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1)
Butterworth 1961
2)
3)
4)
5)
Johnson
6)
by frequent repetition.
Habit is a response to a stimulus or stimuli either intrinsic or
extrinsic, reinforced by the real positive rewards which may persist even
after the stimulus is withdrawn.
A repeated static or functional exercise or ritual is defined as a
habit.
Boucher defined habits as a tendency towards an act or as act that
has become a repeated performance relatively fixed, consistent, easy to
perform and almost automatic.
Classification
I)
Useful habits Include the habits or normal function such as, correct
tongue position, proper respiration, deglutition and normal usage of lips
in speaking.
Harmful habits Include all that calocrt perverted stresses against the
teeth and dental arches such as tongue thrusting, thumb sucking, mouth
breathing, nail biting lip sucking etc.
II)
Intra oral habits Thumb sucking, mouth breathing, lip biting, nail
biting, lip sucking.
Extra oral habits Chin propping, face learning or hand, abnormal
swallowing position.
III)
Extrinsic
1) Thumbsucking.
1) Chin propping.
2) Finger sucking.
3) Tongue sucking.
4) Lip sucking.
5) Cheek sucking.
6) Blanket sucking.
7) Nail biting.
8) Lip biting.
9) Tongue thrusting.
10)Tongue biting.
11) Incorrected swallowing.
12)Mouth breathing.
IV) Meaningful and empty habits (Klein et al 1971). Meaningful
habits are due to psychological problems and has to be located
psychologically.
Empty habits can be treated by habit reminder appliance.
V)
Compulsive habits and noncompulsive habits (Sim and Finn
1987).
Non compulsive habits
The habits which can be easily added or dropped from the childs
behaviour pattern as he matures are termed as non compulsive habits.
It shows more consistent behaviour and an increased level of
maturity children appear to undergo continuing behaviour modification
which permits them to release certain undesirable habit patterns and
form new and more acceptable one.
Compulsive habits
Is a habit that has acquired fixation in the child to the extent that
the revers to the practice of habits whenever his security is threatened
by event which occur around him. He tends to supra increased anxiety
when attempts are made to correct the habits. These habits have deep
seated emotional need, the habit is possibly the only safely value. When
emotional pressure become too much to cope with other causative
factors such as insecurity in the child and lack love and affection from
parents.
BRASH'S CLASSIFICATION
A. Muscular Habit:
1.
2.
3.
4.
B.
Habits 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.
Tongue Thrusting
Tongue Thrusting
Before the complex problems of tongue thrusting are discussed, it
will be appropriate to discuss in brief the normal function of oral
maturation.
After the new born infants respiratory reflex is established the
next priority physiologically is to obtain milk and transfer it into the
GIT. This is accomplished in 2 maneuvers, sucking and swallowing.
During sucking when the milk is squirted into the mouth, it is only
necessary for the infant to grove the tongue and allow the milk to flow
posteriorly into the pharynx and oesophagus. The tongue is placed
anteriorly in contact with the lower lip, so that milk is deposited on the
tongue. This is infantile swallow which is characterized by active
contractions of musculature of lips, tongue tip is brought contact with
the lower lip and little activity of the posterior tongue or pharyngeal
musculature.
Review of Literature
Toda M.J. (1962) 78 stated that the magnitude of the mean swallowing
pressures exerted by the tongue in the anterior and lateral hard palatal
areas were greater than that found in the central area of the hard palate.
Stolzenberg J. (1962) 70 proposed that swallowing patterns were an
inherited involuntary act which can be treated by hypnosis. It is easier
to acquire conditioned response in the trance state.
Subtelny J.D. and Subtelny D.J. (1962) 73 found that the incidence of
tongue thrust among defective speakers was twice as high as it was
among normal speakers. Sixty percent of the children with speech
defects protruded the tip of the tongue between the incisors during
swallowing. A number of the normal speakers and 60 percent
of the
Gross M.A. et al (1990) 29 found that labial and lingual rest swallow
patterns were related to poor coordination of lip and tongue movements.
Williamson, Hall and Zwemer (1990) 88 concluded that patients with
aberrant swallowing patterns should be examined for T.M.J. dysfunction
because they used a tongue thrust open jaw swallowing pattern, and had
an anterior open bite and a habit of holding the tongue between the
teeth.
Boucher (1963) 5 defined tongue thrust as thrusting of the tongue
between the anterior teeth specially in the initial stage of swallowing, it
is often combined with a resting position also between the teeth that can
inhibit normal eruption and so produce an open bite.
