Habits and its management /certified fixed orthodontic courses by Indian dental academy

HABITS AND
ITS
MANAGEMENT
www.indiandentalacademy.com

INDIAN DENTAL ACADEMY
Leader in continuing dental education


Definitions:

William James: An acquired habit, from
psychological point of view, is nothing but a
new pathway of discharge formed in the brain,
by which certain incoming currents ever after
tend to escape.
Moyers: Habits are learned pattern of muscle
contraction, which are complex in nature.
Finn: A habit is an act, which is socially
unacceptable.

Classification of habits
According to William James:
Useful habits:
These habits include the habits of normal function
such as correct tongue posture, proper respiration
etc.
Harmful habits:
These are the ones which exert stresses against
the teeth and dental arches such as mouth
breathing, lip sucking, thumb sucking.

According to Finn and Sim:
• Compulsive habits:
When the habit has acquired a fixation in the
child to the extent that he retreats to the practice
of this habit whenever his security is
threatened.This is his safety valve when
emotional pressures become too much to cope
with.
• Non-compulsive habits:
Habits which are easily dropped or added
from the child behaviour pattern as he matures.

Various habits are:
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Thumb sucking/finger sucking
Tongue thrusting
Mouth breathing
Lip biting and lip sucking
Postural habits
Nail biting
Masochistic habits
Bobby pin opening
Frenum thrusting
Bruxism
Cheek biting/sucking

Thumb sucking/finger sucking
Gellin: Defines digit sucking
as placement of thumb or one
or more fingers in various
depths into mouth.
Moyers: Repeated and
forceful sucking of thumb with
associated strong buccal and
lip contractions.

Psychology of thumb sucking
• Freudian theory: He suggests that orality in the infants
is related to pregenital organization and thus, the object
of thumb sucking is nursing. He believes that abrupt
interference in such basic mechanism will likely lead to
substitution of such antisocial tendency such as
stuttering.

• Oral drive theory (Sears and Wise): He suggests

that the strength of oral drive is in part a function of how
long a child continuous to feed by sucking. Thus it is not
the frustration of weaning but, rather oral drive which has
been strengthened by the prolongation of nursing.

•

Benjamins theory: He proposed two theories-

1.

Thumb sucking is an expression of a need to suck that
arises because of association of sucking with primary
reinforcing aspects of feeding.
Thumb sucking arises from the rooting and placing
reflexes common to all mammalian infants.

2.

•

A multidisciplinary research team at the
university of Alberta support the theory that digital
sucking habits in humans are simple learned
response.


Clinical aspects of digital sucking:
Prenatal/ antenatal:
Shortly before the child passes through
the birth canal, the fetus shows increased
muscular activity and the thumb may find
its way into the mouth, thus initiating
thumb sucking habit before birth. The
fetus seeks a ‘position of comfort’ which
occasionally interferes with post natal
dentofacial development.

Postnatal:
A: Finger sucking from birth to 4 yrs of
age:

Infants generally start sucking habit in the
first three months of life, which may be due
to feeding problems, emotional stress with
which they are unable to cope, insecurity
and desire to attract attention.
For the 1st 4yrs of life damage to occlusion is
confined largely to the anterior segment.
The damage is temporary, provided the
child starts with normal occlusion.
An exerciser or pacifier was developed
which is hoped to greatly reduce the need
and desire of the infant for thumb sucking
between meals and at bed time.
e.g Nuk sauger nipple.
Edwall functional nursing nipple.

Nuk sauger
nipple

Conventional nipple

B Active finger sucking after 4 yrs of age:
The permanence of malocclusion increases if the habit
persists beyond 4 yrs of life.
Trident of habit factors:
• DURATION
• FREQUENCY
• INTENSITY
Duration: duration of sucking i.e hours per day of sucking,
plays a major role in tooth displacement.
Frequency: frequency of habit during day and night affects
the end result.
Intensity: more the intensity of sucking more the perioral
muscles function and more is the damage.

Effect of thumb sucking
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The of effect of sucking habit
depends on:
Position of thumb in mouth
Leverage effect the child gains
against the other teeth and the
alveolus.
Apposition of sucking finger on
the maxilla:
In case the finger rests on the
lower incisors as a fulcrum
Promotes the development of
class I, class II div I
malocclusion.
Anterior open bite.
Protraction of maxillary anterior
teeth.
Labial tipping of mandibular
anterior teeth.

