- Email: [email protected]
Oral myofunctional therapy
56 Rb;nnermanand Thilander
Am. J. Orthod. .lanuar?; 1978
Fig. 7. Patient AR, a girl 15 years 9 months of age. The upper left and lower right second and lower right first deciduous molars had been extracted early. The space conditions have not been influenced by these early losses as crowding also is observed on the nonextraction sides. The bimaxillary crowding is due to mesiodistal tooth width that is larger than normal.
Fig. 8. Patient I.J., a girl 15 years 7 months of age. Early extraction of the upper right and left second, upper left first, and lower left second deciduous molars has not influenced space conditiona. Mesiodistal tooth width is small.
differences were found for variable 24 (ArW uj), indicating a wider arch in the group without lack of space, and for variable 27 (ToothW uj), and variable 34 (ToothW lj) .with higher values in the group with lack of space. All differences were significant at the 1 per cent level except for variables 11 (is-m%) and 27 (ToothW uj), which were sign&cant at the 5 per cent level. When children without lack of space,from the extraction and the control groups were
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compared,only one significant difference was found, namely, for variable 19 (NSL-NL), which showed a higher value in the children in the control group (P < 0.01). A corresponding comparison for children with luck of space also showed only one significant difference, in this casefor variable 30 (ArL lj), with a higher value in the children in the control group. The significance was at the 5 per cent level. Discussion
When the craniofacial morphology was comparedin children with and without early loss of deciduousmolars, the two groups did not differ very much. Although all linear measurementswere greaterin the control group, only one significant difference was found (pm-ss), which indicated a shorter maxilla in the extraction group. This finding supports the results of SeipeLzOwho found a diminished mesial growth of the dental arch in children with loss of permanentteeth. In the dental archesa significant difference for spacewas found only in the maxilla, which reflects a greater migration tendency after early losses in this jaw than in the mandible. This is in agreementwith the effect after extraction of permanentmolars.23For relative space, on the other hand, significant differencesexisted in both jaws, which can be explained by the fact that the sum of the mesiodistal tooth width was greater in the extraction group in both jaws, though at a significant level only in the maxilla. The differences found in arch length in both jaws and in arch width in the maxilla indicate a mesial migration of the molars or a combination of this and a distal movement of the incisors. A comparisonbetweenchildren with and without crowding in the extraction group, on the other hand, showedmany significant differences in both craniofacial and dental arch morphology (Table III). The same thing is true of the nonextraction group (Table II). Furthermore,it is evident from the tablesthat children with similar spaceconditions show similar facial and dental arch morphology. Early loss of deciduous molars thus has no general influence on space conditions. Reduction of space, resulting in crowding, is fairly common in children without extraction, and normal developmentmay occur in spite of early extraction (Figs. 3 to 8). This study shows that this difference occurs becausechildren with lack of space,irrespectiveof tooth extraction, have shorter and narrowerjaws, are less prognathic, and have greater mesiodistal tooth width than children without lack of space.On the other hand, neither the mandibular rotation nor the inclination of the incisors seemsto influence the spaceconditions to any appreciabledegree. REFERENCES 1. BjGrk, A.: The face in profile, Sven. TandGk. Tidskr. 40: Supp. 5B, pp. 32-33, 1947 2. Bjiirk, A.: Prediction of mandibular growth rotation, AM. J. ORTHOD. 55: 585-599, 1969. 3. BjGrk, A., and Skieller, V.: Facial development and tooth eruption, AM. J. ORTHOD. 62: 339-383, 1972. 4. Breakspear, E.K.: Further observations on early loss of deciduous molars, Dent. Pratt. Dent. Rec. 11: 233-252, 1961. 5. Broth, J.: Kefalometriske punkters reproduserbarhet, Specialistarbeide i kjeveortogedi, Oslo, 1975, Oslo Universitet. 6. Clinch, L.: A longitudinal study of the results of premature extraction of deciduous teeth between 3-4 and 13-14 years of age, Dent. Pratt. Dent. Rec. 9: 109-128, 1959. 7. Corelius, M., and Linder-Aronson, S.: The relationship between lower incisor inclination and various reference lines, Angle Orthod. 46: 11 l-1 17, 1976.
