ORAL habits IN ORTHODONTICS AND ,MANAGEMENT .pptx

CONTENT
• INTRODUCTION TO ORAL HABITS
• HABITS DEFINITION
• CLASSIFICATION
• THUMB OR DIGIT SUCKING
• TONGUE THRUST
• MOUTH BREATHING
• LIP HABITS
• BRUXISM
• NAIL BITING
• CHEEK BITING
• MASOCHISTIC HABITS

INTRODUCTION TO ORAL HABITS:
• Oral Habits are the part of human development.
• Infants, children or adolescents well-being can be very much affected by oral
habits.
• Oral habit behaviors include digit sucking, pacifier sucking, lip sucking and
biting, nail-biting, bruxism, self-injurious, mouth breathing and tongue thrust.

• HABITS DEFINITION:
DORLAND(1957)-
Fixed or constant practice established by frequent repetition
BUTTERSWORTH(1961)-
Frequent or constant practice or acquired tendency, which has been fixed by
frequent repetition.

MOYER
Habits are learnt pattern of muscle contraction of a very complex nature.
CARL O BOUCHER(1963)-
Habit as a tendency towards an act or an act that has become a repeated
performance relatively fixed, consistent and easy to perform by an individual.

MATHEWSON(1982)-
Learned pattern of muscular contractions
FINN(1987)-
Defined habit as an act which is socially unacceptable

CLASSIFICATION
WILLIAM JAMES(1923)
1) Useful habit- Normal breathing, normal swallowing
2) Harmful habit- Mouth breathing, tongue thrusting
KINGSLEY(1958)
1) Functional- Mouth breathing
2) Muscular- Tongue thrusting
3) Combined- Thumb sucking
4) Postural- Chin propping, face leaning on hand, pillowing

MORRIS AND BOHANNA (1969)
1) Non pressure habit-Mouth breathing
2) Pressure habits-Thumb sucking, tongue thrusting
3) Biting habits-Nail biting
KLEIN(1971)
1) Empty hands- have no psychological association e.g., pencil biting
2) Have strong psychological affliction e.g., thumb sucking

• FINN AND SIM(1987)
1) Compulsive habit- acquired fixation in child e.g., thumb sucking
2) Non compulsive habit- easily added or dropped e.g.,passive placement of
thumb in the oral caviy
• FINN(1987)
1) Primary habit- thumb sucking
2) Secondary habit- nose probing, hair pulling

• THUMB SUCKING
It refers to placing the thumb or fingers into the mouth many times
every day and night, exerting a definite sucking pressure.
The habit can be repetitive and forceful associated with strong
cheek and lip contractions.
Several theories have been put forward to explain thumb sucking
habit:
1) FREUDIAN THEORY of psychoanalysis is linked to
psychosexual development of human. This theory regards thumb
sucking as a symptom of a deeper emotional disturbance or
neurosis.
ABNORMAL ORAL HABITS: A REVIEW N. SHAHRAKI, S. YASSAEI* AND M. GOLDANI MOGHADAMJOURNAL OF DENTISTRY AND
ORAL HYGIENE VOL. 4(2), PP.12-15, MAY 2012

2) PALERMO THEORY regards thumb sucking arising out of progressive
stimulus and rewards reaction which would spontaneously disappear unless it
becomes an attention getting mechanism.
3) SEARS ORAL DRIVE THEORY believes that the thumb sucking habit is
intimately related to the prolongation of breast feeding. The longer the baby is
breastfed, stronger will be its oral drive and more prone it is to thumb sucking.

BASED ON DEPTH OF PLACEMENT OF THUMB
(SUBTELNY, 1973)
TYPE A - Whole digit into the mouth with the pad of thumb, pressing over
the palate
Seen in 50% of children
TYPE B -Thumb not touching the vault of palate
Seen in 13-24% of children
TYPE C - Thumb is placed just beyond the first joint contacting hard palate
and maxillary incisors only.
seen in 18% of children
TYPE D - Very little portion into the mouth
seen in 6% of children

• ACCORDING TO MOYER:
• PHASE I: Normal and sub clinically significant sucking seen from birth to 3
years. If vigorous sucking persists at the end of phase 1,it may be carried to the
next phase, so preventive measures can be substituted by physiological barrier.
• PHASE II: Clinically significant sucking seen in 3-7 years of age. It may be due
to clinically significant anxiety and it is the best time to solve dental problems.
• PHASE III: Intractable sucking, if habit persist into phase 3,the problem is more
serious and will require psychotherapy.

