Introduction Types of pressure habits = intrinsic = extrinsic = functional Thumb sucking Tongue thrust and abnormal swallowing Abnormal tongue posture Tongue sucking Bottle feeding Abnormal posture Lip sucking and lip biting Nail biting Pillowing habits

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Dr. Mohammed Alruby
Abnormal pressure habits
Prepared by
Dr. Mohammed Alruby

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Dr. Mohammed Alruby
Introduction
Types of pressure habits
= intrinsic
= extrinsic
= functional
Thumb sucking
Tongue thrust and abnormal swallowing
Abnormal tongue posture
Tongue sucking
Bottle feeding
Abnormal posture
Lip sucking and lip biting
Nail biting
Pillowing habits

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Dr. Mohammed Alruby
Abnormal pressure habits
Children acquire a number of habits that may be temporarily or permanently harmful to
dental occlusion and the teeth supporting structures. Special care should be taken to manage
these habits.
Normal dental and facial development depends to a certain extent on normal development
and maintenance involves a balance of forces between the musculature of the lips and check
outside the dental arches and the tongue inside. The teeth tend to move whenever there is an
imbalance of forces.
The movement of the teeth is possible, since the bone readily respond to pressure. Extra-
oral or intra-oral habits of long duration may create new and unfavorable muscular balances.
Muscular pressure may cause tooth movement in various directions until distorted forces
establish a new balance. This abnormal balance will lead to dental and facial deformity.
Depending on the nature, intensity, direction, and duration of the muscular pressure, oral habits
influence the dento-facial functions (mastication, deglutition, speech, respiration) and dental and
facial esthetics.
Abnormal pressure habits definitely are a factor that must be considered in the study of
the cause of malocclusion. It is generally accepted that dental and facial deformities may be the
result of many etiological factors such as:
= endocrine dysfunction.
=nutritional factors.
= environmental factors.
= malformed or supernumerary teeth.
= premature loss or prolonged retention of deciduous teeth.
=loss of permanent teeth.
As well as abnormal pressure habits, all of which may function singly or may be superimposed
upon each other.
N: B: = law of bisexual hereditary:
Galton’s law of bisexual hereditary gives the following mathematical proportions that can be
inherited from our forefather.
1- ½ is derived from parents.
2- ¼ is derived from the grandparents.
3- 1/8 is derived from the great-grand parents.
4- 1/16 is derived from the great-great-grand parents.
Abnormal pressure habits are of the following types:
1- Pressure habits within the mouth.
2- Pressure habits on the face.
3- Functional pressure.
Intrinsic:
1- Thumb sucking.
2- Finger sucking.

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Dr. Mohammed Alruby
4- Lip sucking.
5- Check biting.
6- Blanket sucking.
7- Nail biting.
8- Lip biting.
9- Tongue biting.
10-Tongue thrust.
11-Macroglossia, over growth of the tongue.
12-Abnormal swallowing.
13-Mouth breathing.
Extrinsic:
1- Chin propping.
2- Face leaning on hand.
3- Abnormal pillowing positions, leaning on forearm or hand.
4- Habitually sleeping on the right side of the face may cause the nose to turn leftward or
vice-versa.
Functional pressure:
1- Narrowing of the external auditory meatus on one side by sleeping on that side of the head
more than on the other.
2- Flattening of an infant head by lying infant habitually in one position for prolonged
periods.
Today mothers do not permit their babies to lie too long in one position but turn the infant
frequently.
3- Kyphosis or round shoulders common among dentist school children, trailers caused by
occupational pressure.
Thumb sucking:
It is repeated forceful sucking of the thumb with associated strong buccal and lip
contractions, the clinical aspect of this problem are divided into three distinct phases of
development:
Phase I: normal and subclinical significant thumb sucking:
This phase extended from three months to three years as most infants display a certain amount of
thumb sucking during this period, particularly at the time of weaning. Ordinary, the sucking is
naturally resolved toward the end of this phase and the use of rubber pacifier is much less
harmful than vigorous thumb sucking. Some children chew on finger during teething but this
activity ceases when the teeth erupt.
Phase II: clinical significant thumb sucking:
This phase extended roughly from three to four years and sucking plasticized during this time
will result in temporary damaged to the child. A definite and firm program of corrected occlusion
is indicated at this time.
Phase III: active thumb sucking:
The child continuing this habit after four years of age that lead to development of malocclusion.
This type of malocclusion dependent upon the position of the thumb during sucking and
associated muscle contraction of the cheeks.

