DELETERIOUS ORAL HABITS IN CHILDREN CLASSIFICATION AND MANAGEMENT INTRODUCTION Oral habits in children have concerned dentists for

many years. It may be a part of normal development but if continued for a long periods of time there is a possibility of harmful unbalanced pressures which may be brought to bear upon the immature highly malleable alveolar ridges, the potential changes in position of teeth and occlusions which may become decidedly abnormal. A wide array of oral habits has been a subject under discussion for many years. Digit sucking lip and nail biting, bruxism, mouth breathing, tongue thrusting, etc may be considered as some of the common habits seen in children. he data on the etiology age of onset, self!correction and treatment modalities for the various habits differ greatly. "ence, for a successful management of the habit, an understanding of the dental implication and manifestation of the habit should be pursued. One of the most valuable services that can be rendered as part of the interceptive orthodontic procedures is elimination of the abnormal habits before they can cause any damage to the developing dentition. #ince the $edodontist is at an advantage in that he can see the child during the period that the habit is developing, he gets the opportunity to examine the child before the detrimental effect of the habit manifest itself as derangement in occlusion and unfavourable aesthetics. DEFINITIONS Dorland (1957): "abit can be defined as a fixed or constant practice established by fre%uent repetition. B !!"r#$or!% (19&1): defined habit as a fre%uent or constant practice or ac%uired tendency, which has been fixed by fre%uent repetition. Ma!%"$#on (19'(): oral habits are learned pattern of muscular contractions. Bo )%"r (19&*): defined habit as a tendency towards an act or as act that has become a repeated performance relatively fixed, consistent, easy to perform and almost automatic.

F+nn defined habit as an act, which is socially unacceptable. "abit can also be defined as a settled tendency in response to a specific cause resulting from repeated learning. CLASSIFICATION I ,AMES -. (19(*) &. '#()'* "A+I # Include the habits of normal function such as correct tongue position, proper respiration, proper deglutition and normal usage of lips in speaking. ,. "A-.)'* "A+I # Include all that exert perverted stresses against the teeth and dental arches such as tongue thrusting, thumb!sucking, mouth breathing, lip biting, nail biting, lip sucking etc. II /INGSLE0 (195') a/ )unctional oral habits eg. .outh breathing b/ .uscular habits ! ! Individual habit eg. *ip sucking "abits in which there is combined activity of the muscles of the mouth and jaws and of the thumb0finger inserted into the mouth eg. humb sucking ! .uscular action combined with the introduction of passive objects into the mouth. eg. $encil biting. c/ "abits in which muscles of the mouth and jaws take no active part, the effects on the position of dentition being extraneous pressures. eg. Abnormal pillowing, face leaning on hand, etc. III MORRIS AND BOHANA (19&9) a/ $ressure habits and 1on!pressure habit b/ +iting habits I1 /LEIN (1971)

&. .eaning habits 2 suggests the existence of a direct psychological cause and effect relationship. A consultation with a paediatrician0psychologist may be necessary before any treatment ,. (mpty habits 2 are simple habits without a detectable cause. 3lein classified abnormal pressure habits into intrinsic and extrinsic a/ Intrinsic pressure habits 4within the mouth/ ! ! ! ! ! ! ! ! humb sucking, lip sucking )inger sucking, cheek sucking ongue sucking, nail biting *ip biting ongue biting ongue thrusting .outh breathing Incorrect swallowing

b/ (xtrinsic pressure habits 4face/ ! ! ! ! 5hin propping )ace leaning on hand Abnormal pillowing position, leaning on forearm or hand "abitually sleeping on the right side of the face may cause the nose to turn leftward or vice versa, a deviated septum may also result from this sleeping habit. c/ )unctional pressure .alocclusion developed in musicians from pressure exerted on their teeth or face. 1. BARRETS (197') &.Intra oral habits ! ! ! ! ! ! humb sucking .outh breathing *ip biting 1ail biting *ip sucking ongue thrusting

! !

+ruxism 1ail biting

,. (xtra oral habits 5hin propping, face leaning on hand, abnormal pillowing positions, habitual sleeping on one side of the face. 1I. FINN CLASSIFICATION I. a/ 1on compulsive oral acts 2 are those habits that are easily dropped from the child6s behaviours pattern as he matures. It shows a more consistent behaviour and an increased level of maturity and responsibility. 5hildren appear to undergo continuing behaviour modification, which permits them to release certain undesirable habit pattern and form new and more socially acceptable ones. b/5ompulsive habits It is a habit that has ac%uired fixation in the chid to the extent that he reverts to the practice of this habit whenever his security is threatened by events, which occur around him. "e tends to suffer increased anxiety when attempts are made to correct the habit. hey have deep seated emotional need and is possibly the only safety value when emotional pressure become too much to cope with. II. a/ $rimary habits ! thumb sucking and finger sucking b/ #econdary habits 2 these are performed along with other habits. (g. "air pulling, nose probing, pulling the ear, fondling favourite toy, twisting the blanket around the finger, nose pulling etc. 1II. ORAL HABITS CAN ALSO BE CLASSIFIED AS Obsessive 4Deep rooted/ 1on!obsessive 4(asily learned and dropped/