Genetic factors
Inherited variation in orofacial form that precipitate a tongue
thrusting pattern.
b)
c)
II)
a)
Learned Behaviour
Improper bottle feeding which results in abnormal functional
patterns of lingual movement in the form of tongue thrusting.
b)
c)
d)
e)
III)
a)
Maturational
Tongue thrust present as part of a normal childhood oral behaviour
pattern that is gradually modified as the lingual space and
suspensory system change.
b)
c)
IV)
a)
Mechanical restirction
Constricted dental arches, which cause the tongue to function in a
lower position than usual.
b)
c)
V)
a)
Neurological disoders
Hyposensitive palate which precipitates crude patterns of food
manipulation and swallowing.
b)
c)
VI)
a)
b)
2.
3.
4.
5.
6.
An imbalance between the number and size of teeth and the size of
the oral cavity.
physiological
discrepancy
manifested
by
milk.
Subsequent
adaptive
response
to
the
associated
orbicularis oris muscle are brought into use, resulting in everted lips,
habitually apart, called Bottle mouth.
normal
swallowing
habit
closes
off
temporarily,
the
nasopharynx, eustachian tube and larynx from the pharynx while the
bolus of food is passing it. This causes a partial vacuum which helps to
drain part of the nasopharynx and eustachian tube and relaxes the
muscles after the act.
Classification
Moyers Classified Tongue Thrusting Into 3 Types:
Simple tongue thrust swallow
-
Straub 72 classification of abnormal swallowing habit : Group I There is a diastema between the upper central incisors, tongue action
may be a little bit different and there are many variations of the tongue
in this classification.
Group II : A non-occlusion/open bite is seen not only between anterior
teeth but in posterior teeth as well, usually from first molar forward or
if 2nd molars are in plane from second molar forward. Formerly these
were the most difficult cases to treat but with the advent of habit
therapy and correction of abnormal swallowing habit they respond fast.
Group III - This type of abnormal swallowing is the side thrust. Non
occlusion in the premolar and canine area has been created by lateral
displacement of the tongue. These are most difficult to correct and
usually recurrence of the abnormal swallowing following treatment is
common.
Group IV - This type of abnormal swallowing is seen in the so
called closed bite case. These are also more difficult to correct and most
difficult to detect. The patient although he has a severe close bite opens
his mouth sufficiently to accommodate the tongue between the teeth
when he swallows abnormally.
important.
E.g.: Flat low lying tongue with a forward posture is significant in
the development of Class III malocclusion.
In Class I with a short mandible and stop mandibular plane,
tongue may be positioned forward. Posture of the tongue is examined
clinically, with the mandible itself in the rest position. It is important to
note that a tongue thrust swallow does not always cause a malocclusion
where as an altered rest position, also leads to malocclusion. 2
significant variations from the tongue posture can be seen:
a) Retracted tongue.
b) Protracted tongue.
(a) Retracted tongue: Here tongue is withdrawn from all the anterior
teeths and may spread laterally. Incidence is less than 10% of all
children causes posterior open bite since it spreads laterally. Seen
more frequently in edentulous adults or in bilateral loss of several
posterior teeth.
(b) Protracted tongue :
-
Endogenous type.
Macroglossia
Microglossia
Size checking As the patient to touch his chin with tongue lip.
Test: Place the hand over the temporal muscle and press tightly with
finger tips in this region, give patient water and ask to swallow. During
normal swallow, temporal muscle can be felt to contract as the mandible
is elevated and the teeth are held together, whereas in teeth apart
swallow, no contraction of the temporal muscle will be noticed.
Differential diagnosis:
Normal infantile swallow, normal mature swallow, simple tongue
thrust swallow, complex tongue thrust swallow, retained infantile
swallow.
Normal infantile swallow:
During the normal infantile swallow, the tongue lies between the
gum pads and the mandible is stabilized by obvious contractions of the
facial muscles. Buccinator muscle is particularly strong in infantile
swallow.
Normal nature swallow:
It is characterized by very little lip and cheek activity and the
contraction of the mandibular elevators bringing into occlusion.
Simple tongue thrust swallow:
Typically displays contractions of the lips, mentalis muscles and
mandibular elevetes and the teeth are in occlusion as the tongue
protrudes in to an open bite and seals open bite.
is
defined
as
predominant
persistence
of
the
infantile
Effects
It may cause an openbite, protrusion of the upper
anterior
segment of both arches with spaces between the incisor and cuspids.
It may be present in tongue thrusters where they have pushed both
upper and lower anterior teeth labially creating spaces and in some cases
an edge to edge bite. The habit may be aided by unusually large tongues
causing severe open bite.