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Dr. Mohammed Alruby
Effects:
1- Protrusion of the maxillary anterior teeth.
2- Spacing of upper anterior teeth.
3- High palatal vault.
4- Retraction of mandibular anterior teeth.
5- Crowding of mandibular anterior teeth.
6- Excessive over-jet.
7- Class II division 1 malocclusion and sometimes class III when the mandible is pulled
forward.
8- High negative pressure within the mouth, with narrowing of maxillary arch that upset the
force system in and around the maxillary complex. So it often impossible to the nasal floor
to drop vertically to the normal position during growth.
N B: the severity of the effects produced by thumb sucking will depend on its force, duration, and
frequency.
Treatment of thumb sucking:
Firstly, the child must understand that is done for his benefits and not as a sort of punishment.
The steps of treatment are gradual and sequential.
A- Control of undesirable oral habits that is usually begun in phase II, it is wise to begin with
discussion of the problem with the child alone, attempt should be made to learn about the
child’s attitude toward the habit.
The child may be shown a cast or photographs of mouth of children, who have had
determinate sucking habits, show the treated results too, to establish what can be done
with the dentist ‘help.
B- As the child inter the period of trying to control the habit alone, a talk should be made
with one or both parents, emphasize that no one should discuss the problem with the child
nor should it become a subject for family discussion.
C- If the child is in phase III, the next step is the insertion of habit correcting appliance. The
ideal appliance to aid in the correction of the thumb sucking habit should:
 Not restrain normal muscular activity.
 Not depend on one’s remembering to use it.
The best appliance is a lingual arch wire with short spurs soldered at strategic location to
remind the thumb to keep out. This short spurs provide discomfort each time the thumb is
inserted.
The oral shield can be used to aid in correction of thumb but it requires an unusual amount
of patient cooperation and is not used continually.
Tongue thrust and abnormal swallowing habits
The subject of tongue thrusting and abnormal swallowing habits is extremely
controversial, and the correlation between these habits and dental malocclusion is to
establish. Firstly, we need to give an idea abnormal swallowing as follow:
Normal infant swallowing:
= the tongue lies between the gum pads.
= the mandible stabilized by the contraction of facial muscles.
= the buccinators muscles are strongly acting.

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Dr. Mohammed Alruby
= this type is present in the neonate and gradually disappears with the eruption of the
buccal teeth in primary dentition.
= the cessation of the infant swallow and appearance of mature swallow is not on and off
phenomena but there is a transitional period or transitional swallowing.
Normal mature swallowing:
= teeth present in centric occlusion.
= muscles of facial expression are in rest.
= contraction of the elevator muscles to bring the teeth into occlusion.
1- Simple tongue thrust swallowing:
Contraction of the lips, mentalis, mandibular elevators muscles.
The teeth are in occlusion (teeth together swallowing) but the tongue is thrust to give an
anterior seal for the open bite.
The open bite is well circumscribed and has definite beginning and ending, this open
bite is due to thumb sucking.
The incidence of simple tongue thrust swallow is diminishing with increasing the age.
Treatment: steps in treatment are as follow:
= Acquaint the patient with abnormal swallow by placing the index finger on the tip of
the tongue and then at the junction of the hard and soft palate and saying to the patient
(most people swallow with this part of tongue on this part of palate. Now put your tip up
here, close your lips, close your teeth and swallow while holding the tongue in this
position), the patient should be instructed to practice correct swallowing at least 40
times / day.
= when the new swallowing pattern has been learned on the conscious level, it is
necessary to reinforce it subconsciously. At the second appointment the patient should
be able swallow correctly at will. However, abnormal unconscious swallow will be seen
flat sugarless fruit drops on the tip of tongue and to hold the fruit drops against the
palate in the correct position until the candy has dissolved completely. At first the child
will be able to hold the fruit drop in place for only a few seconds, but gradually the
periods will lengthen.
= a well-adapted soldered lingual arch wire having short, sharp, strategically placed
spurs can be inserted. Protectively, the tongue is withdrawn from the abnormal position
and placed properly during swallowing. Do not place such an appliance as the first step
in therapy, because it is much traumatic to the patient.
2- Complex tongue thrust swallowing:
= there is a contraction of the lips, mentalis, facial muscles and lack of contraction of
the mandibular elevators.
= the patient is suffering from naso-respiratory distress, the open bite of this type is
more diffused than simple and difficult to define.
= when examined the dental casts there is poor occlusal fit and instability of inter-
cuspation because the inter-cuspal position is not repeatedly reinforce during
swallowing. This type does not diminish by age.
= it is possible to have a complex tongue thrust but no open bite if the tongue is
positioned even a top of all teeth during swallow.