Intentional or .eaningful (g7 nail biting,

.asochistic or self!inflicting injurious habit

'nintentional or empty eg7 Abnormal

)unctional habits eg7 mouth breathing, etc

Digit sucking, *ip biting.

eg7 8ingival #tripping

pillowing, chin propping

THUMB SUC/ING humb sucking habits are often considered within a broad category of habits that includes finger sucking. "ence, thumb sucking and finger sucking habits are more generally termed 9digit sucking: habits. A broader category of sucking habits includes any form of non!nutritive sucking 411#/ that involves pacifiers, hair, etc. DEFINITION humb sucking is defined as placement of the thumb or one or more finger in varying depths into the mouth. CLASSIFICATION 5lassification logically proceeds from an understanding of the factors that seem to influence the severity of the habit. he classification presents a series of levels designed to increase in numerical value with increasing habit severity. A 4;/ or 4!/ sign is added to each level to indicate the willingness of the patient to cooperate with treatment. A level II 4;/ classification, for example, may apply to boy younger than eight years with a 11# habit that occurs across one setting such as at school or at home or while watching television during waking hours. he patients would demonstrate a fairly high level of desire to break the 11# habit. On the other hand, a level II 4!/ classification may apply to a similar patient who has little or no desire to step thumb sucking. CLASSIFICATION OF NON2NUTRITI1E SUC/ING HABITS LE1EL *evel I 4;0!/ *evel II 4;0!/ *evel III4;0!/ DESCRI3TION +oy or girl of any chronological age with a habit that occurs during sleep. +oy under the age of < years with a habit that occurs at one setting during waking hours +oy under the age of < years with a habit that occurs across multiple setting during waking hours

*evel I= 4;0!/

8irls under the age < years or a boy over the age of < years with a habit that occurs at one setting during waking hours

*evel = 4;0!/

8irl under the age of < years or a boy over the age of < year with a habit that occurs across multiple setting during waking hours

*evel =I 4;0!/

8irl over the age of < ears with a habit during waking hours.

4;/ or 4!/ designates the willingness of the patient to participate in treatment. ! ! $sychoanalytic theory of psychosexual development as proposed by )reud and he learning theory

Despite difference the psychoanalytical and learning theories are similar in that both describe factors responsible for the origin and maintenance of the habit. ORIGIN OF THE HABIT +oth theories support the idea that some developmentally normal condition promotes the origin of 11# ! he psychoanalytic theory holds that this original response arise from an inherent psychosexual drive. )reud differentiated 11# from the need for nourishment suggesting that 11# is a pleasurable erotic stimulation of the lips and mouth. One of the concepts of thumb sucking that is brought out by the psychoanalytic theory is that humans possess a biologic sucking drive. his concept is supported by the observation of intra uterine sucking and by the neonate reflex of rooting and placing as described by +enjamin 4&>?@/ ! In the rooting reflex if a well defined area around the mouth is touched by an object an infant turns the head toward the object and opens the mouth

he placing reflex is the sucking activity tat occurs with the object making contact with the infant6s mouth.

,. he learning theory advocates that 11# stems from an adaptive response 4$alermo, &>A?/ )or instance, an infant associates sucking with such pleasurable feeling as hunger, satiety and being held. hese events will be recalled by transferring the sucking action to the most suitable object available namely to the thumb or fingers. $erhaps the origin of thumb sucking eventually will be explained by a combination of these two theories. A combined explanation suggests that all developmentally normal children possess an inherent biological drive for sucking. )urthermore, environmental factors contribute to the transfer of this sucking drive to non!nutritive sources such as the thumb or fingers. MAINTENANCE OF THE HABIT +oth theories attempt to explain the maintenance of a 11# habit beyond its adaptive usefulness. he psychoanalytic theory suggests that as children mature they tend to lose autoerotic habits previously associated with early pleasure Bones. hus, it would be expected that most children would lease 11# early in their developmental process 4by the age three years/. his concept supports the view that children who persist in 11# beyond early childhood have some underlying psychological disturbance. +ecause digit sucking according to the psychoanalytic theory represents type of anxiety management by the child abruptly distinguishing it could be detrimental to the normal emotional of the chid. )urthermore such treatment could result in substitution of the symptom 411#/ by another behaviour. he learning theory assumes no underlying psychologic cause to prolonged 11#. It views all forms of 11# as something that had adaptive value at some earlier developmental stage. his theory suggests that prolonged thumb sucking in most children is a learned habit that found its support through years of contingent positive reinforcement. he response is thus a learned behaviour that has persisted beyond its adaptive usefulness. It follows that direct and aggressive treatment of the habit would not place the patient at risk for symptom substitution.

