Habits
Question 1. Write short note on tongue thrust habit.
Or
Write briefly on tongue thrusting habit.
Or
Write briefly on management of tongue thrusting.
Answer. It is defied as “placement of the tongue tip forward between incisors during swallowing”.
Classification of Tongue Thrusting
- Moyer’s Classification
- Simple tongue thrusting.
- Complex thrusting.
- Retained infantile swallow.
Read And Learn More: Orthodontics Question And Answers
- According to James S Braner and Holt
- Type 1: Non-deforming tongue thrust
- Type 2: Deforming anterior tongue thrust
- Subgroup 1: Anterior open bite
- Subgroup 2: Anterior proclination
- Subgroup 3: Posterior crossbite
- Type 3: Deforming lateral tongue thrust
- Subgroup 1: Posterior open bite
- Subgroup 2: Posterior crossbite
- Subgroup 3: Deep overbite
- Type 4: Deforming lateral and anterior tongue thrust
- Subgroup 1: Anterior and Posterior open bite
- Subgroup 2: Proclination of anterior teeth
- Subgroup 3: Posterior crossbite
Etiology of Tongue Thrust
Fletcher proposed following factors as cause for tongue thrusting.
Genetic Factors
They are specifi anatomic or neuromuscular variations in the orofacial region. For example, Hypertonic orbicularis oris activity.
Learned Behavior
- Tongue thrust can be acquired as a habit.
- Some predisposing factors of tongue thrusting are:
- Improper botte feeding.
- Prolonged thumb sucking.
- Prolonged tonsillar and upper respiratory tract infections.
- Prolonged duration of tenderness of gum or teeth can result in a change in swallowing pattern to avoid pressure on the tender zone.
Maturational Factor
The infantile swallow changes to a mature swallow once the posterior deciduous teeth start erupting.
Sometimes, the maturation is delayed and thus, infantile swallow persists for a longer duration of time.
Mechanical Restrictions
Such as macroglossia, constricted dental arches or enlarged adenoids.
Neurological Disturbance
Neurological disturbance affcting the orofacial region such as hyposensitive palate and moderate motor disability.
Psychogenic Factor
Tongue thrusting habits can develop due to forced discontinuation of other habits such as thumb sucking.
Clinical Features
Common Clinical Features of Tongue Thrusting Habit
- Proclination of the anterior teeth.
- Presence of bimaxillary protrusion
- Presence of anterior open bite
- In the lateral tongue thrust there is posterior open bite and posterior crossbite
Simple Tongue Thrusting
- Normal tooth contact in posterior region.
- Anterior open bite.
- Contraction of lips, mentalis muscle and mandibular elevators.
- Posterior teeth show good intercuspation.
- Forward placement of tongue in achieving anterior lip seal
Complex Tongue Thrusting
- It is characterized by teeth apart swallow.
- Anterior open bite can be either diffuse or absent.
- Absence of temporal muscle constriction at the time of swallowing.
- Contraction of circumoral muscles at the time of swallowing.
- Occlusion of teeth can be poor.
Retained Infantile Swallow
- Jaw lie apart and the tongue is placed between the gum pads.
- Mandible get positioned.
- Lips and tongue guides the swallow.
Treatment/Management
Interception as well as treatment of tongue thrusting is always age and severity dependent.
In young child whose age is of 3 years, no intervention is needed but children who are older than this age should be trained for the tongue swallowing exercises.
Treatment of tongue thrusting is as follows:
Reminder Therapy/Interception of Habit
- Fixed and removable habit breakers i.e. cribs and rakes should be used. Removable appliances which can be used are upper Hawley’s plate with tongue cribs and the roller balls for tongue exercise.
- Teach correct method of swallowing to child.
Corrective Therapy
It consists of
- Obstruction removal
- Tongue exercises
- Lip exercises
- Habit breaking appliance
- Treatment of Malocclusion
Obstruction Removal
- Surgery should be done for the adenoid and macroglossia
- Anterior and posterior open bite should be closed by either fixed or removable orthodontic appliance.