• ACCORDING TO COOK:
ALPHA GROUP: The thumb pushes the palate in a vertical direction and displays
only little buccal wall contractions.
BETA GROUP: Strong buccal wall contraction seen and a negative pressure is
created resulting in posterior cross bite.
GAMA GROUP: Alternative positive and negative pressure is created.

• ETIOLOGY
PROLONGED
SUCKLING
FEELING OF
INSECURITY
IMPROPER/
INADEQUATE
NURSING
LEARNING
PATTERN WITHOUT
UNDERLYING
CAUSE
CHILD DEPRIVED
OF PARENTAL
LOVE AND CARE
ATTENTION
GETTING
MECHANISM
HABIT DURING
ERUPTION OF
TEETH
FEELING OF
PERSONAL
INADEQUACY
FEELING OF
HUNGER

Types of malocclusion that may develop depends upon a number of variables
• Position of the digit
• Associated oro-facial muscle contraction
• The position of the mandible during sucking
• The facial skeletal pattern
• Effect of digit sucking on oral structures: The effect of any pressure habit is
dependent upon the Trident of habit factors:
1) duration
2) frequency
3) intensity

• Digit sucking results in development of features of Class II malocclusion
• Proclination of the upper incisors is the first and most common sign of persistent
thumb sucking
• The proclination is self-maintaining because of the cushioning effect of lower
lips and upper lip becomes redundant
• These proclined incisors are prone to trauma.

• VERTICALAND HORIZONTAL EFFECTS:
The digit which is usually placed ventrally against the palate and against the
lingual surface of the upper incisors, is positioned at an angle and forms a fulcrum
which consists of the digit, the wrist and the forearm.
Force produced by lever principle
Vertical vectors Horizontal vectors
As little as 35gms of force can tip a tooth.
4-6 hours of force per day is probably the minimum necessary to cause tooth
movement

• CLINICAL FEATURES
1. Exaggerated mentalis activity may be seen because of the
effort of the lower lip to attain a lip seal anteriorly.
2. Maxillary arch shows constriction due to unopposed
pressure from buccal musculature. Posterior
crossbite tendency may occur.
3. Mandibular incisors may be retroclined or upright.
4. Mandible experiences downward and backward rotation
due to lowered position while sucking.

5. An increase in ANB angle is seen due to both maxillary prognathism and
mandibular retrognathism.
6. Patient may develop tongue thrusting due to appearance of spaces in the
anterior region.
7. The thumb is cleaner due to frequent use in the mouth. Constant irritation from
the teeth may cause formation of callus.

DIAGNOSIS
• HISTORY
EXTRAORAL EXAMINATION
• THE DIGITS
• LIPS
• FACIAL FORM
INTRAORAL EXAMINATION
• TONGUE
• DENTOALVEOLAR STRUCTURES
• GINGIVA

• PREVENTION
• There are various preventive measures which can be executed like:
• Motive based approach
• Engaging child in various activities
• Parents involvement in prevention
• Duration of breast feeding
• Mothers presence and attention during bottle feeding
• Using physiological nipple
• Using dummy/pacifier

• SIX STEPS IN CESSATION OF HABIT (LARSON AND JOHNSON)
1. Screening for psychological component
2. Habit awareness
3. Habit reversal with a competing response
4. Response attention
5. Escalated DRO(differential reinforcement of other behaviours)
6. Escalated DRO with reprimands (consists of holding the child, establishing eye
contact, and firmly admonishing the child to stop the habit)

• MANAGEMENT
• According to Forrestor(1981) three main areas should be considered in
constructing treatment plan
1) Emotional significance of the habit
2) The age of the patient
3) The status of the child’s occlusion

• EMOTIONAL SIGNIFICANCE OF THE HABIT
• To determine whether the thumb sucking is a meaningful or an empty habit
• Consultation with a psychiatrist is considered if the sucking habit is a symptom
of an abnormal behaviour problem

• TREATMENT OF AN INFANT (BIRTH TO 2 YEAR)
• Thumb sucking during infancy is of no concern to the dentist or the parent if no
physical effect is produced on the teeth
• When sucking is abnormally vigorous enough to displace the teeth the problem
is of concern and also could act as a symptom of:
1)Insufficient feeding
2)Inadequate love
3)Bored, unhappy or over fatigued child

• No attempt should be made to cure the habit in a malnourished or sick infant
who may obtain significant gratification from it.
• Frequently, the only treatment necessary may be a little more cuddling and
playing with the child and simple instruction to the mother in the technique of
feeding the infant.