DIAGNOSIS he diagnosis of a digit sucking habit may be obvious if the child is actively performing the habit or information may be receive directly from the parents. )re%uency, duration, intensity and home remedies carried out should also be en%uired. his will indicate the amount of effect on the dentition to be expected. I. E4TRA ORAL E4AMINATION he objective of the examination is to determine which digit is sucked how it is placed to examine the digit and classify growth pattern. he dentist should check all the patient6s digit according to )orrester 4&><&/, digit which are induced in an active regular habit will appear reddened, exceptionally clean, chapped and with a short fingernail, i.e., a clean 9dishpan thumb:. he severe chronic thumb sucker fre%uently has a fibrous roughened callus on the superior aspect of the thumb or finger that is sucked. 5hronic thumb suckers are fre%uently characteriBed by a short, hypotonic upper lip. tonsils accompanied by mouth breathing. II. INTRA ORAL E4AMINATION #evere finger or thumb sucking habits where the digit is applied on anterior part of the upper dentition and palate will result in flared maxillary anterior with diastema. *eft or right side of the anterior maxillary arch is deformed related to whether the child sucks his right or left thumb. +uccal crossbites and narrow palates occur when children suck their digits with a pronounced constriction of their buccal musculature. EFFECTS Chen the digit is placed in the mouth and sucked a number of changes take place around the teeth that may contribute toward an imbalance of occlusion. #alBmann 4&>@D/ stated that the effects of the sucking habit on the dental arches and the bone including the occlusion of teeth depends on a trident of factors. ! Duration indicate the number of years the habit is continued hey may have enlarged

)re%uency denotes how often the habit is practiced.

he child who

sucks sporadically or just when going to sleep is much less likely to do any damage than one who constantly has his finger in his mouth. ! Intensity implied how vigorously the habit is pursued. In some children, the sucking can be heard in the next room, the perioral muscle function and facial contortion are easily visible. In other the thumb sucking habit is little more than a passive insertion of the finger in the mouth with no apparent buccinator activity. he damage produced also depends on the associated muscle contraction of the lip and cheeks, osteogenic development, the genetic endowment of the chid and the state of health of the child. Dentofacial changes associated with prolonged 11# habits. (ffects on the maxilla ! ! ! ! ! ! Increased proclination of the maxillary incisors. Increased maxillary arch length Increased anterior placement of apical base of the maxilla Increased #1A Decreased palatal arch width Increased trauma to maxillary central incisor

&. (ffect on the mandible ! ! ! Increased proclination of mandibular incisors Increased mandibular inter molar distance Increased distal position of + point.

,. (ffect on the inter arch relationship ! ! ! ! ! Decreased maxillary and mandibular incisor angle Increased over jet Decreased over bite Increased posterior cross bite Increased unilateral and bilateral class II occlusion

E. (ffects on lip placement and function ! Increased lip incompetence

! ! ! ! Other effects ! ! !

Increased lower lip function under maxillary incisor Increased tongue thrust Increased lip to tongue resting position Increased lower tongue position. -isk to psychologic health Increased deformation of digit Increased risk of speech defects especially lisping.

D.(ffects on tongue placement and function

3RE1ALENCE A review of the literature revealed that thumb sucking and finger sucking seemed to be influenced by many culturally and socially dependent factors most notably by child rearing practices. )or instance 5urBon 4&>@D/ reported no evidence of thumb sucking in &,FFF (skimos children. "e pointed out that the (skimo child is carried on its mother6s back all day for up to three years, with bottle of milk constantly at hand. he author concluded that, 9accordingly the opportunity and necessity for thumb sucking does not exist:. It is also interesting to note the inverse relationship between pacifier used and the level of thumb!sucking within the same group. A comparison of the studies conducted in #weden from &>D> to &><, demonstrated a decrease in digit sucking habits with an increase in pacifier use. CONTRIBUTING FACTORS (1ARIABLES) An understanding of the factors contributing to the 11# may aid in identifying those variable that ultimately contribute to the severity and maintenance of the prolonged habit. &. 8(1D(- DI))(-(15( .ost research supports the finding that girls demonstrate a higher level of 11# and more persistent sucking habits than hoys. It seems likely that for most socio cultural groups more girls than boys re%Dre orthodontic treatment for ortho facial deformities caused by 11# habits. )urthermore the research presented support the idea that the digit sucking habit in girls is likely to be ore persistent and therefore more difficult to treat than in boys.

,. I1)*'(15( O) A8( A O1#( A1D 5(##A IO1# ! O1#( 7 studies by rainsman and aisman 4&>A</ -oberts 4&>DD/ and +raBelton 4&>A?/ demonstrated that the majority of children with a 11# habit began the habit during the first three months of life. he rest started during the remainder of their first year. It is not likely therefore that children initiate an 11# habit after the first year ! 5essation7 every study that linked thumb sucking with age demonstrated a decreased prevalence of 11# habits with increased age. 4*arson &>@&G +aklud &>?EG Infante &>@?/.

E. +-(A# )((DI18 =(-#'# +O

*( )((DI18

"anna 4&>?@/ in a study designed specifically to investigate the effects of breast!feeding versus bottle!feeding on 11#, found no correlation between thumb sucking and mode of feeding. raisman and traismBn also concluded that breast!feeding was not a significant factor in the incidence of thumb sucking. It would seem that the mode of early feeding i.e, breast versus bottle has little effect on the prevalence of 11# D. D'-A IO1 O) )((DI18 I1 I1)A15H raisman and traisman found that the time spent in nutritive sucking was significant factors in the incidence of thumb sucking. It was observed that infants who had thirty to sixty minute periods f feeding were more likely to form a thumb sucking habit than those with an average feeding time of ten to twenty five minutes. +ut +acklund found no correlation between length of the breast!feeding period and thumb sucking.