Tongue Exercises
Some of the exercises of tongue to adapt it to new swallowing pattern with removable or fied orthodontic appliances is advised as habit is intercepted. These are as follows:
- Elastic band swallow exercise: Held up the small orthodontic elastic band to the tongue tip against the palate during swallowing and patient should be asked to practice this. If the swallow is correct, patient is able to hold the elastic, otherwise it falls and can be swallowed.
- Water swallow exercise: Advise to patient, to keep water in mouth and a mirror in hand and practice the swallowing daily.
- Candy swallow exercise: Place a flat sugarless candy between tongue and the palate and practice the swallowing. This exercise reinforces the learning of new swallowing pattern to be transferred to subconscious level.
- Speech exercise: Syllables such as c, g, h, k are practiced by patient by keeping an elastic band between tongue and the palate.
Lip Exercises
Patient practices the stretching of lips to achieve the anterior lip seal.
Habit Breaking Appliance
- Fabrication of fied tongue spike is done with 0.040 inch stainless steel alloy. Appliance is V shaped with 3 to 4 projections extend to the cingulum of mandibular incisors and are soldered to molar bands or crown. It should be placed in between 5 to 10 years of age.
- A modified tongue crib is used in patients with lateral tongue thrusting habit.
Treatment of Malocclusion
Treatment of malocclusion is carried out with either removable or fixed orthodontic appliances.
Question 2. Write short note on mouth breathing habit.
Or
Define and classify habits. Describe in detail the etiology, clinical features and management of mouth breathing habit.
Answer.
Mouth breathing is defined as “habitual respiration through the mouth instead of nose”.
Classification of Mouth Breathing by ‘Finn’
- Obstructive: Increased resistance to or complete obstruction of normal airflw through nasal passage.
- Habitual: As a mattr of habit or persistence of the habit even aftr elimination of the obstructive cause.
- Anatomical: Short upper lip leads to incompetence of lips and hence mouth breathing.
Etiology
- Anatomic causes: Short upper lip and underdeveloped nasal cavity.
- Obstructions: Nasal polyp, Enlarge adenoid, deviated nasal septum, upper respiratory tract infection.
- Obstructive sleep apnea.
- In association with other habits such as thumb sucking.
Clinical Features
- Protrusion of maxillary and mandibular incisors
- Narrow maxillary arch.
- Posterior dental crossbite.
- Palatal vault is high.
- Posterior teeth get supraerupted.
- Anterior open bite.
- Increased incidence of caries.
- Steep mandibular plane.
- Anterior facial height is excessive.
- Lip posture incompetent with lip trap.
- External nares are widely flred.
- Cervical column get inclined forward.
- Head posture is extended.
- In anterior region marginal gingivitis is present.
Diagnosis
- Observe the patient:
- Mouth breathers—lips will be apart.
- Nasal breathers—lips will be touching
- Mirror test (jog test): Two surfaced mirror is placed on the patients upper lip. If air condenses on upper side of mirror the patient is nasal breather and if it does so on the opposite side than he is a mouth breather.
- Massier’s water holding test: Patient is asked to hold the mouth full of water. Mouth breathers cannot retain the water for a long time.
- Butterfly test: Take few fibers of cotton and place it just below the nasal opening on exhalation if the fiber of the cotton flutter downwards, patient is nasal breather and if fiber flutter upward, he is a mouth breather.
- Cephalometrics: This helps to assess amount of nasopharyngeal space, size of adenoids and diagnosing long face.
- Rhinomanometry: Study of nasal airflw characteristics using airflow devices such as flw meter and pressure gauges. Estimation of airflow via nasal passage and the amount of nasal resistance.
Treatment
- Removal of nasal or pharyngeal obstruction.
- Interception of the habit—By use of a oral screen. Mainly passive oral screen is used and breathing holes should be place which are removed gradually.
