Oral habites

DR: Tahani Jamal Al semah

Out line
• Introduction
• Definition , Effects, diagnosis and management of :
• Lip sucking
• Tongue thrust
• Mouth breathing
Introduction
• The laws of physics state if any object is subjected to a
set of forces but remains in the same position, any forces
must be in balance or equilibrium.
• the dentition is obviously in equilibrium because the teeth are
subjected to a variety of forces but do not move to a new
location under usual circumstances.
• if the balance between long-duration pressure from the
tongue versus lip or cheek pressure changes, tooth movement
would be expected

• E.g if restraining pressure by the lip or cheek is removed, the

teeth move outward in response to unopposed pressure from
the tongue
Teeth normally experience forces from masticatory
effort, swallowing, and speaking but do not move.?

• A (periodontal ligament [PDL] and alveolar bone) are

constructed to withstand heavy forces of short duration
• As with masticatory forces, the pressure magnitudes would be
great enough to move a tooth, but the duration is inadequate

• The result is that only light force of long duration (6 hours or so per
day) is important in determining whether there is enough of an
imbalance of forces to lead to tooth movement,

.
Definition
• Oral habit:
Dorland (1.963): Fixed or constant practice
established by frequent repetition.

Moyers: Habits are learned patterns of muscle

contraction, which are complex in nature.
Can habits affect development
of the jaws?

identical twins, aged 11. (A) Occlusal relationships in the thumb-sucking girl and (B)
her non– (C) Cephalometric tracings of the two girls superimposed on the cranial base
of the two girls., the cranial base morphology is nearly identical.
Note the forward displacement of not only the maxillary dentition but also the maxilla
itself.
• The severity of displacement of the teeth and investing
tissues depends on the following factors:
I. Duration: Amount of time spent on sucking: longer
the duration of each sucking period, greater is the
damage.
II. Frequency of indulgence: Number of times the
habit is practiced: Frequent and continuous
sucking is more damaging than occasional, short
time practice.
III. Intensity of force: Amount of force exerted on teeth
while practicing the habit: More the force applied,
greater is the damage
Thumb sucking

• Definition :
• Gellin (1978): “placement of thumb or one or more fingers in
varying depth into the mouth.”
•
Moyer: “Repeated and forceful sucking of thumb with
associated strong buccal and lip contractions.”
• .
Thumb sucking

• It can be seen as early as 29th week of intrauterine life.

• It may disappear spontaneously during normal growth
between the ages of 1 and 3½ years
• as a general rule, sucking habits during the
primary dentition years have little if any long-term effect.

habits persist beyond the time that the permanent teeth

begin to erupt, malocclusion is the likely result

•
• The severity depend on Duration, Frequency and Intensity of
force
Children who suck vigorously but intermittently may
not displace the incisors much if at all, whereas others,
particularly those who sleep with a thumb or finger between
the teeth all night, can cause a significant malocclusion.
Effects of thumb sucking

➢ flared and spaced maxillary incisors

➢ lingually positioned lower incisors,

➢Increase overjet

➢ eruption of some incisors is impeded.

➢maxillary intercanine and intermolar width is narrowed,

resulting in a posterior crossbite with a V-shaped arch form

➢Anterior open bite,

Effects of thumb sucking
➢flared and spaced maxillary incisors, lingually positioned
lower incisors
The thumb or finger usually positioned at an angle so that it
presses lingually against the lower incisors and labially against
the upper incisors
Effects of thumb sucking
➢narrow upper arch ,posterior crossbite with a V-shaped arch
form
• Due to an alteration in the balance between cheek and
tongue pressures.
• the thumb is placed between the teeth lower
position of tongue tongue pressure against the
lingual of upper posterior teeth + cheek pressure against
these teeth is increased (buccinator muscle)
•
. Cheek pressures are greatest at the corners of the mouth,
this probably explains why the maxillary arch tends to become
V-shaped.
• A child who sucks vigorously is more likely to have a narrow
upper arch than one who just places the thumb between the
teeth
Effects of thumb sucking
anterior open bite due to :
➢interference with normal eruption of incisors
➢excessive eruption of posterior teeth
The interposed thumb directly impedes incisor eruption.
At the same time, the separation of the jaws alters the
vertical equilibrium on the posterior teeth, and as a result,
there is more eruption of posterior teeth

1 mm of elongation posteriorly
opens the bite about 2 mm anteriorly
1stmolars have been
elongated 2 mm(red tracing.)
the result is 4 mm of
separation of the incisors
If the thumb is placed on one side instead of in the midline, the
symmetry of the arch may be affected.