Despite the contradictory views presented most evidence suggested that the duration of early feeding in infancy has little effect n the development of a 11# habit. A. $A##A8( O #*(($ Colf and *oBoff 4&><>/ demonstrated a correlation between the proximity of the caregiver to the child during passage to sleep and the incidence of object attachment and thumb sucking. 5hildren who sucked their thumbs were less likely to have a caregiver present as they full asleep. )urthermore, the authors found that E,I of the object!attached children were thumb suckers compared with &DI of non object attached children. ?. #I+*I18# A1D 11# *arsson and Jarvheden 4&>@&/ in a study of EF< children found no correlation between a 11# habit and the number of siblings, the order of birth, or whether the mother worked outside the home during the child6s first year of life. siblings with the same sucking habits. @. #O5IO (5O1O.I5 5alisti et al 4&>?F/ in a study of D>& preschool children, found that children from a high socio!economic group demonstrated oral habits 4finger sucking, finger nail biting, tongue habits and lip and cheek habits/ more fre%uently than children from a middle or low socio!economic class. *arsson found that children of parents with an extensive education were more likely to develop a finger sucking habit whereas children whose parents had little or no theoretical education were more likely to develop a pacifier habit. he influence of the educational level of parents on parental response to 11# is probably related to the influence of education on child rearing philosophy and practice. here was a correlation, however, between the level of thumb sucking and the number of

TREATMENT he proper timing of thumb sucking treatment is a matter of considerable controversy. On the basis of the age related development of dentofacial deformities, many authors suggested that treatment begin at four years of age. It has been suggested recently that the time of treatment be specific for each habit. Accordingly, therapy should be postponed until the risks 4dental, emotional, psychologic/ of the thumb sucking habit outweigh the benefit to the patient. his does not presuppose that the habit is maintained, however by some underlying psychologic disturbances in every case, because it is reasonable to assume that the positive reinforcement of the habit 4enjoyment/ might extend into later years of development. In most cases, treatment for a prolonged 11# habit should be initiated between the age of four years and the eruption of the permanent incisors. hree main areas should be assessed in constructing a treatment plan. ! ! ! (motional significance of the habit he age of the patient he status of the child6s occlusion

he treatment plan can be broadly divided into the followingG &. $sychological therapy ! #creen the patient for the underlying psychological disturbances that sustain a thumb sucking habit. Once psychological dependence is suspected the child is referred to professionals for counselling. ! ! humb sucking children between the ages of D and < years of age need only reassurance, positive reinforcement and friendly reminders. Awareness of the habit can be accomplished by emphasiBing the positive aspects of habit cessation. =arious aids are employed to bring the habit under the notice of the child such as study models, mirrors, etc. ! 5hildren and parents are informed about existing dentofacial deformities and the long!term risks of a sustained habit. $atient should be presented with positive mental and visual images of the dentofacial ideals expected from habit cessation and subse%uent orthodontic treatment.

During the treatment ade%uate emotional support and concern should be provided to the child by the parents. Destructive approaches in the form of nagging, shamming and belittling ought to be strictly avoided

he use of positive behaviour modification techni%ues and even hypnosis has been effective in digit habit therapy. Chen the habit is discontinued, the child can be rewarded with a favourite new toy or special outing.

Dunlop6s beta hypothesis7 "e believed that if a subject can be forced to concentrate on the performance of the act at the time he practices it, he can learn to stop performing the act. )orced purposeful repetition of a habit eventually associated it with unpleasant reactions and the habit is abandoned. he child should be asked to sit in front of a mirror and asked to such his thumb, observing himself as he indulges in the habit.

,. -(.I1D(- "(-A$H his can be divided into the following ! (xtra oral approaches 2 it employs hot tasting, bitter flavoured preparations or distasteful agents that are applied to finger or thumbs. (g. $epper, %uinine, asafoetida. his is effective only when the habit is not firmly entrenched. Allen devised thermoplastic thumb post in &>>& where a thermoplastic material was placed on the offending digit. A total of ? weeks of treatment time was re%uired for elimination of habit. ! Intra oral approaches 2 various orthodontic appliances are employed to attenuate and eventually break the habit. -emovable appliances used may be palatal rib, rakes, palatal arch, lingual spurs. )ixed appliances such as upper lingual tongue screens appear to be more effective in breaking in these habits. If the child has made appreciable changes in his habit by E months, the appliances can be safely removed for a testing period. If gross signs of anxiety are aroused. (g. +ed!wetting, bad dreams, etc. E. .(5"A1O "(-A$H he appliance should be removed.

)ixed intra oral anti thumb sucking appliance. Intra oral appliance attached to the upper teeth by means of bands fitted to the primary second molars or the first permanent molar. A lingual arch forms the base of the appliance to which are added interlacing wires in the anterior portion in the area of the anterior part of the hard palate. It works by preventing the patient from putting the palmer surface of the thumb in contact with the palatal gingival thereby robbing the pleasure of sucking.

