
Management :

There are cases in which tongue thrust therapy is not to be

administered
1. When the malocclusion has been stable for several months or
years and is not serious enough to warrant orthodontic correction
where patient and parent are cautioned to watch carefully for the
sign of change in severity of malocclusion.

104
2. When patient demonstrates either through a history of failure
speech therapy, resistance to therapy, or unwillingness to
comply with practice requirements as they are explained to
him, a poor attitude towards the remedy of his problem

3. In patients with severe mental retardation, brain damage or

behavioural disorders.

105
4. When parent and other responsible person cannot or
will not observe the child, and observe the child and provide
feed back to him and to the therapist concerning his
performance.

The best stage to start treatment is the mixed dentition, by

interceptive procedures called functional compensation

106
Functional compensation should be regarded as the ability of an
organ or a system to modify its behaviour.
The compensating appliance called “Bi prax” because they allow a
physiologic display of two namely buccal “praxisms” speech and
deglutition. It is complied like a removal appliance, of an acrylic
resin base and metal elements. It is essential to know the
orientation and mode of action of the muscle fibres of the different
masticating muscle before its use

107
The other line of therapy is the use of muscle forces by simple
orthodontic appliance may be fixed or active removable plate.
. Mixed dentition being the most frequent and optimal time
for therapy

108
Oral screen
It is vestibular screen, to avoid the outward thrust of the tongue
and to control the proclination of the anteriors.
Used together with breathing holes. is used also in the control of
mouth breathing.

Double screen
A small lingual screen is attached
to the vestibular screen with
0.036” wire.

109
Modified Bionator screened the adverse tongue pressure,
promote mandibular development with forward construction
bite and labial bow helps in retraction of anterior teeth.

110
If the habit is noticed in its beginning stages and the patient is
willing for a treatment, one can advocate self corrective treatment
procedure such as:

Acquaint the patient with the normal swallow by placing the

index finger on the tip of the tongue and then on the junction
of the hard and soft palate and instruct the patient to place
the tongue there while swallowing.

111
Instruct the patient to close the lips and swallow while
holding the tongue position.

Use of tactile signals help the patient to understand what to

do. One is asked to practice 40 minutes a day.

112
Single elastic swallow :
A small orthodontic elastic can be paced in the tongue tip and
patient asked to swallow with the tip against the palate.
If the swallow is correct, the elastic will retain ; if incorrect
the elastic will be swallowed.
practice 2-3 times/sessions each day.

113
When the new swallowing pattern is being learnt on a conscious
level, it is necessary to reinforce it subconsciously. Then sugarless
fruit drops can be used to reinforce the unconscious swallow.
A removable cribs appliance or a spur appliance will help the
tongue to be reminded and redirected towards the correct
swallowing pattern.
Psychologic aspects of disruption of tongue thrust or tongue
sucking by means of a dental appliance.

114
Hay rake appliance: A device called Hay rake can be removable
or non-removable appliance cemented to the Childs teeth to
prevent tongue sucking and tongue thrust.

115
Quad Helix described as an appliance used in thumb
sucking as well as tongue thrust when tongue spurs
are used to inhibit the habit.

116
Treatment with bioactivator and headgear: as it
effects on dentition and also on the skeletal structure. Effects
were increased in the sagittal than vertical plane thus reducing the
increased FMA angle accompanied due to tongue thrust and lower
positioning of mandible.
Class II division I malocclusion with an activator head gear
showed that during maximal bite the activity of the posterior
temporal muscle decreased in a group with head gear and in
activator.

117
Active vertical corrector: A non-surgical alternative for
skeletal open bite together with tongue thrust habit. It a
simple removable or fixed orthodontic appliance that intrudes
the posterior teeth in both the maxilla and mandible by
reciprocal forces.
Frankles I, II, IV are also used depending on the type of
malocclusion present and acompanying growth pattern
existing in the patient.

