oral habits in orthodontics
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Bon jour
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CONTENTS
IntroductionDefinitionsTheories of developmentClassificationThumb suckingTongue thrustingMouth breathingLip habitsBruxism
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INTRODUCTIONOral habits in children bring about harmful unbalanced pressures tobear upon the immature, highly malleable alveolar ridges, thepotential changes in position of teeth, and occlusions, which maybecome decidedly abnormal if these habits are continued for a longtime.The data on the etiology, age of onset, self-correction and treatmentmodalities for the various habits differ greatly. Hence for asuccessful management of the habit, an understanding of the dentalimplications and manifestations of the habit should be pursued.
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Habit: DefinitionsMoyer
Habits are learnt pattern of muscle contraction of a very complex nature
Boucher As a tendency towards an act or an act that has become a repeated performance, relatively fixed ,
consistent, easy to perform and almost automatic
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Theories for development of habitClassical Freudian theory (1905)
Inherent psychosexual drivesuggesting that digit sucking is apleasurable erotic stimulation ofthe lips and mouth.
The learning theory :(Davidson1967)Non-nutritive sucking stems from
an adaptive response.
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Oral drive theory :( Sears and wise
1982)Strength of oral drive is in part afunction of how long the child continuesto feed by suckling.
Johnson and Larson 1993:Combination of psychoanalytic
and learning theories which explainsthat all children possess an inherent
biological drive for suckling.
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Habits: ClassificationJames (1923)/ Graber
Useful
Harmful
Useful habits: these include habits that areconsidered essential for normal function such
as proper positioning of the tongue, respirationand normal deglutition.
Harmful habits: these include habits that have
a deleterious effect on the teeth and theirsupporting structures such as thumb sucking,tongue thrusting etc.
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Klein (1977)
Empty meaningful
Empty habits: they are habits that are
not associated with any deep rootedpsychological problems
Meaningful habits: They are habits thathave a psychological bearing.
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Morris and Bohanna (1969) Pressure habit
Non pressure habit
Non pressure habits :
Habits which do not apply a direct force on theteeth or its supporting structures are termed non-pressure habits. Anexample of a non-pressure habit is mouth breathing.
Pressure habits:
Sucking habit
Lip sucking, Thumb sucking, Tongue thrusting
Biting habit
Nail biting, Needle and Thread holding Posturing habit
Pillow, Hand rest
Miscellaneous
Bruxism, Cheek biting
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Finn (1987) Compulsive habits
Non-Compulsive habitsCompulsive habits
These are deep rooted habits that haveacquired a fixation in the child to the extend
that the child retreats to the habit wheneverhis security is threatened by the events whichoccur around him. The child tends to sufferincreased anxiety when attempts are made tocorrect the habit
Non compulsive habitsThey are easily learned and dropped as thechild matures.
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THUMB SUCKING
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Definition
GellinPlacement of the thumb or one or morefingers in varying depths into the mouth
Synonyms Thumb sucking/ Digit sucking/ Finger sucking
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Classification
Thumb sucking
Normalthumbsucking
Abnormal thumbsucking
HabitualPsychological
1-2yr
31\2 -4 yrNo malocclusion
Preschool
malocclusion
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Sucking reflex Starts at 29 week I.U.
Disappear by 3 - 4 yr First coordinated muscular
activity
Psychological and nutritive need
Rooting(Placing) reflex Well defined sensory area
around mouth
Head turning and opening ofmouth by stimulation
Lasts for 7 mnths of age
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Grading of classificationThumb sucking
(Subtelny1973)
Type A Type B Type C Type D
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1.Type A:-- 50% of the children- Whole digit is placed inside the mouth
with the pad of thumb pressing the palate.- Maxillary and mandibular
anterior contact is maintained.
2.Type B :-- 13 24% of children- Thumb is placed into the oral cavitywithout touching the vault of the palate.-Maxillary and mandibular anterior contactis maintained
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3. Type C :-- 18 % of the children- thumb is placed into the mouthjust behind the first joint andcontacts the hard palate and onlythe maxillary incisors.
4. Type D :-- 6 % of the children- very little portion of the thumb isplaced in the mouth
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Causative Factors
Parent occupationWorking mother
No. of siblingsOrder of birth of the child.
Social adjustment and stress
Feeding practices
Age of the child
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Factors affecting thumb sucking
Intensity Amount of force that is applied to the teeth while performing the habit (i.e.Sucking).
Duration Amount of time spent sucking a digit.
Frequency Number of times habit is practiced throughout the day.
