efinitions

1)

Frequent or constant produce or acquired tendency which has been

fixed by frequent repetition.
-

Butterworth 1961
2)

Habit may be defined as a fixed constant, settled practice or custom

established by the frequent repetition of the same act.
Markus 1928

3)

An acquired habit is nothing but a new pathway of discharge formed

in the beam, by which certain in covering currents tend to escape.
- William James
1923

4)

Habit is defined as an act which is socially unacceptable.

Finn 1972

5)

Habit is an aptitude or nuclination for some action acquired by

frequent repitition and showing itself in increased facility to
perform or in decreased power of resistance.
P. 1938

Johnson

6)

A repeated status or functional exercise or ritual is defined as a

habit.
Dorland defines habit as a fixed or constant practice established

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after the stimulus is withdrawn.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 and harmful habits (William James 1923)

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)

Intraoral and extraoral habits (Barrette 1955)

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)

Pressure habits (Graber 1952)

Intrinsic

Extrinsic

1) Thumbsucking.

1) Chin propping.

2) Finger sucking.

2) Face leaning on head.

3) Tongue sucking.

3) Abnormal pillowing position.

4) Lip sucking.

4) Abnormal sleeping on the side,

5) Cheek sucking.

the force which may cause nose

6) Blanket sucking.

to turn to opposite side.

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.

Individual habit : Eg. lip sucking.

2.

Habits in which there is combined activity of the muscles of the

mouth and jaws and of the thumb / finger inserted into the mouth.
Eg. Thumb sucking.

3.

Muscular action combined with the introduction of passive objects

into the mouth. Eg. Pencil Biting.

4.

Functional disturbance, E.g.: mouth breathing habit.

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.

As semisolid and eventually solid foods are added to the diet, it is

necessary for the child to use the tongue in a more complex way to
gather up bolus, position it along the middle of the tongue and transport
in posteriorly.
The transitition from infantile to adult swallow occurs from the
age of 2-4 years.
Definitions
It is that condition in which tongue makes contact anterior to first
molar at any degree in the act of swallowing.
Or
Tongue projects in between the teeth either anteriorly or laterally
in the act of swallowing.
Tongue makes contact with anterior teeth during swallowing.
Or
Thrusting of the tongue between the anterior teeth especially in
the initial stage of swallowing. It is often combined with a resting
position also between the teeth, can exhibit normal eruption and so
produce on open bite Boucher 1982 5 .

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

children with defective speech had what is known as tongue thrust.

Graber T.M. (1972) 23 reported that the change to a mature swallow
usually begins to occur by age one and parallels the eruption of the
primary teeth and the dietary change to solid foods. However, this
progression may occur over a period of years and some children may not
exhibit a consistently mature swallow until some point in the mixed
dentition period. A child may exhibit both types of swallowing during
this transistion period.
Proffit W.R. (1972) 58 reported that most persons adopt a swallowing
pattern in which the tip of the tongue is placed in the rugae area and a

pressure of roughly 100 gm per cm 2 is exerted upward and backward.

When the tip of the tongue is placed or pushed against the anterior teeth
it exerts a pressure of roughly 500 gm/cm 2 .
McWilliams R.R. and Kent J.N. (1973) 42 suggested detachment of
genioglossus muscles from the mandibular spines. Because it is chiefly
responsible for protrusion of the tongue.
Goldberger J.M. (1973) 22 reported that a 9 year old girl with tongue
thrust habit and malocclusion was found to have tongue tie. A
mandibular lingual frenectomy was performed and the patient was able
to swallow properly.
Proffit W.R. (1975) 59 concluded that the resting tongue pressures have a
greater correlation with incisor protrusion and arch widths than do
tongue pressures during swallowing and speaking.
Melsen D.F. et al (1983) 43 concluded that persons who swallow with
tooth contact have the best prognosis for normal development of
occlusion and that tongue thrust swallowing is more detrimental than
teeth apart swallowing.
Fink S.F. (1986) 18 developed the lignometer to diagnose abnormal
tongue force. A positive response will indicate need for a tongue
retraining program in addition to orthodontic treatment in order to
minimize relapse.

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.

Incidence of tongue thrusting :

There is a general agreement about the co-existence of tongue
thrust and malocclusion.
Tongue thrusting present in 97% of new born children (Lewis and
Connihan in 1965).
Incidence at 9 years of age is 25-30% (Fletcher in 1961) 19 . 49% of
patients with malocclusion exhibit tongue thrusting. Incidence in total
population is 29% (Rogers 1961). Rogers has shown that 82.1% of
children have a normal swallowing pattern and only 17.9% of children
have tongue thrusting.

Kortsh in 1965 confirmed these findings and added that 44.8% of

children with tongue thrusting had Class II malocclusion.
Etiology : There is no particular cause of the habit that can be singled
out as the most important reason of the problems.
Fletcher 19 has developed the following out line to indicate
proposed etiologic factors for tongue thrusting syndrome:
I)
a)

Genetic factors
Inherited variation in orofacial form that precipitate a tongue
thrusting pattern.

b)

Genetically predetermined pattern of mouth behaviour.

c)

Inherited orbicularisis oris hypertony resulting from specific

anatomic configuration and neuromuscular interplay and generating
a tongue thrusting pattern.

II)
a)

Learned Behaviour
Improper bottle feeding which results in abnormal functional
patterns of lingual movement in the form of tongue thrusting.

b)

Protracted period of tenderness as soreness of gums and teeth,

keeping the teeth apart during swallowing and there by changing the
swallowing pattern.

c)

Prolonged thumb sucking with the habitual movements generalized

to tongue activity.

d)

Tongue held in open spaces during mixed dentition and extension

and habituation of such postures into other mobile activities of the
tongue.

e)

Prolonged tonsillar and other upper respiratory tract infections,

which cause adaptive pattern in tongue movement, that are retained
after the infection subsides.