• TREATMENT IN A PRE-SCHOOL CHILD(21/2 – 3 YEAR)
At these years, child begins to assert his/her independence from the mother and
inevitably tensions and frustrations may occur causing an occasional short-lived
sucking episode.
In the pre-school child thumb sucking which is practiced only before going to bed
may be disregarded being a benign activity, and correction may prove harmful.
However if it is frequently indulged during the waking hours, the child is over
fatigued bored or unhappy, then suitable factors in the environment should be
corrected.

• TREATMENT IN 3-7 YEAR OLD
This age group child may be more of a concern depending on the type of habit
and whether the child is pulling the maxilla anteriorly or just sucking his digit with
buccal constriction.
The child with good molar intercuspation and little anterior pull i.e., the passive
sucking child should be counseled and the dentist should work along with the
parent with contingent behavior modifications.
90% children stop by the age of 3-6 years. If continues beyond that it needs to be
treated.

• TREATMENT APPROACH
Treatment to be initiated between 4-6 years, with child’s willingness
1) Counselling
2) Reminder therapy
3) Reward system
4) Adjunctive therapy

• COUNSELLING
• Simple, widely applicable
• Discussion about the problems and changes due to non nutritive sucking
• Show photographs, videos
• Scolding, nagging or frightening should be avoided because it can cause
negativism.

• BETA HYPOTHESIS(1929)
Dr. Knight Dunlop discovered the concept of negative
practice.
Forceful purposeful repetition of habit associates it with
unpleasant reactions and habit is abandoned.
When applied to oral habits a child is encouraged to
watch himself in a large mirror while sucking the digit.
The sight of oneself sucking thumb will hamper the
pleasure derived from the activity, and the child will
slowly avoid indulging in the same.

REMINDER THERAPY:
INDICATION:
In an older child of at least 6-7 years who wants to break the habit but is
unable to do so
Modalities
1) Chemical Method:
It is less effective bitter and sour chemicals have been used over the
thumb to terminate the practice.
e.g., quinine, asafetida, pepper, castor oil. Now a days new anti-thumb
sucking solution like femite, thumb-up, anti-thumb are also available.

• RESTRICTIVE METHODS:
Application of bandages to thumb, finger, elbow may
be done.
Bandages on the thumb will take away the pleasure from
the act.
Bandaging the elbow will prevent bending the elbow to
suck thumb.

• INTRAORALAPPLIANCES
• These appliances should be used in age group of 3 1/2 – 4 1/2 year children.
• Appliances like palatal bar, palatal arch, palatal crib, hay-rake, blue grass
appliance, bakers modification of bluegrass appliance, quad helix, clear crib,
invisalign

• PALATAL CRIB
• One of the principal habit reminders.
• It consists of a 0.030 inch round lingual arch wire attached
to the upper first molar bands with an anterior platform
• This keeps the thumb or finger from exerting pressure on
the soft tissue of the palate.

• BLUE GRASS APPLIANCE
• Introduced by HASKELL (1991)
• Consists of a six-sided roller made of Teflon slipped over a
0.045 stainless steel wire soldered to bands placed on
molars.
• The roller is placed in most superior aspect of the palate
and must not be in contact with the palatal tissue so that
patients can roll them with their tongues.
• This appliance is placed for 3-6 months and in early or
mixed dentition period.

• CLEAR CRIB
• The crib is fabricated from 1.5mm
thermoformed acrylic sheet.
• Initially vertical spikes are fabricated in the
maxillary cast at the desired position using
0.036” stainless steel wire.
• Final appliance is similar to an Essix/clear
retainer with erupted molds of the spikes.

• INVISALIGN
• Small areas of the aligner are occlusally flipped
like a bite ramp, in palatal surface of upper
incisors, in order to discourage the habit.
• Widely accepted among adolescents.
• Duration of treatment is 8 months with no
behavioral therapy.

• DISADVANTAGES:
1) A period of emotional upset until they get used to the appliance
2) Speech being affected temporarily
3)Difficult in eating with the use of fixed orthodontic habit breakers
4)Increase tendency for caries
5)Decalcification of enamel surfaces
6)Gingival inflammation may occur

• TONGUE THRUSTING, SWALLOWING HABIT OR
RETAINED INFANTILE SWALLOW:
The tongue is a powerful muscular organ which exerts
tremendous pressure during swallowing at frequent intervals,
24 hours a day, during the sleep time as well as during the day.
Normal mature swallowing takes place without contracting
muscles of facial expression.
The teeth are momentarily in contact and tongue remains
inside the mouth
Tongue thrust is the placement of the tongue tip forward
between the incisors during swallowing
TONGUE THRUSTING HABIT: A REVIEW SUCHITA MADHUKAR TARVADE, SHEETAL RAMKRISHNA INTERNATIONAL JOURNAL
OF CONTEMPORARY DENTAL AND MEDICAL REVIEWS (2015), ARTICLE ID 151214, 5 PAGES