Direction Manner in which force is applied
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Evaluate emotional status
History Questions regarding frequency, intensity & duration
Enquiry the feeding patterns, parental care of the child
Presence of other habits
Diagnosis
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Some Important Questions toConsider/Ask
Can the habit be considered normal for a particular age/stage ofdevelopment?
Why has the child acquired the habit?
What are the psychologic implications of allowing the child to continue thehabit?
Is the habit harmful or potentially harmful to the mouth or related oral
structures?
If the habit is harmful, will the damage to the mouth & related structures
disappear spontaneously when the habit is discontinued or will the harmful
results of the habit persist?
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Extra Oral ExaminationDigits
Appear reddened, exceptionally clean, chopped
Dishpan thumb clean with a short finger nail
Callus formation on superior aspect
Lips Upper lip --short and hypotonic, passive or incompetent
Lower lip --- hyperactive
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Facial form: Either straight or convex
Other features:- Presence of other habitsHigh incidence of middle
ear infections, enlarged
tonsils due to mouth
breathing
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Effects on the
maxilla: Proclination of maxillary incisors.
Increased maxillary arch length
Decreased palatal arch width
Increase trauma to the maxillary
central incisors
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Effects on mandible:- Retroclined mandibular anteriors
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Effects on interarch relationship:- increase overjet
decreased overbite
posterior cross bite
unilateral or bilateral
Class II malocclusion.anterior open bite
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Effect on tongue:- Increased tongue thrust
Effect on Gingiva :- Inflamed gingival tissues in the maxillary arch.
Gingiva is hyperplastic
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Radiological evaluationIncreased SNA
SN
A
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Other EffectsRisk to psychological health
Increase deformation of digits
More prone to trauma
Speech defects especially lisping
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MANAGEMENT
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Treatment ConsiderationsPsychological approach:-Dunlop's BETA HYPOTHESIS
Conscious, purposeful repetitions
Reminder therapy Non Appliance Bandaging the thumb
Thermoplastic thumb post
Thumb cap
Socks covering finger or hand
Thumb Cap
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Treatment Considerations:-Chemical approach Pepper dissolved in a volatile
medium
Quinine
Asafetida
Femite
Note:- These should be used in patients as a positive attitude and
wants treatment to break the habit.
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Appliance therapyA. Removable appliance
1. Tongue spikes2. Tongue guard3. Spurs/ rake
Palatal crib Roller applianceSpikes
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Management: Mechanical or reminder therapyB. Fixed applianceTriple loop corrector: Barber (1960) Modified palatal arch
Similar to transpalatal arch with 3 loops
Blue grass appliance: Bruce Haskell (1991) Between 713 yr
Teflon roller appliance
3 6 month placement time
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1. Quad helix2. Hay rakes3. Maxillary lingual arch with palatal crib.
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Quad helix
Hay rakes Spurs/ rake
Palatal crib
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Maxillary lingual arch with palatal crib.
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Tongue spikes
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Tongue Thrusting
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DefinitionBrauer (1965)
Tongue thrust is said to be present if the tongue is observed
thrusting between and the teeth did not close in centric
occlusion during deglutition
Tulley (1969)Forward movement of tongue tip between the teeth to meet
the lower lip during deglutition and in sounds of speech , so
that the tongue becomes interdental
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Tongue Thrusting
Prevalence Newborn 97% 5-6 yrs 80%
By 12 yrs 3%
Physiology At birth- soft structure confined in skeletal environment-
Large tongue Forward movement
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Tongue ThrustingSignificance
Function governs form
Adverse muscle forces Abnormal form
Occurrence Younger children with normal occlusion Transitional stage in physiologic maturation
At any age with displaced incisors-
Adaptation for seal
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Tongue ThrustingClassification Physiologic
InfancyHabitual
Present after correction of malocclusion Functional (Profit)
Overjet, Open biteAnatomical
Macroglossia
Simple classification of TT Simple TT Complex TT
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EtiologyRetained infantile swallowURTIAdenoidsLymphoid tissue (Tonsils)Neurological disturbancesFunctional adaptability Lack of anterior seal
Feeding practicesInduced due to other habitsHereditary
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EtiologyTongue size
Macroglossia
Anesthetic throat Congenital physiologic discrepancies- Abnormal
handling of bolus and Tongue thrust
Soft diet- Disuse atrophy of musculature
Trauma Persistent traumatic condition leading to abnormal
deglutition
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DiagnosisHistory Sibling, Parent
Previous respiratory infections , sucking habits , neuromuscular problem
Examination Lips - separation Tongue
Size
Macroglossia - Lateral scalloping
Shape
Asymmetry
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DiagnosisAbnormal tongue
posture Retracted tongue
Withdrawn tongue tip from
anterior
Posterior openbite with
lateral spread
10 % of all children
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DiagnosisProtracted tongue Result in openbite Types
Endogenous
Retention of infantile swallow
Continuous presence of tonguebetween teeth
Excessive vertical anterior face
height
Acquired
Transitory adaptation due to
enlarged tonsils or pharyngitis
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CLINICAL FEATURESExtra oral Lip posture
Lip separation
Mandibular movement
Upward and backward with tongue moving forward
Speech
Speech disorder
Sibilant distortion, lisping, problem in articulation ofs, n, m, t, d, l, th, z, v
Facial form
Increased Anterior face height
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Intraoral Tongue posture
Downward and forward
At rest- lower
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Malocclusion In relation to maxilla
Increased overjet
Generalized spacing
Maxillary constriction
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In relation to mandible
Retroclination or proclination of mandibular teeth
In relation to Intermaxillary relationship
Ant. Or post. Openbite
Posterior crossbite
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Treatment considerations Malocclusion
Correction of malocclusion
Speech defect
Speech therapy during elementary school yr.
