HABITS

PERNICIOUS HABIT

• A habit is considered to be pernicious when they

interfere with the child’s physical, emotional or
social functioning.

• The severity of the ill-effects of a habit depends

upon (Trident of factors)
• Frequency—How often the habit is performed (number of
times per day).
• Intensity—How vigorously is it practiced?
• Duration—Total number of years/months/weeks/days since
the habit is being performed.
 HABITS CLASSIFICATIONS

• Earnest Klein (1971)

• Empty (Non intentional habits): psychological disturbance
• Meaningful (Intentional habits) : no need for support

• Brash
• Purely muscular, e.g. tongue thrusting, lip sucking.
• Combined activity of the muscles of jaw, mouth and thumb, e.g.
thumb sucking.
• Muscular action combined with introduction of passive object
into the mouth, e.g. pencil chewing.
• Habits in which muscles of the mouth and jaw take no active
part, the effect on the position of the teeth are produced by
extraneous pressure, e.g. abnormal pillowing.
• Functional disturbance, e.g. mouth breathing.
3
 HABITS CLASSIFICATIONS

• Morris and Bohana (1969)

• Non pressure habits- mouth breathing
• Pressure habits-
• Sucking habits-lip sucking, thumb and digit sucking
• Biting habits- nail biting, needle holding
• Postural habits- chin rest, pillow rest
• Biting habits—pencil biting, etc.
 HABITS CLASSIFICATIONS

• Sydney Finn (1975)

• Compulsive : fixation in child, deep seated, psychological cause,
child security, threatened
• Non- compulsive: easily added or dropped, need continual
behavior modification, no abnormal emotional effects

• Sydney Finn
• Primary
• Secondary

5
 HABITS CLASSIFICATIONS

• William James
• Useful (suckling, nasal breathing)
• Non- useful/ Harmful (mouth breathing, tongue thrusting)

6
BUCCINATOR MECHANISM

Tongue

7
DIGIT SUCKING HABIT
 DIGIT/ THUMB SUCKING HABIT

Sucking reflex

First coordinated
neuromuscular activity of
infant
29 week of I.U. life

Normal: 1- 3.5 years

>50 % preschool children

show thumb sucking

THUMB SUCKING HABIT

 DEFINITION

According to Gellin

―it is the placement of thumb or one or more fingers

in varying depths into the mouth‖

THUMB SUCKING HABIT

 COOK CLASSIFICATION

• The thumb pushes the palate in a vertical direction

α and displays only little buccal wall contractions
(sucking action is minimum or nil)
group • Characteristic features: deep palate with no posterior
crossbite.

β • Strong buccal wall contractions are seen and

a negative pressure is created resulting in

group posterior crossbite.

• Alternate positive and negative pressure is

γ created.

group • Posterior crossbite may be a feature

THUMB SUCKING HABIT

Little / no
buccal wall contraction

Buccal wall contraction

SUBTELNY’S CLASSIFICATION (1973)

Type A • Whole digit placed in mouth pad of thumb pressing

over the palate
(50%) • Maxillary & mandibular anteriors contact present

Type B • Thumb placed in to oral cavity with out touching

vault of the palate
(13-24%) • Maxillary & mandibular anteriors contact

• Thumb placed in to mouth just beyond first joint

Type C contacts hard palate
(18%) • Maxillary incisors in contact
• No contact with mandibular incisors
Type D
• Very little portion of thumb placed in to mouth
(6%)
THUMB SUCKING HABIT
SUBTELNY’S CLASSIFICATION (1973)
 ETIOLOGICAL THEORIES

• Freudian / Psychosexual/Psychoanalytical theory

(1905)

• Learning theory (Davidson, 1967)

• Oral drive theory (Sears and Wise, 1982)

• Benjamin’s Theory (rooting reflex)

THUMB SUCKING HABIT

 CLINICAL FEATURES

The type of malocclusion seen is dependent on the

• Position of the digit

• Associated contraction of the musculature
• Mandibular position
• Facial skeletal pattern
• Duration, intensity and frequency