• In tongue thrusting habit, a normal sized tongue or one that is overdeveloped
thrusts between the upper and lower teeth each time the patient swallows
producing an open bite.
• Sometimes the patient allows the tongue to rest in the open bite space between
the act of deglutition, preventing the bite from closing.
• Rix(1953) recognised two sharply contrasting types of tongue behaviour:
1) Non dispersing behaviour of the tongue: those cases in which the tongue does
not come forward to exert any force on the lingual surface of upper and lower
incisors.

• The lips may or may not contract excessively
• The upper and lower incisors are upright or retroclined.
2) Dispersing behaviour of the tongue:
Those cases in which the actions of tongue and lips are associated with a
dispersal of upper and lower incisor relations.

CAUSES OF TONGUE THRUSTING:
• MATURATIONAL FACTORS:
Tongue thrust may develop as a sequel of prolonged thumb sucking and retained
infantile swallow.
A transitional period from infantile swallow to mature swallow also exhibits
tongue thrusting.
• ANATOMIC FACTORS:
In macroglossia, there is overgrowth of the tongue. Pressure is exerted against the
lingual surfaces of the teeth causing them to become spaced.

Indentations on the tongue often appear where tongue pushes against the teeth.
Adenoids or tonsils cause the tongue to be positioned anteriorly to prevent
blocking of the oropharynx.
Tongue thrusting is also called an adaptive behaviour. If large spaces are present
anteriorly between upper and lower teeth, then tongue will try to move into these
spaces to achieve the anterior seal.
• OCCLUSION- Open bite in deciduous dentition caused by tongue dysfunction
as a residuum of a sucking habit.

• HABITUAL POSITION: The tongue is positioned forward during functioning
thus impeding the vertical development of the dentoalveolar structures around the
upper and lower anterior teeth.
• NEUROGENIC FACTORS: Hyposensitive palate causes the tongue to be pushed
forward.
• CONFIGURATION OF THE CRANIOFACIAL SKELETON AND
DYSFUNCTION
The morphology of the facial skeleton and the effects of tongue thrusting are
correlated to a certain degree.

• A horizontal growth pattern in conjunction with tongue thrust usually results in a
bimaxillary dental protrusion
• In vertical growth pattern with tongue thrust the lower incisors are in lingual inclination.
• UPPER RESPIRATORY TRACT INFECTION
• MOUTH BREATHING
• CHRONIC TONSILLITIS
• HYPERTONIC ORBICULARIS ORIS MUSCLE

• CLASSIFICATION (JAMES BRANER AND HOLT)
TYPE I : Non deforming tongue thrust
TYPE II : Deforming anterior tongue thrust ‘
Subgroup 1: anterior open bite
Subgroup 2: anterior proclination
Subgroup 3: posterior cross bite
TYPE III : Deforming lateral tongue thrust
Subgroup 1: posterior open bite
Subgroup 2: posterior cross bite
Subgroup 3: deep bite

• TYPE IV: Deforming anterior and lateral tongue thrust
SUBGROUP 1: Anterior and posterior open bite
SUBGROUP 2: Proclination of anterior teeth
SUBGROUP 3: Posterior cross bite

• CLASSIFICATION
• SIMPLE TONGUE THRUST:
Features: Normal tooth contact in posterior region
Anterior open bite
Contraction of lips, mentalis muscle and mandibular elevators
• LATERAL TONGUE THRUST:
Features: Posterior open bite with tongue thrusting laterally
• COMPLEX TONGUE THRUST:
• Features: Generalized open bite
Absence of contraction of lip and muscle
Teeth contact in occlusion

• TYPES OF TONGUE THRUSTING:
1. PHYSIOLOGIC TONGUE THRUST:
During infantile swallow the tongue is placed between the gum pads. After six
months of life, several maturational events occur that alter the functioning of
orofacial musculature.
With the arrival of incisors the tongue assumes a retracted posture.
If the transition of infantile to mature swallow does not take place with the
eruption of teeth then it leads to tongue thrust swallow.