An asymmetrical increase in overjet in a

patient with a habit of sucking one finger on
the right hand.
Diagnosis
• History
• Extraoral Examination
Examination of digits may reveal the following:
Offending digits is exceptionally clean and readily
noted
The digit can be reddened or sometimes deformed.

Intraoral Examination
Same as described in the effects of thumb sucking
Management

• Consideration
• Non dental intervention
• Appliance therapy
• Corrective mechanotherapy
Management
Consideration :

• It may disappear spontaneously during normal growth between the

ages of1 and 3½ years.

• Mild displacement of the primary incisor teeth is often noted

in a 3- or 4-year-old thumb-sucker, but if sucking stops at this
stage, normal lip and cheek pressures soon restore the teeth to their
usual positions.
• Screening of patient for underlying psychological
disturbances and referral to professionals for counseling.
Management
Non dental intervention

If the habit persists after the permanent incisors

have begun to erupt
Patient wants to stop?
yes no

discussion between the child and the dentist that

expresses concern and includes an explanation of
the problems caused by the habit

No treatment
Parent try reward system

Reminder Therapy

Mechanical Chemical
methods method
Management
Non dental intervention
Reminder Therapy

1.Mechanical methods:

Thermoplastic thumb post that covers the offending digit.

Taping of the offending digit or tying it to the elbow.

an elastic bandage loosely wrapped around the elbow prevents
the arm from flexing and the fingers from being sucked.
If this is used, wearing it only at night and 6 to 8 weeks of intervention
should be sufficient. The child should understand that this is not
punishment.
Management
Non dental intervention
• Chemical methods: : Hot tasting or bitter flavored
preparations or distasteful agents are applied to the offending
finger/thumb.
such as
• Cayenne pepper

• Quinine

• Asafetida.
Management
Appliance Therapy.
• a removable reminder appliance
cooperation is important
is contraindicated if lack
of compliance is part of the problem

• Fixed
• As long as the habit stops before the eruption of the
permanent incisors, most of the changes resolve
spontaneously with the exception of posterior crossbite

Gradual closure of the open bite, without a need for further

intervention, usually occurs
in patients with normal facial proportions after habits stop.
 A patient aged 10 years with a
dummy-sucking habit: (a) at presentation; (b) 4
months after habit stopped.
Management of thumb
sucking
• Corrective mechanotherapy:
After cessation of the habit any residual malocclusion present is
treated by removable orthodontic appliances or fixed
Tongue Thrusting
Definition :

Tongue thrust is a forward placement of the tongue

between the anterior teeth and against the lower lip during
swallowing.
Classification

• Etiologic Classification :

I. Physiologic : This comprises the normal tongue thrust swallow

of infancy.

II. Habitual: is developed due to repeated placement of the

tongue.
•
III. Functional: When the tongue thrust mechanism is an adaptive
behavior developed to achieve an oral seal.
• E.g :as in cases with increased overjet,
•
IV. Anatomic : due to macroglossia (enlarged tongue).
Etiology
• Genetic Factors
Inherited hyperactivity of orbicularis oris with specific
anatomic configuration and neuromuscular activity.
• Persistence of Infantile Swallow Pattern
• Adaptive Learned Behavior
1) Improper bottle feeding.
2) Prolonged tenderness of gums or teeth and thus the child learns to keep
teeth apart during swallowing.
3) Prolonged tonsillar/upper respiratory tract infection, which causes
adaptive tongue patterns that are retained even after the infection
subsides.
4) Tongue held in open spaces during natural exfoliation of primary teeth
or extractions.
5) Prolonged thumb-sucking habit:
When there is no oral seal due to increased overjet or open bite
compensatory tongue thrust develops to establish oral seal for swallowing
act.
Effects of Tongue Thrusting
• proclination of Maxillary anterior.
• Increased overjet .
• Generalized spacing between the teeth.
• posterior cross bite as a result of lowered posture of tongue.
• Anterior open bite
• Posterior open bite—In case of lateral tongue thrust.
• It may be unilateral or bilateral
• Effect on speech: Hampered speech
Diagnosis
• History
Any upper respiratory tract infections
Digit-sucking habit
Neuromuscular problems
Swallow pattern in siblings and parents to check for
hereditary factor