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)

Tongue thrust pattern as evidence of late maturation from infantile

sucking swallow.

c)

Late maturation from retention of immature patterns of general oral

behaviour.

IV)
a)

Mechanical restirction
Constricted dental arches, which cause the tongue to function in a
lower position than usual.

b)

Macroglossia Which, because of limited space in the oral cavity

forces a forward thrust to manipulate bolus.

c)

Enlargement of the tonsils and adenoids, which reduces the space

available for lingual movement.

V)
a)

Neurological disoders
Hyposensitive palate which precipitates crude patterns of food
manipulation and swallowing.

b)

Description in the tactile sensory control and coordination of

swallowing.

c)
VI)
a)

Moderate motor disability and loss of precusion in oral function.

Psychogenic factors
Substitution of tongue thrust for forcibly discontinued thumb
sucking.

b)

Exaggerated motor image of tongue.

Etiology of Tongue Thrusting

I. Genetic Influence:
There is a complexity of factors, which might predispose a child
toward tongue thrust pattern like:
1.

A tendency toward allergies and upper respiratory congestion.

2.

An extremely high or narrow palatal arch.

3.

An usually large tongue.

4.

A restricted nasal passageway due to small nares or a deviated

septum.

5.

Hypertonus of orofacial musculature.

6.

An imbalance between the number and size of teeth and the size of
the oral cavity.

II. Thumb Sucking

Moyers writes that tongue thrust habit often accompanies or is a
residual of thumb sucking. Since, the thumb depresses the tongue and
keeps the teeth apart and opens the bite, it is not unreasonable to suspect
that it also induces malfunction of the tongue in deglutition.
Andersen (1963) in his study of 405 students, only 312 of the
questionaries returned and among 48 who were diagnosed as having
tongue thrust 54.2% had a history of thumb or finger sucking whereas
the among 264 students with normal swallow only 25% had sucked their
thumb or fingers.
Hanson and Cohen (1973) found thumb sucking to be significantly
associated with the retention or development of tongue thrust in children

and it is not possible to swallow in a normal fashion with the thumb in

mouth.
III. Open Spaces During Mixed Dentition:
When a child loses a deciduous tooth especially a canine or an
incisor, the tongue frequently protrudes into the space at rest and during
speech and swallowing activities.
IV. Gap Filling Tendency
Any space around the dental arches not occupied by teeth will
tend to be filled by the tongue due partly to exploratory excursions of
the tongue and partly to preventing the escape of food during
deglutition.
V. Tonsils and Adenoids
The enlarged or inflammed tonsils theoretically contribute by
fastening a low forward posturing of the tongue and the adenoids by
interfering with free nasal breathing. When both are enlarged mouth
breathing is encouraged which further contributes to a forward habitual
rest position of the tongue.
VI. Allergies
Allergies affecting the upper respiratory system are similar in
their effects to tonsil and adenoid problems.

Hansen and Cohens research in 1973, found that children in

whom the allergies are so persistent as to contribute to frequent nasal
congestion, certainly mouth breathing is encouraged and a number of
studies have found relationship between persistent mouth breathing and
tongue thrusting.
VII. Mouth Breathing
Hanson and Cohen 1973 found a significant relationship between
the presence of mouth breathing and the retention or development of
tongue thrust.
VIII. Macroglossia and Microglossia
Ballard and Bond 1960 describe situations in which the tongue is
inadequate to fill the oral space resulting in a forward thrusting tongue.
Macroglossia has not been found to be the cause of deglutition on
the contrast it has been found in subjects who swallow normally.
IX. Anesthetic Throat
Congenital
hyposensitivity

physiological

discrepancy

manifested

by

brings about abnormal handling of the bolus of food

and thus tongue thrust.

X. Brain Injury
Birth trauma, maldevelopment of brain and other dysfunction of
the central nervous system have been attributed to the etiology of tongue

thrusting. In cerebral palsy and athetosis there may actually be

disruption of the pharyngeal stage of swallowing.
XI. Soft Diet
Oral laxity is encouraged with resulting underdevelopment of
orofacial muscles. The tongue lies flat from disuse although it spreads
between the teeth in deglutition because it is not restrained in the arch
by the emerging contraction of the masticatory muscles.
XII. Physiological Arrest
Deviated swallowers are psychologically disturbed or impaired
and their swallowing is a manifestation of their psychological rather
than physiological arrest.
XIII. Orthodontic Treatment
In some instances malfunction develops during the course of
orthodontic treatment as a direct result of such treatment. But most
commonly the aberrant patern of deglutition has been present from the
start.
XIV. Oral Trauma
A number of patients have been seen mostly adults in whom a
traumatic condition persisted for a sufficient time to effect changes in
deglutition.
XV. Sleeping Habits

Some patients when they sleep on their back on a low pillow an

open mouth results, the tongue rests in the mandibular arch and moves
forward against the teeth during swallowing.
XVI. Oral Sensory Deficiency
The front of the mouth is more sensitive than the posterior
portions and that increased discrimination is found at the midline rather
than in the lateral regions.
A Developmental Theory
Oral function is not a static behaviour from its earliest
appearance, the twelth week of menstrual age to its maturation in the
adult, the swallow adapts to changes in anatomy, diet and general state
of the organism.
William R. Profit (1975) 59 in his Equilibrium Theory says that,
since the teeth are positioned between lips and the cheek on one side
and the tongue on the other side, the opposite pressures from these
should be major determinants of dental equilibrium.
A consideration of the dental equilibrium requires that a
distinction be made between the amount of force generated against a
tooth and duration. But clinically tongue and lip pressures are never
balanced during swallowing. Hence, it seems logical that the patients
who swallowed incorrectly should have protruding incisor or open bite

because of different tongue and lip pressures. It was observed clinically

that tongue pressures and position of teeth did not correlate well. But
clinically in normal swallowing we cant expect equilibrium. Since there
are so many excessive pressures during swallowing and hence to bring
about the change in dentition the so called abnormal pressure should
exist for longer period. So the next logical step is to think immediately
of Time as a variable and to see. If longer duration of pressure, effects
the balance?
The answer is possibly not due to the pressure of an abnormal
swallow but due to the pressure of an abnormal tongue posture. It is
further stated that tongue thrust swallow is the result of an open bite and
not the cause.
Bottle feeding : Much importance has been given to theory that
improper feeding resulted in tongue thrusters. Straub (1960) 72 has
reported that out of 478 tongue thrusters only 2 had been breastfed. Non
physiological design of the nipple on the baby bottle can force the
tongue and cheeks to perform atypical and compensatory function to
extract

milk.

