tongue and malocclusion - Copy.pptx

CONTENT
• Introduction
• Development of tongue .
• Anatomy of Tongue
• Muscles of tongue.
• Nerve & Blood supply of Tongue.
• Tongue In Orthodontics.
• Examination of tongue.
• Tongue Thrust and Malocclusion.
• Abnormal tongue posture.
• Conclusion.
• References.

Introduction
• Tongue is a muscular organ situated in the floor of mouth.
• It is a mass of striated muscle covered with mucous membrane.
• Shape – triangular.
• Attachment – with mandible and hyoid bone.
• Has an apex, body and root that plays role in manipulating food for
chewing and swallowing .
•It is the primary organ of taste.
B.D.Chaurasia: Human Anatomy For Dental Students:First edition;270-274.

The tongue, with its wide variety of possible movements, assists in
forming the sounds of speech.
It is sensitive and kept moist by saliva, and is richly supplied with nerves
and blood vessels to help it move.
As for as animals are concern tongue is considered as SPOON.
B.D.Chaurasia: Human Anatomy For Dental Students:First edition;270-274.

Development of tongue
Tongue, a soft muscular tissue is mainly made of mucosa, muscles and
its vascular and nerve supply.
First pharyngeal arch mucosa of body of tongue
( anterior 2/3rd )
Third pharyngeal arch mucosa of base of tongue
(posterior 1/3rd)
Human Embryology: Inderbir 6 Singh, G.P.Pal: 7th Ed

Development of tongue occurs in end of fourth week.
By the following arches .
First arch.
Third arch.
Fourth arch.

Anterior 2/3-
i) from 2 lingual swelling and one tuberculam impar i.e. from first
branchial arch.
ii) supplied by lingual nerve ( post – trematic) and chorda tympani ( pre
– trematic).
Posterior 1/3 –
i) from the cranial half of the hypobranchial eminence i.e. from third
arch.
ii) Supplied by glossopharyngeal nerve.

Posterior most
i) from the fourth arch
ii) supplied by vagus nerve
Muscles develops from the occipital myotomes which are supplied by
hypoglossal nerve.
Connective tissue develops from local mesenchyme.

Human Embryology:Inderbir 6 Singh, G.P.Pal: 7th Ed

ANATOMY OF TONGUE
The Tongue has tip, body and root
B.D.Chaurasia: Human Anatomy For Dental Students:Fourth edition;270-274.
Tip of tongue lies behind the upper incisor teeth.
Forms the anterior free end.

Root of tongue
Attached to,
- Mandible and soft palate above and Hyoid bone below
- Because of these we are not able to swallow the tongue itself.

Body of tongue
A . Dorsum of tongue
It is a convex in all direction .
It is divided in to two parts by V Shaped groove, the sulcus terminalis.
a. oral part.
b. pharyngeal part.
The 2 limits of the V meet at the median pit named foramen caecum
B. Inferior of tongue
Inferior surface is confined to the oral part only

MUSCLES OF THE TONGUE
INTRINSIC
Superior longitudinal.
Inferior longitudinal.
Transverse .
Verticle .
EXTRINSIC
Genioglossus
Hyoglossus
Styloglossus
Palatoglossus

INTRINSIC MUSCLES
1.SUPERIOR LONGITUDINAL MUSCLE
shortens the tongue and make dorsum concave.
2.INFERIOR LONGITUDINAL MUSCLE
shortens the tongue and make dorsum convex.
3.TRANSVERSE
makes the tongue narrow and elongated.
4.VERTICLE
makes the tongue broad and flattened.

EXTRINSIC MUSCLES
Genioglossus - mandible
Hyoglossus - hyoid bone
Styloglossus - styloid process
Palatoglossus – palate

GENIOGLOSSUS
Protrudes the tongue out of the mouth by pulling posterior part forward.
HYOGLOSSUS
Depresses the tongue .
STYLOGLOSSUS
pulls it upward and backward.
PALATOGLOSSUS
Brings both arches together, thus shutting the oral cavity.

Blood supply
Arterial supply of the tongue
Lingual artery main and
Ascending pharyngeal
Venous drainage
Deep lingual vein is the
largest and principle vein
of the tongue.