The perverted swallowing habit may separate not only the anterior
teeth but also most of the posterior teeth including premolars and in rare
instances the first molar unilaterally.
Treatment:
Exercises for Correction of Improper Tongue Position
The One Elastic Swallow
The exercise used for anterior positioning of the tongue is called
the one elastic swallow. The patient puts a 5/16 inch elastic on the tip of
the tongue, the tip of the tongue is raised to a designated spot just
posterior to the incisive papilla and the patient is asked to clench the
back teeth, open the lips and swallow with the lips open.
Tongue Hold Exercise
A 5/16 elastic is placed on the tip of the tongue to hold it in a
designated spot for a prescribed period of time. Gradually the holding
time is extended from 5 minutes.
pharyngeal wall in this swallow. It is done with the lips open in order to
break the reflex of tongue meeting the lips during swallowing.
Exercise for Masseter Muscle
This is an isometric and resistance exercise. The patient is asked
to bite the posterior teeth together while counting to ten and forcing the
masseter muscle to activate. This strengthens the muscle as it adapts to
the stress of the biting action.
The lower lip is placed over the upper lip and massages it. It is
intended to exercise several orofacial muscles and at the same time
extend the upper lip.
Simple tongue thrust It is defined as a tongue thrust with teeth
together with swallow. The malocclusion usually associated is well
circumscribed open bite in the anterior region. If there is excessive
protrusion of upper incisors, treatment of tongue thrusting should not
begin until the incisors have been retracted. Many tongue thrust corrects
spontaneously during ortho therapy.
Steps in treatments are:
1.
Aquiant the patient with normal swallow by placing the index finger
on the tip of the tongue and then on the junction of hard and soft
palate and tell the patient to close, his lips and swallow with the
tongue tip in this position of the palate. The use of tactile signals
help the patient understand better, where the tongue should go. Ask
the patient to practice 40 times/day.
2.
patient is asked to swallow with the tip against the palate. If the
swallow is correct elastic will be retained, if incorrect it will be
swallowed. Space the practice over 2-3 sessions/day. When the new
c)
to
be
reminded
and
redirected
towards
the
correct
swallowing position.
tooth
positioning,
careful
equilibration
followed
by
persistent myotherapy.
Myofunctional therapy:
Effective myofunctional treatment given for the purpose of
stabilising the musculature, so that bone and muscle work together in a
favourable environment. It is not to correct malocclusion, rather it is to
create a syncgronized, efficient habitual engram that will enable the
person to chew, gather and swallow saliva, liquids and solids without
having to think to do so.
Myofunctional therapy:
Myofunctional therapy is based upon the earlier work by Wolff
(1892) and Roux (1902). Whenever there is a functional change in the
bone it causes change in the architecture of the bone internally as well
as externally. This is applied in myofunctional appliance. The term %
functional appliance refers to a variety of appliances which are
Criteria:
1)
2)
3)
4)
5)
MOUTH BREATHING
Naso respiratory function and its relation to cranio-facial growth
is of great interest today, not only as on example of the basic biologic
relationship of form and function, but also because it is of great
practical concern to pediatricians, oto-laryngologists, allergists, speech
physiologists, orthodontists, and other members of the health care
community.
An important function of the nose is to prepare and modify
inspired air to a more physiologic state before it enters the lungs. The
quality of the air received by the lungs may influence the health and
function of the lungs themselves. When air first enters the nose it is
immediately screened for large particles by the coarse hairs in the
anterior nares. Air inhaled through the nose passes over the nasal
tubinates in thin layers and develops air currents that cause it to contact
the moist nasal mucosa. This contact removes additional foreign
particles like, dust, pollen and even bacteria. The debris laden mucus
site stop the cilia of the nasal mucosa and is carried by the ciliary action
to the pharynx, where it is swallowed or expectorated. The cleared air is
also warmed and moistened in the nose before it enters the lungs. By
contrast, when air is inspired through the mouth, it assumes a more
cylindrical amount and is not cleaned, warmed or moistened as it would
be in the nose.
There are various factors that influence the amount of air that can
pass through the nose. If a person is unable to ventilate adequately
through the nose, the mouth becomes an alternate breathing passage.
Mouth breathing has been in and out of vogue as a possible
etiologic factor for malocclusion. Because respiratory needs are the
primary determinant of the posture of the jaws and tongue (and to a
lesser extent, the head itself), it seems entirely reasonable that mouth
breathing could cause different head, jaw and tongue posture, which
would then alter the equilibrium and affect both jaw growth and tooth
position.