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In case the finger rests on the
lower anteriors then lingual
displacement of lower anteriors will
occur.
Vertical equilibrium is altered on
the posterior teeth leading to more
eruption of posterior teeth causing
open bite.
Arch form is affected due to
alteration in balance between
cheek and tongue pressures i.e
maxillary arch tends to become vshaped.
Thumb sucking is associated with
tongue thrust to maintain the
anterior seal.

• Narrower nasal floor and high palatal vault
• Maxillary lip hypotonic and mandibular lip
hyperactive
• Hyperactive mentalis muscle
• In case the child bites on both its index fingers, it
leads to protrusion and open bite corresponding
with the side in which the finger is being held

• Bilateral posterior crossbite as the posterior teeth are
forced palatally by the buccal musculature.
Apposition of finger sucking on the mandible:
• In case the fingers are pressed on the lingual side of the
mandibular alveolar process and lower anterior teethlabial tipping of upper and lower incisors is due to forward
and downward displacement of tongue.


• Can lead to class III malocclusion in which mandible jaw
is pulled forward by fingers
• Facial asymmetry may be caused
• Line of occlusion is changed
• Callus formation and low virus infection on fingers which
is continuously been sucked.


Management
• Most of the children discontinue their habit at the age of
4yrs or by 5 yrs
• No treatment is recommended as the malocclusion,if
present, corrects itself as the habit ceases
• Adult approach: As the time of eruption of the permanent
incisors approach, a straight forward discussion with a
dentist is recommended
• Reminder therapy: a simple method is to secure an
adhesive bandage with waterproof tape on the finger that is
being sucked.

• Reward system: if the reminder therapy fails then reward
system is used in which small tangible reward daily for not
engaging in the habit.
• If this fails then elastic bandage loosely wrapped around the
elbow prevents the arm from flexing and finger from being
sucked.
• If this fails then the reminder appliance is fitted to actively
impede finger sucking. eg ,crib, maxillary lingual arch with
crib etc.


• Psychological approach: Dunlop theory (beta
hypothesis)-This theory states that by practicing
a bad habit with the intent to stop it, one learns
not to perform the undesirable act. The child will
not derive any satisfaction from purposeful
repetition of the habit but will experience a
painful reaction in its performance and will
gradually abandon the habit. This is applicable
to older children whose cooperation can be
obtained.
• Chemical approach: In this a hot flavored, bitter
tasting or foul smelling preparations can be
applied on the finger that is being sucked. e.g
red pepper, quinine, asafetide.

Appliances used
Removable appliances:
• Tongue spikes
• Tongue crib
• Rake appliance
• Vestibular screen
Fixed appliances
• Hay rake
• Maxillary lingual arch
with palatal crib

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A crib is a habit retraining
appliance which utilizes a blunt
wire ‘reminder’ which prevents
the child from indulging into the
habit. It serves the following
functions:
To break the suction and force
on anterior segment.
As a reminder.
Make the habit non pleasurable.
Forces the tongue backward,
changing the shape during rest
position from an elongated
mass to a more wider position,
nearly like a normal tongue.

A rake may be removable
or fixed. It discourages not
only thumb sucking but
tongue thrusting and
abnormal swallowing also.
Another appliance by
Haskell and Mink called the
blue grass appliance was
used to stop thumb sucking.
In this a modified six sided
roller machine from teflon
was used.

Time of therapy
• Check up appointments are made at 3-4 wk
interval.
• Appliance to be worn for 4-6 months.
• A period of 3 months of total absence of
finger sucking is good insurance for relapse.
• The appliance is removed in parts i.e after 3
months of habit free interval the spurs are
cut off,3 wks later posterior loop extension
is cut and 3 wks later palatal bar and crown
may be removed.

Tongue thrusting
Definition:
Placement of tongue tip forward

between incisors during
swallowing.
Tongue thrusting may be primary
cause of malocclusion or it may be
secondary adaptive factor as in
case in skeletal open bite.
It is generally associated with long
term thumb sucking children.

Classifications of tongue thrust:

Primary
Secondary

Anterior
lateral,
complex

Endogenous
Habitual
Adaptive
(enlarged
tonsils,pharyngitis)


• Acc to Graber
There are considerable amount of evidences that indicate
that tongue thrust is the retention of the infantile suckling
mechanism. Whatever may be the cause of tongue habit
(size, posture, function) it serves as the effective cause of
malocclusion.

