Bon jour

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CONTENTS
Introduction Definitions Theories of development Classification Thumb sucking Tongue thrusting Mouth breathing Lip habits Bruxism

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INTRODUCTION
Oral habits in children bring about harmful unbalanced pressures to bear upon the immature, highly malleable alveolar ridges, the potential changes in position of teeth, and occlusions, which may become decidedly abnormal if these habits are continued for a long time. The data on the etiology, age of onset, self-correction and treatment modalities for the various habits differ greatly. Hence for a successful management of the habit, an understanding of the dental implications and manifestations of the habit should be pursued.

Habit: Definitions
Moyer
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 habit

Classical Freudian theory (1905) Inherent psychosexual drive suggesting that digit sucking is a pleasurable erotic stimulation of the lips and mouth. The learning theory :(Davidson 1967) Non-nutritive sucking stems from an adaptive response.

Oral drive theory :( Sears and wise 1982) Strength of oral drive is in part a function of how long the child continues to feed by suckling.

Johnson and Larson 1993: Combination of psychoanalytic and learning theories which explains that all children possess an inherent biological drive for suckling.

Habits: Classification
James (1923)/ Graber

Useful Harmful

Useful habits: these include habits that are considered essential for normal function such as proper positioning of the tongue, respiration and normal deglutition. Harmful habits: these include habits that have a deleterious effect on the teeth and their supporting structures such as thumb sucking, tongue thrusting etc.

 Klein (1977)
Empty meaningful

Empty habits: they are habits that are not associated with any deep rooted psychological problems Meaningful habits: They are habits that have a psychological bearing.

Morris and Bohanna (1969)

Pressure habit Non pressure habit

Non pressure habits :

Habits which do not apply a direct force on the teeth or its supporting structures are termed non-pressure habits. An example 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

Finn (1987)
Compulsive habits Non-Compulsive habits

Compulsive habits
These are deep rooted habits that have acquired a fixation in the child to the extend that the child retreats to the habit whenever his security is threatened by the 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 easily learned and dropped as the child matures.

THUMB SUCKING

Definition
Gellin Placement of the thumb or one or more fingers in varying depths into the mouth

Synonyms
Thumb sucking/ Digit sucking/ Finger sucking

Classification
1-2yr 31\2 -4 yr No malocclusion Preschool malocclusion

Thumb sucking
Abnormal thumb sucking

Normal thumb
sucking

Psychological

Habitual

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 of mouth by stimulation Lasts for 7 mnths of age

Grading of classification
Thumb sucking
(Subtelny1973)

Type A

Type B

Type C

Type D

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 cavity without touching the vault of the palate. -Maxillary and mandibular anterior contact is maintained

3. Type C :- 18 % of the children - thumb is placed into the mouth

just behind the first joint and

contacts the hard palate and only the maxillary incisors.

4. Type D :- 6 % of the children

- very little portion of the thumb is

placed in the mouth

Causative Factors
Parent occupation Working mother No. of siblings

Order of birth of the child.

Social adjustment and stress

Feeding practices
Age of the child

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

Diagnosis
Evaluate emotional status History
Questions regarding frequency, intensity & duration Enquiry the feeding patterns, parental care of the child Presence of other habits

Some Important Questions to Consider/Ask

Can the habit be considered normal for a particular age/stage of development? Why has the child acquired the habit? What are the psychologic implications of allowing the child to continue the habit? 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?

Extra Oral Examination

Digits
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

Facial form:
Either straight or convex

Other features: Presence of other habits High incidence of middle ear infections, enlarged tonsils due to mouth breathing

Effects on the
maxilla:
Proclination of maxillary incisors.
Increased maxillary arch length Decreased palatal arch width Increase trauma to the maxillary central incisors

Effects on mandible: Retroclined mandibular anteriors

Effects on interarch relationship: increase overjet decreased overbite

posterior cross bite

unilateral or bilateral Class II malocclusion.

anterior open bite

Effect on tongue: Increased tongue thrust

Effect on Gingiva : Inflamed gingival tissues in the maxillary arch.

Gingiva is hyperplastic

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Radiological evaluation
Increased SNA

Other Effects
Risk to psychological health

Increase deformation of digits

More prone to trauma Speech defects especially lisping

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MANAGEMENT

Treatment Considerations
Psychological 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

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.