Lymphatic drainage
Tip - bilaterally to
submental nodes.
R & L halves of Anterior
2/3rd - submandibular
nodes. Few central
lymphatics drain bilaterally
to same nodes.
Posterior 1/3rd - bilaterally
to jugulo-omohyoid nodes.

Hypoglossul nerve ( XII)
Cranial part of Accessory N (XI)
Nerve supply
1.Motor nerve supply of tongue
All intrinsic & extrinsic muscles except palatoglossus are supplied by
Hypoglossal nerve.
Palatoglossus – cranial part of accessory nerve through pharyngeal
plexus.

Sensory nerve supply of tongue
Anterior 2/3rd : (except circumvallate papillae)
• Lingual nerve (V3) is nerve of general
sensation.
• Chorda tympani is nerve of taste sensation.
Posterior 1/3rd : (including circumvallate papillae)
• Glossopharyngeal nerve (IX) for both general
sensation and taste sensation
Posterior most part of the tongue :
•Vagus nerve (X) through internal laryngeal branch
B.D.Chaurasia: Human Anatomy For Dental Students:Fourth edition.

EQUILIBRIUM THEORY:
As applied in engineering “An object subjected to unequal
forces will be accelerated & there by will move to a different
position in space”
It follows that if any object is subjected to a set of forces but
remains in the same position, those forces must be in balance
or equilibrium
Contemporary Orthodontics, 5th Edition, William R. Proffit (145-146)

From this perspective, dentition is in equilibrium as they do not
move to a new location under usual circumstances
(mastication, swallowing, speaking)
‘Tooth movement occurs only when the equilibrium against
dentition is unbalanced’
The major primary factors in the dental equilibrium appear
to be resting pressures of tongue and lips, and forces
created within the periodontal membrane, analogous to
the forces of eruption. Forces from occlusion probably
also play a role in the vertical position of teeth by affecting
eruption.
Proffit WR. Equilibrium theory revisited: factors influencing position of the teeth.
Angle Orthod. 1978 Jul;48(3):175-86. doi: 10.1043/0003-

Swallowing
According to T.M Graber
Normal mature swallowing takes place without contracting muscles of
facial expression.
Teeth are in contact and tongue remain inside mouth.
Types of swallowing,
1.Normal swallowing
2.Infantile (visceral) swallowing
3.Mature (somatic) swallowing

Normal swallowing
Teeth are in contact, lips-closed
Dorsum of tongue-
closely touch the palate
Tip of the tongue- interdental
papillae of maxi incisors
No tongue thrust

Infantile (visceral) swallowing
According to Graber,
The jaws are apart with tongue pushed
forward between gum pads.
Tip of tongue protrude.
Mandible stabilized by contraction
of oro-facial muscles
& interposed tongue.
Swallow guide -
sensory interchange between lips
& tongue.
Colour Atlas of Dental Medicine; Orthodontic-Diagnosis; Thomas Rakosi, Irmtrud
Jonas & Thomas M. Graber

Retained infantile swallow
Def: ‘As predominant persistence of the infantile swallowing reflex after
the arrival of permanent teeth’
- Rare, may be associated with craniofacial developmental
syndromes/neural defects
Clinical Features :
• Tongue thrust- anterior & lateral
• Contraction of buccinator muscle
• Expression less face(facial muscles – used for
stabilizing mandible)

Mature (somatic) swallowing
Teeth together swallow.
Mandible stabilized contraction
of elevators.
Tongue tip touch
palate lightly above & behind
incisors.
Minimal contraction of the
lips.

• TONGUE IN ORTHODONTICS
Whatever the cause for the tongue habit may be (size, posture
or function ), it serves as an effective cause of malocclusion.
• For an instance, as the tongue thrusts forward constantly,
increasing
the overjet and overbite, the peripheral portion no longer lie
over the lingual cusps of the buccal segments.
• Posterior teeth erupt and gradually eliminate the interocclusal
clearance.
• The postural resting vertical dimension and occlusal
vertical dimension become one and same, with posterior
teeth in contact at all times.

• One side effect may be bruxism; other may be the bilateral narrowing of
the maxillary arch as the tongue drops lower in the mouth, providing
less support for the maxillary arch.
• Clinically this may be observed as a unilateral cross bite , with -a
convenience swing to one side or the other as the mandible is moved
laterally under the influence of tooth guidance.
• The contribution of the forces of the lips, cheeks, and tongue are
of particular interest to orthodontist, in correct treatment
planning.