Subsequent

adaptive

response

to

the

associated

dentoalveolar tissues can lead to malocclusions. In bottle feeding more

milk is ingested than in breast feeding during each swallowing. Hence,
risorious and other facial muscles that serves as antagonist for

orbicularis oris muscle are brought into use, resulting in everted lips,
habitually apart, called Bottle mouth.

Normal Infantile Swallow

Infantile swallow is characterized by active contractions of the
musculature of the lips, the tongue tip is brought forward between the
gumpads and in contact with the lower lip. There is little activity of the
posterior tongue or pharangeal musculature.
The mandible is stabilized by contraction of facial muscles. The
buccinator activity is strong during infantile swallow and nursing.
As the infant matures there is increase in activation of the elevator
muscles of the mandible as the child swallows. As semisolid and
eventually solid foods are added to the diet it is necessary for the child
to use the tongue in a more complex way to gather up a bolus, position
it along the middle of the tongue and transport it posteriorly.
As time passes greater activity by the posterior parts of the tongue
and more complex motions of the pharyngeal structures are required.
The normal infantile swallow is seen in neonates and gradually
disappears with the eruption of the buccal teeth in the primary dentition.
The cessation of infantile swallow and the appearance of mature
swallow intermix during the primary dentition and sometimes extend
into early mixed dentition. This is termed as transitional swallow.

Surveys of American Children indicate that at age 6 about 50%

have achieved an adult swallow while the remaining 50% are still
somewhere in the transition.
In mature or adult swallow pattern in some normal children as
early as 3 years but is not present in majority until about age 6 and in
never achieved in 10% to 15% of a typical population.

Normal Mature Swallow:

The tongue is withdrawn to the floor of the mouth as the initial act
of deglutition. In this position the tip and borders of the dorsal portion
rests against the lingual surfaces of the mandibular teeth.
It then expands against the buccal teeth. Following those original
movements the dorsum of the tongue curves upward contacting in
sequence the maxillary incisors and the palate from before backward.
The food which has thus been forced back along the palate is further
driven on through the isthmus of the fauces as the posterior portion of
the tongue is raised.
In this normal mature swallow there is very little lip and cheek
activity. Contraction of mandibular elevator muscles is seen bringing the
teeth into occlusion.
The

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
-

Teeth are in occlusion during swallowing.

The tongue protrudes into the well circumscribed open bite.

Contraction of lips mentalis muscles and mandibular elevators.

This particular tongue thrust is an adaptive mechanism to

maintain an open bite caused by some other causes (e.g. thumb
sucking).

Complex Tongue Thrust Swallow

-

Teeth apart swallow.

The open bite is diffuse and difficult to define.

Contraction of lip, facial and mentalis muscle.

No contraction of mandibular elevators.

Retained Infantile swallow

-

It is the undue persistence of the infantile swallow well past

the normal time for its departure.

Contraction of facial muscles.

Tongue protrudes markedly and is held between all the teeth

during the initial stages of the swallow.

Low gag threshold.

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.

Examination of the tongue:

Functional examination of the tongue is usually preceded by an

examination of the posture, size and shape of the tongue. In most
malocclusions, the growth, posture and function of

the tongue are

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.

Acquired adaptive type.

Endogenous type May be a retention of infantile postural pattern.

Some individuals do not change their tongue posture during the arrival
of primary incisors and tongue lip persists between incisors. Open bite
can be seen in these cases.
Acquired protracted tongue : It is due to enlarged tonsils, pharyngitis
and tonsilitis.
Size of the tongue:
Normal
Abnormal

Macroglossia

Microglossia
Size checking As the patient to touch his chin with tongue lip.

Clinical testing of tongue thrusting:

Patients is seated upright with vertebral colum vertical and
Frankfort plane parallel to the floor.
Test : Place a small amount of water beneath the patients tongue lip and
ask the patient to swallow, noting mandibular movements. In the normal
mature swallow the mandible moves as the teeth are brought together
during swallow and the lips touch lightly showing scarcity in
contraction. Facial muscles ordinarily do not show marked contraction
in normal mature swallows.

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.

Complex tongue thrusting swallow: it is defined as a tongue

thrusting with a teeth apart swallow. Contraction of lip, facial and
mental muscle, lack of contraction of mandibular elevators, and a
tongue thrust between the teeth, and teeth apart swallow.

Retained infantile swallow behaviour:

It

is

defined

as

predominant

persistence

of

the

infantile

swallowing reflex after the arrival of permanent teeth.

Different types of occlusal problems related to orofacial muscle
imbalance and abnormal swallow are:
1. Simple anterior swallow.
2. Complete swallowing problem.
3. Open bite.
4. Bimaxillary protrusion.
5. Class II malocclusion.
6. Closed bite.
7. Unilateral swallowing problem.
8. Bilateral swallowing problem.

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.

Exercise for the Posterior part of the Tongue

The Three Elastic Swallow
Three 5/16 inch elastics are placed on the tongue and the patient is
asked to swallow. The posterior part of the tongue is placed against the

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.