Associated with other habits
Other habit correction
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TreatmentMyofunctional therapy
Speech therapy
Mechano therapy
Correction of malocclusion
Surgical treatment
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Myofunctional therapy: GarlinerGuidance of correct posture of tongue during swallowing by various exercises Mother delight exercise-
Placement of tongue tip in rugae area for 5 min
Orthodontic elastics and sugarless fruit drops
2 S ,4 S exercises
Identification of Spot
Salivating
Squeezing in spot
Swallowing
Other exercise
Whistling
Yawning
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Myofunctional therapy: GarlinerOne elastic swallow
Two elastic swallow
Lip exercise Tug of war and button pull exercise
Lip massage Lower lip over upper massage
Subconscious therapy Special time for reminding
Subliminal therapy
Placing reminder sign in sight during meal Autosuggestion
6 times swallow before sleeping
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Speech therapy Training of correct position of tongue
Articulation of speech
Repetition of words with S soundNot indicated before 8 yrsMechano therapy Purpose
Re-education of tongue position- Posterio-superior
Maintaining tongue in the confines of dentition
Maintaining the inter-occlusal distance
Prevention of over eruption and narrowing of maxillary buccal
segment
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Tongue Thrusting :TreatmentPreorthodontic trainer for myofunctional training Aids in correct positioning of tongue with the help of
tongue tags
Tongue guard
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Appliance therapy Removable appliance
Hawleys appliance Modifications
1. Active labial bow
2. Addition of palatal crib
Oral screen and vestibular screen
Double oral screen
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Treatment with myofunctional appliance Promote lip closure
Enlarge oral cavity
Move incisors
Improve relation among jaws, tongue, Dentitionand soft tissue
E. g
Activator
Bionator
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Fixed appliance Tongue crib
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Correction of malocclusion
Openbite
Removable
Frankel IV
Vestibular configuration
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Malocclusion - OpenbiteRemovable appliance
Modified activator- intrusionof molars
Fixed orthodontic treatment
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Mouth Breathing
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Mouth BreathingDefinition Sassouni (1971)- Habitual respiration through the mouth
instead of the nose
Merle (1980) -Suggested the term oro - nasal breathing
instead of mouth breathing
Incidence Common among 5 15 yr 85% nasal breathers suffer from some degree of obstruction
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Mouth Breathing- ClassificationFinn (1987) Anatomical
Short upper lip
Obstructive
Obstruction in nasal passage
Habitual
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Mouth Breathing: EtiologyDevelopmental and morphologic anomalies interfering nasalbreathing
Asymmetry of face
Hereditary
Size of nasal passage
Position of nasal septum
Abnormal development of nasal cavity, Nasal turbinates
Abnormally short upper lip
Under developed or abnormal facial musculature
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Mouth Breathing: EtiologyPartial obstruction due to Deviated nasal septumBirth injury
Localized benign tumor
Narrow maxilla
Traumatic injuries to nasal cavity
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Mouth Breathing: EtiologyInfection and inflammation
Ch. Inflammation of nasal mucosa
Ch. Allergic stomatitis
Ch. Atrophic rhinitis
Enlarged adenoids, tonsils
Nasal polyps
Genetic factor
Ectomorphic child
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Mouth Breathing- Clinical featuresGeneral features Purification of inspired air
Pulmonary development
Functional airway- nasal resistance- diaphragm and intercostal
muscles - -ve pressure - Pigeon chest
Lubrication of esophagus
No mucous gland
Dry - Esophagitis
Blood gas constituent
20 % more CO2
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Mouth Breathing: Clinical featuresAdenoid facies Long narrow face Narrow nose and nasal passage
Nose tipped superiorly
Flat nasal bridge
Flaccid lips
Short upper lip
Collapsed buccal segment of maxilla
High palatal vault
Dolicofacial pattern
Expressionless face
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Mouth Breathing: Clinical featuresDental effect
Protrusion with spacing of upperincisors
Decreased overbite
Openbite
Lower tongue position
Posterior cross bite