2. HABITUAL TONGUE THRUST:
It is present as a habit after the correction of the malocclusion.
3. FUNCTIONAL TONGUE THRUST:
It develops to achieve an oral seal
4. ANATOMIC TONGUE THRUST:
It occurs due to macroglossia

• CLINICAL FEATURES OF TONGUE THRUSTING SWALLOW:
The clinical features seen in the tongue thrusting condition are dependent on the
type of tongue thrusting:
1) Simple tongue thrusting:
• Generalised spacing and proclination can be seen in the upper and lower anterior
teeth.
• Increased overjet, reduced overbite or presence of anterior open bite may be
seen.
• Exaggerated perioral musculature activity during swallowing action

2) Complex tongue thrusting:
• The teeth are apart during the swallowing process.
• The tongue spreads laterally in between the upper and lower teeth
• Lateral tongue thrusting is seen in such cases.
• Unilateral crossbite may also be seen.

• METHODS OF EXAMINATION
• Various methods can be used to examine tongue dysfunctions.
• Extraoral examination shows an exaggerated perioral contraction during swallowing.
Increased vertical dimension of face due to over eruption of the molars into the
freeway space is evident.
• Intraoral examination shows appearance of open bite and spacing between the teeth. A
forced tongue may cause gushing of saliva through the spaced dentition.
• The different types of clinical examination are: electronic recordings of the pressure
exerted by the tongue intraorally, roentgenocephalometric analysis, cineradiographic,
palatographic and neurophysiologic examinations.

• The position and size of tongue in relation to the available space can be assessed
using roentgenographic cephalometrics.
• However, in most orthodontic cases registering the position of the tongue is more
important than determining its size.

• PALATOGRAPHY involves recording the contact
surfaces of the tongue with the palate and teeth while
the patient produces speech sounds or performs certain
tongue functions.
• A thin uniform layer of contrasting precise impression
material is applied to the patient’s tongue with a
spatula.
• Once the consonant has been pronounced or the
tongue movement carried out(e.g. swallowing), the
palatogram can be documented photographically using
a surface mirror.

• PALATOGRAM DURING THE PRONUNCIATION OF “S”
• ACCURATE PRONUNCIATION OF “S”:
During articulation, the mandible is lowered slightly
and pushed forwards. The tongue rests on the teeth and
the alveolar processes, and a groove is formed in the
centre through which the air stream is directed onto the
central incisors.
• INTERDENTAL SIGMATISM(LISPING):
During this defective pronunciation of the “S” sound,
the tongue is usually protruded and clearly visible
between the anterior teeth.

• PALATAL SIGMATISM
The abnormal pronunciation is caused by an unphysiologic
friction noise between tongue and hard palate.
• LATERAL SIGMATISM ON THE LEFT SIDE
The tongue rests on the anterior teeth. The column of air
escapes on the left side.

• BILATERAL SIGMATISM
Palatogram of this type of defective articulation in a
patient with macroglossia.
• SIGMATISM DUE TO LATEROFLEXION TO
THE LEFT SIDE:
During this inaccurate formation of the ‘S’ sound, the tip
of the tongue is raised too high and rests on the upper
incisors.
The tip of the tongue deviates to the left of the midline
and the air stream is forced laterally.

METRIC EVALUATION OF TONGUE POSTURE
Assessment of tongue position on the lateral cephalogram
1 = Incisal edge of the lower central incisor
Mc = cervical distal third of the last erupted molar
V = the most inferior point of the uvula, respectively its
projection on the reference line (connecting line between is 1
and Mc)
O = Midpoint on the reference line between is 1 and V
A line is drawn through O perpendicular to the horizontal
baseline, and extended to the palate.
A further four lines are drawn at 30 degree to each other
resulting in a total of seven lines.

TRACING OF THE ANALYSIS ON THE
LATERAL CEPHALOGRAM:
Marking of the contours of the bony palate and
dorsum of the tongue.
Horizontal and vertical reference lines for metric
evaluation
Left: The morphologic relationships in case of a
retracted, elevated tongue
Right: Relationships in case of a downward and
forward tongue posture

Transparent plastic template with an inscribed millimeter scale for
analyzing the position of the tongue on the lateral cephalogram.

INTERCEPTION AND TREATMENT OF TONGUE THRUSTING:
• Interception and treatment of tongue thrusting is age and severity dependent.
• In children below three years, no active intervention is instituted while children
above this age can be trained for tongue swallowing exercises.
• Tongue thrusting treatment would necessitate that anatomic obstruction like
enlarged macroglossia and tonsils are also taken care of.
• An abnormally enlarged tongue could be due to the tumours/cysts in the floor of
the mouth.
• These should be investigated and treated accordingly.