Exercises for the Lips

Tug of War and Button Pull Exercise
A string is tied to two buttons, and one button is placed between
the lips of the patient while the other is held by a parent in the same
position. A tug of war ensures. It is designed to strengthen both lips.
Marshmallow Twist Exercise
Specially designed kits with plastic discs weighing exactly the
same as marshmallows are used. A specially designed type of string is
placed in patients mouth and he lifts the disc by extending the lower lip.
when he can lift one disc easily, two are put on the string and so on until
he is able to lift ten discs. It strengthen the lower lip.
Lip Massage

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.

a) The single elastic swallow of garlinger.

A small orthodontic elastic is placed on the tongue tip and the

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

swallowing pattern has been learned on the conscious level it is

necessary to reinforce it subconsciously. At the second appointment
patient should be able to swallow correctly at will.
b)

Since abnormal unconscious swallow will be seen, flat sugar less

fruit drops can be used to reinforce the correct unconscious
swallow.

c)

A removable or fixed crib appliance or a spur appliance will help

tongue

to

be

reminded

and

redirected

towards

the

correct

swallowing position.

Complex tongue thrusting: 2 main features are:

a) Poor occlusal fit.
b) There is generalized anterior open bite.
It is advisable to treat the occlusion first. The muscle training is
done as for simple tongue thrusting. A maxillary lingual arch wire with
short sharp spurs may be used as a retainer. It is important to do
meticulous

tooth

positioning,

careful

equilibration

followed

by

persistent myotherapy.

Retained infantile swallow:

Is defined as the undue persistance of the infantile swallow will
post the normal time for its departure. Treatment is mainly orthodontic
prognosis is usually poor.

Abnormal tongue posture : The continues effect of abnormal tongue

posture may produce more open bites than the more obvious tongue
thrusting. The posture is usually corrected by attaching sharp spurs to a
bonded anterior sectioned lingual wire or directly to the teeth.
Modified oral screen : Modified double oral screen of Kraus may also
be used in certain cases of tongue thrusting in order to reinforce
treatment.

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

effective primary because of their essential use of extrinsic force,

delivered by the muscle components of stomatognathic system.
In 1879 Norman William Kingsley proposed Jumping the bite by
the abrupt repositioning of the mandible from a distal bite to a more
forward or normal position. He used as maxillary plate with an inclined
plane for jumping of bite in severly retruded case of mandible.
In 1902 Dr. Pierre Robin developed an appliance called Mono
Bloc for bimaxillary expansion.
In 1908 Alfred P. Rogers was the first to recognize the
fundamental importance of the muscles, for growth development and
form of the whole stomatognathic system. He recommended exercises
for the development of the muscles of the face with a view to increase
their functional activity.
First fixed appliance is the Herbst appliance originally introduced
by Emil Herbst of Germany in 1905.
In 1973, Hans Pancherz reintroduced Herbst appliance and shown
that Class II malocclusion could be treated successfully in 6 months.

Criteria:
1)

To bring about changes in bone and developing dentition.

2)

Disarticulate the teeth.

3)

Tight lip seal is achieved in swallowing pattern.

4)

Encourages a new mandibular position that is downward and

forward.

5)

Selective grinding of appliance improves the path of eruption of

particular tooth or teeth.

Classification of myofunctional appliances:

Group I. Are those, which transmits muscle force directly to the
teeth. E.g., Inclined plane, vestibular screen, Lip bumper.
Group II. Where the force is exerted not only on the teeth but also
on the jaws. E.g., Activator, Binator, Herbst appliances.
Group III. Here the abnormal muscle forces are kept away from
acting on developing dental arches and train the muscles function
properly. This also relies on mandibular positional changes but its main
operating areas is in the vestibule, outside the dental arches. Supporting
bone and teeth are influenced by changing the muscles balance through
buccal shields and lip pads. E.g., Frankel appliance.

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.

Schulhof (1978) 66 used a computer aided cephalometric analysis to

assess airway impairment due to adenolds.
Solow and Kreiberg in (1977) 68 postulated what has come to be known
as the soft tissue stretching hypothesis. This scheme involves airway
construction as a key link in a chain of events that they have combined
to field the following cyclic argument.
Soft tissue stretch
Postural change
Neuro muscular Feedback

Differential forces on
the skeleton.
Morpho changes
Obstruction of Airways.

Vig, Showfety and Phillips (1980) have demonstrated that total

obstruction of the nares induces extension of the head.
Montogomery 46 and associates in the early 1980s used CT
scanning for study of the cross sectional area of the airway to determine
the minimum cross-sectional area. they found that the minimum C.S.
area was not necessary at the turbinates.
Vig and Hall in (1980) 81 calculated using pressure flow data of
Holmberg, the corresponding nasal resistance values and fault that even
persons

who

showed

total

obstruction

radiographically,

had

no

significantly high nasal resistance or nasal airflow accepted norms.

Watson, Waven and Fischer (1968) 82 have said that during resting,
conditions, greater effort is required to breath through the nose than

through the mouth the tortuous nasal passages introduce an element of

resistance to airflow as they perform their function of warming and
humidifying the inspired air, the increased work for nasal respiration is
physiologically acceptable upto a point. If the nose is partially
obstructed, the work increases, and at a certain level of resistance to
nasal airflow, the individual switches to mouth breathing. This crossover
point varies among individuals, but is usually reached at resistance
levels of about 3.5 to 4.0 cm H 2 O/ltr minute.

Miller and Vergervie State That

Changes

in

the

dimensions

of

the

respiratory

tract,

i.e.

constriction or obsruction of the tract will decrease the airflow and

result in an adaptation to an oral mode of respiration. Examples of these
can be demonstrated in children with enlarged tonsils or adenoids.
These airflow changes alter the airway resistance, therefore,
respiratory muscles must increase their work to produce changes in intra
pulmonary pressure sufficient for air to be moved in and out of the
alveoli. There is an increased use of muscles of the neck and trunk and
an increase in airflow by breathing through the mouth. These things
alter the neuromuscular function of the craniofacial muscles. It alters
the position of the mandible and tongue, it alters the soft tissue of the
areas affected and alters cranioskeletal form.