- Alternatively adhesive tapes can be used to establish lip seal.
- Rapid maxillary expansion—Patient with narrow, constricted maxillary arches benefi from rapid palatal expansion. Rapid maxillary expansion has been found to increase the nasal air flow and decrease the nasal air resistance.
Question 3. Write briefly on oral habits.
Answer.
Definition of Habits
- A habit can be defied as the tendency towards an act that has become a repeated performance, relatively fixed, consistent and easy to perform by an individual.
- Habit can be defined as “a fixed or constant practice established by frequent repetition”. —Dorland
- Habit is a formed reaction that is resistant to change whether useful or harmful depending on the degree to which it interferes with child’s physical, emotional and social functions.
- Habits are learned pattrns of muscular contractions which are complex in nature.
- A habit is a inclination or aptitude for some action acquired by frequent repetition and showing itself in increased facility to performance and reduced power of the resistance.
Classification of Habits
William James Classification
Useful and Harmful Habit
- Useful habit: These include habits that are considered essential for normal function such as proper positioning of the tongue, respiration and normal deglutition.
- Harmful habit: These include habit that have a deleterious effect on the teeth and their supporting structures such as thumb sucking, tongue thrusting, etc.
Klein’s Classification
Empty and Meaningful Habit
- Empty habit: They are habits that are not associated with any deep rooted psychological problems.
- Meaningful habit: They are habits that have a psychological problems.
Morris and Bohana Classification
Pressure, Nonpressure and Biting Habits
- Pressure habits: These include sucking habits such as thumb sucking, lip sucking, figer sucking, tongue thrusting.
- Nonpressure habit: Habits which do not apply a direct force on the teeth. For example, Mouth breathing.
- Biting habits: These includes nail biting, pencil biting and lip biting.
Finn’s Classification
Compulsive and Noncompulsive Habits
- Compulsive habits: These are deep rooted habits that have acquired a fiation in the child. The child tends to suffer increased anxiety when attmpts are made to correct the habit.
- Non-compulsive habit: They are habit that are easily learned and dropped as the child matures.
Kingsley Classification
Functional, Muscular, Combined Muscular and Postural Habits
- Functional habits: It includes mouth breathing
- Muscular habits: Cheek and lip biting and tongue thrusting
- Combined muscular habits: It includes thumb and figer sucking
- Postural habits: Habits such as abnormal pillowing and chin propping
Pathophysiology of Oral Habits Causing Malocclusion
Tongue Thrusting Habit
Repeated anterior positioning of tongue causes anterior open bite, protruded and spaced anterior teeth and an incompetent anterior lip seal all these effects produces tongue thrusting.
Mouth Breathing Habit
- Child suffering from nasorespiratory blockage because of enlarged tonsils, recurrent throat infection etc keep his/ her tongue low and forward and is unable to maintain anterior lip seal.
- These patients develop mouth breathing habit with open mouth posture. Such children develop long faces known as adenoid facies.
Thumb or Digit Sucking Habit
- Development of normal orofacial function is hampered due to continuation of sucking habits beyond the age of 4 to 5 years.
- At the time of thumb sucking or digit sucking, mouth remain open and tongue is positioned forward and low in mouth, due to this an abnormal pressure is generated by contraction of the cheek muscles which produces an imbalance in intraoral force system.
- Exaggerated buccinator activity at the time of sucking and swallowing produces constricted maxilla, buccal crossbite, lower and backward mandibular posture causing Class II division 1 malocclusion.
Question 4. Write short note on habit breaking appliance.
Answer. These are also known as reminder appliances.
Ideal Requirements of Habit Breaking Appliances
- It should not depend on patient’s cooperation.
- Appliance should offr no restraint to normal muscle activity.
- It should not involve patient’s parents.
- It should not have shame attached to its use.
Mechanism of Action
- Appliance prevents the finger pressure from displacing the incisors.
- Appliance renders the habit meaningless by breaking the suction.
- Appliance re-educates tongue to its normal posture and prevents the maxillary constriction.