All humans are primarily nasal breathers, but everyone breathes
through the mouth under certain physiologic conditions, the most
prominent being an increased need for air during exercise.
Review of Literature:
Even before 1900, there were reports in which there was a degree
of uniformity of the description of facial form associated, with
mouthbreathing noted. Features commonly attributed to mouth breathing
include a high vaulted, V-shaped constricted palate and prcumbent
maxillary incisors.
In 1843, Robert argued that this set of signs was a result of nasal
airway obstruction and a subsequent lack of stimulation that prevented
the down ward growth of the palate.
In 1870, Meyer, one of the first to suggest the possible role of the
tongue position associated with mouth breathing resulted in unopposed
buccal forces on the maxillary dentition. This inbalance could cause the
dental arches to collapse lingually.
In 1891, Korner supported this view, adding that the lips apart
posture of mouth breathers was a further disturbing factor in the
equilibrium that determines the position of the teeth.
Spenson in (1947) emphasized the role of nasopharyngeal lymphoid
tissues and mucosa and proposed that malnutrition often resulted in the
infection of these tissues, thereby occluding the airway and increasing
the probability of bronchitis and rickets.
Bowman in (1951) suggested several factors that might predispose to
mouth breathing like small nostill size, nose tip too low, DNS, enlarged
turbinates swollen membranes, nasal polyps etc.
Rickets (1968) 61 studied cephalogram of 20 children and concluded that
malocclusions, are created by inadequate space for nasal respiration.
The lack of function in the nose seems to hold the front of the palate
upward or prevent its downward descent.
Differential forces on
the skeleton.
Morpho changes
Obstruction of Airways.
who
showed
total
obstruction
radiographically,
had
no
in
the
dimensions
of
the
respiratory
tract,
i.e.
is
present.
The
primary
cause
is
an
increased
vertical
development.
O. Ryan et al (1982) 52 stated that chronic nasal obstruction leads to
mouthbreathing which causes altered tongue and mandibular positions.
If this occurs over a long period of active growth the outcome is
development of the adenoid facies.
Proffit, Fields and Nixon (1983) 60 reported that long faced adults have
significantly less occlusal force during swallowing, chewing and
maximum biting.
Miller, Vargervik and Chierici (1984) 44 in his studies on rhesus
monkey adapted to nasal obstruction for 2 years concluded that they
ETIOLOGY
I. Developmental and Morphologic Anomalies which Interferes with
Nasal Breathing.
a) Asymmetry of the face resulting is asymmetry of nasal passage
due to intrauterine pressure during the period of embryonic
development.
b) Hereditary characteristics of facial form may be a factor in size
of nasal passages and position of the septum.
c) Abnormal development of nasal cavity.
d) Abnormal development of nasal turbinates.
e) Abnormally short upper lip, preventing proper lip seal.
f) Under development or abnormal facial musculature.
Adenoids:
The adenoids are a mass of lymphoid tissue situated at the roof of
the nasopharnx in the form of a beehive.
Pruzansky has noted considerable variation in the dimension of
adenoid tissue from age to age and speculated that its size at any
specific age might he related to individual response to stress.
Adenoid tissue was observed to become evident by 6 months to 1
year of life and to be quite abundant, occupying about one half of the
nasophyaryngeal cavity by 2-3 years of age. Therefore, it increases in
dimension until its greatest mass. In longitudinal ceph. Studies, the peak
mass was observed to occur as early as 9-10 years of age and as late as
14-15 years. Thereafter, the adenoid mass seems to gradually diminish
and the nasopharyngeal airway space greatly increased.
The adenoids also respond to and increase in size due to nasorespiratory infections and allergies. At, times it may be seen to
apparently obstruct in a vertical relation ship, a major portion of the
posterior nasal choanae. If this is significant, normal passage of air
through the nasopharynx may be abnormally reduced or impeded,
necessitating oral respiration.
Nasal Turbinates:
Growth of the naso-maxillary complex may be, in part, related to
a functional responses to the naso-respiratory inflow.
The hypertrophied turbinates may be responsible for severely
limiting nasal airflow. The bony turbinates are lined with respiratory
These
by
its
postural
effect
on
changes
equilibrium,
could
affect
produces
vertical
and
As the tongue in kept low and forward, the cheek exerts a force
against the buccal surfaces of the maxillary posterior teeth that is
not balanced by the presence of the tongue in the palatal area. This
causes palatal constriction and a V. shaped narrow maxillary arch.
