Bad oral habits in orthodontic..... pptx

Oral habits are important environmental factors that may lead to dental malocclusion, some of the negative sequelae associated with prolonged habits like thumb sucking and tongue thrusting

1. Bad Oral Habits in Orthodontic Dr. Asawer Ahmed Fayyad / BDS

2. Malocclusion can be interpreted as an irregular dental arch and/or occlusion. Malocclusion is considered to be multifactorial condition, the factors causing malocclusion can be widely classified into two broad categories; general etiological factors and local etiological factors. It also associated with congenital and acquired factors, including harmful oral habits such as digit sucking, tongue thrust, lip habit, habitual mouth breathing, and unilateral mastication habit. Oral habits are important environmental factors that may lead to dental malocclusion, some of the negative sequelae associated with prolonged habits like thumb sucking and tongue thrusting . INTRODUCTION

3. Acquired oral habits: include behaviors which are learned and can be readily stopped when the child grows up and acquire a new behavior. Compulsive oral habits: include behaviors which appeared to be constant. Classifications of Oral Habits

4. Physiological habits (Functional): such as nasal breathing, chewing, articulation and swallowing. Oral habits also classified into: Non-physiological habits (Parafunctional): which are often called harmful or parafunctional such as thumb or lip sucking, mouth breathing and tongue thrus

5. Anatomical: For example, posture of the tongue. Mechanical Interferences: Mechanical interferences lead to undesirable oral habits, e.g. in a child with normal breathing and swallowing, if permanent incisors erupt ectopically, then to achieve a proper anterior seal/ vacuum when swallowing, the child must thrust the tongue and resultant mouth breathing occurs due to loss of lip seal. Pathological: Certain conditions of oral and perioral structures can cause an undesirable oral habit, e.g. tonsillitis, DNS, hypertrophy of inferior nasal turbinates (can cause mouth breathing) Etiological Agents in the Development of Oral Habit

6. 4. Emotional: Upset children regress towards infancy, assume infantile postures, e.g. digit sucking which gives the child a feeling of security. 5. Imitation: Young children are extremely observant and sensitive to environment and highly affected by parents and siblings. The child may imitate jaw positions/speech disorders of parents. 6. Random Behavir: Behavior appears purposeless if not completely accidental

7. Thumb sucking is the most common oral habit and it is reported that its prevalence is between 13 to 100% in some societies. The habit of thumb sucking that prolonged can cause malocclusion. Malocclusion related to the combination of pressure directly from the thumb and change patterns of pressure cheeks and lips. Oral Habits Digit-sucking habit (Thumb/finger-sucking)

8. The Nutritive sucking: It is the sucking observed during Breast and bottle-feeding, which provides essential nutrients to the infant. It include; Forms of digit sucking Breast-feeding: Flow of milk is regulated by biting and releasing the lacteal glands. Bottle-feeding: Two types of nipples are available which non-physiologic nipple and physiologic nipple

9. 2. The Non-nutritive Form: It is the earliest sucking habit adopted by infants in response to frustration and to satisfy their urge and need for contact. Children who neither receive unrestricted breast feeding nor have access to a pacifier may satisfy their need with habits like thumb sucking which ensures a feeling of warmth and sense of security but may be detrimental to their dentofacial development

10. Active: In this type, there is a heavy force by the muscles during the sucking and if this habit continues for a long period, the position of permanent teeth and the shape of mandible will be affected. Passive: In this type, the child puts his/her finger in mouth, but because there is no force on teeth and mandible, so this habit is not associated with skeletal change Type of thumb sucking

11. According to many authors the type of malocclusion that may develop in a thumb sucker is dependent on a number of variables. These include: Position of digit Associated orofacial muscle contractions Position of the mandible during sucking The facial skeletal morphology Duration of sucking Diagnosis

12. The diagnosis of thumb sucking consists of the following diagnostic procedures : 1. History of Digit Sucking Information on whether the child has had a history of digit sucking is obtained from the parents. When there is a positive answer, one should inquire about: a) Frequency: Number of times/day habit is practiced. b) Duration: Amount of time spent on habit c) Intensity: Amount of force applied to the teeth during sucking