Oral screen is a functional appliance that produces its effects by redirecting the pressure of the muscular and soft tissue curtain of the cheeks and lips. It prevents the child from placing the thumb or finger into the oral cavity during sleeping hours. )orces can be delivered to procumbent and spaced maxillary anterior by cutting them from the cast and resting them in a more palatal position so that oral screen touches only the proclined incisors and is not in contact with the teeth in the buccal segment.

+lue grass appliance 2 "askell 4&>>&/ introduced this appliance, for children with a continued thumb sucking habit, which is affecting the mixed or permanent dentition. It consists of a modified sided roller machined from bands. eflon to permit purchases of the tongue. his is slipped over a F.FDA stainless steel wire soldered to molar orthodontic his appliance is placed for E!? months. Instructions are given to turn the roller instead of sucking the digit. Digit sucking is often seen to stop immediately.

! ! !

Kuad helix 2 this appliance prevents the thumb from being inserted and also corrects the malocclusion by expanding the arch. It comes under psychotherapy. -eward system 2 If the child discontinues the habit for a specified period of time, he is told that he will receive a reward. $lacing stick on stars on a homemade calendar and verbal praise are other methods of the reward system.

DelacruB and 8eboy 4&><E/ used contingency management for the elimination of thumb sucking. humb sucking was reduced by making

the presentation of filmed cartoons contingent upon non!thumb sucking. #tory reading eliminated bedtime thumb sucking. TONGUE THRUSTING D"5+n+!+on#: ! +raver 4&>?A/7 A tongue thrust was said to be present in the tongue was observed thrusting between and the teeth did not close in centric occlusion during deglutition ! ulley 4&>?>/7 #tates tongue thrust as the forward movement of the tongue lip between the teeth to meet the lower lip during deglutition and in sounds of speech, so that the tongue becomes interdental ! +arber 4&>@A/7 ongue thrust is an oral habit pattern related to the persistence of an infantile swallow pattern during childhood and adolescence and thereby produces an open bite and protrusion of the upper anterior segments ! #chneider 4&><,/7 ongue thrust is a forward placement of the tongue between the anterior teeth and against the lower lip during swallowing. Cla##+5+)a!+on I. .oyer6s 5lassification &. #imple tongue thrust swallow ! ! ! ! eeth are in occlusion during swallow he tongue protrudes into the well circumscribed open bite 5ontraction of lip, mentalis muscle and mandibular elevators his tongue thrust is an adaptive mechanism to maintain an open bite caused by some other causes. (g. humb sucking ,. 5omplete tongue thrust swallow ! ! ! ! eeth apart swallow he open bite is diffuse and difficult to define 5ontraction of lip, facial and mentalis muscle 1o contraction of mandibular elevators

E. -etained infantile swallow ! ! ! ! It is the undue persistence of the infantile swallow well past the normal time for tis departure 5ontraction of facial muscles ongue protrudes markedly and is held between all the teeth during the initial stages of swallow *ow gag threshold

II. James and ownsend6s classification 4&>?A/ heir classification is based on resulting deformities ype I 2 1on deforming tongue thrust 1on!deforming means that the interdigitation of the teeth and the profile were acceptable and within the normal range. It may be non!deforming, either because the thrust is mild in nature, or because there is sufficient torus of the lips and cheek to prevent deforming changes. ype II 2 Deforming anterior tongue thrust #ub group & 2 Anterior open bite he tongue is usually thrust forcefully between the anterior teeth during swallowing. his results in the intrusion or lack of eruption of these teeth and the characteristic spacing through which the tongue can easily protrude #ub group , 2 Associated procumbency of anterior teeth If the tongue is directly primarily towards the maxilla the result is procumbency of the maxillary teeth. his pattern of atypical swallowing is generally been in association with class II division & malocclusion. his type of tongue thrust produces the 9reverse curl: when the tongue thrust forward against the upper teeth and upon withdrawal, exerts a lingual force on the lower anteriors. Chen the anterior vector of force is directed primarily toward the mandibular arch, there is usually an abnormally low postural position of the tongue which, together with the low tongue thrust habit results in a wide mandibular arch form and

undeveloped maxillary arch. Anterior and posterior cross bites are common in this pattern of swallowing and tongue posture. #ub group E 2 Associated posterior cross bite ype E 2 Deforming lateral tongue thrust he tongue is forced laterally between the posterior teeth with the resultant posterior open bite and an associated posterior cross bite. #ub group & 2 $osterior open bite #ub group , 2 $osterior cross bite #ub group E 2 Deep over bite D. ype I= 2 Deforming anterior and lateral tongue thrust his can be mild or devastating in nature. During swallowing the tongue comes upto and covers the occlusal and incisal surfaces of all the teeth 4except second molars/. Individuals with a decreased degree of control of their tongue and as cerebral palsy and neuromuscular disease patients fall into this category. III. Jeanne .. 8oldberger6s classification 4&>@E/ &. ,. E. D. ype I 2 the person thrusts his tongue against the anterior teeth ype II 2 the patient pushes his tongue against the anterior region and the posterior region ype III 2 the tongue is thrust unilaterally or bilaterally ype I= 2 the patient may open his mouth as much as an inch to thrust his tongue forward between his teeth when swallowing. I=. +arrel6s classification 4&>@</ he classification is based on Angles system. A fre%uently recurring subtype is identified under each basic category. (ach type is examined as follows. ! 5lassification of molar occlusion

! ! ! !