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Dr. Mohammed Alruby
= the patient attention must have brought to the problem and the difficult prognosis
explained carefully at the start of treatment, the patient should know at the start of
treatment that much responsibility for successful therapy lies with himself or herself.
Treatment:
= it is advisable to treat the occlusion first, when the orthodontic treatment is in its
retentive stage, careful occlusal adjustment is completed. The muscle training program
the begun that similar to that for a simple tongue thrust with minor modification:
 When teaching patient to swallow properly, great emphasis must be placed on keeping the
teeth together and the first step of treatment is prolonged.
 It is always necessary to use the third step of treatment, for considerable time to reinforce
the newly learned reflexes. A maxillary lingual arch with sharp short spurs may be used as
a retainer, even after the patient has mastered the newly swallow and the abnormal action
of the lip and mentalis are seen no longer.
3- Retained infantile swallowing:
= persistence of infant type of swallow after present of permanent teeth, this patient demonstrates
very strong contraction of lips and facial muscles.
= tongue thrust strongly between the teeth anterior and posterior.
= patient has inexpressive face, and facial muscles used for stabilizing the mandible during
swallow.
= patient has high difficulties in mastication, the patient occludes only on one molar in each
quadrant.
= patient restrict to the soft diet.
= this type occurs due to defect on the transitional phase of swallowing from infant to adult
swallow.
= the prognosis for correction of this type of swallow is poor. Fortunately, the true retained
infantile swallow is rare.
N: B: the following clinical observation regarding improper swallowing habits is made by
Atkinson:
== Hold your hand on the chin of the patient while the patient in the act swallowing, if the jaw is
opened during the act of swallowing, the supra-hyoid muscle will pull the body of the mandible
downward, bending it just anterior to the angle of the jaw.
== The abnormal swallowing habit should be detected and corrected early to facilitate normal
development of the palate and dentition. In its early detection, it should correct immediately with
mechanical appliance to limit the tongue into its proper position.
Abnormal tongue posture
= the continuous effect of abnormal tongue posture may produce more open bite than more
obvious tongue thrust.
= there are two forms of protracted tongue posture: endogenous and acquired
= during the arrival of the teeth, the tongue normally changes its posture and come to rest inside
the encircling dentition, some children have an inherent abnormal tongue posture persist lying
between the incisors.
The great majority of the endogenous protracted posture problem are not esthetics and there is
stability of the incisor relationship even a mild open bite is seen.