EXAMINATION OFTONGUE
1. MORPHOLOGICAL EXAMINATION.
2. FUNCTIONAL EXAMINATION.

Morphologic Examination:
The Tongue should be examined for size and shape .
The best clinical sign of a tongue too large for its dental arch is the presence of
scalloping on the lateral borders.
Symmetry of the tongue position is checked by asking the patient to protude the
tongue followed by asking the patient to relax the tongue and allowing to drape over
the lower lip.
Morphologic asymmetries will persist in the draped position.
Any asymmetry of tongue has clinical implications to dental arch symmetry, dental
midlines, maintenance of treated incisal relationships, open bites, etc.

Functional examination
• Study the posture of the tongue while in the postural position
•Sometimes it can be done if lips rest apart, or tongue posture can be noted
in the lateral cephalogram of mandibular posture.
• Observe the tongue during various swallowing procedures. Do not
separate the lips to see what is happening, rather observe the contraction
of orbicularis oris and mentalis muscles and deduce from their activity
the tongue’s position during swallowing.
• Observe the tongue during mastication speech.
•Proffit – “Tongue posture is far more adapt to cause of an openbite than
tongue thrust, because the tongue is always there exerting a mild
continuous force.”

Functional analysis
Metric evaluation- lateral cephalograph
Palatography
Cineflourography

Metric evaluation of tongue posture

Measuring the distance
between superior surface of tongue
& roof mouth-size- but it
must be supported by
clinical examination
Retracted & elevated
tongue
Downward & forward
tongue posture

Palatography
Recording the contact areas of the tongue with the palate & teeth during
speech/certain tongue functions
A thin layer of contrasting impression material is applied on tongue
Tongue movements-speech/swallowing
Palatogram records photographically
Evaluation of the influence of functional orthodontic appliance therapy
Colour Atlas of Dental Medicine; Orthodontic-Diagnosis; Thomas Rakosi, Irmtrud Jonas
& Thomas M. Graber

Cineflourography
Tongue movements using camera & film is made during
swallowing.
Tracing- Tongue thrust is measured by drawing straight line
through labial surfaces of U/L incisors.
Colour Atlas of Dental Medicine; Orthodontic-Diagnosis; Thomas Rakosi, Irmtrud Jonas
& Thomas M. Graber

Tongue thrusting
Definition:
Proffit- “placement of the tongue tip forward between the incisors during
swallowing” (1950&60s) OR
Tulley 1969 - states Tongue thrust as the forward movement of the tongue
tip between the teeth to meet the lower lip during deglutition and in sounds
of speech, so that the tongue becomes interdental.

Etiology
According to Fletcher
1.Genetic factors -anatomic/neuromuscular
eg: hypertonic orbicularis oris activity
2.Learned behavior (habit)-acquired as habit
- prolonged thumb sucking, tonsillitis & URTI, improper bottle
feeding
3.Maturational –infantile swallow persists in adulthood

4.Mechanical restriction - macroglossia, constricted dental arches, enlarged
adenoids
5.Neurological disturbances - hypersensitive palate, motor disability of
tongue
6.Psyhcogenic factors – forced discontinuation of thumb sucking
7.Younger children with reasonably normal occlusion-transitional stage in
physiologic maturation

Classification
Backlund (1963)
a. Anterior tongue thrust
b. Posterior tongue thrust
Pickett’s (1966)
a. Adaptive - missing teeth/thumb sucking
b. Transitory
c. Habitual-postural problem, habit/OB

• James S. Brauer and Townsend V. Holt (AngleOrtho., 35: 106-12; April,
1965)(University of NorthCarolina)
This classification is based on deformity observed rather than on etiology.
Type I: Non-deforming tongue thrust
Type II: Deforming anterior tongue thrust
sub group 1- associated with AOB
sub group 2- anterior proclination
sub group 3- posterior cross bite
Type III: Deforming lateral tongue thrust
sub group 1- posterior open bite
sub group 2- posterior cross bite
sub group 3- deep overbite
James S. Brauer, Townsend V. Holt; Tongue Thrust Classification. Angle Orthod 1 April 1965; 35 (2): 106–112.
doi: https://doi.org/10.1043/0003-3219(1965)035<0106:TTC>2.0.CO;2