13. Cleaner digit Redness, wrinkling or chapped and blistered due to regular sucking. Dishpan thumb—clean thumb with short nails. Fibrous/roughened wart like callus on superior aspect of the digit, ulceration, corn formation. Rarely finger deformity seen. Short upper lip Higher incidence of middle ear infections, blocked eustachian tubes, enlarged tonsils and mouth breathing 2. Extra-oral Examination

14. Proclination of maxillary incisors Increased arch length Increased anterior placement of apical base of maxilla with increasing in SNA angle Increased clinical crown length of maxillary incisors Increased counter clockwise rotation of occlusal plane. Decreased width of palate Effect of Thumb Sucking Habit 1. Effect on Maxilla

15. Left/right side of anterior maxillary arch is usually deformed with deformation related to whether the right or left thumb is sucked. Atypical root resorption of primary central incisors. Trauma to maxillary central incisors (Primarily dueto their prominance).

16. Proclination of mandibular incisors Increased mandibular inter-molar width. More distal position of point B: Mandible is more distally placed relative to the maxilla. Mandibular incisors experience a lingual and apical force. 2. Effect on Mandible

17. Decreased inter-incisal angle Increased overjet, Decreased overbite, Posterior cross-bite Anterior open-bite Narrow nasal floor and high palatal vault 3. Effect on Inter-arch Relathionship

18. Lip incompetence Hypotonic upper lip Hyperactive lower lip: Since it must be elevated by contractions of orbicularis oris and mentalis muscle to a position between malposed incisors during swallowing. 4. Effect on Lip placement and Function

19. Tongue thrust Lip to-tongue rest position Lower tongue position 5. Effect on Tongue placement and Function 6. Other Effects Affects psychological health Risk of malpositioning of the teeth and jaws Deformation of digits Speech defects (lisping).

20. No active intervention regardless of type and severity of malocclusion because of general emotional immaturity. Most children outgrow the habit by 5 years of age. Malocclusion is self-correcting if ceased by the time of eruption of permanent teeth. Parents are advised to ignore habit and give more attention to the child when not sucking. If occlusion Class II, advise need for future orthodontic treatment. Treatment Treatment Consedration According to Age Younger than 3 years

21. More concern about finger sucking than thumb sucking due to anterior orthopedic force vectors associated with finger sucking leverage. Watching and counseling Working with parent on contingent behavior modification 3 -7 years old Anterior open bite will not close by itself due to established functional patterns. Therefore, orthodontic intervention is needed 7 years and older

22. Some authors states that the best way to break a habit is by conscious, purposeful repetitions, i.e. the subject should sit in front of a large mirror and suck observing as he does so. The timing of sucking should conflict with some pleasurable activity the child enjoys. By practicing the bad habit with the intent to stop it, one learns not to perform that undesirable act. This is especially practiced in older children (8 years and over). Psychologic Approach

23. Mechanical methods: These include the following: Thermoplastic thumb post that covers the offending digit. Taping of the offending digit or tying it to the elbow. According to Pinkham there are three categories of treatment Reminder Therapy 2. Chemical Therapy Hot tasting or bitter flavored preparations or distasteful agents are applied to the offending finger/thumb. In this method, agents, such as cayenne pepper, quinine, asafetida are used to paint the finger.

24. 2. Reward System In reward system procedure, the child is motivated to stop the habit by gingiva. In reward system procedure, the child is motivated to stop the habit by giving a suitable reward, if discontinued within a suitable period of time. Reward system involves placing a star for each observed day free of thumb sucking, on a calendar. Finally, a reward is given to the child after a set of stars have been earned. Constant praise and motivation is required for the child from the parents and dentists.

25. These are passive appliances which are retained in the oral cavity by means of clasps and usually have one of the following additional components: a. Tongue spikes b. Tongue guard c. Spurs/rake 3. Appliance Therapy A. Removable Appliances

26. a. Quad helix B. Fixed Appliances c. Maxillary lingual arch with palatal crib b. Hay rakes

27. Four to six months. A period of 3 months of total absence of finger sucking is convincing evidence of absence of relapse. The ideal appliance for correction of posterior cross-bite due to a digit sucking habit is the Quad Helix. It is an adjustable lingual arch that requires little patient cooperation as it is fixed and is reliable and easy to use. Constructed with 38 mil steel wire shaped in the form of a 'W', consisting of 2 anterior and 2 posterior helices. These helices increase the range and springiness of the appliance. The helices in the anterior palate are bulky, which can effectively serve as reminders to aid in stopping the habit. Time of Therapy