118
 Mouth breathing :

The mode of respiration is examined to establish

nasal breathing is impeded or not.
Chronically disturbed nasal respiration represents a
dysfunction of the oro-facial musculature

119
Classification :

a. Obstructive
b. Habitual
c. Anatomic

Obstructive:
mouth breathers are children who have an increased
resistance to or complete obstruction of the normal
flow of air through the nasal passage.

120
Because of the difficulty in inspiring the expiring air to the
nasal passage, the child is forced by sheen necessity to breathe
through his mouth.
Habitual:
these mouth breathers are children who continually breath
through the mouth by force of habit, Even if the abnormal
obstruction has been removed.

121
Anatomical:
The anatomic mouth breathers are those ,whose short
upper lip does not permit complete closure without undue
effort.
Anatomic mouth breathers are frequently ectomorphic
children, who possess long, narrow faces and
nasopharyngeal space.
These children are more prone to nasal obstruction.

122
Etiological factor :

1. The nasal obstruction may be due to

a. Deviated nasal septum.
b. Nasal polyps
c. Chronic inflamed nasal mucous, hypersensitive nasal mucosa
as in chronic allergic rhinitis
d. Localized benign tumors.
123
e. Congenital enlargements of tubrinates
f. Tonsillitis
g. Adenoid, which are enlarged.
-The “adenoid facies” is the most often ectopic factor of mouth
breathing.
-Adenoid are a mass of
lymphoid tissue situated
at the roof of the
nasopharynx in the
form of bee hive.

124
2. Mouth breathing related with thumb sucking and lip biting
Thumb sucking and lip biting are often accompanied by mouth
breathing.
Thumb sucking alone does not produce deformities beyond those
of the dental arch and teeth, while the accompanied mouth,
breathing does much more harm.

125
 3] Hereditary
Some individuals are more susceptible to this habit.
It occurs more frequently in long faced (dolico facial)
tall, slender person (ectomorphic) in whom the pharyngeal
space is more long but narrow.

126
Diagnosis :

1. Study the patient breathing unobserved. Nasal breathing

usually show the lip sucking during relaxed breathing whereas
mouth breathers keep their lips apart
2. The patient is asked to take a deep breath. Most respond
by inspiring through the nose with the lips lightly closed, but
not mouth breathers.

127
3. The patient is asked to take a deep breath with lips closed,
and breath through the nose.
nasal breathers normally demonstrate good reflex control on
the alar muscle, which control the size and shape of the external
nares, therefore they dilate external nares, on inspiration.
Mouth breathers even though are capable of breathing through
the nose, do not change the size and shape of the external nares.

128
4. Placement of a double surfaced mirror on the upper lip. If the
patient is a nasal breather, the upper surface will cloud, if mouth
breather, the lower surface will cloud.
5. Butterfly cotton wool test: Is a placement of small cotton in front
of each nostril, if it is pushed away during expirating, patient is said
to be a nasal breathers.
6. Patient asked to hold a piece of paper between his lips. A mouth
breather cannot hold his lip together for too long.

129
Other diagnostic evaluation have been formulated are;
Use of plethysmograph with a air flow transducer is used to
determine the total nasal air flow and oral air flow. This is a
quantitative analysis stated by Warren.
The advent of lateral cephalograms have enabled to identify the
size the extent of obstruction of the naso pharyngeal passage.
Adenoids in lateral cephalograms showed a y- ray picture, and
one could identify small, moderate and large adenoids,
obstructing the nasopharyngeal space.

130
Rhinomanometry and respirometry
Stedman’s medial dictionary defines
Rhinomanometry= as study of nasal obstruction and nasal
airflow characteristics. Since this term refers only to nasal
airflow measurements direct oral respiratory measurements
is termed= respirometry, and implies the study of both nasal
and oral respiratory function

131
Snort:
Simultaneous nasal and oral respirometric technique for
quantitative assessment of respiratory mode by Gurley, Vig
This system has an accuracy and reproducibility of 97% and
make it possible to monitor, record and calibrate continuously
both oral and nasal inspiration and expiration. The output is
in the form of waves.