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Dr. Mohammed Alruby
= the acquired protracted tongue posture is a simpler matter, since it usually results from
chronic pharyngitis, tonsillitis or other naso-respiratory disturbance, sometimes the
nasopharyngeal condition no larger exist but the tongue remain in a forward position.
N:B: an adaptive tongue posture is sometimes seen when the maxilla is narrower than the
mandible, since the tongue must aid in the encircling seal to complete the swallow. It may adapt
a posture a top on the lower teeth, when rapid palatal expansion is completed and posterior
inter-cuspation is correct, a normal posture usually return, posterior open bite are more often
postural problems than lateral tongue thrust.
Treatment:
This posture usually can be induced to change by simple sharp spurs to a bonded anterior
sectional lingual wire.
Mouth breathing
Definition: habitual respiration through the mouth instead of the nose.
Recognition: to institute treatment of the actual cause, it is very important to determine the type
and degree of mouth breathing. The habit can be habitual or obstructive.
In mouth breathing, the patient is not aware of the habit which is present at night during sleep;
mouth breathing may be total or partial, continuous or intermittent.
Linder Aronson and Bushey discuss three hypotheses for mouth breathing:
1- Adenoid enlargement leads to mouth breathing, resulting in a particular type of facial
form and dentition.
2- Enlarged adenoids may lead to mouth breathing and do not influence the facial form and
type of dentition.
3- Enlarged adenoids in certain type of faces and dentition may lead to mouth breathing.
Linder Aronson’s studies are the most detailed research in humans, his reports on the
relationship between reduced respiratory function and facial type and dentition. He studied
children who had undergone adenectomies to clear the nasal passage, the finding after 5 years
from mouth breathing to nasal breathing are:
== Normalization of upper incisors inclination.
== Improvement of lower during first year.
==Return to normal bi-molar arch width.
== Normal depth of the nasopharynex.
==Improvement in the mandibular plane and lower face height.
==Improvement in the head posture, which was altered prior to surgery.
Patient with long term mouth breathing is characterized by:
1- Open mouth posture.
2- Short upper lip.
3- Tendency to open bite.
4- Nostrils are small and poorly developed.
5- Nose appears to be flattened.
6- Narrow and high palatal vault.

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Dr. Mohammed Alruby
7- Posterior cross bite.
These morphologic adaptations are believed to be result from alteration in activity of specific
facial muscles related to mouth breathing.
It was observed that children with open mouth posture displayed a significantly slower pattern of
maxillary growth compared with children who displayed anterior lip seal posture.
N:B: maxillary arch width was determined by placing a millimeter boly- gauge against the
maxillary lingual cusp at the cemento-enamel junction of upper 1st
molar and the other 1st
molar
on the other side.
Mouth breathing in allergic children:
Study was made in 45 Caucasian in both sexes age ranging from 6 to 12 years. Thirty is
chronologically allergic mouth breathing and fifteen non-allergic mouth breathing and the study
indicated that:
1- Anterior facial height is significantly larger in mouth breathing.
2- Angular measurements of Sella- Nasion to palatal, occlusal and mandibular plane were
greater in mouth breather.
3- Gonial angle is larger than normal.
4- Over-jet is greater than normal.
5- Maxillary inter-molar width narrower than normal and also associated with posterior
cross bite, all these features support that nasal airway obstruction is associated with
defect in the facial growth.
N:B: arch width is measured from mesio-buccal cusp tip from one side to the other side.
Treatment:
Mouth breathing should be treated during the mixed dentition period to prevent or correct the ill-
effects on occlusion. Before any type of treatment is instituted, it is recommended to refer the
child to a pediatrician for nasopharyngeal and general examination. The actual treatment can be
divided into three parts:
1. Reduction of nasal or pharyngeal obstruction, prior to any dental treatment the child
should be referred to philologist for the removal of nasal and pharyngeal obstruction, if
present by surgery or local medication, if the respiratory allergy is present this should be
brought under control.
2. Interception of the habit, many children continue to breathe through the mouth especially
at night, even after removal of adenoids. In such cases the habit must be corrected. An
oral screen is a simple and efficient appliance (a piece of plastic material that rests in the
labial and buccal vestibule and prevents the passage of air through the mouth after
adenoidectomy.
Adequate nasal function by rhinologist. Deep breathing and lip exercises are
advantageous.
3- Correction of malocclusion:
Tongue sucking
This habit can occur habitually or due to macro-glossia and its activity is similar to the
thumb sucking and usually disappear about the 2nd
year of life. Tongue sucking may cause
posterior or anterior open bite.
Bottle feeding