THUMB SUCKING HABIT

 CLINICAL FEATURES

Digits
• Short clean finger/ thumb nail (dish pan thumb)
• Fungal infection, keratotic lesions—on the thumb

THUMB SUCKING HABIT

THUMB SUCKING HABIT
 CLINICAL FEATURES

• Altered equilibrium: Abnormal muscle

activity

• Upper incisors labially

• Lower incisors lingually
• Increased overjet
• Hypotonic upper lip and hyperactive
lower lip
• Tongue placed inferiorly, Cheek pressure
increased leading to posterior crossbite
due to maxillary arch contraction (V
shaped maxillary arch)
• Narrow nasal floor and high palatal vault

• One side thumb: asymmetry

THUMB SUCKING HABIT 20

 Decreased over bite/ Open
bite

 Associated with simple

tongue thrust, which is an
adaptive response to open
bite

 Posterior teeth eruption

 If stopped: may normalize

THUMB SUCKING HABIT 21

• Maxilla protrusion
• Mandibular retrusion
• Excessive mentalis muscle contraction during
swallowing.
• Increased anterior facial height (normal posterior
facial height)
• Convex/ Straight soft tissue profile
• Speech of the child - normal / altered
• Saddle nose (due to pressure of index finger)

THUMB SUCKING HABIT

PHASES OF DEVELOPMENT OF THUMB
SUCKING HABIT

• Extends from birth to 3 years

Phase • Normal and subclinically significant sucking

1 • Preventive measures can be instituted

•Extends from 3 to 6-7 years

Phase •Clinically significant sucking.

2 •Habit may be meaningful or empty

•Necessary to manage or correct habit at this stage

•Intractable sucking
Phase •More serious

3 •May require psychotherapy

 TREATMENT

• Psychological therapy
• Reminder therapy
A) Extra oral approaches
B) Intra oral approaches
• Reward

THUMB SUCKING HABIT

 PSYCHOLOGICAL THERAPY
• First step  make child understand that habit is causing problem & needs to be
stopped.

• Second step  differentiate whether the habit is meaningful (treating the etiology
first ) or empty

• No threats or shamming should be done

• Audio-visual Aids: Photographs, video or casts of other child before and after
treatment is shown.

• Dunlop β hypothesis: The patient is made to sit in front of the mirror and asked to
suck his thumb. This will make him realize, how awkward he looks and wants to stop
sucking his thumb.

• Child is given a card to score number of times he has sucked his thumb. After 2
weeks it is assessed to study severity of the habit. Process of keeping record will tend
to reduce number of times the child sucks thumb.

THUMB SUCKING HABIT

 REWARD THERAPY

• When the child agrees to stop the habit, he/she is

asked to maintain a calendar/ card
• The child marks the dates when he/she refrains from
the habit.
• The child is then rewarded based on the number of
marks.

THUMB SUCKING HABIT

 REMINDER THERAPY

• When reward system fails

• Bitter substance(asafeotida, neem paste, pepper)
/nail polish applied on thumb
• Habit reminders: In cooperative patients
• Thumb guard made of acrylic
• Palatal bar, hay rake
• Bluegrass appliance
• If nocturnal component, an elastic bandage
wrapped loosely from middle of the forearm to
biceps area to prevent thumb reaching mouth

THUMB SUCKING HABIT

THUMB SUCKING HABIT
 BLUEGRASS APPLIANCE
• Haskell and Mink
• A modified, six-sided roller
machined from Teflon, which
permits purchase of tongue, is
constructed to skip over 0.045-inch
stainless steel wire that is soldered to
molar orthodontic bands

THUMB SUCKING HABIT

 OPEN BITE DUE TO THUMB SUCKING

• The occurrence of an anterior open bite is often related,

initially at least, to a thumb- or finger-sucking habit.
• After the space has been created in the anterior region,
it is retained by thrusting the tongue forward or merely
allowing the tongue to occupy the space.
• According to Gellen, if an open bite has its origin in the
primary dentition and will later close spontaneously,
initial closure begins by 10 years of age in 90%, of
children."
• Thus the dentist may be justified in waiting until the child's
tenth birthday before taking active steps to correct an
anterior open bite.