132
There are 4 recordings ;
- Oral inspiration
- Oral expiration
- Nasal inspiration
- Nasal expiration

The electrical signal can be converted to digital form and

stored.

133
Features of SNORT
1 Allows precise recording of respiratory function
2. Capable of representing oral and nasal inspiration and
expiration in detail.
3. Able to record and measure airflow simultaneously for
oral, nasal inspiration and expiration.
4. Does not generate undue discomfort for subject.

134
5. Provides a comparison between total inspired air
volume with expired air volume.
6. Inspirations can be compared with expiration.
7. Generates numerical values for variation in nasal
respiratory functional and oral breathing, thereby
permitting the objective determination of both
normal and pathologic state.

135
 Plethysomography with airflow
transducer:
A quantitative technique for assessing
nasal airway impairment has been
described by Donald Warren.
The methods involve a modification of the theoretical hydraulic
principle and unables the clinician to:
1. Estimate the size of the airway during
breathing.
2. Distinguish between normal and impaired nasal
respiratory function

136
Clinival effects and feature :

Divided as
a. Local
i. Soft tissue
ii. Hard tissue
b. Remote organs
c. Psychic effects

137
Local effects:
Lip become black and stay open, so that the upper lip is
shortened and elevated over the upper incisor, while the lower
lip becomes heavy and everted and usually lies beneath and
behind the upper incisor instead of over them. Thus modeling
action of lips on upper incisors is lost. Resulting protrusion of
those teeth.
Cheeks:
As the mouth is habitually held open, the cheeks are pulled
downward and becomes narrow and full like values with each
inspiration.
Chin : Is receded

138
Gingiva:
Becomes hypertrophied and also inflamed persistent
marginal gingivitis limited to the anterior cuspid to cuspid
region. This continuous impact of cold air, irritates the oral
tissue caused drying of the lips, and may result in chelitis. As
the lips do not close, the anterior teeth loose their natural
cleaning with saliva resulting in collection of food debris and
tartar formation around the teeth.

139
Mucous Membrane:
Becomes prone to inflammation due to drying and irritation.

Nasal mucosa:
becomes atrophied due to disuse. The bacteriostatic action of the
nasal secretion is lost and pathway is permitted whereby disease,
particularly viral infection, may safely enter the lungs.

Speech:
Acquires a “nasal” tone;. This is because the paranasal sinuses
are not fully formed, whose function is to give resonance to the
voice.

140
Smell:
the sense of smell is dulled and taste sensation and appetite
is lost.
Nasal turbinates:
Are swollen and enlarged

141
B. Hard tissue
1. Inhibits the growth of pre maxilla
2. Upper dental arch is decreased in width and becomes V shaped.
The malar process of the maxilla instead of taking cold upward
sweep, develop a download curve at its functions with the malar
bone this display a general narrowing of the face when viewed
from the front.

142
To breath through the mouth, one must open up and
maintain an oral airway.
3 changes in posture are needed to accomplish this
- Lower the mandible
- Positioning of tongue downward and forward
- Extending the head

143
The severity of the deformities depends on
1. Age of the child
2. Degree of adenoids and subsequent mouth breathing
3. Duration
4. Degree of cause

144
Remote effects:
1. Older children snore at night, difficulty in swallowing
2. Mucous secreted by the adenoids is swallowed in large
quantities and produce rearrangement of stomach and intestine
with failure of growth and general health.

145
Psychic effects:
The general appearance and accompanying malocclusion leads
to an introvert personality. The child fails to command respect
from others. The child is victim of mockery by his
fellowmates. The child develops inferiority complex, becomes
different and fail to succeed in the normal way of life. The
child always remain backward and shows mental deficiency.