Appliance therapy
A. Removable appliance 1. Tongue spikes

2. Tongue guard
3. Spurs/ rake

Palatal crib

Spikes

Roller appliance

Management: Mechanical or reminder therapy

B. Fixed appliance Triple loop corrector: Barber (1960)
Modified palatal arch Similar to transpalatal arch with 3 loops

Blue grass appliance: Bruce Haskell (1991)

Between 7 13 yr Teflon roller appliance 3 6 month placement time

1. Quad helix 2. Hay rakes 3. Maxillary lingual arch with palatal crib.

Quad helix

Palatal crib

Hay rakes

Spurs/ rake

Maxillary lingual arch with palatal crib.

Tongue spikes

Tongue Thrusting

Definition
Brauer (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

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

Tongue Thrusting
Significance
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

Tongue Thrusting
Classification
Physiologic

Infancy
Habitual

Present after correction of malocclusion

Functional (Profit)

Overjet, Open bite

Anatomical

Macroglossia

Simple classification of TT
Simple TT Complex TT

Etiology
Retained infantile swallow URTI
Adenoids Lymphoid tissue (Tonsils)

Neurological disturbances
Functional adaptability
Lack of anterior seal

Feeding practices
Induced due to other habits Hereditary

Etiology
Tongue 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

Diagnosis
History
Sibling, Parent Previous respiratory infections , sucking habits , neuromuscular problem

Examination
Lips - separation Tongue

Size Macroglossia - Lateral scalloping Shape Asymmetry

Diagnosis
Abnormal tongue posture
Retracted tongue

Withdrawn tongue tip from anterior Posterior openbite with lateral spread

10 % of all children

Diagnosis
Protracted tongue
Result in openbite Types Endogenous

Retention of infantile swallow Continuous presence of tongue between teeth Excessive vertical anterior face height Acquired Transitory adaptation due to enlarged tonsils or pharyngitis

CLINICAL FEATURES
Extra oral
Lip posture

Lip separation
Mandibular movement

Upward and backward with tongue moving forward

Speech

Speech disorder Sibilant distortion, lisping, problem in articulation of s, n, m, t, d, l, th, z, v

Facial form

Increased Anterior face height

Intraoral
Tongue posture

Downward and forward At rest- lower

Malocclusion
In relation to maxilla

Increased overjet

Generalized spacing

Maxillary constriction

 In relation to mandible

Retroclination or proclination of mandibular teeth

In relation to Intermaxillary relationship

Ant. Or post. Openbite Posterior crossbite

Treatment considerations
Malocclusion

Correction of malocclusion

Speech defect

Speech therapy during elementary school yr.

Associated with other habits

Other habit correction

Treatment
Myofunctional therapy

Speech therapy
Mechano therapy Correction of malocclusion Surgical treatment

Myofunctional therapy: Garliner

Guidance 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

Myofunctional therapy: Garliner

One 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

Speech therapy
Training of correct position of tongue Articulation of speech Repetition of words with S sound

Not indicated before 8 yrs

Mechano 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

Tongue Thrusting :Treatment

Preorthodontic trainer for myofunctional training
Aids in correct positioning of tongue with the help of tongue tags

Tongue guard

Appliance therapy
Removable appliance

Hawleys appliance
Modifications 1. Active labial bow 2. Addition of palatal crib Oral screen and vestibular screen Double oral screen

Treatment with myofunctional appliance

Promote lip closure Enlarge oral cavity Move incisors Improve relation among jaws, tongue, Dentition and soft tissue E. g

Activator Bionator

 Fixed appliance
Tongue crib

Correction of malocclusion
Openbite

Removable

Frankel IV Vestibular configuration

Malocclusion - Openbite
Removable appliance
Modified activator- intrusion of molars

Fixed orthodontic treatment

Mouth Breathing

Mouth Breathing
Definition
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

Mouth Breathing- Classification

Finn (1987)
Anatomical

Short upper lip

Obstructive

Obstruction in nasal passage

Habitual

Mouth Breathing: Etiology

Developmental and morphologic anomalies interfering nasal breathing
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

Mouth Breathing: Etiology

Partial obstruction due to
Deviated nasal septum Birth injury Localized benign tumor Narrow maxilla

Traumatic injuries to nasal cavity

Mouth Breathing: Etiology

Infection and inflammation
Ch. Inflammation of nasal mucosa Ch. Allergic stomatitis Ch. Atrophic rhinitis Enlarged adenoids, tonsils Nasal polyps