Incisal relationship #tatus of teeth during swallowing $resence or absence of facial muscle contraction or movement Anterior of tongue

ype & 2 incisal thrust Occlusion 2 5lass I, may have cross bite Incisors 2 Overjet, lowers moderately retruded eeth 2 apart $erioral muscles 2 usually a generaliBed contraction of lip and cheek muscles ongue action 2 pressure concentrated on the incisors in a wedging action driving the uppers and lowers apart anteroposteriorly #ubtype 2 Differentiating characteristic ! 'pper incisors relatively normal, lowers excessively retruded and often supra erupted. ype , 2 )ull thrust Occlusion 2 5lass II division & Incisors 2 marked labioversion of uppers, lowers, retroclined, classically a jumbled but direct line from cuspid to cuspid. Incisal edges do not contact when molars are occluded eeth 2 apart $erioral muscle 7 "yperactive mentalis *ower lip on lingual surface of upper incisors ongue action 7 Dispersing action, spread between teeth around the dental arch

from approximately first molar to first molar, an exaggeration of type & #ub type 2 Differentiating characteristics Accompanying anterior open bite perhaps arising from teeth occluded against tongue and causing infraeruption of all affected teeth.

ype E 2 .andibular thrust Occlusion 2 5lass III usually in the absence of true prognathism often referred to as functional class III *ower molars usually contained within uppers, may have unilateral cross bite. Incisors 2 'ppers relatively normal may have constricted upper arch. *owers protrusive may display spacing. eeth 2 #lightly parted, although cusps may overlap a bit $erioral muscles7 )acial grimace, particularly tension in triangularis and upper fibers of orbicularis oris. ongue action. Apex thrust against lower incisors or symphysis of mandible #ub type 2 Differentiating characteristics Anterior Open bite eeth 2 apart $erioral muscles 2 similar but strong contraction of buccinator ongue action spread between incisal edges in contact with upper lip. ype D 2 +imaxillary protrusion Occlusion 2 5lass I Incisors 7 +oth upper and lower in labioversion, often some spacing of lowers. eeth7 Apart only slightly or closed $erio 2 oral muscles 2 .ild contraction ongue action 2 thrust against lingual margins of upper and lower incisal edges. #ub type 2 Differentiating characteristics 5lass II div. & occlusion7 often appears to be a basic type D swallowing pattern superimposed on a different dentoskeletal structure. ype A 2 Open bite Occlusion 2 class I Incisors 2 1ormal anterioposterior relation. +oth upper and lower infraerupted. Incisal edges parallel in molar occlusion. eeth 2 Apart close only to contact tongue

$erioral muscles7 8eneraliBed moderate constriction of facial network especially of mentalis. ongue section7 hrust into contact with lower lip before molar occlude #ub type7 Differentiating characteristics. .ore circumscribed, constricted. Incisors7 Incisal edges, a well defined oval when molars are occluded eeth 2 5losed $erioral muscles7 mentalis. ype ? 2 5losed +ite Occlusion 2 5lass I Incisors 2 1ormal relationship or slight moderate overjet both upper and lower may be supraerupted eeth 2 apart. 8reat excursion of the mandible as it drops to allow tongue protrusion. $erio oral muscles 2 *ittle contraction ongue action 2 )laccid generaliBed protrusion #ub type ! Differentiating characteristics 5lass II Div. & occlusion Incisors 2 (ntire lower arch constricted ongue action 2 #pread over lower arch #trong circumoral contraction particularly buccinator causing 'sually overdeveloped constriction of both arches all molars tipped lingually.

ype @ 2 'nilateral thrust Occlusion 2 5lass I may have crossbite on the side opposite tongue thrust. Incisors 2 1ormal centrals. *ateral incisors, cuspids and first bicuspids or one side under erupted. Display unilateral open bite. eeth 2 'sually closed $erioral .uscles 2 #trong generaliBed contraction. ongue action7 hrust at a DAF angle toward the induced cuspid

#ub type7 Differentiating characteristics. 'nilateral open bite distal to basic type. $erioral muscles7 -educed contraction ongue action7 hrust toward induced first or second bicuspid

ype < 2 +ilateral thrust Occlusion7 5lass III, may be class I in younger patients. +ilateral open bite in molar region. Incisors7 1ormal relationship or slight retrusion of uppers eeth7 Apart $erio oral muscles7 *ittle or no contraction ongue action7 #pread bilaterally between buccal teeth often centering at the first molar but may be slightly distal or may extend as for mesially at the cuspids, tongue tip usually traced against lower incisors in order to execute thrust. #ub type7 Differentiating characteristics 5lass II division , occlusion. +ilateral open bite less pronounced. =. #ilva ) et al 4&><?/ &. $rimary tongue thrust his is the type of tongue thrust where tongue thrust alone is the major cause of malocclusion. ,. #econdary tongue thrust Chen tongue thrust accompanies a pre!existing morphological condition created by digit or pacifier sucking in which case the tongue only adapts itself to an already established open bite. =I. 8iven by ulley 2 types of tongue thrust &. ongue thrust as a habit his is not seen commonly past the age of && years. )acial pattern is good and there is slight open bite and increased overjet with a class I or II relationship. ,. ongue thrust which is endogenous or innate