As some form of nasal obstruction seems to be the chief culprit

for mouth breathing, a brief discussion of the adenoid ties and growth
and the nasal turbinates and growth would facilitate proper clinical
perspective for mouth breathing management.
Linder Aronson and Backstrom (1968) 36 studied the facial dimensions
in mouth and nose breathing children and found that children with long
narrow faces or high narrow palates have a greater nasal resistance to
breathing than those with short wide faces or low broad palates.
Schenden et al (1976) stated that examination of patients with long face
syndrome revealed an upper third of the face usually within normal
limits, the middle third reveals a narrow nose, narrow alar base and
depressed nasolabial areas. The lower third reveals excessive exposure
of maxillary anterior teeth, poor upper lip to tooth relationship long face
syndrome - vertical maxillary excess.
Large interlabial distance, long lower third of face and coordinate
exposure of maxillary teeth and gingiva on smiling.
Niinimaa et al (1981) 99 reported that about 10-15% of the adult
population breathes orally out of habit rather than need.
McNamara (1981) 41 stated that when adenoidal hyperplasia is the cause
of airway obstruction surgical excision may allow normal breathing and
facial growth may assume a normal pattern within 1 year.

He also concluded that there is a potential interaction between

alterations in respiratory function and craniofacial growth pattern.
Harvold et al (1981) 28 predicted that oral - nasal differential pressures
are not very high except when the nasopharyngeal isthmus is almost
complexly obstructed. This suggests adenoid hypertrophy enough to
produce an opening of less than 0.1 cm 2 .
Sain in (1982) 64 found that in mouth breathing patients there is
increased lower facial height, increased maxillary height, increased
nasal height, a tendency towards open bite and a decreased facial axis.
Another distinguishing factor is that of a Class II molar relationship
which

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

maintained a lower mandibular posture for the entire 2 year period.

Certain craniofacial and tongue muscles remained rhythmically active
throughout the entire 2 year period. This suggests that nasal obstruction
can induce neuromuscular changes which extend beyond the period of
obstruction and remain after the original stimulus for neuromuscular
change has been removed.
Warren et al in (1984) 83 concluded that, a nasal airway cross sectional
area of less than 0.4 cm 2 may represent an inadequate airway and some
mouth breathing would be expected. Only a large adenoidal obstruction
can affect airway resistance. However if nasal airway resistance is high,
large adenoids would present a serious problem and cause mouth
breathing. When nasal airway resistance is high the mouth will open
approximately 0.4 to 0.6 cm 2 , this reduces airway resistance to a normal
level.
Hinton and Warren (1985) 32 concluded that abnormal airway pressures
do not occur in nasally impaired individuals therefore it is questionable
whether airway pressures produce morphologic changes.
They also suggested that slight lip opening (2 to 3 mm) would
significantly reduce airway pressures, and the assumptions that nasally
impaired persons generate abnormal breathing pressures which directly
influence facial growth are questionable.

Hellsing and L'Estrange (1987) 31 concluded that there was a decrease

in upper and lower lip pressures between nose breathing and mouth
breathing whereas there was a significant increase in pressure when the
subject extended the head 5 during mouth breathing.
Warren et al (1988) 84 concluded from their study that 97% of subjects
with nasal size <0.4 cm 2 were mouth breathers and about 12% with an
adequate airway were habitual mouth breathers. In adults an air way
<0.4 cm 2 is impaired.
Hairfield, Warren and Seaton (1988) 26 reported that habitual oral nasal
breathing represents a postural behaviour retained after an extended
period of nasal airway impairment during childhood.
Cheng, Enlow et al (1988) 10 concluded that in the breathing impaired
group, black subjects showed a larger mandibular length, wider dental
arches and palates, a larger midcranial base angle a more backward
alignment of the mandibular rami and the younger the breathing
impaired subject, the less marked is the expression of these craniofacial
morphologic and occlusal characteristics.
Tumpkin and Kudlick (1989) 79 concluded that impedance of the
functional airway was associated with high mandibular plane angles, a
decrease in horizontal distance between the hyoid bone ad epiglottis and

a decrease in horizontal distance between the hyoid bone and genial

tubercles.
Ung et al (1990) 80 reported a tendency among mouth breathers towards
a Class II skeletal pattern and retroclination of maxillary and
mandibular incisors.
Fields et al (1991) 16 concluded that individuals without significant
differences in airway impairment can have significantly different
breathing modes that may be behaviorally based rather than airway
dependent.

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.

II. Partial Observation Due To

a) Deviated nasal septum : It can be a result of birth injuries /
exogenous nasal trauma. It can cause bilateral blockage
creating an S shaped deformity or more typically a unilateral
one creating a C shaped obstruction.
b) Localized benign tumors.
c) Narrow nasal passage associated with narrow maxilla.
d) Leontiasis ossea
III. Infection and Inflammation:
a) Chronic inflammation of nasal mucosa.
b) Chronic allergic stomatitis
Musosal nasal swalling is primarily the base for inflammatory
process or allergic stomatitis.
c) Chronic atrophic rhinitis.
d) Enlarged adenoids and tonsils. This is the most frequent cause
in children.
e) Sinusitis.
f) Nasal polyps.
g) Choannial polyps - arises from the maxillary sinus and
obstructs the posterior portion of the nasal chamber.
IV. Traumatic injuries to the nasal cavity.

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.

During these stages of development, the nasomaxillary complex is

growing well, and with a continued drop of the palate away from the
cranial base, an adequate nasopharyngeal space is usually maintained.
However, if the adenoids attain an abnormally large size, there is
usually a switchover to oral respiration. This creates postural changes,
lips part, the mandible repostures in a downward and forward position
away from the soft palate to open an oral pharyngeal airway channel.
This position of the mandible causes more vertical facial growth.
Continuously opened mouth, stimulate the continued eruption of
the posterior teeth thereby increasing lower facial height and
increasing the potential for an anterior open bite.
The mandibular plane angle was also found to the steeper,
diverging more as it progressed from the gonial region to the sympysis.
It seems that there is a greater divergence of the lower border of the
mandible relative to the names, on ante-gonial notching may also be
found to increase the lower anterior face height.