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8. Hasund, A., and Remme. T. W.: Prognati og ansiktsharmoni i relasjon till tannbuenes plassforhold pa norske barn mellom 3-7 Hr (with English summary), Nor. Tannlaegeforln. Tid. 77: 319-338, 1967. 9. Linder-Aronson, S.: The effect of premature loss of deciduous teeth: A biometric study in 14. and ISyear-olds, Acta Odontol. Stand. 18: 101-122, 1960. 10. Lund&m, A.: The significance of early loss of deciduous teeth in the etiology of malocclusion. AM. J. ORTHOD. 41: 819-826, 1955. 11. Lund&m, A.: Tooth size and occlusion in twins, Basel, 1948, S. Karger, pp. 55-59. 12. Meredith, H. V., and Knott, V. B.: Childhood changes of head, face and dentition: A collection of research reports, Iowa Orthodontic Society, 1973. 13. Moorrees, C., Gron, A. -M., Lebret, L., Yen, P.. and Frohlich, F.: Growth studies of the dentition: A review, AM. J. ORTHOD. 55: 600-616, 1969. 14. Norderval, K., Wisth, P. J., and Bde, 0. E.: Mandibular anterior crowding in relation to tooth size and craniofacial morphology, Stand. J. Dent. Res. 83: 267-273, 1975. 15. Richardson, M.: The relationship between the relative amount of space present in the deciduous dental arch and the rate and degree of space closure subsequent to the extraction of the deciduous molar, Dent. Pratt. Dent. Rec. 16: 111-118, 1965. 16. Riinnerman, A.: Early extraction of deciduous molars and canines: Its incidence and influence on spacing, Trans. Eur. Orthod. Sot., pp. 153- 168, 1965. 17. Rijnnerman, A., Effect of early loss of primary molars on tooth eruption and space conditions: A longitudinal study, Acta Odontol. Stand. (In press.) 18. Ronnerman, A., and Thilander, B.: A longitudinal study on the effect of unilateral extraction of primary molars, Stand. J. Dent. Res. 87: 306-316, 1977. 19. Sagne, S.: The jaws and teeth of a medieval population in southern Sweden, OSSA 3: Supp. 1, pp. 68-72, 1976. 20. Seipel, C. M.: Variation of tooth position, Sven. TandU. Tidskr. 39: Supp. p. 119, 1946. 21. Siersbaek-Nielsen, S., and Helm, S.: Trangstilling i den permanente dentition efter tidligt tab af temporaere molarer og hjometaender (with English summary), Tandlaegebladet (Dan. Dent. J.) 77: 600-610, 1973. 22. Solow, B.: The pattern of craniofacial associations, Acta Odont. Stand. 24: Supp. 46, pp. 25-27,42, 1966. 23. Thilander, B., and Skagius, S.: Orthodontic sequelae of extraction of permanent first molars: A longitudinal study, Trans. Eur. Orthod. Sot., pp. 429-442, 1970. S-400 33 Gdieborg
Oval myofunctional
therapy
Marvin L. Hanson, Ph.D. Salt Lake City, Utah
R
ather than an attempt to presentvarious approachesto the treatment of oral habit disordersor to rationalize or defend a single approach,the presentarticle represents an effort to describe my personal philosophy and procedures.I acknowledgethe early training receivedfrom Richard Barrett as the foundation of this philosophy; the tutelageof George A. Kopp also contributed greatly to my understandingof the nature of habits and their modification, and the years of close association with William Zickefoose helped shapethe approachto remediation that I proposeto set forth in this article. An earlier article2reviewed sometwenty-odd principles that I consideredimportant in administering effective therapy for tongue thrust. I believe that most of these principles are still valid and recommendthem for your reading. I attempt the extremely difficult task of putting myself in the position of the orthodontist who, for the benefit of his patients, must ask himself many questions about tongue thrust. It is difficult for me to be objective. I steppedinto the office of Boyd V. Sheets back in 1958 and found him working on a researchproject. When I askedhim about the nature of the research,he answered:“It has to do with tongue thrust.” I heard no more about it until 1963, when my departmentsent me to Tucson to learn tongue-thrusttherapy from Mr. Barrett, becausethere were patientsin Pocatello, Idaho, who neededtreatment. I moved to Salt Lake City the next year and found the orthodontistseagerto have me see their patients. There seemedto be little doubt in any of their minds regardingthe necessity for such treatment; they had tried to ignore the behavior for years and were continually confronted with relapses.Experimentationwith cribs and rakes proved ineffective, and they were anxious to give therapy a try. Over the years, our relationshiphasbeenmutually beneficial, from all the feedbackthat reachesme and in Salt Lake City nearly all the thirty or more orthodontists routinely refer their patients with tongue thrust for therapy before initiating orthodontic treatment. In this area, at least, such therapy appearsto have stood the test of time. The questions which follow, along with their answers, representa close association with orthodontists, generaldentists, and pedodontistsover a number of years. While we wait for more definitive answersfrom researchregardingthe role of the tongue in malocclusion, we do the best we can with therapy, borrowing from learning theorists, clinical psychologists, speechpathologists,and othersin an attemptto give the orthodontic patient the best treatment available, Should speech therapy ever be given? One of the best argumentsI am confronted with is the patient who experiencesorthodontic relapse. Recently, two such patients, a teenFrom the Division of Speech Pathology and Audiology, Department of Communication, University of Utah.