28. Tongue thrusting habit is defined as the placement of the tongue tip forward between incisors during swallowing (fig. 1-10). This anterior tongue position may be termed as tongue thrust, deviate swallow, visual swallow or infantile swallow. Tongue thrust is actually a ‗misnomer‘ as it means that tongue is forcefully thrusted forward whereas actually. The tongue is only placed forward. Tongue Thrust Habit

29. Genetic or heredity factors: They are specific anatomic or neuromuscular variations in the orofacial region that can precipitate tongue thrust. Endogenous Tongue Thrust: The tongue thrust is due to neuromuscular mechanism. Learned behavior (habit): Tongue thrust can be acquired as a habit. The following are some of the predisposing factors that can lead to tongue thrusting 1. Improper bottle feeding 2. Prolonged thumb sucking Etiology of Tongue Thrust

30. Prolonged tonsillar and upper respiratory tract infections Upper respiratory tract infections such as mouth breathing, chronic tonsillitis, allergies, push the tongue forward due to pain and decrease in the amount of space which brings about a tongue thrust swallow. Prolonged duration of tenderness of gum or teeth can result in a change in swallowing pattern to avoid pressure on the tender zone Upper respiratory tract infections Feeding practices: Prolonged bottle feeding and improper swallowing pattern has been attributed as one of the etiological factors of tongue thrusting

31. Physiologic: This comprises of the normal tongue thrust swallow of infancy. Habitual: The tongue thrust swallow is present as a habit even after the correction of the malocclusion. Functional: When the tongue thrust mechanism is an adaptive behavior developed to achieve an oral seal, it can be grouped as functional. Anatomic tongue thrust: Persons having enlarged tongue can have an anterior tongue posture. Classification of Tongue Thrust

32. Simple Tongue Thrust Types of Tongue Thrust It is associated with well-circumscribed open bite in the anterior region. If there is excessive labioversion, the teeth has to be retracted first, if it is a case of simple tongue thrusting. Swallowing exercises should be taught along with the appliance to the patients

33. Extraoral Features of simple tongue thrust Usually dolichocephalic face, Increased lower anterior facial height, Incompetent lips, Expresion less face as the mandible is stabilized by facial muscles instead of masticatory muscles during deglutition., Speech problems like sibilant distortions and lisping etc.. Abnormal mentalis muscle activity is seen.

34. Proclined, spaced and sometimes flared upper anteriors resulting in increased overjet, Retroclined or proclined lower anteriors depending upon the type of tongue thrust, Presence of an anterior open bite, Presence of posterior crossbites. Intraoral Features of simple tongue thrust

35. Complex Tongue Thrust It is defined as tongue thrust with a teeth apart swallow. It is usually associated with chronic nasorespiratory distress, mouth breathing, tonsillitis, and pharyngitis. Clinical Feature Proclination of anterior teeth, Bimaxillary protrusion, This kind of tongue thrust is characterized by a teeth apart swallow, The anterior open bite can be diffuse or absent, Absence of temporal muscle constriction during swallowing.

36. Treatment Patients with a complex tongue thrust combine contractions of the lip, facial and mentalis muscle, The occlusion of teeth may be poor. Poor occlusal fit, no firm intercuspation, Posterior open bite in case of lateral tongue thrust, Posterior crossbite . The preliminary step is the tongue exercises and habit-breaking appliances. Treatment or correction of malocclusion follows later

37. Mouth breathing is clinically observed in patients with some nasal obstruction as well as in those who have a habit to stay and sleep with open mouth. Mouth Breathing Intraoral Features Proclination of anteriors, Distal relation of mandible to maxilla, Lower anteriors elongate and touch the palatal tissues, Upon gingival tissue, Constant wetting and drying of the gingiva causes irritation, saliva about the exposed gingiva tends to accumulate debris resulting in an increase in bacterial population.

38. Extraoral Features Lips slack and stay open, Short upper lip Moulding action of upper lip on incisors is lost thereby resulting in proclination and spacing. Lower lip: heavy and everted. Tongue is suspended between upper and lower arches resulting in constriction of buccal segment (V shape arch).