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

mucosa which can become chronically swollen incident to inflammation

and allergic stresses and project into the normal airstream to the extent
that they may ostruct the nasal air passage ways. The turbinates
especially inflamed turbinates may nearly approximate the nasal septum
and produce a mechanical blockage to nasal airflow.
Woodside and Linder Aronson; found, with increment in age, a
progressively greater lower anterior facial height capable of nasorespiratory activity. Clinically some degree of maxillary retrusion, some
degree of anticlockwise rotation of the palate and some degree of
reduction in maxillary width is frequently observed when nasal
respiration is not possible.
Experiments conducted by Harvold 28 and their associates on young
maccaca mulatta. Monkeys in which the nasal openings were closed with
latex plugs. The first noticeable changes were functional in nature and
were an altered pattern in neuromuscular activity to accomplish oral
respiration. Individual monkeys met this challenge in different ways.
Some of the animals learned to posture their mandible with a
downward and backward opening. Some postured their jaw downward
and forward.Some rhythmically lowered and raised their mandible with
each breath.

Dramatic morphological changes were seen as mentioned earlier at

the gonial and the chin region. The distance from the nasion to the chin
increased significantly as did the distance from the nasion to the hard
palate. This indicates that the lowering of the mandible was followed by
a downward displacement of the maxilla.
Those animals that rotated their mandible in a posterior and
inferior direction developed a Class II skeletal open bite or a class II
malocclusion. Those that maintained a more anterior position of the
mandible developed a Class III malocclusion.

Classification of mouth Breathers by Finn:

Mouth breathers can be classified into 3 groups.
1. Obstructive.
2. Habitual
3. Anatomic
Obstructive: Mouth breathers are children who have an increased
resistance to, or a complete obstruction, of, the normal flow of air
through the nasal passages.
Because of the difficulty of inspiring and expiring air through the
nasal passages, the child is forced by shear necessity to breath through
the nasal passages.

Habitual: The habitual mouth breather is a child who continually

breathes through his mouth by force of habit, although the abnormal
obstruction has been removed.
Anatomical: The anatomical mouth breathes is one whose short
upperlip does not permit complete closure without undue effort.
Obstructive mouth breathing is frequently observed in ectomorphic
children who possess long, narrow faces and nasopharyngeal space,
these children are more prone to have nasal obstruction.
Nasal obstruction: Could be due to:
1. Nasal Polyps.
2. Chronic inflammation of the nasal mucosa, hypersensitivity of
nasal mucosa Chronic Allergic Rhinitis.
3. Localized benign tumors.
4. Congenital enlargement of turbinates.

Clinical Effects Of Mouth Breathing

To breathe through the mouth, one must open up and maintain an
oral airway. Three changes in posture are needed to accomplish this.
i) Lower the mandible.
ii) Positioning the tongue downward and forward.
iii) Extending (tipping back) the head.
Mouthbreathing
malocclusion.

These

by

its

postural

effect

on

changes

equilibrium,
could

affect

produces
vertical

and

horizontal position of the teeth perhaps could influence the growth of

the jaws to a lesser extent.
The type of malocclusion most often associated with MB is called
skeletal open bite or the long face syndrome or the Classic Adenoid
Facies.
Features:

Long and narrow face.

Narrow nose and nasal passages.

Flaccid lips with the upper lip being short.

Dolicofacial skeletal patterns.

The nose is often tipped superiorly in front.

Long narrow face is often somewhat expressionless.

There is a flaring or of the incisors and decrease in overbite and

increase in overjet.

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.

Further, mouthbreathing causes excession dryness of the teeth and

gingivae.

The xerostomic effect is most commonly seen in maxillary and

mandibular anterior regions. This chronic dryness causes increased
susceptibility of the gingiva to chronic inflammation and dental
caries.
Experiments on human subjects have shown a change in posture

due to nasal obstruction.

For instances, when the nose in completely blocked there is an
immediate change of about 5 degrees in the craniovertebral angle. The
jaws move apart by elevation of the maxilla as the head tips back and by
depression of the mandible. In the experimet, when the nasal obstruction
was removed, the posture immediately returned.
This physiologic response occurs to the same extent in individuals
who already have some nasal obstruction. It is clear that altered posture
is the mechanism by which growth changes are produced.

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?

The various methods are.

1.

Study the patients breathing unobserved. Nasal breathing usually

show the lips touching lightly during relaxed breathing, whereas
mouth breathers keep their lips apart.

2.

Ask the patient to take a deep breath. Most respond by inspiring

through the mouth, although an occasional nasal breather will
inspire through the nose with the lips tightly closed.

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.

Place a double surfaced mirror on the upper lip. If the patient is a

nasal breather the upper surface will cloud, if a MB, the lower
surface will cloud.

5.

Place a wisp or a butterfly of cotton in front of each nostril, if it is

pushed away during expiration, the patient is a nasal breather.

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.

Ask the patient to hold a piece of paper between his lips.

Disadvantages:
1.

It is perfectly possible for an individual to breathe through his nose

while the lips are apart. To do this, it is only necessary to seal off
the mouth by placing the tongue against the palate. Since little lip
separation at rest is normal in children, many children who appear
to be mouth breathers, may not be.

2.

Simple clinical tests for mouth breathing can also be misleading.

The highly vascular nasal mucosa undergoes cycles of enlargement
and shrinkage. The cycles alternate between the two nostrils, when
one is clear, the other is atleast slightly obstructed. Hence clinical
tests showing one partially obstructed nostill should be interpreted
as a problem with normal breathing.
Instrumentation that simultaneously measures nasal and oral

airflow is required to accurately establish the percentage of nasal

compared to oral respiration.
Warren

did

quantitative

assessment

of

nasal

airway

improvement. The only reliable method of determining the mode of

respiratory function in the use of a PLETHYSMOGRAPH with a AIR
FLOW TRANSDUCER to determine total nasal airflow and oral airflow.