Genetic factor
Ectomorphic child

Mouth Breathing- Clinical features

General 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

Mouth Breathing: Clinical features

Adenoid 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

Mouth Breathing: Clinical features

Dental effect
Protrusion with spacing of upper incisors Decreased overbite

Openbite
Lower tongue position Posterior cross bite

Mouth Breathing: Clinical features

Increased overjet

Constricted maxillary arch

Mouth Breathing: Clinical features

Narrow palate and cranial vault Narrow long face

Mouth Breathing: Clinical features

Lips
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

Mouth Breathing: Clinical features

Gingiva
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

Mouth Breathing: Cl F
Other 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

Mouth Breathing : Diagnosis

History
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

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

Mouth Breathing: Treatment

Elimination 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

Mouth Breathing: Treatment

Maxillothorax myotherapy
Macaray activator

Oral screen Newell 1912

Solid acrylic shield- rests against labial folds- confirms to vestibulefrenum relief. Worn in day & entire night Kraus breathing holes Rehak acrylic projection, wire loop Polyamide/ thermoplastic

Mouth Breathing: Treatment

Correction of malocclusion
Cl I

Oral screen

Cl II Div-1

Noncrowded dentition (5-9 yr) Monobloc

Mouth Breathing: Treatment

Cl III
Interceptive chin cap

Lip habits

Habits that involve manipulation of lips and perioral structures. 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

Lip Habits
Lip sucking Entire lower lip with vermilion border pulled in mouth

Mentalis habit Vermilion border everted

Lip Habits: Etiology

Association with digit sucking
Increased overjet Lip seal (Graber)

Incompetent upper lip

Position of lower lip behind upper incisors

negative pressure for swallowing

Lip Habits: Etiology

Malocclusion
Cl II Div-1

Large overjet and overbite

Emotional stress
Increases the intensity and duration

Lip Habits: Clinical Features

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

Accentuated mentolabial sulcus Malocclusion
Winder -- force equilibrium Lip tongue

1.

Protrusion of upper incisors

1. Flaring with interdental spacing

2.

Retrusion of lower incisors

1. Collapse with crowding

3.

Openbite

Lip Habits: Treatment

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

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

Bruxism
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Bruxism-Definitions
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
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
Systemic
Intestinal parasites GI disturbance Nutritional deficiencies - Mg deficiency Enzymatic distress Allergies - Food Endocrine disorder

Bruxism: Etiology
Psychological theory
Associated with feeling of anger, aggregation Stress Emotional status inability to express the emotion

Other causes
Genetics Occupational factors

Enthusiastic student , compulsive overachiever Competition sports

Bruxism
Causal hypothesis

Ped. Dent:1995;7-12

Malocclusion can initiate and maintain forceful grinding or clenching Mechanism

Occlusal discrepancies PD mechanoreceptors Sensory input

Activation of jaw closing muscles

Clenching or grinding

Bruxism
Indicators
Presence of dental wear Attrition

Bruxofacet

Grinding or clenching

Bruxism
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

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 Pain Dull , unilateral

Bruxism: Clinical Features

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
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
Restorative
Severe abrasion

Pulp therapy Stainless steel crown

Psychotherapy
Counseling

Tension relief
Habit awareness -Increase voluntary control

Bruxism: Treatment
Relaxing training
Tensing and relaxing exercise

Voluntary relaxation
Hypnosis
Behavior Conditioning Physical therapy

Musculoskeletal pain and stiffness

Drugs
Placebo Vapocoolant Ethyl chloride for pain -TMJ

Local anesthetics - TMJ

Tranquilizers, sedatives, muscle relaxants Diazepam Anxiety and alteration of sleep arousal Tricyclic antidepressants- Reduce REM

Bruxism: Treatment
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
If the orthodontist gets the oppurtunity to examine the child before the detrimental effect of the habit manifests itself, as derangement of occlusion and unfavorable esthetics, it is his or her responsibility to provide timely intervention of the same. One of the most valuable services that can be rendered as part of the interceptive orthodontic procedures is the elimination of such habits before they can cause any damage to the developing dentition.

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REFERENCES
Profitt WR: Contemporary Orthodontics. Robert E Moyers : Handbook of Orthodontics. Brauer J, Holt T. Tongue thrust classification. Angle Orthodontics. 35(2): 106-112, 1965 Ogaard, Larsson, and Lindsten : Effect of sucking habits on posterior crossbite. Am J Orthod 1994;161-166 Ellingsen, Vandevanter, Shapiro and Shapiro : Temporal variation in breathing. Am J Orthod 1995 :411-417 Meyers and Hertzberg : Bottle-feeding and malocclusion. Am J Orthod 1988 ;149-152 Marks : Bruxism in allergic children. Am J Orthod 1980;48-59

Adieu..

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