39. Diagnosis of Mouth Breathing Ask the patient to take a deep breath Mirror test: Cotton test/Massler's butterfly test: Water test

40. Management of Mouth Breathing ENT referral for management of nasopharyngeal obstruction is necessary any orthodontic treatment. Prevention and interception It usually ceases at puberty or after it due to increase in size of passage during period of rapid growth. Mouth breathing can be intercepted by use of an oral screen. Myofunctional therapy

41. This is a bad habit of scraping upper jaw and lower jaw teeth, it can arise at childhood as well as adults. Bruxism Clinical Features Occlusal trauma (tooth mobility, bone loss)  Tooth structure (attrition of upper teeth, attrition of lower teeth) Muscular tenderness (tenderness of jaw muscles, muscular fatigue, hypertrophy of masseter) TMJ disorder (TMJ joint pain) Headache Other signs and symptoms (soft tissue trauma, ulceration)

42. Management of Bruxism Psychotherapy like relaxation exercises. Drugs like local anesthetic injections into TMJ for muscles, sedatives, and muscle relaxants. Occlusal adjustments to bring the jaws to normal relaxed state of physiologic movements. Bite planes also help. Bite planes/occlusal splints/ bite guards Restoration of lost vertical dimension—cast crowns/stainless steel crowns. Electrogalvanic stimulation for muscle relaxation, Ultrasound Provides analgesic effect for masti- catory pain. 8. TENS Transcutaneous electrical nerve stimulation 9. Acupressure For relaxation. Other methods (Oral exercises, Desensitizing agents, Occlusal correction  Counseling on nutrition, Supplement deficiencies).

43. Lip-sucking is a compensatory activity that results from an excessive overjet and the relative difficulty of closing the lips properly during deglutition. It is easy for the child to cushion the lip to the lingual side of maxillary incisors. To achieve this position, mentalis muscle extends the lower lip upwards. Lip Sucking Proclination of anteriors  Distal relation of mandible to maxilla, Lower anteriors elongate and touch the palatal tissues, Upon gingival tissue, Constant wetting and drying of the gingiva causes irritation, saliva about the exposed gingiva tends to accumulate debris resulting in an increase in bacterial population.

44. Marked flattening and crowding of lower anterior segment occurs,, Maxillary incisors may be forced upward and forward into a protrusive relationship in lower lip-sucking, In severe cases, the lip itself shows the effects of abnormal habit, The vermilion border becomes hypertrophic and redundant during rest, Reddening below vermilion border is seen, Flaccid lip, Mento-labial sulcus becomes accentuated. Clinical features

45. Lip over lip exercises Playing bass instruments. Oral screen Management Lips bumper/shield: Lip bumper appliance is a good treatment alternative for breaking the habit and correcting the resultant malocclusion.Treatment effects of the mandibular lip bumper appliance, such as arch length gains, control of molar rotation, and anchorage.

46. Tongue constantly wets the lips due to dryness/ irritation which later becomes a habit. It starts as idle play and develops into a tooth displacing habit by keeping centrals apart Lip Wetting Treatment Orthodontic correction for spacing.

47. May involve either of the lips, features seen are cuts and abrasions, marks of incisors on lips along with reddening of lips Lip Biting This habit rarely seen in children and patient has spaced upper permanent incisors as holds the labial frenum between teeth for several hours. Frenum Thrusting

48. Biting the cheeks, if unchecked may contribute to ulceration, pain, discomfort or malignance Cheek Biting Etiology Buccoversion of erupting third molar, Flabby cheeks, Lack of proper coverage of lower teeth by upper teeth buccally, Atrophy of muscles seen in paralysis. Treatment Identify the cause, Analgesics, Appliance therapy, Oral screen

49. It is a common and untreated medical problem among children. This habit starts after 3 to 4 years of age and is in its peak in 10 years of age. Nail Biting Complication of Nail Biting Malocclusion of the anterior teeth, teeth root resorption intestinal parasitic infections, change of oral carriage of Enterobacteriaceae, bacterial infection and alveolar destruction. one fourth of patients with temporomandibular joint pain and dysfunction have been shown to suffer from nail biting habit. It is seen in clinic that boys with nail biting have a kind of psychological disorder especially attention deficient hyperactivity disorder (ADHD) more than girls

50. Treatment of Nail Biting In mild cases no treatment is needed Encourage outdoor activities Reminder like nail polish Psychotherapy and pharmacotherapy In severe cases intraoral fixed deterrent appliance may be used

51. Dr. Asawer Ahmed Fayyad / BDS