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aged boy and a teen-agedgirl, were referred for therapy following relapse.The girl had seemedlike a good, conscientiouspatient, but her bite, which had been closed down completely, had reopened2 m m . in a period of 3 months.Her orthodontistassuredme that in her casethe only explanationhe could find for the relapsewas the tonguethrust, which he had observedin full bloom at the time of her last visit to him. The boy had receivedtongue-thrusttherapytwice previosly and had admittedly cooperated as poorly with the two therapistsas he did with his orthodontist, who had finally given up becauseof the patient’s unwillingnessto wear his positioner. His orthodontist, who, by the way, prefershypnotherapyfor tonguethrust, also insistedthat even if the boy were to wear the positionerfaithfully, retention would not be possibleunlesshe overcame his tongue thrust. The tongue was clearly pushing forcefully, during rest and during swallowing, againstthe bilateral spaceswhich reappearedfollowing removal of bands. This pattern, recurring in countless casesin the past, wherein orthodontic relapse seemedto be repeatedlyassociatedwith tongue habits, has resulted in widespreadacceptanceof oral myofunctional therapy as a preventive measure.A question associated with this first decision is: “Is the tongue thrust likely to disappearspontaneously,either becauseof natural maturationalprocesses,or becauseof the orthodontic alteration of its environment?” The best answer that can be given at the present time is: “Possibly. Sometimes.” Another possibility is that the alteredenvironment,especiallyin the caseof a correctedoverjet, which is the most common type of orthodontic problem referred for tongue-thrusttherapy, m ight encouragethe continuanceof the thrusting pattern by decreasingthe anteroposteriordimensionof the oral cavity.3 Until more definitive knowledge is available, the decisionto completeorthodontic treatmentwhen a tongue thrust is presentis a seriousgamble. Who should provide the speech therapy? Dental assistants,dental hygienists, speech pathologists,generaldentists, orthodontists,and physical therapistshave been trained to do the work. The clinician, whatever his academictraining m ight be, should know the anatomy and physiology involved; understandhuman behavior, normal and abnormal; have training and experiencein motivation; and have substantialtraining and experience in oral myotherapy.No amount of reading can preparehim to treat patients successfully. He needsextensiveobservationof effective clinicians and, eventually, feedbackconceming his own efforts at therapy. Training standardsare now being proposedby the Intemational Association of Oral Myology. Efforts of this organizationare directed toward the upgradingof such training through standardizationand through affiliation with university training programs. At what age should therapy be given. 7 The decision is, of course, dependentupon many variablesand must be made separatelyfor each patient. Most clinicians shy away from treating 4- and Syear-old children, becausesuch young children are not ready to accept the responsibility of carrying out assignments.If the child is unusually mature, intelligent, and motivatable, and the clinician proceedsat the child’s level with patience, successis sometimesforthcoming. Important preventive procedurescan be taken at this age, primarily concernedwith promoting easy nasal breathing. The 6- to &year-old patient is usually receptiveto suggestionsand tries hard. “Scanning” (the trying out of all kinds of behavior)is easierat this agethan later, becauseof the constantly changing oral environmentthe tongue has in which to function. Even at this
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age, however, significant self-correction occurs, and many children would be treated unnecessarily. Most clinicians prefer to wait until the child is about 9 years old before beginning treatment. At that age he is mature enough and is motivated socially to work to achieve nice teeth. The approachof orthodontic treatment provides extra motivation for him. I have had good success,as have most clinicians, with adults, and do not hesitateto accept them as patients. The extra years of habit strength seem to be compensatedfor by the strong motivation found in most adult patients. When should therapy for tongue thrust not be administered?