The lack of tonicity in the lips and the possibility of a short upper
lip decreases the labial support for the maxillary anterior teeth
causing a labial flaring of the maxillary incisors and possibly an
anterior dental open bite.
Diagnosis:
How can one till who is a mouth breather? How much do you have
to breathe through your mouth to be classified as a mouth breather?
1.
2.
3.
Ask the patient to close the lips and take a deep breath through the
nose. Nasal breathers normally demonstrate good reflex control on
the alar muscle, which control the size and shape of the external
nose, therefore they dilate the external nares on inspiration. Mouth
breathers, even though are capable of breathing through the nose, do
not change the size or shape of the external nares and occasionally
actually contract the nasal orifice while inspiring.
4.
5.
6.
Ask the patient to take a mouthful of water and keep it in his mouth
itself. If the patient is a mouthbreather, he cannot retain the water in
his mouth for long.
7.
Disadvantages:
1.
2.
did
quantitative
assessment
of
nasal
airway
1.
2.
Cephalometric Diagnosis:
The presence and size of the adenolds and tonsills can be
estimated on the lateral cephalogram. This indicates whether the
nasopharyngeal passage is free or partially or totally obstructed.
McNamaras 41 analysis helped in the measurement of the upper pharynx.
Which also shows the amount of nasopharyngeal space available.
Linder and Aronson have suggested that the use of radiographs to
diagnose nasal airway impairment has been discouraged because,
radiographs are two dimensional super impositions of shadows of
structure and do not provide a true indication of airway patency. Such
radiographs artifacts caused by superimposition of shadows may lead to
grossly misleading conclusions.
Disadvantages:
A body pletysmograph is too insensitive to rapid changes in
airflow.
SNORT: GURLEY AND VIG 1982
SNORT
which
stands
for
simultaneous
Nasal
and
Oral
and
makes
it
possible
to
monitor,
record,
and
calibrate
continuously both oral and nasal inspiration and expiration. The output
is in the form of waveforms.
Airflow is monitored through four pneumotachographs that record.
1. Oral inspiration.
2. Oral expiration.
3. Nasal inspiration.
4. Nasal expiration.
The electrical signals can be converted to digital form and stored
in a computer, for subsequent display and analysis of various
parameters.
Features of Snort:
1.
2.
3.
4.
5.
6.
7.
8.
9.
2.
3.
Effects
Head : In order to breath, the child bends the neck forward straightening
the oro-nasopharyngeal path.
Thorax : The diaphragm muscle moevements become impaired and due
to air swallowed during breathing the child develops a pot belly.
Face : The type of malocclusion most often associated with mouth
breathing is called Long face syndrome 69 or the Classic adenoid
facies or Skeletal open bite.
I. Appearance:
a) Lips are held more than ordinarily wide apart.
b) There is lack of tone of oral musculature and resulting in
holding the mouth habitually open.
c) The upper lip is short and the upper teeth show.
d) The chin is receeded and the face has a typical pigion face
appearance.
e) The nose is often tipped superiorly in front.
f) Long narrow face - leptoproscopic.
g) The face is expressionless.
2)
As the tongue is kept low and forward and the cheek exerts a force
against the buccal surface of the maxillary posterior teeth leaving
them unopposed by the tongue in the palatal area. This causes paltal
2)
3)
4)
5)
6)
V. Lymphoid Tissues
Adenoids becomes hyperplastic due to chronic inflammation and
may occlude the eustachian tube resulting in defective hearing and
possibly a suppurative condition leading to it's many complications.
In chronic mouth breathers, the infected tonsils and inflamed
condition of the respiratory tract with improper interchange of gases in
the lungs causing deficiency in oxygenation of blood results in GIT
disturbances leading to a condition of autointoxication which in turn
through the blood stream acts as an irritant to the mucous membrane of
the nose causing still more obstruction to nasal breathing.
Management
Mouth breathing should be treated in order to prevent the possible
malocclusion that migh manifest due to chronic mouth breathing. Before
2.
3.
Myofunctional Therapy:
First of all, lip seal must be established, and MFt should follow
(HOCKEL).
During the day, the patient can hold an object such as a pencil
(tongue blade etc.) between the lips. This brings the lip seal to the level
Indication:
In the management of mouth breathing with an oral screen, it is
very important to note that the oral screen should be given to only those
patient with mouth breathing when the airways are open.
2.
3.
the obstruction were in the lower anterior part of the nasal passages.
Maxillary Protraction:
Maxillary deficiency is a problem not only in width, but also in
height and depth. Stimulation in maxillary development may not only
reside in opening the mid-palatal suture, but also may be necessary to