Massler and Jwemers Butterfly test 40

A wisp of cotton or tissue paper is held alternatively in front of

the nose and the mouth. The child should be asked to close his eyes, it is
more accurate when he is asleep. This helps to differentiate between
nasal breathing and mouth breathing.
If the child doesnt have any breathing problem even after
vigorous exercise, then the cotton will move according to the air
movement of the nostrils when placed in front of the nostrils. If there is
an obstruction the cotton will not move but it will move when placed
infront of the mouth. This patient should be referred to the rhenologist
for diagnosis and correction. Snoring during sleep is also indicative of
nasopharyngeal obstruction.
The patient is asked to hold a mouth full of water, if he has any
nasal obstruction and he is a mouthbreather then he cannot retain the
water for a long time.
If a child keeps the mouth open continuously it is not indicative
that he is a mouth breather, because the drooping mandible could be due
to a lack of muscular tonicity.
Ask the patient to hold a piece of paper between his lips, a
mouthbreather cannot retain it for long.

Disadvantages of the Techniques:

1.

It is possible for the individual to breathe through the nose while

the lips are apart. So it is necessary to seal the mouth by placing the
tongue against the palate.

2.

Clinical tests can be misleading because the nasal mucosa undergoes

cycles of enlargement and shrinkage with the flow of blood.

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.

Rhinomanometry and Respirometry

Stedmans Medical dictionary defines rhinomanometry as the
study of nasal obstruction andnasal airflow characteristics. Since this
term refers only to nasal airflow measurements, direct oral respiratory

measurements is termed RESPIROMERY and implies the study of both

nasal and oral respiratory function.
Silvermann and Whittenberger (1950) were among the first to
describe the Pneuomotachograph, a device consisting of a flowmeter, a
pressure measuring manifold and a recording instrument.
The flowmeter or the Prime Mover is a tube containing an
electricity connected screen. As air flowing through the tube passes the
resistance screen, a pressure drop occurs. The screen is heated to
prevent linear condensation of moisture, which would distort the data.
There is a linear relationship between airflow and a pressure drop across
the screen.
Estimation of the airflow through the nasal passages was based on
the rationale that airflow was primarily a function of resistance. This
reasoning has established that nasal resistance values are an important
diagnostic tool. The assumptions are as follows.
1. Lip incompetence signifies mouth breathing.
2. Mouth breathing becomes a biologic necessity due to nasal
obstruction.
3. A given critical value of nasal resistances consistutes nasal
obstruction to force a change from nasal to oral breathing.

Aschan, Drettner and Range (1965) and (1958):

Reported a technique for measuring nasal resistance to airflow.

Their method features a nasal mask in conjunction with a small oral
tube, one end of which is positioned in the nasopharynx. Another tubes
is placed in the mask to direct nasal airflow through a heated flowmeter.
The two tubes therefore provide a means of measuring air pressure
before its entry into the nasal airway and after it passes into the nostrils.
The subject is asked to close his lips and exhale nasally, the resulting
pressure differential is measured and used to calculate the nasal
resistance to airflow.
As the above method had no means of defining the oral component
of airflow, Comrac, Botello and Dubairs (1959) developed a method in
the form of a body plethysmograph. It consisted of a large chamber
within which the subject was seated.
A spirometer measured total respiratory output while an attached
nasal mask coupled to a pneumotachograph recorded nasal airflow.

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

Respirometric Technique, is a technique for quantitative assessment of

respiratory mode. This system has an accuracy and reproducibility of

97%

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.

Allows precise recording of respiratory function.

2.

Capable of representing oral and nasal inspiration and expiration in

detail.

3.

Able to record and measure airflow characteristics simultaneously

for oral nasal inspiration and expiration.

4.

Does not induce significant alterations in respiratory rate.

5.

Does not generate undue discomfort for subject.

6.

Provides a comparison of total inspired air volume with expired air

volume therefore error can be estimated.

7.

Inspiration can be compared with expiration without changing the

experiment conditions.

8.

Permits the objective quantification of the ratio of oral to nasal

airflow.

9.

Generates numerical values for variations in nasal respiratory

function and oral breathing, thereby permitting the objective
determination of both normal and patho states.

Plethysmography with Airflow Transducer:

A quantitative technique for assessing nasal airway impairment
has been described by Donald Warren.
The method involves a modification of the theoretical hydraulic
principle and enables the clinician to.
1.

Estimate the size of the airway during breathing.

2.

Distinguish between normal and impaired nasal respiratory function

and

3.

Determine quantitatively, the effects of surgical and/or orthodontic

treatment for improving nasal respiration.

The technique is based upon hydrokinetic principles using

instruments capable of accurately measuring respiratory parameters.

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.

h) The bridge of the nose is flat.

Gwyme and Ballard (1957) 25 said that in the vast majority of
children with the so called adenoid facies, the adenoids were not at
fault. These children did not suffer from nasal obstruction and were not
mentally dull nor would they develop any permnent nasal, facial or oral
deformities.
Their facies was a normal type of natural physiognomy related to
hereditory factors than to any structural defects. It is possibly related to
asthma and periodic syndrome. This facies was not influenced by any
type of remedial exercise or oral appliance infact uncessary institution
of these was likely to lead to frustration and mental distress.

II. Dental and Skeletal Effects

1)

Protrusion with spacing of the upper incisors. There is lack of

tonicity in the lips and upper lip is shortened and elevated from over
the upper inisors, while the lower lip becomes heavy and everted
and usually lies beneath and behind the upper incisors. The molding
action of the lips is thus lost causing this effect and also an anterior
dental open bite, decrease in overbite and increase in overjet.