his kind of tongue thrust is marked in the sibilant sounds of speech and is often seen in siblings and in one of the parents. It can occur when there is perfectly normal occlusion or when there is adverse facial pattern. E. ongue thrust as an adaptive behaviour In this tongue is not only forward in functional movement but postured forward over the lower incisors at rest to seal with the lower lip. mandibular plane angle. 3ydd and 1eff 4&>?D/ reported that a normal adult reports the normal swallowing pattern between &,FF and EFFF times a day. During the waking hours, he swallows approximately twice a minute and while sleeping about once a minute. A6nor7al #$allo$"r 8 Ton9 " !%r #! An abnormal swallower is described as a person who positions the tip of the tongue against or between the teeth during swallowing. he midportion of the tongue does not contact the hard palate, but its posterior aspect contact the posterior area of the hard palate and does not assume a DAF angulation relative to the posterior pharyngeal wall. .asseter muscle activity is prevented and there is no molar contact during deglutition. .entalis muscle activity is active. #traub 4&>?,/ replaced the terms abnormal, prevented and reverse swallowing by the term tongue thrust swallowing which describes the process and is readily acceptable to both the parent and the child and does not carry the unfortunate implications of the terms reverse, perverted and abnormal. )letcher 4&>@&/ listed the patterns characteristic of tongue thrust. ! ! ! ! ! A thrusting movement of the tongue against or between the anterior teeth #light or no contraction of the muscles of mastication #trong contraction of the lip musculature .ovement of the hyoid bone in the obli%ue or forward direction Distortion of speech sounds. his posture is associated with an adverse skeletal pattern in which there is a high )rankfurt

In)+d"n)" and :r";al"n)" )letcher 4&>?&/ reported that over AFI of ? to @ year old children demonstrate tongue thrusting and fewer than ,AI of &? to &< years olds demonstrate this pattern. .unshi and #hetty 4&>></ in a study conducted on DA>F school children showed that E.F,I had tongue thrusting. A higher prevalence was seen in the lower age group 4E!? years/ and among males. #traub 4&>A&/ says that the perverted swallowing habit is more prevalent in females than in males. -ogers 4&>?&/ reported that D>.,I of orthodontic patients exhibited tongue thrusting. In a study by the 'nited #tates department of "ealth 4&>@E/ in ? to && year aged children. <AI of children between ? to < years of age were found to be tongue thruster, while &AI continued into early adolescence. E!+olo9<: he cause of tongue thrust remains controversial several theories have been proposed based on clinical observation and existing research result. &. -etained infantile swallow here is a considerable amount of evidence which suggests that tongue is merely retention of the infantile sucking mechanism with the eruption of the incisors at six months of age, the tongue does not drop back as it should and continues to thrust forward. or schedule. ,. -esiduum of finger sucking habit Anderson 4&>?E/ point out that tongue thrust is often a residuum of the finger sucking habit. In his study, AD.,I of those with the habit of tongue thrust had a history of finger sucking. Among those without tongue thrust, only ,AI had prior ongue posture during rest is also forward. Cith the continuation of the finger habit as a built in pacifier, the mature swallowing pattern does not develop

thumb or finger sucking habits. On the %uestion of breast!feeding versus bottle! feeding, the results again indicate a positive correlation with greater tongue thrust tendency in the bottle 2 fed group. In his sample, >&.@I of tongue thruster were bottle!fed and only <.EI were breast!fed. Obviously, this is not the only factor but should be considered contributory. E. 'pper respiratory tract infections #uch as mouth breathing, chronic tonsillitis, allergies etc. promote a more forward tongue posture due to pian and decrease in the amount of space which brings about a tongue thrust swallow it may also be present due to the physiological need to maintain an ade%uate airway. D. 1eurological disturbances "ypersensitive palate, moderate motor disability, disruption of sensory control and co!ordination of swallowing can lead to tongue thrust. A. )unctional adaptability to transient change in anatomy he tongue can protrude when the incisors are missing. )ollowing the loss of deciduous teeth and prior to full eruption of the permanent incisors, there exist a natural opening for the tongue. he tip of the tongue may protrude into the open area during swallowing. It has been observed that this protrusive activity will change with the full eruption of the permanent incisors. ?. Induced due to other oral habits During these stages of development, thumb and finger sucking habits may still be prevalent in many children. when this habit has created a malocclusion such as an anterior open bite, the tongue is seen to protrude between the anterior teeth during swallowing. Cith correction of the habit end with normaliBation in occlusion, a change in the protrusive tongue activity can take place. @. "ereditary he type of maxillary structure that favours the development of tongue thrust may be hereditary. )or example, inherited hyperactivity of orbicularis oris with specific anatomic configuration and 1euro muscular activity.