146
Management :

The first step is look for any obvious and definite cause of nasal
obstruction and to treat them if any.
After ENT specialist has eliminated all air passage obstruction,
the first problem is to divide if the child should have immediate
orthodontic treatment. Ballard is of the opinion that there is
seldom any need to embard any treatment in young child, as he
believes that orthodontic treatment need not be necessary as
adenoids regress by age of 12 years.

147
Prevention and interception of the habit
The habit ceases automatically around and after puberty.
This is because of the fact that the nasal and pharyngeal
passages increase in size during the period of rapid growth of
the child it is during this period when one can advocate self
corrective treatment and muscle exercise. These include –
self-reminding scheme to keep the lip closed and breath
through the nose at all the times.

148
Reminder:
A silent signal arranged between parent and child serves as
constant reminder to the child.
card:
A piece of card held between the lip while reading listening to
radio, home work and at other odd times during the day is
helpful in keeping the lip closed for a certain number of times
each day.

149
 Exercises:
Lip exercise:
Blow under the upper lip and hold under tension to a slow
count of four. Repeat 25 times each day.
Draw upper lip down over the upper incisor and held it under
tension for a count of 10. Repeat 10 times, four times daily
repeat with altering the above two exercises

150
stick a tape to lip at night using cellulose tape in form of an X.
It is necessary that no mouth breathing occurs during the 8
hours or so at night.
Webb’s exercise called 0. Oris exercise, design to reestablish
function and tonicity. The exercise is carried out by using first
two fingers of the right hand.
Alternate contraction and relaxation until a feeling of slight
fatigue is experienced. Repeat at least 20 times.

151
Wilson’s exercise: Is useful when the underdeveloped and
hypotonic lips are due to chronic breathing. The effects of this
exercise are to lengthen all the muscle of lateral nasal wall, to
increase the size and capacity of the nasal cavity.
Patient routine: Close the teeth in correct position, close lip
tightly.
Contract the muscle at left corner of mouth causing the corner to
be pulled backward and upwards.

152
While holding this position with fingers of left hand placed on
the right cheek tissue forward and lift. The tissue at the left
corner of the mouth must continue the contraction all through
the muscle pulling.
While those tissue at left corner are still conracted and right
cheek is under pressure by the finger, breath deeply, 3 times
through the left nostril.

153
Relax the muscle and remove hand.
Repeat with right corner of the mouth
using right hand.
.This help in good lip seal and probably
reduces the overjet produced as a
consequence of mouth breathing habit.

154
Masseter temporal exercise
The patient is instructed to place the tip of the tongue against the
mucous membrane directly behind the mandibular incisor teeth and
with each contraction of the alveolar process this exercise trains the
tongue to remain in its proper position and has a tendency to prevent
the narrowing of the mandibular arch, facilitating the earlier
removal of the retentive appliance

155
Orthodontic appliances used
Oral screen:
Introduced by Newell 1912 and since then many modifications have
taken place.
However, one has to carefully use this appliance for mouth breathing
where nasal passage is clear.
It can also be fabricated of self curing resin. breathing holes are
included initially during treatment to get adapted to the appliance.
The appliance fills the vestibular cavity thus prevents mouth
breathing. The appliance is worn through out the night A ring can
be attached on the front of the oral screen to exercise the lips

156
Frankle regulator: showed a greater downward shift of
mean frequency of masseter and temporalis muscle. Then
downward shift might have been associated with change in
muscle fiber length.
Slow maxillary expansion can be applied to mandibular
arch, while rapid maxillary expansion can be used for the
narrow maxillary arch, however the benefit of expansion in
maxillary arch and increase in the nasal air passage, would
be possible if the obstruction in the nasal airway is in the
lower anterior part of the nasal passage.