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

cnstriction and a "v" shaped narrow maxillary arch. The palatal

vault is high.
3)

Mandible is retruded and hangs open in a slack manner.

III. Effect on the Periodontium

A consequence of mouthbreathing is chronic keratinized marginal
gingivitis in the maxillary and mandibular anterior regions secondary to
dessication of tissues. Mucous and plaque become more tenacious
therefore, good oral hygiene is critical and bad breath is a common
complaint.
Michael Cohen (1977) 8 said that contact of the upper lip against
the gingiva impedes the removal of crevicular debris and interferences
with the physiologic and biochemistry of crevicular fluid.
Immediate treatment of anterior gingivitis is lubrication of the
tissues with petrolatum or use of an oral screen that covers the tissues
during sleep - if it is left untreated chronic destructive periodontal
disease follows.

IV. Other Structures

1)

Maxillary sinus and nasal cavity - Frequently become narrowed as

the upper arch is contracted with further narrowing of the face.

2)

Turbinates : becomes swollen and engorged.

3)

Nasal mucosa : Becomes atrophic from disuse.

4)

The speech acquires a nasal tone.

5)

The bacteriostatic action of nasal secretions is lost and a pathway is

permitted whereby disease, particularly virus infection may enter
and cause further aggravation of mouth breathing.

6)

Sometimes sense of smell as diluted and with it taste sensations and

apetite are affected.

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

any form of treatment is instituted, the patient is refined to the

paediatrician or a thorough general and ENT examination.

Management consists of the following steps.

1.

Removal of nasal or pharyngeal obstruction by an ENT surgeon. An

adenotonsillectomy may be carried out based on the severity of the
obstruction, consistutional symptom etc. It should be remembered
that after 10-12 years the lymphyoid tissue regresses. At 10 years of
age 180% of what is present at 18 years is there. Obstructive
adenolds usually regress.

2.

Prevention and interception of habit without surgery.

3.

Correction of dental effects by the orthodontist.

2. Prevention and Interperception of Habit

The habit ceases automatically around an after puberty. This is
because of the fact that the nasal and pharyngeal passages increases in
size during the period of rapid growth of the child and sometimes due to
atrophy of the adenoid after puberty occurs.

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

of conscious awareness and also strengthen the tip musculature. Keep

for 2-3 mm at first and then increase the time.
At night, the patient should tape the lips together with 1 surgical
tape while sleeping. These procedure should be successful in abolishing
new habits within 3 months.
Keep a notebook to keep a record of the time spent concentrating
on hip lip posture.
Lipseal can also be achieved by doing the exercise of keeping a
sheet of paper between the lips as adviced by Frankel.
The lip exercise help in increase the tonicity of the perioral
musculature apart from helping to achieves a lip seal. This helps in
probably reducing the overjet produced as a consequence of the mouth
breathing habit.

Vestibular or Oral Screen:

The vestibular screen was introduced by Newell in 1912 and its
current usage has been advocated by kravs, Hotz, Nord and modified by
Frankel.

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.

The simplest form of the vestibular screen, is a commercially

available thermoplastic blank which is contoured onto a plaster model
after heating.
It can also be fabricated with a self curing acrylic.
The vestibular screen prevents mouth breathing completely as it
fills the entire vestibular cavity. It is important to make a few holes in
the anterior part of the screen and with each appointment reduce the size
and sequentially close the holes. This is to prevent a sudden obstruction
of oral breathing and gives patient time to switch over to a nasal node of
respiration.
The appliance is to be worn throughout the night.
The ring attached on the front of the oral screen can be used to do
the routine lip exercises with the oral screen itself. This would increased
the tonicity of the peri-oral musculature.
The alternative to the placement of a ring is to pass a string with a
button on its end from inside out, so that the string can be pulled on
while resisting displacement of the screen with the lips.
Garliner feels that these exercise for 30 minutes daily are
necessary for beneficial results.
Further, as the oral screen is resting on the protruding maxillary
incisors, with the cheeks held away from the canine and premolar areas

arch form can improve by reduction of overject due to the pressure of

lip translated onto the incisors thereby decreasing the overjet.
The buccal part of the screen is wide enough to keep the pressure
off the posteior teeth (2-3 mm clearance on each side), the tongue active
function moulds the posteior segment and helps to expand narrow dental
arches (Only in cases without posterior crossbite).

Conservative line of treatment:

If the obstruction is within the maxillary section of the airway,
relief may be found by widening.
If an MAXILLARY EXPANSION appliance is used and expanded,
this will force the maxillary bones apart together with the palatine, and
displays the pterygoid processes of the sphenold bore.
There are some downward and forward movements, so the nasal
cavity can be said to increase in all three dimensions, but because of the
triangular opening the greatest increased will be in width of the floor.
As the nasal cavity is high and narrow, a small increase in width
will produce a greatest increase in cross-sectional area, and permit the
passage of a vastly increased volume of air.
Kressner reports that the maximum increase will be in the lower
meator.

With 8-10 mm of dental expansion, it is not difficult to achieve a

few extra millimeters of basal maxillary width.
Wertz and Griffin report that good results were obtained with a
more 3 mm of dental expansion, delivering 1-1.5 mm of nasal
expansion.
The expansion should be limited to a point of expansion where
upper palatal cusps are in the region of the lower buccal cusps.
The risks of increasing the malocclusion are not great and the
following points can be remembered.
1.

Relatively little expansion is required if a rigil appliance is used.

This applies especially if the patient is young.

2.

Approx half the dental expansion can be expected to relapse.

3.

Slow expansion can be applied to the mandibular arch to match the

RME.
Wertz (1968) has concluded that benefit would be achieved only if

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

enhances development in maxillary vertical and anterior-posterior

dimension.
The Delaire and Vendon, orthopedic face mask have been used
along with RME to orthopedically offer the ability to widen and to
increase the horizontal and vertical dimension of the naso-maxillary
area.