1. When the malocclusion has been stable for several months or years and is not seriousenoughto warrant orthodontic correction. In this case, the patient and parentsare cautionedto watch carefully for signs of changesin the severityof the malocclusionand to arrange for a re-evaluation in the event the teeth begin to move away from normal occlusion. 2. When the patient demonstrates,either through a history of failure in speechtherapy, resistanceto therapy, or unwillingnessto comply with practice requirementsas they are explained to him, a poor attitude toward the remediationof his problem. 3. When lingual behavior is inconsistent, and normal (nonthrusting) patterns predominate. 4. In patients with severemental retardation,brain damage,or behavioraldisorders. 5. When parentsor other responsiblepersonscannot, or will not, observethe child and provide feedbackto him and to the therapist concerninghis performance. What steps should precede treatment for tongue thrust?
1. An orthodontic evaluation. 2. A thorough evaluation of the oral myofunctional disorder by a qualified person. 3. Elimination or ameliorationof any untoward condition through medical treatment or surgery. This includeslarge, chronically inflamedtonsils and adenoids;restrictednasal passages;severeankyloglossia;and chronic allergies which impede nose breathing. 4. In certain cases, orthodontic treatment for such conditions as extremely narrow maxillary arch, severelingual cross-bite,extremeoverjet making habituationof closed-lip posture difficult, and large anterior maxillary diastemas.When either of the last two problemsis present,I prefer to postponespeechtherapyuntil relatively rapid orthodontic treatmenthas significantly lessenedthe severity of the diastemaor overjet. What results can one expect? If the clinician is conscientiousand effective, from 80 to 90 per cent of the patientshe seesshouldcompletetherapysatisfactorilyand retain proper tongue habits and occlusion. This successrate representsa meanof posttreatmentstudies that have been conductedin the United States.Most of the 10 to 20 per cent who do not succeedare those who do not comply with assignmentsand do not completetraining. If the orthodontist, the parents,and the myotherapistdo not work togetherto detect signs of relapse,especiallyduring the retentionperiod, the successrate will decreaseconsiderably, Treatmentshould not be consideredcompleteduntil at least 1 year following removal of the retainer or positioner. How long should treatment take? The few clinicians who use hypnotherapyonly see the patient in from two to six sessions,usually a week apart. At the other extreme are therapistswho routinely give twenty or more weekly lessons.Most treatment, though,
62 Hanson consists of from seven to ten weekly sessions, followed by variably spaced rechecks which persist through orthodontic treatment. The program ordinarily requires nine weekly visits, with return visits after 2 weeks, then 3 weeks, then 4. The patient is then seen at 2-month intervals three or four times, then every 6 months until bands are to be removed. It is important that he be examined whenever his oral environment is being significantly altered, that is, when bands are attached or removed and a retainer or positioner is placed or discontinued. My patients are seen, albeit infrequently, for from 4 to 6 years. The total number of visits in this period of time is from sixteen to twenty or more. What concomitant problems need attention? Any habits or conditions which facilitate a forward posturing of the tongue may contribute to the total oral habit pattern. Mouth breathing fosters a habitual low, forward positioning of the tongue. Dentalization of the linguo-alveolar speech sounds ( “t,” “d,” “n,” “1,” “s,” “z,“) promotes habitual anteriorization, even during nonspeech periods. Thumb- or finger-sucking prevents normal linguopalatal contact during swallowing. Enlarged tonsils are definitely linked with the perpetuation of the “infantile” swallow pattern. How can the patient be motivated to modifjl oral habits.7 The best motivator is the orthodontist, who explains to the patient that teeth in malocclusion over a period of several years tend to return to that state following orthodontic treatment if acted upon by adverse muscle forces. Most orthodontists in the Salt Lake City area refuse to treat a tonguethruster until they receive a report from the oral myoiogist indicating that proper patterns have been established. When the patient is so informed, he receives his most important motivational influence. The myotherapist confirms what the child has learned from the orthodontist. He explains that therapy is enjoyable, but that practice requirements must be met if treatment is to be continued. These instructions are given to the patient*: You probably swahow once a minute all day long, and you continue to swallow while you are asleep. All these swallows have to be done correctly and automatically. The only way for you to reach this goal is for you to accept all responsibility for remembering to carry out the assignment. During the first few weeks there must be three practice sessions each day. These should be held at specific times. If during the entire week you miss more than one practice session you are to phone the therapist’s office and tell him you have missed practices. You then may be asked to continue the same assignment for an extra week before coming for your next visit.