157
Other habits :

Occlusal mannerisms may be defined as

position of the teeth and surrounding
structures assumed by the patient
involuntarily when they experience stress
anxiety and total etc.
158
 Bruxism /slider dentium :

Occlusion neurosis, Karoli effect etc. refers to the involuntary

mandibular excursions which produce inaudible or audible
clenching and other traumatic effects. Rarely is the patient aware of
such a habit. The titanic contractions of the masticatory muscles
and rhythmic grinding cause malocclusion.
This habit may be caused by physical discomfort or may be an
expression of mental unrest, and neuromuscular overplay. Nervous
tensions tends a most gratifying release in clenching and bruxism.
159
Discovering the habit by the patient of his own
unconscious biting or clenching during waking
hours is of diagnostic value and is often first
step towards correction.
Treatment includes, to exploit the weak links of
the psychogenic demands, performed crowns
and bridges.

160
 Nail biting :

(Onychophagy) is a condensed manifestation of multiple

motives and deficiencies. However, some nail biting may be
transitory in nature.
It is therefore necessary to study the Childs physical,
mental and social difficulties if the root of the habit are to
be removed

161
fingernail biting is usually absent below age of 3 years and a
rapid increase at 6 years. There is a constant trend to 10 years
in girls and 10 years in boys followed by a sharp 2-year rise in
puberty. This should decline by the age of 16 in boys

Kanner and Bawkin found that biting of toenails occurred

exclusively in girls.

The habit is usually replaced after adolescence by lip bitingor

gum chewing. Nail biting usually of a severe type is especially
seen among people showing personality disturbances.

162
Treatment
Punishment, scolding and restraints are of no value.
Clinical examination of teeth or nail biters may disclose
induced crowding, rotation and attrition of incisal edges of
incisal teeth especially mandibular incisors. These
malocclusions are due to upward pressures induced during
nail biting.

163
Lip biting :

Lip biting may occur as a variant of a lip sucking or as a

substituted for thumb or finger sucking.
Clinicaliy the lip is seen to be trapped between the upper
anteriors. The diagnostic features could be proclined upper
anteriors and or swollen and cracked lips due to chronic
sucking and prone to infection due to moist nature.

164
Treatment consists of constant reminding if the habit has a
psychogenic factor involved like an expression of stress or
anxiety one has to educated the patient and teach him to cope
with stress and anxiety.

A cooperative hand of parents would be very effective and

highly essential

165
Pillowing habit :

Postural defects during sleep have been considered an etiologic

factors in malocclusion. Children and adults do not lie in one
position during sleep, but move at frequent intervals. Those
movements are largely involuntary and are produced by
nervous reflexes.

166
Posture during the Childs waking hours is more important
than position during sleep, in the production of dental
malocclusion.
Deformity, flattening of the skull and facial asymmetry may
occasionally developed during the first year in infants who
habitually lie in the superior position with the head turned to
right or left

167
Such changes in the Cephalic index as one brought about by
inducing infant to lie in one position are not usually
persistent. There is a tendency for the inherent pattern to
manifest itself in later life.
Self mutilation – is a repetitive act that result in physical
damage to the individual is extremely rare in the normal
child.

168
However the incidence of self mutilation in the mentally retarded
population is between 10-20% .It has been suggested that self
mutilation is a learned behaviour, to gain attention.
A frequent manifestation of self-mutilation is biting of lips, tongue
and oral mucosa.
.

169
Frenum thrusting :

If the upper anterior teeth are spaced, the child may lock his
labial frenum between them and resort to frenum thrusting. It
may develop into a tooth displacing habit by keeping the central
incisors apart, just as in case of abnormal frenum attachment.

170
Bob pin opening :

the upper and lower anteriors are commonly

affected and teeth partially denuded of labial
enamel, seen commonly in girls.

171
Conclusion :

Very few malocclusion are the result of a single specific

cause. Practice of a habit causes a clinically significant
variation from normal growth resulting from the interaction
of many factors during development.

Habits leads to malocclusion which originate because of

imbalance among the developing system that form the
craniofacial complex.

Thus one has to deal the habit, its practice, with great
concern and elimination of etiological factors to provide a
successful treatment for the resulting malocclusion and
psychological support for complete success of the habit and
elimination of resulting malocclusion. 172
Thank you …

173