Removable Appliances
Removable habit retraining appliance consists of palatal wire assembly embedded in the removable acrylic appliance. The appliance is retained by clasps on maxillary deciduous 2nd molars or lst permanent molars.
- Cribs
- Rakes/spurs.
Fixed Appliances
- Consist of maxillary lingual arch with cribs or rake soldered or inserted in lingual sheath in the anterior region.
- The lingual arch is soldered to the metal bands fabricated on maxillary deciduous 2nd molars or permanent lst molars.
- Lingual arch with palatal crib
- Lingual arch with rakes / spurs
- Quad helix.
Blue Grass Appliance
- Teflon made six rollers are incorporated into stainless steel wire and is soldered to the molar bands.
- Patient is instructed to turn the roller when he/she feels like sucking figer.
- Total time for wearing of appliance is 3–6 months.
Working of Habit Breaking Appliance
- Cribs: Incorporated in removable or fixed appliances the palatal crib acts as follows:
- Renders the habit meaningless by breaking the suction.
- Makes the habit non-pleasurable as thumb cannot touch the palate.
- Breaks the thumb and tongue pressure applying on maxillary incisors.
- Appliance forces the tongue backward, distributes the pressure to posterior teeth as well.
- Act as reminder not to indulge in the habit.
- Rakes/spurs: The blunt spurs projecting into palatal vault discourage not only thumb sucking but also tongue thrusting and improper swallowing habits as well.
- Quad helix: It includes the following:
- It is the ideal appliance for correction of posterior crossbite caused due to digit sucking habit. Activation of Quad helix causes expansion of the dental arch.
- Its anterior portion with two helixes placed near the anterior palatal region acts as a reminder.
Question 5. What is digit sucking. What is a triad of a habit. Describe how thumb sucking brings about malocclusion.
Answer. Digit sucking is defied as placement of the thumb or one or more figers in varying depths into the mouth.
Triad of Habit
Triad of habit consists of three factors, i.e.
- Duration of habit: Amount of time spent indulging in the habit.
- Frequency ofhabit: Number of times habit is activated in a day.
- Intensity of the habit: It is the vigor with which the habit is performed.
Mechanism of Thumb Sucking Causes Malocclusion
Mechanism of thumb sucking in causing malocclusion is:
![Orthodontics Habits Thumb Sucking](https://bdsnotes.com/wp-content/uploads/2023/05/Orthodontics-Habits-Thumb-Sucking.png)
Children who sleep in night with thumb between the teeth suffer from malocclusion as pressure applied is for 6 hours or more.
Development of malocclusion depends on various number of factors, i.e.
- Position of digit.
- Position of mandible at the time of sucking.
- Associated orofacial muscle contractions.
- Intensity, duration and degree of sucking.
- Skeletal morphology.
Question 6. Write short note on butterfly test.
Answer. It is also known as cotton test or Massler’s butterfly test.
- The test is used to assess the difference between mouth breathing and nose breathing.
- Butterfly shaped cottn piece is placed over the upper lip just below the nostrils.
- Breathing of the patient is observed.
- If cotton flutters down it means patient is a mouth breather. In this case test is positive.
- If cotton does not flutters down it means patient is a nasal breather. In this case test is negative.
Question 7. Write short note on thumb sucking habit.
Or
Write short answer on thumb sucking habit.
Or
Define and classify habit. Describe clinical features and treatment of thumb sucking habit in detail.
Or
Write short note on management of thumb sucking habit.
Answer.
Thumb sucking is defied as placement of the thumb in varying depths into the mouth.
Etiology
- Socioeconomic status: In high socioeconomic status mother is in a bettr position to feed the baby and babies hunger is satisfid in a short time while in low socioeconomic status mother is unable to provide suffient breast milk to infants so here the infants suckle intensively for long time and exhausting the sucking urge.
- Working mother: Children of working mother remain in the hands of caretaker and develop the feeling of insecurity.