<. ongue siBe ongue siBe as well as tongue function is an important consideration. 5onditions such as congenital aglossia and macroglossia can have an effect on the dentition. >. Open spaces Chen a child loses a deciduous tooth, especially a canine or an incisor, the tongue fre%uently protrudes into the space at rest and during speech and swallowing activities. D+a9no#+# Diagnosis can range from the determination of the presence or absence of abnormal behaviour to the detailed description of history, possible etiology, severely and scope of the problem. ! "istory should include %uestions pertaining to the relevant details &. Determine the swallow pattern of siblings and parents to check for hereditary etiologic factor ,. Determine whether or not remedial speech was ever provided E. Information regarding upper respiratory infections, sucking habits and neuromuscular problems ! (xamination #tudy the posture of the tongue while the mandible is in postural position. his can be done if lips rest apart. swallowing procedures. ongue posture can also, be noted in the lateral Observe the tongue during various he cephalogram of the mandibular posture.

he unconscious swallow, the command swallow of saliva,

and the command swallow of water, unconscious swallow during chewing. following clinical features should be checked during swallowing. &. #imple tongue thrust ! ! ! 1ormal tooth contact in posterior region Anterior open bite 5ontraction of the lips, mentalis muscle and mandibular elevators.

,. 5omplete tongue thrust 8eneraliBed open bite with the absence of contraction of lip and muscle and teeth contact in occlusion. E. *ateral tongue thrust $osterior open bite with tongue thrusting laterally. ! $alatographic examination of tongue i/ $recision impression material of a thin layer is coated on the tongue. After few functional movements of the tongue, a polarised light is made use of and a surface mirror is also used. (valuation of the palatogram is possible ii/ Dr. (verrit $ayne used erabase with &I sodium fluorescein solution in a water!soluble base and applied to the tongue. After functional movements, utilisation of black light techni%ue will reveal exactly where the tongue is placed during the swallowing act. EFFECTS In!ra Oral F+nd+n9# &. ongue .ovements he swallowing se%uences are seen to be jerky and inconsistent in the tongue thrust group. he movements are also irregular from one swallow to another within the individuals. he chin point was found to be posterior in the tongue thrust group as compared to the normal position. $roffitt 4&>@,/ reported that most person adapt a swallowing pattern in which the tip of the tongue is placed in the rural area and a pressure of roughly &FF gm0cm , is exerted upward and backward. Chen the tip of the tongue is placed or pushed against the anterior teeth, it exerts a pressure of roughly AFF gm0cm,. ,. ongue $osture he tongue tip at rest was lower in the tongue thrust group. his could be because of the anterior open bite present and also because of the longer period of time re%uired for the tongue tip to move from rest to second stage of swallowing in the tongue thrust group.

E. .alocclusion 2 can be further subdivided as a. )eatures pertaining to the maxilla ! ! ! $roclination of maxillary anteriors resulting in an increase in overjet 8eneraliBed spacing between the teeth .axillary constriction

b. )eatures pertaining to the mandible -etroclination or proclination of mandibular teeth depending on the type of tongue thrust present. c. Intermaxillary relationship ! ! Anterior or posterior open bite based on the posture of the tongue $osterior teeth cross bite

II. E=!ra Oral 5+nd+n9# &. *ip posture *ip separation was greater in the tongue thrust group both at rest and in function. his observation may suggest some lack of compensatory lip activity during swallowing in these subjects.

,. .andibular movements he mandibular movements during swallowing in the tongue thrust group were more erratic and no correlations could be found between the movement of the tongue tip and of the mandible itself. In the tongue thrust group, the average path of mandibular movement was upward and backward with the tongue moving forward. E. #peech ongue thrust children are more likely to have various speech disorders, such as sibilant distortions, lisping problems in articulation of s, n, i, d, l, th, B, v sounds D. )acial form Increase in anterior face height

Tr"a!7"n! he treatment of tongue thrust can be divided into various steps. &. raining of correct swallows and posture of the tongue a. .yofunctional exercises he patient can be guided regarding the correct posture of the tongue during swallowing by various exercises. he child is asked to place the tip of the tongue in the rugae area for A minutes and is asked to swallow Orthodontic elastic and sugarless fruit drop exercise. hese can be held by the tongue tip against the palate on the rugae area during practice. DA exercises7 'se the pressure point on the papilla to show where the spot is. he tip is against this spot at rest position. he child then learns the ,A exercise7 spot and s%ueeBe. 9s%ueeBe: is done by s%ueeBing the tongue vigorously against the spot with the teeth used, followed by relaxing. Chen the child has done the ,A exercises, have him do the DA exercises. $lace the tongue on the spot, salivate, s%ueeBe against the spot and swallow. he child is asked to perform a serves of exercised such as whistling, reciting the count from ?F to ?>, gargling, yawning etc. to tone the respective muscles. Once the patient is familiar with the new tongue position an appliance is given for training the correct positioning of the tongue. b. $re!Orthodontic trainer for myofunctional training his appliance aids in the correct positioning of the tongue with the help of tongue tags. ! 1ance palatal arch appliance In this the acrylic button can be used as a guide to place the tongue in the correct position.