THUMB SUCKING HABIT

 PORTER APPLIANCE
(SOLDERED W ARCH )
• For the correction of posterior crossbites
• Anterior crossbites can also be corrected by
extension of the arm to include the canine, laterals,
and centrals.
• May simultaneously function as a reminder
appliance in some posterior crossbites associated
with thumb sucking.
TONGUE THRUST HABIT
 CLASSIFICATION

According to Moyer’s

1. Normal swallow
• Infantile swallow
• Adult swallow
2. Simple tongue thrust
3. Complex tongue thrust
4. Retained infantile swallow

TONGUE THRUST HABIT

 CLASSIFICATION

According area of tongue thrusting

1. Anterior
2. Lateral

TONGUE THRUST HABIT

 INFANTILE SWALLOW

• Maturation of oral function is characterized as a gradient from

anterior to posterior. Lips are mature at birth

• At birth the tongue protrudes anteriorly between the gum

pads with tongue tip against lower lip beneath the nipple to
establish lip seal (SUCKLING)

• Therefore the infant swallows viscerally for the first 1 to 2 years

of age

• Mandible stablised by muscles of VII nerve innervation: facial

muscles

• Relaxation of elevators (mouth is wide open)

TONGUE THRUST HABIT 36

 ADULT SWALLOWING PATTERN

• Physiologic transition in swallowing begin during the first

year of life and normally continues till 4 to 5 years

• A mature swallow pattern is characterized by relaxation

of the lips, placement of the tongue behind the maxillary
incisors, and elevation of the mandible until posterior
teeth are in contact

• Mature swallow: Mandible stablised by muscles of V

nerve (trigeminal) innervation: elevators (contraction)

• If infantile swallow persists beyond the fourth year, it is

considered as an orofacial dysfunction

TONGUE THRUST HABIT 37

 TONGUE THRUSTING

Simple tongue thrusting (teeth together swallow)

• Mandible stabilized by elevators
• Slight contraction of facial muscles
• Posterior teeth are in stable interdigitation

Complex tongue thrusting (teeth apart swallow)

• Mandible not stabilized by elevators
• Facial muscles active
• Poor occlusal interdigitation

Retained infantile swallow

• Facial muscles active
• Very poor prognosis

TONGUE THRUST HABIT 38

 SIMPLE TONGUE THRUSTING
(TEETH TOGETHER SWALLOW)
• Mandible stabilized by elevators

• Slight contraction of facial muscles, contraction of

lip, mentalis (So when the child swallows tight
pursing of the lips with puckering of the chin due to
mentalis contraction is seen)

• Well-circumscribed anterior open bite

• Posterior teeth are in stable interdigitation

• Seen along-with thumbsucking habit

TONGUE THRUST HABIT
 COMPLEX TONGUE THRUSTING
(TEETH APART SWALLOW)
• Mandible not stabilized by elevators

• Facial muscles active (Combined lip, facial and

mentalis contraction)

• Poor occlusal interdigitation with generalized

anterior open bite is characteristic

• Tongue thrusts in between the teeth

• Likely to be mouth breathers

TONGUE THRUST HABIT

RETAINED INFANTILE SWALLOW

• Due to persistence of the infantile swallow

• Usually occlude on one molar in each quadrant

• Strong contraction of facial muscles during swallowing

• Tongue protrudes markedly and is held between all the

teeth during the initial stages of the swallow

• Expressionless face

• Children restrict themselves to soft diet

TONGUE THRUST HABIT

 Examination Normal swallowing Tongue thrusting

Patient seated • Mandible rises as teeth • The teeth are apart

upright: A little are brought together • Lips are pursed tightly
water is placed in • The lips touch each other and active contraction
patient’s mouth lightly showings scarcely is seen
and asked to any contraction • Contraction of muscles
swallow • Facial muscles do not of facial expression is
show any marked clearly seen
contraction
Examiners hand is Temporalis No temporalis
lightly placed over Muscle contracts as the Contraction can be felt
the temporalis mandible is elevated
And the patient is
asked to swallow
the water