• TREATMENT CONSIDERATIONS OF TONGUE THRUST
It requires a positive attitude and strong desire by the patient to overcome abnormal habit
along with suitable mechanotherapy
• Reminder therapy: Palatal appliances- palatal cribs, spurs, palatal rolling ball, Nance
palatal arch appliance
• Corrective therapy:
1) Removal of obstruction: Surgery of adenoids, macroglossia
2) Closure of anterior open bite, posterior open bite and/or anterior spaces with either a
fixed or removeable orthodontic appliance.
• AGE: Tongue thrust often corrects itself by 8 or 9 years of age. Self correction is due to
improved musculature balance during swallowing.
• Presence and absence of associated manifestation: Treatment is not recommended when
tongue thrust is present without malocclusion or a speech problem.

Training the tongue for correct swallow and posture
Tongue exercises: ELASTIC BAND SWALLOW
The elastic band is kept on the tip of the tongue against the palate and
swallowing is practised.
WATER SWALLOW
To keep water in mouth and a mirror in hand and swallowing is practised daily.
CANDY SWALLOW
A candy is placed between the tongue and palate and swallowing is practised
SPEECH EXERCISES
Patient practises syllables like c, g, h, k while keeping an elastic band between
the tongue and palate

4) Lips exercises
Patient practises stretching of lips so as to achieve anterior lip seal
MYOFUNCTIONAL EXERCISE: The child is asked to place the tip of the tongue in
the rugae area for 5 minutes
• 4 S exercise -it includes identifying the spot
- salivating
- squeezing the spot
- swallowing
• Ask the child to perform series of exercises like whistling, reciting count from 60 to
69, yawning to tone the muscle
• Fixed habit breaking appliance with tongue crib can be given. For posterior open bite
modified habit crib is used.

MOUTH BREATHING HABIT
The mode of respiration is examined to establish whether the nasal breathing is
impeded or not.
Chronically disturbed nasal respiration represents a dysfunction of the orofacial
musculature it can restrict development of the dentition and hinders the
orthodontic treatment.
The obstruction may be temporary and recurrent.
While more often it is partial then complete.
The airway resistance may be enough to force the subject to breath through mouth.

Causes of obstruction to nasal passages are:
1) Allergic rhinitis
2) enlarged tonsils or adenoids
3) deviated nasal septum
4) Nasal polyps
5) Enlarged nasal turbinate's

CLINICAL FEATURES
• The term respiratory obstruction syndrome was used to describe the constellation
of characteristic features associated with obstruction of the nasal airway during
the years of facial growth.
• Other common terms for mouth breathers are long face syndrome and vertical
maxillary excess
• The clinical features are:
1. Excessive lower anterior face height
2. Incompetent lip posture
3. Excessive appearance of maxillary anterior teeth, ‘gummy smile’

4. A nose that appears to be flattened, nostrils that are small and poorly developed
5. Steep mandibular plane
6. Posterior crossbite
7. Open mouth posture
8. A short upper lip and a fuller lower lip
9. A narrow shaped upper jaw with a high narrow palatal vault
10. A class II skeletal relationship
11. Gingivitis of upper anterior teeth

All these features contribute to ‘adenoid facies’
ADENOID FACIES was the term coined by TOMES(1872) to describe
dentofacial changes associated with chronic nasal airway obstruction

DIAGNOSIS OF MOUTH BREATHING:
• HISTORY – From family/parents
• Check for clinical features of adenoid facies
• Various test can be performed for diagnosis of mode of
respiration
1. Water holding test: Patient is asked to hold water in his
mouth. Instability to keep the mouth closed for more than 2
minutes confirms nasal obstructions and therefore mouth
breathing habit.

2. Mirror condensation test: A two surface mirror is
placed under the nose. If the upper surface condenses, then
breathing is through the nose, but if the condensation
occurs on the lower surface then
breathing is through the mouth
3. Cotton wisp test: A small wisp of cotton (butterfly-
shaped) is placed below the nostrils in a butterfly shape. If
the upper fibres are displaced then the breathing is through
the nose. If the lower fibres are displaced then it is mouth
breathing habit.

• EXAMINATION OF ALA
MUSCULATURE
The size and shape of the external nares of a
patient with nasal respiration during inspiration
and expiration.
The very noticeable changes in cross-section of
the nasal orifices are typical for nasal breathers.
The mirrors are held in front of both nostrils.
In nasal breathers the mirror will cloud with
condensed moisture during expiration
The very noticeable changes in the cross-
section of the nasal orifices are typical for
nasal breathers

• In oronasal respiration alar muscles are
inactive nares do not change their size which
is clinical feature of increased oral respiration.
• The alar muscles are inactive- nares do not
change their size- which is a clinical feature of
increased oral respiration.
Clinical feature of increased oral respiration

• Classification of adenoids on the lateral cephalograms
Small-sized adenoids: The radiographic image of the adenoid
on the lateral cephalogram appear as a slight curvature on the
upper rear wall of the nasopharynx.
Medium-sized adenoids: noticeable proliferation of lymphoid
tissue
Large-sized adenoids: the lymphatic tissue occupies most of
the nasopharyngeal pneumatic cavity.