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Mouth Breathing: Clinical featuresIncreased overjet
Constricted maxillary arch
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Mouth Breathing: Clinical featuresNarrow palate and cranial vaultNarrow long face
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Mouth Breathing: Clinical featuresLips
Incompetent upper lip
Everted, heavy lower lips
Voluminous curled lower lips
Gummy smile
External nares
Slit like external nares with narrow nose
Atrophied nasal mucosa
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Mouth Breathing: Clinical featuresGingiva Ch. Keratinized marginal gingivitis
Classic rolled margin and enlarged interdental papilla
Heavy plaque deposition
Salivary flow and bacterial overgrowth
Periodontal disease Pocket formation and interproximal bone loss
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Mouth Breathing: Cl FOther effects Narrow maxillary sinus and nasal cavity
Turbinates- Swollen and engorged
Atrophic nasal mucosa
Speech- Nasal tone
Infection of Lymphoid tissue
Otitis media
Dull sense of smell
Loss of taste
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Mouth Breathing : DiagnosisHistory
Lip apart posture
Tonsillitis, allergic rhinitis, otitis media
Examination
Observation of breathing
Lip posture
Reflex alar contraction- dilation of external nares Nasal orifices
Mouth Breathing: Diagnosis
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Clinical test
Mirror test- fog test
Masslers butterfly test
Water holding test
Inductive plethysmography
Airflow through nose and mouth
Cephalometrics
Nasopharyngeal space, adenoids,
skeletal pattern
Rhinomanometry
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Mouth Breathing: TreatmentElimination of cause
Removal of nasal or pharyngeal obstruction
Interception of habit
Exercises Physical deep inhalation exercise
Lip
Upper lip extension exercise
Upper, lower lip combined exercise
Playing wind pipe
Disc holding exercise
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Mouth Breathing: TreatmentCorrection of malocclusion Cl I
Oral screen
Cl II Div-1
Noncrowded dentition (5-9 yr) Monobloc
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Mouth Breathing: TreatmentCl III Interceptive chin cap
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Lip habits
Habits that involve manipulation of lips and perioral structures.
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p f p p
Higher predominance of lower lip
Vary with imagination of child Basic type ( Schneider 1982)
Wetting of lip with tongue Pulling the lip into mouth between teeth
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Lip HabitsLip sucking-
Entire lower lip with vermilion border pulled in mouth
Mentalis habit- Vermilion border everted
Lip Habits:Etiology
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Association with digit sucking (Graber)
Increased overjet
Lip seal
Incompetent upper lip
Position of lower lip behind upper incisors
negative pressure for swallowing
Lip Habits: Etiology
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Malocclusion
Cl II Div-1 Large overjet and overbite
Emotional stress Increases the intensity and duration
Lip Habits: Clinical Features
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Lip Reddened , irritated, chapped area below vermilion
border
Vermilion border
Relocation outside the mouth due to constant wetting
Redundant and hypertrophied
Ch. Herpetic infection
Cracking
Lip Habits: Clinical Features
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Accentuated mentolabial sulcusMalocclusion Winder -- force equilibrium
Lip tongue
1. Protrusion of upper incisors1. Flaring with interdental spacing
2. Retrusion of lower incisors1. Collapse with crowding
3. Openbite
Lip Habits: Treatment
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Not self- correcting
Deleterious with age
Treating primary habit Correction of digit sucking followed by habit reminder
(Hawleys appliance)
Chemical reminder
Correction of malocclusion ClI Div-1-
Fixed or removable appliance
Activator
Lip Habits: Treatment
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Appliance therapy
Oral shield Cl I malocclusion
Lip exercise for improvement of lip
tonus
Lip bumper
Prohibits excessive force on
mandibular incisors
Reposition of lower lip away from
upper incisors
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Bruxismwww.dentistpro.org to find more
Bruxism-Definitions
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Ramfjord(1991)
Habitual grinding of teeth when the individual is not
chewing or swallowing
Rubina(1986) Nonfunctional contact of teeth which may include