Type IV: Deforming anterior & lateral tongue thrust
sub group 1- anterior & posterior open bite
sub group 2- anterior proclination
sub group 3- post cross bite

According to Moyers (1970)
a. simple tongue thrust swallow
b. complex tongue thrust swallow

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

• Defined as tongue
thrust with teeth
together swallow .
Extra oral features seen in patients are:
• 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.
• Abnormal mentalis
activity
Simple tongue thrust
Textbook of orthodontics, Gowri sankar singaraju,Chetan kumar: TONGUE THRUST HABIT

Intra oral features
• Proclined, spaced and some times flared upper
anteriors resulting in increased overjet.
• Presence of an anterior open bite.
• Presence of posterior crossbites.
• The simple tongue thrust is characterized by a normal tooth contact
during the swallowing act. They exhibit good intercuspation of posterior
teeth in contrast to complex tongue thrust.
• The tongue is thrust forward during swallowing to help establish an
anterior lip seal. At rest the tongue tip lies at a lower level.

• It is defined as tongue thrust with a
teeth apart swallow.
• Etiology
• Pain and decrease of space in the
throat precipitates a new forward
tongue posture and swallowing
reflex. Because maintenance of
airway patency is a more primitive
and demanding reflex than the
mature swallow, the later is
conditioned to the necessity for
mouth breathing. The jaws are thus
held apart during swallow in order
that the tongue can remain in a
protruded position.
Complex tongue thrust

The following features are seen :
• Proclination of anterior teeth .
• Bimaxillary protrusion
• The anterior open bite can be diffuse or absent.
• Absence of temporal muscle constriction during
swallowing.
• The occlusion of teeth may be poor. Poor occlusal fit,
no firm intercuspation.
• Posterior open bite in case of lateral tongue thrust
• Posterior crossbite

Simple
1. Open bite is well defined with
definite beginning and ending
2. Mandible is stabilized by muscles
of mastication
3. Facial muscle contraction during
swallowing is not seen
4. Proper, secure, posterior occlusal
fit
5. Usually will have a previous
history of thumb sucking
6. Treatment is simple. with less
relapse tendency
7. Occlusal equilibration may be
needed
Complex
1. Open bite is diffuse, ill defined
2. Mandible is stabilized by
muscles of lips and cheeks
(facial muscles)
3. Facial muscle contraction can be
seen during swallowing
4. No proper posterior occlusal fit
5. Usually will have history of
tonsillitis or airway obstruction
6. Treatment is difficult with more
relapse tendency
7. Occlusal equilibration is
mandatory

Diagnosis
Extra oral-
Facial profile,
Open Bite,
Anterior facial height
Examination of – 1. tongue posture
- Protracted
- Retracted
2.tongue function

Tests for diagnosis
1. Swallowing: when jaw drops- lips, mentalis muscle contracts
strongly - tongue thrust
2. Separate the lips while swallowing to watch tongue thrust, and in
doing so, strong muscle contractions can be felt
Methods of examination tongue dysfunction:
1.Position & size- LATERAL CEPH
2. Tongue pressure- EMG, cineradiography
palatograpic, neurolophysiologic examination

Treatment
Should be start before the correction of incisor proclination.
Three phases (Moyers):
1. Conscious learning of new reflex-cognitive approach
2. Transferring to subconscious level-reflexive approach
3. Reinforcement of new reflex.
Textbook of orthodontics, G.Singh : TONGUE THRUST HABIT (602)

Conscious Learning of the New Reflex
1. Single elastic swallow of Gardiner Using
orthodontic elastic band of 1/4 " or 5/16" placed
on the tip of the tongue plus speech exercises-
'D"t’.
2. Double elastic swallow
• Place 1 elastic each at tip and middle of
tongue contact with tip and mid part of palate.
• Lips open with buccal teeth together
• Speech exercises 'C', 'h', 'g'.
• If correct swallowing - elastic will be
retained
• Incorrect swallowing - elastic will be
swallowed.
• 2-3 times a day.