• Acc to Proffit
Whenever there is an open bite due to tongue sucking
habit a compensatory muscle activity of the tongue
develops which accentuates the deformity. Bringing the lips
together and placing the tongue between anteriors is
successful maneuver to make an anterior seal. After the
sucking stops, the anterior open bite tends to close
spontaneously otherwise an anterior seal by tongue tip
remains necessary.

In modern view point:
Tongue thrust swallow is seen in two circumstances, in
younger children in normal occlusion in whom it represents
a transitional stage in normal physiologic maturation and in
individuals of any age in displaced anteriors. Therefore
tongue thrust swallow should be considered the result of
displaced incisors and not the cause.

Acc to equilibrium theory:
The pressure generated is very less to effect the equilibrium
but if there is forward resting posture of tongue the duration
of pressure ,even if very light could effect tooth movement.


Effects of tongue thrusting
• Increase in overjet and overbite.
• Tongue no longer lie on the lingual cusps of the buccal
segment and posterior teeth erupt; thus eliminating
interocclusal clearence.
• May lead to bruxism.
• Narrowing of maxillary arch as the tongue drops lower in the
mouth. Clinically this may be seen as unilateral cross bite.
• In horizontal growth pattern, tongue dysfunction leads to
bimaxillary protusion.
• In vertical growth pattern, tongue dysfunction leads to lingual
inclination of lower incisors.
• Diastemas may be present.
• Deep bite in lateral tongue thrust.

Careful differentiation must be done
among simple, complex tongue
thrust and retained infantile
swallowing pattern and faulty
tongue posture.
• Prognosis is good for simple
tongue thrust.
• Not very good for complex
tongue thrust.
• Poor for retained infantile
swallowing pattern.
Protracted tongue posture can be:
• Endogenous- no certain
treatment
• Acquired- can be corrected

Normal tongue

Tongue thrust

Method of examination tongue dysfunction
• Electronic recording.
• Electromyographic examination.
• Recording of pressure exerted by tongue intra
orally.
• Roentgenocephalometric analysis.
• Cine-radiographic.
• Paltographic.
• Neurophysiologic examination.


Management
• Simple tongue thrust: it is the tongue thrust with teeth
together swallow.
If there is excessive labioversion of maxillary incisors,treatment
of tongue thrust should be done after retraction of incisors.
Patient should be taught swallowing exercises with sugar less
mint and should be instructed to practice 40 times a day and
maintain the record.
On second appointment, patient should be able to swallow
correctly at will. Sugar less drops may be used to reinforce
the unconscious swallow.
If the problem continues, soldered lingual arch wire having short
and sharp spurs can be inserted.

To summarize;
Conscious learning of new reflex.

Transferal of control of the new swallow
Pattern to the subconscious level.

Reinforcement of the new
reflex.


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Complex tongue thrust:

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It is the tongue thrust with teeth apart swallow.
Malocclusion present are:
Poor occlusal fit.
Generalized anterior open bite.
Open bite may not be present if
the tongue is seated evenly atop
of all teeth.

Treatment:
Treat occlusion first.
When the treatment is in retentive phase- muscle
training is begun.
Maxillary lingual arch appliance is necessary for
these patients.
There may be chances of relapse and prognosis is
not very good

• Retained infantile swallow: It is
defined as the undue persistence of the
infantile swallow well past the normal time
for its departure. These patients occlude
only on one molar in each segment.
These patients do not have expressive faces.
They have difficulty in breathing.
Low gag threshold
It is a problem of neuromuscular
development.
Appliance used is tongue crib with 3-4 vshaped projections which extend
downward up to the cinguli of lower
incisors when the casts are occluded.
Prognosis is poor.

• Abnormal tongue posture:
Endogenous tongue posture: it is an inherently abnormal

tongue posture and the tip of the tongue persists in lying
between incisors.
There is stability of incisor relationship even though a mild open
bite is seen.
Prognosis poor.
Acquired tongue posture: it is due to chronic pharyngitis,
tonsillitis, nasorespiratory disturbance.
Refer the patient to otolaryngologist for the precipitating factors.
Followed by lingual arch wire with sharp spurs.
This is correctable after the precipitating factors are corrected.
Adaptive tongue posture: This is due to narrow maxilla.
When rapid palatal expansion is completed and posterior
intercuspation is correct normal posture returns.

Mouth breathing
Respiratory needs are the primary determinant of the posture of jaws and
tongue. Therefore it is reasonable that an altered respiratory pattern,
such as breathing through mouth rather than nose, could alter the
equilibrium of pressure on jaws and teeth and affect both jaws growth
and tooth position.