clenching, gnashing and tapping of teeth
Vanderas(1995) Nonfunctional movement of mandible with or without an
audible sound occurring during the day or night
Bruxism: Etiology
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Local theory Reaction to an occlusal interference
High restoration, irritating dental condition
Disturbed afferent impulses from PD
CNS Cortical lesions, cerebral palsy, mental retardation
Bruxism: Etiology
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Systemic
Intestinal parasitesGI disturbance
Nutritional deficiencies - Mg deficiency
Enzymatic distress
Allergies - Food
Endocrine disorder
Bruxism: Etiology
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Psychological theory
Associated with feeling of anger, aggregation
Stress
Emotional statusinability to express the emotion
Other causes
Genetics
Occupational factors
Enthusiastic student , compulsive overachiever
Competition sports
Bruxism Ped. Dent:1995;7-12
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Causal hypothesisMalocclusion can initiate and maintain forcefulgrinding or clenching
Mechanism
Occlusal discrepancies
PD mechanoreceptorsSensory input
Activation of jaw closing muscles
Clenching or grinding
Bruxism
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Indicators
Presence of dental wear -
Attrition
Bruxofacet
Grinding or clenching
Bruxism
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Clinical manifestation
Occlusal trauma mobility
Morning time
Tooth structure Nonfunctional occlusal wear
Sensitivity
Atypical shiny wear facet with sharp
edges Pulpal exposure
# crown, restoration
Bruxism: Clinical Features
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Muscular tenderness Temporalis, Lateral pterygoid, masseter on palpation Fatigue on waking Hypertrophy of masseter
TMJ disturbances Crepitation , clicking , Restriction of mand. Movement Deviation of chin PainDull , unilateral
Bruxism: Clinical Features
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Headache Muscular contraction type
Other signs and symptoms Sounds- Grinding and tapping
Soft tissue trauma
Small ulceration or ridging on buccal mucosa opposite
the molar teeth
Bruxism: Treatment
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Occlusal adjustment Disappearance of habitual
grinding
Coronoplasty
High point correction
Occlusal splints (Night guard) Vulcanite splint to cover occlusal
surfaces
Reduction of increased muscle tone TMJ appliance
Prefabricated intra oral appliance for
TMJ disorder
Bruxism: Treatment
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Restorative Severe abrasion
Pulp therapy
Stainless steel crown
Psychotherapy Counseling
Tension relief
Habit awareness -Increase voluntary control
Bruxism: Treatment
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Relaxing training Tensing and relaxing exercise
Voluntary relaxation
Hypnosis
Behavior Conditioning
Physical therapy
Musculoskeletal pain and stiffness
Drugs Placebo
VapocoolantEthyl chloride for pain -TMJ
Local anesthetics - TMJ
Tranquilizers, sedatives, muscle relaxants
DiazepamAnxiety and alteration of sleep arousal
Tricyclic antidepressants- Reduce REM
Bruxism: Treatment
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Biofeedback
Positive feedback to learn tension reduction EMG
Electrical method Electro galvanic stimulation
Muscle relaxation
Orthodontic correction Cl II,III, Ant. Openbite, Crossbite
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Conclusion
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If the orthodontist gets the oppurtunity to examine the child beforethe detrimental effect of the habit manifests itself, as derangementof occlusion and unfavorable esthetics, it is his or her responsibilityto provide timely intervention of the same.One of the most valuable services that can be rendered as part of theinterceptive orthodontic procedures is the elimination of such habitsbefore they can cause any damage to the developing dentition.
www.dentistpro.org to find more REFERENCES
http://www.dentistpro.org/http://www.dentistpro.org/ -
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Profitt WR: Contemporary Orthodontics.Robert E Moyers : Handbook of Orthodontics.Brauer J, Holt T. Tongue thrust classification. Angle Orthodontics.35(2): 106-112, 1965Ogaard, Larsson, and Lindsten : Effect of sucking habits onposterior crossbite. Am J Orthod 1994;161-166Ellingsen, Vandevanter, Shapiro and Shapiro : Temporal variationin breathing. Am J Orthod 1995 :411-417Meyers and Hertzberg : Bottle-feeding and malocclusion. Am JOrthod 1988 ;149-152Marks : Bruxism in allergic children. Am J Orthod 1980;48-59
Adieu..
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