The lower lip is Patient is able to swallow Swallow will be inhibited, as

lightly held with normally strong mentalis and lip
thumb and finger contractions are needed
And the patient is for mandibular stabilization
asked to swallow and water will spill out of
water mouth
42
 CLINICAL FEATURES

• Proclination and flaring of incisors resulting in midline

diastema

• Anterior open bite/ Lateral open bite

• Short and flaccid upper lip

• Posterior crossbite

• Speech disorders , such as sibilant distortions, lisping,

problems in articulation of s, n, t, d, l, th, z, v sounds

TONGUE THRUST HABIT

 PROGNOSIS

• Simple tongue thrust — Excellent

• Complex tongue thrust — Good

• Retained infantile swallow — Very poor

TONGUE THRUST HABIT

 MANAGEMENT

• Tongue and swallowing exercises

• Habit breaking appliances

TONGUE THRUST HABIT

 MANAGEMENT

• Although appliances are often recommended for the

treatment of tongue thrust, myofunctional therapy
should be attempted first.

• Andrews recommends that the patient be instructed to

practice swallowing correctly 20 times before each
meal. Holding a glass of water in one hand and facing a
mirror, the child takes a sip of water, closes the teeth into
occlusion, places the tip of the tongue against the
incisive papilla, and swallows.

• This is repeated and each time is followed by the

relaxation of the muscles until the swallowing progresses
smoothly.

TONGUE THRUST HABIT

 SWALLOWING EXERCISES

• The patient is instructed to put the tip of the tongue

at the correct position and swallow with lips pursed
and teeth in occlusion. This helps the patient to
learn a new reflex on the conscious level (40
times/day in 2-3 sessions)

• The patient can be guided regarding the correct

posture of the tongue during swallowing by the use
of sugarless fruit drop and orthodontic elastics (one
or two elastic swallow)

TONGUE THRUST HABIT

 SWALLOWING EXERCISES

• The patient is instructed to put the tip of the tongue

at the correct position and swallow with lips pursed
and teeth in occlusion. This helps the patient to
learn a new reflex on the conscious level (40
times/day in 2-3 sessions)

• The patient can be guided regarding the correct

posture of the tongue during swallowing by the use
of sugarless fruit drop/ sugarless mint(successful
management of simple tongue thrusting) and
orthodontic elastics (one or two elastic swallow)

TONGUE THRUST HABIT

ONE OR TWO ELASTIC SWALLOW
 4S EXERCISE
• Spotting exercise (1S) - Spot should be the rest
position of the tongue
• Salivation exercise (2S) - The tongue is placed on
the spot, which results in salivation
• Squeezing exercise (3S) - The tongue is squeezed
vigorously with the teeth closed against the spot
followed by relaxing
• Swallowing exercise (4S) – After squeezing, the next
step is to swallow the spot

This new swallowing pattern should be practiced at

least 40 times a day  control of reflex is transformed
from conscious to unconscious level
 OTHER EXERCISES

• Whistling
• Reciting count from 60-69
• Gargling
• Yawning

LIP EXERCISES
• Tug of war and button pull exercises
• Oral screen exercises
• Lip massage
 APPLIANCE THERAPY

• After the patient has trained the tongue and

muscles to function properly during swallowing, a
mandibular lingual arch with a crib or an acrylic
palatal retainer with a fence may be constructed as
a reminder to position the tongue properly during
swallowing

• The appliance therapy is initiated for children

above 9 years

TONGUE THRUST HABIT

TONGUE THRUST HABIT
MOUTH BREATHING
 CLASSIFICATION

• Sydney Finn (1987)

• Anatomic (e.g. short upper lip, DNS)