Reinforcing the New
Swallow Subconsciously
• To avoid abnormal
unconscious swallow - 2nd
visit.
• Flat sugarless fruit drops-citric
flavoured(lemon).
• Fruit drop on tip of tongue -
hold against palate until
dissolves.
• Record timing.
• Initially - less time ,later more
time.
• Distraction & self -
competition
• Once a day.

Myofunctional Therapy
• Orofacial myofunctional therapy includes exercises of the cervical and
facial muscles for the improvement of proprioception, tone, and mobility.
• Orofacial myofunctional therapy acts as an adjunct to orthodontic
treatment and helps in harmonizing the orofacial function.
Muscle Exercises
1. Barnet's tongue positioning exercises
a. Identify the incisal papilla as the spot behind front teeth.
b. Practice touching spot with the tongue tip.
c. Swallow with lips and teeth closed and tongue tip touching the incisal
papilla.
d. Have patient practice this with lips apart.

2. Andrews recommends practice of swallow correctly 20 times before
meals with water in the mouth and mirror in hand. Each practice is
followed by relaxation of muscles until the swallowing progress smoothly.
3.Peanuts and elastic band Patient chews peanuts but not to swallow it.
The chewed peanuts are placed in the middle of the tongue.
• Place elastic at tip of tongue.
• Instruct the practice of swallow.
• Speech exercises - 'C', 'g', 'k’.
4. Lip exercises
a. Lip pull exercises - to strengthen lips
b. Lip over lip exercises - to strengthen lips.

REINFORCEMENT OF NEW REFLEX
• This is achieved by means of mechanical restraints which may be
removable or fixed.
• Cribs or rakes are valuable in breaking the habit .
• Oral screen also may be used
Oral screen

Reinforcing the New Reflex
Tongue crib
• Ni-Cr or stainless steel, 3-4
projections (spurs) of 1mm or
19 gauge wire.
• Follows the palatal contour.
• Forms barrier or picket fence
just behind cingulum of
mandibular incisors.
• Duration: depends on severity
of open bite(4-9months).
After habit interception,
treatment of malocclusion,
associated with removable or
fixed orthodontic appliances.

Removable and fixed appliance
therapy
-Palatal crib
-Blue grass appliance
-Nance palatal arch
-Fixed tongue crib with quad helix
Tongue trainer
Fixed tongue crib with quad helix
Blue grass appliance

Complex tongue thrust treatment
fixed orthodontic treatment– 1st Correction of malocclusion.
Muscle exercise similar to simple tongue thrust with minor modification.
Swallowing with teeth together
Prolonged removable and fixed appliance therapy.
• Habit-breaking appliances like tongue cribs act as reminders and
restrict the forward movement of the tongue.
Myofunctional therapy to correct the position of the tongue at rest
and during swallow

Surgical treatments
In case of macroglossia Partial Glossectomy can be done.
In case of skeletal open bite cases with macroglossia
A partial glossectomy was performed before the orthognathic surgery.
Then the orthognathic surgery performed.
Morgan L. Allison, Charles W. Miller, Marlin F. Troiano, William R. Wallace, 13 Partial Glossectomy for
Macroglossia, The Journal of the American Dental Association, Volume 82, Issue 4, 1971, Pages 852

Tongue plays a major role in the maintaining the normal occlusion as well
as it influences the development of the dental arches
Position of tongue and its function plays an important role or a contributing
factor in dental malocclusion.
Correction of an abnormal tongue behavior is a proper treatment goal for us
only if it is directly related to the etiology of malocclusion and the ultimate
treatment goals.
Tongue thrust troubled orthodontic treatment, discouraged orthodontists as
there is more relapses due to continuous force by tongue.
CONCLUSION

1. Human Anatomy Vol. 3, 4th Edition, B. D. Chaurasia
2. Embryology, I. B. Singh
3. Textbook of orthodontics, Gowri Sankar Singaraju, Chetan kumar: TONGUE
THRUST HABIT
4. Handbook of Orthodontics, Robert E. Moyer
5. Textbook of orthodontics, G.Singh : TONGUE THRUST HABIT (602)
6. Contemporary Orthodontics, 5th Edition, William R. Proffit
7. Colour Atlas of Dental Medicine; Orthodontic-Diagnosis; Thomas Rakosi, Irmtrud
8. Colour Atlas of Dental Medicine; Orthodontic-Diagnosis; Thomas Rakosi, Irmtrud
REFERENCES

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