oral habits in orthodontics

8/3/2019 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


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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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


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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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oral habits in orthodontics

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