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Dr. Mohammed Alruby
The mass of the tissue taken into the mouth by the child nursing at the breast exerts spreading
action on the jaws and aids in their normal growth. In addition, the tongue movement inside the
mouth during breast feeding is ideal and so help in development of normal swallowing behavior.
In the bottle of baby this spreading action may be absent, the milk from the bottle is follow by
action of sucking that produce a negative pressure in the mouth which contract the cheeks and
compress the jaws, and requires no further movement of the tongue so abnormal swallowing may
develop.
Abnormal posture
Poor postural condition can cause malocclusion.
1- Chin propping habit:
A chin propping habit (extrinsic pressure, unintentional) will cause a deep anterior closed bite,
and may also cause the mandible to be retracted. Note that there is little of lower anterior teeth is
visible when the jaws are in closed position.
2- Face leaning:
Lateral pressure from face leaning (extrinsic pressure unintentional) may cause lingual
movement of maxillary teeth on that side. The mandible being less affected because it does not
have a rigid attachment and slide away from the pressure.
3- Head posture:
Faulty head postures can cause abnormal changes in the form of jaw bones. Curvature of the
neck and cervical spine causes forward and upward positioning of the head which is commonly
associated with class II malocclusion.
Robin suggested that child must held in an upright posture to prevent pressure on the face.
4- Mandibular postures:
Low mandibular postures associated with mouth breathing initiate abnormal neuromuscular
reflexes. That may be responsible for production of class II malocclusion and open bite.
5-lip posture
The lip may be incompetent when the face in repose position this may be responsible for
production of bi-maxillary protrusion or class II division 1 malocclusion
6-Tongue postures:
= The normal tongue posture is important for the development of normal occlusion. The tongue
posture over the occlusal surface of the teeth is responsible for open bite
= lateral tongue thrust may produce open bite
= in case of Bell’s palsy the tongue and lips are usually affected and its normal position is
changed so the occlusion is changed if the condition is prolonged
Lip sucking and lip biting
Lip sucking may appear by itself or may be seen with thumb sucking, the lower lip is the most
frequently involved and also the upper lip may be involved.
This habits leads to:
1- labioversion of maxillary anterior teeth.
2- linguoversion of mandibular teeth.
3- Increased over-jet and over-bite.

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Dr. Mohammed Alruby
4- Lip hypertrophy.
The deformity reaches its maximum when the discrepancy between the maxillary and mandibular
incisors becomes equal to the thickness of lower lip.
Treatment:
The incisors must be positioned correctly; some lip habits are then self-corrected, but
hyperactive mentalis muscle remains, the modified oral shield is useful.
Nail biting
One of the most common habits in children and adults, it is a sign of internal tension.
Absent under 3 years of age, there is a rapid increase at 6 years of age followed by sharp rise at
puberty and followed by rapid decline after age of 16 in boys.
After the age of 15 year, the nail biting is replaced by pencil biting, lip biting, nose picking, and
hair twirling, or smoking in boys.
Clinical nail biters show:
1- Crowding and rotation.
2- Attrition of incisal edge of incisors teeth especially the lower incisors.
3- Tendency to class III malocclusion.
Management:
= in mild cases of nail biting, treatment is usually not indicated, since the child will probably
transfer to some other activity at later age.
= treatment should be by removing the basic emotional factors causing the act. The child should
be encouraged to pursue vigorous muscular activity outdoors, such as running or ball playing.
These activities serve to relieve his pent- up energy that otherwise would be expressed as tension,
leading to nail biting.
== Application of finger nail polish may be helpful in girls; light cotton mittens may be worn at
night.
Pillowing habit
 Postural defect during sleep are considered as an etiologic factor in the development of
malocclusion. The effect depends upon the frequency, duration and the amount of pressure
exerted by the abnormal postures; also depend upon the resistance of the bone to
deformation.
 Flattening of the skull and facial asymmetry may occasionally develop during the 1st
years
of life where the infant in supine position with the head turned to the right or left for longer
time.
 The pillow of the child must be at the level of his shoulder and not too high or low, and the
mother must change the position of her child at frequent intervals.
With my best wishes for you.