Finn classified mouth breathing into 3 different categories:
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OBSTRUCTIVE
HABITUAL
ANATOMIC


• Obstructive mouth breathing:
These are the children who have complete obstruction of
normal air flow of air through the nasal passages. Due to
difficulty in breathing through nose child is forced to breath
through mouth.

• Habitual mouth breathing:
This is a child who continuously breath through mouth by
force of habit, even if abnormal obstruction is removed.

• Anatomic mouth breathing:
They are the one whose short upper lip does not permit
complete closure without undue effect.

Factors considered for mouth
breathing
• For an average individual, when ventilation exchange rate of
40-45l/min. is reached, there is a transition to partial oral
breathing.
• Heavy mental concentration could lead to increase air flow
and a transition to partial mouth breathing.
• If nose is partially obstructed, or there is a tortuous passage
an individual shifts to mouth breathing.
• Swelling of nasal mucosa accompanying common cold
converts one into mouth breathing.
• Chronic respiratory obstruction produced due to inflammation
within the nasorespiratory system can lead to mouth
breathing
• Pharyngeal tonsils and adenoids can cause mouth breathing.

Clinical features
• Associated with impeded maxillary growth.
• Narrow jaw with high palate, dental crowding as well as
retrognathism of maxilla.
• Prognathism of mandible.
• Tongue lies flat on th floor of mouth so it does not play its role
in development of maxilla.
• Hyperactivity of facial muscles especially buccinator,
impedes the development of maxilla.
• In class II malocclusion there is increase in overjet.
• Bilateral cross bite.
• Hyperplasia of gingiva.
• Extra oral appearance of these patients is often conspicuous
and is termed ‘adenoid facies’.

• There is downward and backward rotation of mandible to
maintain postural changes leading to open bite anteriorly.
• Two different tongue posture are possible:
type I -in class III malocclusion tongue is flat and protruding.
type II- in class II malocclusion tongue has a flat and
retracted position.

Examination of breathing mode:
Cotton pledget test: A cotton butterfly is placed below the
nostrils and observed. The nasal breather will displace the
cotton pledget on expiration where as the mouth breather will
not.
Mirror test: mirror is held in front of both the nostrils, in nasal
breather the mirror will cloud with condensed moisture during
expiration.
Observation of nostrils: Alar muscles are inactive in mouth
breathers i.e do not change their size on inhalation or
expiration where as nasal breathers do.

Management
• If mouth breathing is due to nasal
obstruction, then operation by an E.N.T
surgeon is indicated i.e in case of allergic
rhinopathy.
• If patient has habitual mouth breathing
then pre-orthodontic therapy should be
carried out by: breathing exercises,
incorporation of oral or vestibular screen.
In case in which vestibular screen is
used holes can be slowly closed as the
patient starts breathing through nose.
• Myofunctional exercises like to hold a
piece of card board to improve lip seal.

Bruxism
Definition : it is the habitual grinding of teeth, during sleep.
this term is applied to clenching of teeth and also to
repeated tapping of teeth.

Incidence: 5- 20 %
Etiology (Nadler
and Meklas):
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Local
Systemic
Psychological
occupational


Local: These factors are associated when there is mild form of
occlusal discomfort during transition from deciduous to
permanent dentition.

Systemic:-gastrointestinal disturbances.
- sub clinical nutritional deficiencies.
- allergy or endocrine disturbances.
- hereditary background.

Psychological factors: they are believed to be most
common causes of bruxism. emotional tension such as fear,
rage, rejection.

Occupations: athletes engaged in physical activities often
develop bruxism.
in which work has been more precise such as watch makers.
voluntary bruxism in those who have habit of chewing gum,

Tobacco or objects such as pencil or tooth picks.

Clinical features (Glaros and Rao): divided into six
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categoriesEffect on dentition: severe wearing or attrition of teeth- both
occlusal and interproximal.
Effect on periodontium: loss of integrity of periodontal
structures, resulting in loosening, drifting of teeth, gingival
recession with bone loss.
Effect on masticatory muscles: hypertrophy of masticatory
muscles, particularly masseter muscle, cause trismus and
alter opening and closing movements of jaw.
TMJ disturbance may be seen.
Head pain and facial pain.
Psychological and behavior effects.

Management
• If the underlying cause of the bruxism is an
emotional one, the nervous factor must be
corrected if the disease is to be cured.
• Removable rubber splints can be worn at night to
immobilize the jaws.
• A vinyl plastic bite guard that covers the occlusal
surfaces of all teeth plus 2mm of the buccal and
lingual surfaces can be worn at night to prevent
abrasion.