• TREATMENT OF MOUTH BREATHING
• Treatment consideration
• There are various factors which should be considered during treatment of mouth
breathing habit. They are as follows:
• Age of child: Most of the time mouth breathing habit is self-correcting after
puberty.
• ENT EXAMINATION: An otorhinolaryngologist examination may be advised
to determine whether conditions which require treatment are present in the
tonsils, nasal septum or adenoids.
• If the mouth breathing habit continues even after the removal of cause then it is
habitual.

• Prevention and interception: Mouth breathing can be intercepted by use of an
oral screen.
• Remove the cause: Etiological agents for mouth breathing habit should be treated
first. If any nasal or pharyngeal obstruction is present then removal of
obstruction by surgery or local medication should be pursued. If a respiratory
allergy is present, it should be brought under control.
• Intercept the habit: Interception of habit is very important. even after the removal
of the obstruction if the habit continues then it should be corrected.

• METHODS OF CORRECTION
• EXERCISES
Various exercises are recommended for correction of mouth breathing habit. it
includes:
A) Hold a sheet of paper between the lips.
B) Patients with short hypotonic upper lip should stretch the upper lip to maintain
lip seal or stretch in downward direction toward the chin.
C) Button pull exercise: a button of 11⁄2” diameter is taken and a thread is passed
through the button hold. The patient is asked to place the button behind the lip and
pull the thread, while restricting it from being pulled out by using lip pressure.

D) Tug of war exercise:
This involves two buttons, with one placed behind the lips while the other button
is held by another person to pull the thread. Blow under the upper lip and hold
under tension to a slow count of 4 repeat 25 times a day. Draw upper lip over the
upper incisors and hold under tension for a count of 10.

• ORAL SCREEN
• It was first introduced by NEWELL in 1912.
• It is a myofunctional appliance that is easy to fabricate and easy to
wear. It works on the principle of both force application and force
elimination.
• Principle of oral screen: It is a functional appliance which produces its
effects by redirecting the pressures of the muscular and soft-tissue
curtain of the cheeks and lips. It works on the principle of both force
application and force elimination.
• For example, anterior teeth proclination can be corrected utilizing the
principle of force application. The screen comes in contact with the
proclined teeth so that the forces from the lips are transmitted directly
to the proclined teeth through the screen.

Posterior cross bite can be corrected utilizing the principle of force elimination by
providing a spacer between the teeth and the screen.
• RAPID MAXILLARY EXPANSION (RME)
• Patients with narrow, constricted maxillary arches benefit from RME procedures
aimed at widening of the arch. It increases nasal air flow and decrease nasal air
resistance. Increase in intranasal space occurs due to outer walls of nasal cavity
moving apart.

• LIP HABITS:
The various habits can be divided into lip sucking and
lip insufficiency
Lip dysfunctions can be observed while the patient is
speaking and swallowing
The lower lip and tip of the tongue are often in contact.
In such cases, the lower lip is sucked in and pressed
against the tip of the tongue
Lip sucking: the lower lip is positioned behind the
upper incisors. In many patients malpositioning of the
lips occurs in conjunction with hyperactivity of the
mentalis muscle.

• Lip thrust: Characteristic profile of the lower
third of the face in case with hyperactivity of the
mentalis muscle.
• In many patients this type of lip habit is combined
with the lingual inclination of the incisors.
• Lip sucking habit can be eliminated by lip pads in
the lower arch

• CHEEK DYSFUNCTIONS:
In case of cheek sucking or cheek biting the soft tissues
are interposed between the occlusal surfaces of the teeth,
which promotes the formation of a lateral open bite or a
deep overbite.
Increased lateral pressure by the cheek musculature on for
example the mandible impedes the transverse
development of the jaw
This type of cheek dysfunction is common in cases with
buccal nonocclusion

• HYPERACTIVITY OF MENTALIS MUSCLE
The deep mentolabial sulcus is a characteristic of hyperactive
mentalis muscle.
This habitual pattern of muscle behavior impedes the forward
development of the anterior alveolar process in the mandible
The abnormal mentalis function often occurs together with
lip-sucking or lip thrust.
The hyperactive mentalis muscle pulls the lower lip upward
and rearward and presses it against the lingual surfaces of the
upper incisors.