• Tongue Examination
Tongue posture at rest:
1)It can be examined using lateral cephalogram or
2) by seating the patient upright. In these patients, tongue usually
assumes a lower posture at rest with the tip touching the cingulum/lingual
fossae of lower anteriors, instead of resting behind upper incisors.

Tongue activity/function observed during swallowing.

Management
• Considerations
Self-correcting tongue thrusting: by the time the
permanent anterior teeth erupts completely (7–8 years of age ).
Tongue thrusting without malocclusion or speech disturbance:
Treatment is generally not recommended
• Tongue thrusting with malocclusion: Orthodontic correction of the
malocclusion caused by tongue thrusting will usually eliminate the
tongue thrusting habit.

• Associated with other oral habits: If the patient has both thumb
sucking and tongue thrusting, the thumb sucking should be treated
first
Management
• Treatment

1) Training of correct swallow and posture of the tongue

a. Myofunctional exercises:
place the tip of the tongue in the rugae area for 5 min
and is asked to swallow.
b. Orthodontic elastics and sugarless fruits drop exercise:
This can be held by the tongue tip against the palate on the
rugae area.
Management
2) Appliance Therapy :
a). Habit-breaking appliance with tongue crib

b) Nance palatal arch appliance: In this appliance,

acrylic button can be used as a guide to place the
tongue in the correct position.

C )Oral screen.
Is tongue thrust an etiological factor for malocclusion
or it is a result ?
• A tongue thrust swallow is more likely to be the result of
malocclusion , not the cause.
• The abnormal pressure from forward resting posture of the tongue
, and the duration of this light pressure could affect tooth position,
vertically or horizontally., whereas if the postural position is normal,
the tongue thrust swallow has no clinical significance.

• The modern viewpoint is that tongue thrust swallowing

is seen primarily in two circumstances:
a) transitional stage in normal physiologic maturation; in younger
children with normal occlusion .
b) an adaptation to the space between the teeth. As in The presence
of a large overjet and anterior open bite.
. From equilibrium theory,Tongue thrust swallowing
simply has too short duration to have an impact on tooth
position.
Pressure by the tongue against the teeth during a typical
swallow lasts for approximately 1 second
A typical individual swallows
about 800 times per day while awake
only a few times per hour while asleep

The total per day = under 1000. seconds ̰ few minutes,

Which not nearly enough to affect the equilibrium
 Prevalence of anterior open bite, thumb-sucking, and tongue
thrust swallowing as a function of age.

• It shows, at every age above 6,

the number of children reported to
have a tongue thrust swallow
is about 10 times greater than the
number reported to have an
anterior open bite.
• It conclude that :
Tongue thrust swallow not always
implies an altered rest position and
will lead to malocclusion.
In a child who has an open bite,
tongue posture may be a factor, but
the swallow itself is not.
MOUTH-BREATHING HABIT

Definition
habitual respiration through the
mouth instead of the nose.”
Classification:

Obstructive
Habitual:
child continuously breathes through the mouth even
after the obstruction has been removed.
Anatomic:
is seen in those, whose short upper lip does not permit
complete closure without undue effort.
Etiology
• Facial Form: Genetic Predisposition
genetic type of tapering face and
nasopharynx, these children are more prone to have
nasal obstruction
Nasal Obstruction
a) Enlarged adenoids

b) Hypertrophy of turbinate

Intranasal Defects
Deviated nasal septum.
Nasal polyps.
Thick septum.
• breathing through the mouth rather than the nose,
could change the posture of the :
head,
jaw,
tongue.
• This in turn could alter the equilibrium of pressures on
the jaws and teeth and affect both jaw growth and tooth
position.
•
When breathe through the mouth, one must lower the mandible
and tongue and extend (tip back) the head.
• If these postural changes were maintained, three effects on growth
would be expected:
(1) anterior face height would increase, and posterior teeth would
super-erupt;

(2) unusual vertical growth of the ramus, the mandible would rotate
down and back, opening the bite anteriorly and increasing overjet

(3) increased pressure from the stretched cheeks might cause a

narrower maxillary dental arch.
Clinical Findings
Extraoral
➢ Adenoid facies: characterized by long, narrow face
with narrow nose and nasal passages.
➢ Dolichocephalic facial form: With vertical skeletal
growth pattern.
➢ Increased facial height.
➢ Short and flaccid upper lip with heavy and everted
lower lip.
➢ Incompetant lips.
➢ Gummy smile.
• Intraoral
1) Proclination of maxillary anteriors.
2) Increased overjet
3) Constricted maxilla with narrow-shaped palate.
4) Posterior crossbite.
5) Mandibular incisors may be retroclined.
6) anterior open bite
7) Mandible is distal in relation to maxilla.
8) Gingiva: Gingiva is hyperplastic, especially in relation
to maxillary anterior teeth due to continuous exposure
of the tissue to dry air. Marginal gingiva in this area is
rolled out and inter-dental papilla is enlarged.
Diagnosis

• History
• Clinical Examination:
a) Mirror test: used double-sided mirror
Test is positive: If fogging occurs on mirror
facing oral cavity
b ) Cotton test/Massler’s butterfly test:
Butterfly-shaped cotton strand is placed over the upper
lip below nostrils.
Test is positive: If cotton flutters down

c) Water test:
patient is asked to drink water
and retain it for a period of time
Test is positive: If patient is unable to hold the
water in the mouth,
Diagnosis
Cephalometric Analysis : it reveals

• Increased mandibular plane angle

• Vertical growth pattern
• Retrognathic maxilla
• Retrognathic mandible.
Diagnosis
Rhinomanometry:
• is to establish how much of the total air flow goes
through the nose and how much through the mouth
using
• This allows the percentage of
nasal or oral respiration to be calculated.
Management

• Considerations
1. ENT referral: ENT referral for the management of
pharyngeal obstruction.

2. Correction of mouth breathing: Mouth breathing

should be corrected during mixed dentition period to
prevent or correct its harmful effects on occlusion.

4. Symptomatic treatment: Symptomatic treatment of

gingival and periodontal tissue should be done.
Management
• Treatment
1. Elimination of cause: Any nasal or pharyngeal
obstruction should be removed by referring the patient
to the ENT surgeon.
2. Interception of habit: If the habit continues even
after the removal of the obstruction then it should be
corrected.
Correction can be done by the means of the following:
a. Exercises: Breathing and lip exercises are instructed
in patients with no physiologic cause.
b. Wind instrument: Playing a wind instrument may
be a useful interceptive orthodontic procedure.
Management
3. Rapid maxillary expansion:
Rapid maxillary expansion, removable or fixed orthodontic
appliances, helps in widening the constricted arches
thereby increasing the nasal airflow and decreasing
nasal resistance
Management
• 4. Oral screen:
The most effective way to establish nasal
breathing is to prevent air from entering the oral cavity.
To do this either the lips or the mouth should be closed.
For this purpose, oral screen can be used
Studies

• cephalometric tracings for a

group of Swedish children
requiring adenoidectomy for
medical purposes, compared
with a group of normal
controls.
The adenoidectomy group had
statistically significantly greater :
anterior face height and steeper
mandibular plane angles than
the controls, but the differences
were quantitatively not large.
• Comparison of mandibular plane angles in a group of post
adenoidectomy children compared with normal controls.
• Note that the differences existing at the time of
adenoidectomy decreased in size but did not totally disappear.