Lip sucking and lip biting
Lip sucking is a compensatory
activity which results from an
excessive overjet and relative
difficulty of closing the lips during
deglutation. In most cases it is the
mandibular lip that is involved in
sucking, although biting habits of
maxillary lip is also seen.
The deformity reaches maximum
when the discrepancy between the
maxillary incisors and mandibular
incisors becomes equal to the
thickness of the lip. (B.J.Johnson).

Common features:
• Labioversion of maxillary teeth and lingual
displacement of mandibular teeth.
• Vermillion border is hypertrophic and redundant
during rest.
• Flaccid lip due to lengthening.
• Chronic herpes with areas of irritation and
cracking of lips.
• If a patient has lip sucking habit during sleep
then telltale
• Redness and irritation extending from mucosa
to skin of lower lip is seen.
• If patient is class II div1 malocclusion then the
lip suking habit is only adaptive.

Management :
If the patient is having class II div 1 malocclusion then the
treatment should be done orthodontically. The lip sucking
habit generally ceases after the treatment.
If the habit continues then, the lip appliance i.e lip plumper is
given.
The appliance can be modified by adding acrylic between base
wire and auxillary wire.
Removal of appliance is done in parts i.e first the auxillary wire
then the base wire is removed.
A period of 8-9 months is required to cease the habit
completely.


Postural habits
Poor postural position may also lead to malocclusion.
A stoop shoulder child, with head hung so that, a chin
rests on the chest, has been accused of creating his
own mandibular retrusion.
Child and adults do not lie in one position during sleep,
they keep on changing which are induced by
nervous reflexes. Before the sleeping position can
produce any deleterious effect on jaw growth, the
child would have to be suffering from some
osteogenic deficiency.

Posture during the child’s waking hours is more
important then position during sleep in the
production of dental malocclusion.
Deformity, flattening of the skull and facial asymmetry
may occasionally develop during first year in infant
who habitually lie in the supine position with head
turned to right or left.
Poor posture may accentuate an existing
malocclusion, but this remains to be proved or
disapproved conclusively.

Nail biting
This habit is often mention as a cause of of
tooth malpositions. High strung, nervous
children most often display this habit.
Nail biting is absent under 3yrs of age. There is
rapid increase from 6yrs of age up to 12 yrs in
girls and 14 yrs in boys, followed by rapid
decline after the age of 16 yrs.
It is more commonly seen in adolescence in
boys than among girls.

Clinical features:
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may induce crowding
rotations of incisors
attrition of incisal edges
these malocclusions are due to the untoward
pressures introduced during nail biting.

Management:
• It is important to study child’s physical, mental and
social difficulties if the roots of the habit are to
removed.
• If the child continues after suggestions he may be in
need of psychiatric consultation.

• He may be associated with toe nail biting. Kanner
and Bakwin found toe nail biting only in girls.
• Arousing a new interest such as nail polish has
been found helpful in girls and boys may be given
reward for sparing his nails.
• Punishments, scolding and restraints are of no
value.
• Light cotton wittens may be worn at night to act as a
reminder.
• Nightsuits which encase the feet may be worn at
night.
• Rewards are sometimes of value.

Masochistic habits
In this habit a child uses his finger nails to strip the
gingival tissues from the labial surface of the lower
cuspid.
sometimes a child completely denudes the tooth of
marginal gingiva and unattached gingival tissues,
exposing the alveolar bone.

Management :
Psychiatric assistance.
Taping the finger.

Bobby-pin opening
This is opening bobby pins with anterior incisors to
place them in hair.
Mostly seen in teen aged girls.

Clinical features:
• Notched incisors
• Teeth partially denuded
of labial enamel may be
observed.

Management:
Calling attention to the harmful result is generally all
that is necessary www.indiandentalacademy.com
to stop the habit.

Frenum thrusting
If a child has spaced incisors , the child may lock his
labial frenum between these teeth and permit it to
remain in this position for several hours.
This habit is rarely seen.
This develop into tooth displacing habit by keeping the
central incisors apart.

Management:
Orthodontic correction of incisors.


Cheek sucking/biting
This habit may persist as a substitute for thumb
sucking or tongue thrusting.

Effects:
• May lead to posterior open bite.
• Wet like horizontal swelling may
be formed as a result of
constant irritation.

Management:
Removable lateral crib may be used.
Vestibular screen or oral screen may be used.

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Habits and its management /certified fixed orthodontic courses by Indian dental academy

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