• Obstructive (enlarged adenoid, nasal polyps, etc.)
• Habitual

MOUTH BREATHING HABIT

PIGEON FACE

56
 CLINICAL FEATURES
Facial appearance of a child with mouth breathing habit
is termed as 'Adenoid Facies’ and is characterized by
• Long narrow face, narrow nose and nasal passage
• Flaccid and short upper lip, everted lower lip
• Dolichofacial skeletal pattern
• Nose tipped superiorly
• External nares - Disuse atrophy
• Slit like external nares with a narrow nose
• Palatal plane upwards anteriorly
• Expressionless face

MOUTH BREATHING HABIT

• Labial flaring of the maxillary incisors
• Increased onerjet
• Narrowed maxillary arch
• Mouth breathing gingivitis (Anterior marginal gingivitis )
• Anterior open bite
• Increased caries incidence in maxillary anterior teeth
• Narrowed, atrophy nasal mucosa
• Nasal tone of speech
• Dilution of smell
• Bacteriostatic activity decreased
• Defective hearing (hyperplastic adenoids)
 EXAMINATION

• Observe the patient unknowingly while at rest,

• In a nasal breather: The lips touch lightly
• But in a mouth breather: The lips are kept apart
• Patient is asked to take deep breath
• Nasal breather keeps the lips tightly closed
• Mouth breather takes a deep breath, keeping the mouth
open.
• Ask the patient to close the lips and take a deep breath
through the nose.
• Nasal breather: Dilatation and contraction of nares is present
• Mouth breather: No change the size or shape of the external
nares.

MOUTH BREATHING HABIT

 EXAMINATION

• Butterfly test(Massler’s) : Take a piece of cotton and

shape it into a butterfly. Place it on the philtrum and
check for the movement of the cotton fibers. If they are
moving in a direction towards the nose then the patient
is a mouth breather.
• Two surface mirror test: A double sided mouth mirror is
taken. It is kept on the philtrum. If the fog if formed on
the mirror facing the mouth, then the patient is a mouth
breather.
• Water holding test: The patient is asked to hold a
mouthful of water for few minutes without swallowing. If
the patient is a mouth breather he/she will not be able
to hold the water in the mouth for long period.

MOUTH BREATHING HABIT

 DIAGNOSIS

• Inductive plethysmography (Rhinomanometry)

• Air flow transducer
• Determines total nasal airflow (Rhinomanometry) & oral
airflow (respirometry)

• Cephalometrics:
• Size of adenoids
• Amount of nasopharyngeal space

• SNORT (Simultaneous nasal & oral respirometric

technique) Gurley & Vig (1982)
• Quantitative assessment of oral & nasal air flow
 TREATMENT

• Identification and correction of nasal obstruction.

• Physical exercise
– Respiratory exercise
– Lip exercise—horn and flute
– Stretching and twisting of upper lip
• Mechanical—oral screen

• Correction of malocclusion

MOUTH BREATHING HABIT

• Deep breathing, playing wind instruments

• Lip exercises: 30 mins per day

• Holding thin objects: sheet of paper, pencil
• Button pull exercises, Tug of war, oral screen
• Lip massaging, holding & Pumping of water
• Taping lips together at night: surgical tape
 Lip pulling exercise Lip pressing exercise

Lip puffing exercise Card pulling exercise

BUTTON PULL EXERCISE
 ORAL SCREEN

Modifications:
– If the patient feels difficult to
breathe, then multiple holes
can be made that are closed
one by one over a period of
time.
– A metallic ring is made and
placed in the midline of the
appliance which will help to
hold the oral screen (Hotz
modification).
– Double oral screen can be
given with a similar additional
lingual screen in tongue
thrusting habit.

MOUTH BREATHING HABIT

1. Complex tongue thrust swallow is characterised by all except
• Contraction of lip, facial and mentalis muscle
• Anterior open bite
• teeth apart swallow
• Temporalis contraction

2. Patient with lower lip biting habit, choice of appliance is

• Lip bumper
• Denholtz appliance
• Herbst appliance
• Jasper jumper

3. Which of the following is not a sequelae of thumb sucking

• Deep bite
• Proclined upper incisors
• Unilateral posterior cross bite
• Bilateral posterior cross bite
4.