- Number ofsiblings: More the number of siblings less is the attention given by the parents to the children. A child who feel neglected develop feeling of insecurity by means of habit.
- Order of birth of child: Younger child in the family have more chances of developing the habit.
Mechanism of Thumb Sucking
![Orthodontics Habits Thumb Sucking](https://bdsnotes.com/wp-content/uploads/2023/05/Orthodontics-Habits-Thumb-Sucking.png)
Clinical Features
- Presence of maxillary anterior teeth protraction.
- Presence of postural retraction of mandible.
- Lingual tipping of mandibular incisors.
- Presence of anterior open bite.
- Maxillary arch becomes narrow.
- Palatal vault becomes high.
- Upper lip becomes hypotonic.
- Lower lip becomes hypertonic.
Diagnosis
It is solely based on the clinical findings:
- Parents and children provide history of thumb sucking.
- Child is asked for his/her feeding habits.
- Thumb and thumb nail of child should be checked. If his/her thumb is clean then or if callus in figer is present, it is diagnostic of thumb sucking habit.
- Active thumb sucking have high incidence of middle ear infections and have enlarged tonsils accompanied by mouth breathing.
- Patient has convex profile.
Management/Treatment
There are three stages which are considered for the management of the thumb sucking habit:
Stage 1: Normal and subclinically signifiant sucking.
Stage 2: Clinically signifiant sucking.
Stage 3: Intractable sucking.
Stage 1: Normal and Subclinically Signifiant Sucking
- The stage lasts from birth of child to 3 years of age.
- At this time usually almost most of the infants develop thumb sucking habit and this indicates normal growth.
- Thumb sucking habit resolves by its own at end of stage I.
- At this stage children are treated by medications of pepper, neem, etc. as well as by pacifirs.
- If any malocclusion occurs to children, prophylactic therapies are adopted.
Stage 2: Clinically Significant Sucking
- This stage lasts from 3–7 years.
- At this stage film plan of treatment is needed.
- Counseling and appliances are used.
Stage 3: Intractable Sucking
- After 4th year the habit creates problem.
- Treatment given is with psycotherapy as well as appliances.
Methods of Correction
Psycologial Therapy
- Friendly discussion is carried out between child and the dentist about ill effect of habit.
- Various photographs and study models are shown and explained to the child who had deleterious sucking habits.
- A record is made and is given to the children for scoring in each morning to indicate whether the thumb sucking was attmpted in the night. This produces good results.
Reminder Therapy or Mechanical Therapy
- This therapy is effective in child who desires of withdrawing the habit.
- An adhesive bandage is given with waterproof tape over the figer which has to be sucked.
- Asafoetida, neem or pepper medications are applied over the sucking thumb or finger.
- An elastic bandage is loosely tied around the elbow so that arm could not be flexed and finger should not be sucked.
Reminder Appliance or Habit Breaking Appliance
Removable Appliance
Upper Hawley appliance along with tongue spikes or cribs is applied in between canines.
Fixed Appliance
Fixed Re-education Appliance
- Its assembly consists of loops and spurs which are formed by 0.40 thickness of wire which is bent at 45° to occlusal plane and soldering is done to crowns in deciduous second molar.
- Regular check ups should be done from 3 to 4 weeks.
- Appliance should be worn for 4 to 6 months.
Blue Grass Appliance
- The appliance is for the children with the continued thumb sucking habit which is affcting the permanent or mixed dentition.
- It consists of modifid six sided roller machine from Tefln.
- This is slipped over a 0.045 stainless steel wire soldered to molar orthodontic bands.
- Appliance is placed for 3 to 6 months.
- Instructions are given to turn the roller instead of sucking the digit.
- Thumb sucking is often seen to stop immediately.
Oral Screen
- It is a functional appliance.
- It produces its effects by redirecting the pressure of muscular and soft tissue curtain of cheeks and lips.
- It prevents the child from placing the thumb or figers into oral cavity during sleeping hours.
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