The upper lip remains relatively motionless
The normal lip seal is disturbed and the tongue is displaced downward
This type of soft tissue morphology aggravates the dentoalveolar
malocclusion.

• BRUXISM:
Bruxism in the simplest terms refers to the clenching
and gnashing of the teeth against each other.
Ramfjord and Ash described it as nocturnal
subconscious activity but can occur in the day or night
and may be performed consciously or subconsciously.
Sleep bruxism is an entity that is very common with
children.
The adult may bruxise in either day or night.

• ETIOLOGY
• Emotional tension seems to be the major cause
• Occlusal interferences such as faulty restorations
• Childhood bruxism is related to other oral habits such as
chronic biting and chewing of toys and pencils, thumb and
finger sucking, tongue thrusting and mouth breathing.
• Nutritional and vitamin deficiencies
• Athletes indulge in bruxism due to increased muscular activity
• Neurologic disturbances like epilepsy, lesions in cerebral
cortex

• CLINICAL FEATURES
• Teeth that are abnormally worn down, flattened or chipped
• Atypical occlusal facets – worn tooth enamel, exposing the dentin of the tooth
• Increased tooth sensitivity
• Jaw pain or tightness in the jaw muscles
• Earache because of severe jaw muscle contractions
• Headache and chronic facial pain
• Hypertrophy of masseter muscle
• Teeth grinding and clenching

• TREATMENT
• PSYCHOLOGICAL counselling to identify and treat
any psychological distress, tension or emotional upset
• Correction of any occlusal interferences by coronoplasty
• Temporary relief can be brought by bite plates or
occlusal splints that will help in relieving the pain in
muscles
• Oral analgesics for muscular pain

Physiotherapy has proven useful in relieving the symptoms of
bruxism
1) Low intensity ultrasonic radiation therapy,
2) Accupressure/acupuncture
3) Transcutaneous electric nerve stimulations(TENS)

• NAIL BITING
• Nail biting usually develops after the sucking age i.e after 3 yrs
of age.
• It does not assist in the production of malocclusion since the
forces or stresses applied in nail biting are similar to those in
the chewing process.
• However in certain cases of nail biting a marked attrition of the
lower anterior teeth, crowding and rotation have been observed.

• Onychophagy is a nail disease caused by repeated injuries of
nails.
• The need to bite or eat fingernails is related to a psycho
emotional state of anxiety.
• A nail biting child is exhibiting an evolutionary disturbance
related to the oral stage of psychological development
(PEARSON GHJ, 1948)

• About one forth of patients with temporomandibular joint pain and dysfunction
have been shown to suffer from nail biting habit
• Treatment putting nail polish or distasteful liquids on nails

• SELF – MUTILATION / SELF-INJURIOUS HABITS
• Self-mutilation, results in physical damage to the individual, and is extremely
rare in the normal child.
• The incidence of self-mutilation in the mentally retarded population is between
10 and 20%.
• Self-mutilation is a learned behavior which manifests biting of the lips, tongue
and oral mucosa.

• Any child who willfully inflicts pain or damage to
himself should be considered psycho-logically abnormal.
• Self-mutilation has also been associated with disorders,
such as LESCH-NYAN SYNDROME
• It is associated with biting tongue and lips initially
followed by finger biting and head banging

• CONCLUSION
• Abnormal pressure habits changes the alveolar bone and regulate teeth because
the bone-building cells on the receiving end of pressure or stimulus cannot
differentiate whether that pressure or stimulus is intentional or unintentional.
• The face, with its cartilaginous bone, yields easily to stimulus and pressure,
especially during growth spurts, and presents the most complicated growth
problem in the entire skeleton.
• Since the greatest growth changes in the head are being made by the facial
structures, it logically can be assumed, therefore, that all abnormal pressures
should be kept away from its most vulnerable target.

• REFERENCES:
1) Textbook of contemporary orthodontics By Profitt 6th
Edition
2) Orthodontic Diagnosis – Thomas Rakosi, Jonas And Graber
3) Textbook of orthodontics – Omprakash Kharbanda
4) Jonathan Gillis (1996). Bad habits and pernicious results: Thumb sucking and
the DISCIPLINE OF late-nineteenth-century paediatrics. medical history, 40,
PP 55-73
5) Haskell BS, Mink JR. An Aid To Stop Thumb Sucking: The “Bluegrass”
Appliance. Journal of clinical orthodontics 1991;13(2):83–85.

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