The child whose parents are well motivated is more willing to cooperate. The parents are involved early in treatment. In order for the clinician to have insight into the child’s oral behavior, the father and mother are asked to observe him carefully for a week or more and to write comments concerning chewing, lip and tongue resting postures. and mouth or nose breathing. Adults and adolescents can usually dedieate themselves wholeheartedly to the task of relearning oral sensorimotor patterns when motivated by goals of better appearance and dental health. Younger patients, though, often need more immediate goals and rewards. The enthusiasm of the clinician following a demonstration of improvement after a week of good practice is very important. Frequent smiles, nods of approval, and verbaI rewards from parents help a great deal. In addition to these things, however, I have found the application of proven behavioral modification principles to be very effective. Behavioral modification is an approach involving (1) the establishment of a base line (a thorough knowledge of the child’s present behavior); (2) a program of detailed steps
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leading toward well-defined goals (each step dependsupon skills learned in previous steps);and (3) a systemof reinforcementor rewards.Baseline is determinedthrough the efforts of the clinician and parents, along with self-observationsof the child. The reinforcementtechniquesapplied include the following: The practice chart. Child and parenttogethermaintain a recordof practices, with a box provided for eachexerciseor assignmentin eachlesson.The chart is brought to therapyeach week. A “plus-minus” system. This can be appliedto any aspectof training, but we use it principally for work on proper resting posturesof the tongue and lips. Whenthepatient(on his honor for a given period of time-15, 20 or 30 minutes) has kept his tongue and lips in their proper positions for this time, he so informs a parent and placesa plus (+) on a chart on the wall. When the parent seesthat the patient’s lips have been closed for the given period of time, he should tell the child and place a plus on the chart. Any time the parent seesthe child with the lips in an open position at rest, or with the tongue forward at rest, he signals him and placesa minus (-) on the chart. Each time someoneplacesa mark on the chart he must inform the other. At the end of eachweek, the marks are tallied and rewardsor punishments(tasks,restrictionson hours, etc.) are meted out, according to the previous agreements. Some clinicians prefer to use only positive reinforcement,without punishment. In either case,during the first week of this program,the patientis rewarded if he earns more pluses than minuses. During the secondweek, he must earn twice as many pluses as minusesto earn a reward, three times as many in the third week, and four times as many during the fourth week. If the child succeeds in getting “plus” weeksfour times in a row, he is given a “bigger” reward for having done so, also accordingto previous agreementwith the parents. Written comments are entered in the child’s manual or notebook, commending him for good work. Special privileges in the therapy room are awarded for specific achievements. The child may be allowed, for example,to spin a dial and receive a toy or prize of some sort according to the number indicated by the pointer. Many clinicians have an “honor board,” a bulletin board on which are placed the photographsof patientswhen they reach a certain stageor degreeof competencein therapy. What are the objectives of treatment ? The principal aim is the elimination of all abnormallingual or labial pressuresagainstthe teeth. This encompasses rest positionsof the tongue and lips; automatic swallows of food, liquid, and saliva; speech;and related habits, such as biting the lower lip, digit-sucking, bruxism, and tongue-sucking.Treatment cannotbe consideredsuccessfuluntil all aspectsof the problemhave beencorrected at a subconsciouslevel. A consequentend product should be the arrestof progressof a related malocclusion and, in some cases,a 1 to 2 mm. improvementin malocclusion. Such improvementis sometimesseenwithin 4 months after the first therapysession.Very rarely doestherapy for tongue thrust obviate orthodontic treatment. Viewed from a different perspective,the aim of therapyshouldbe the establishmentof physiologically efficient oral habits. Proper function should be producedwith the least possibleexpenditureof energy and without negativeeffects on structure. What is the nature of therapy? The $rst assignment I make concerns resting postures
64 Hanson of lips and tongue.’ The child is provided with “reminder
cards” which he is to place around the home, on loose-leaf notebooks, in his locker, and to use as bookmarks at school. His parents are asked to give a simple signal, without accompanying verbal reminders, when they see him with his lips resting in an open position. They record the number of times they use this signal daily. At the fifth or sixth lesson, this attention to resting postures takes the form of the plus-minus system discussed earlier. I consider this to be the most important part of therapy. Parents are made responsible for providing feedback to the patient during and following all orthodontic and oral habit treatment. The establishment of new muscle habit patterns progresses in phases, from the anterior to the posterior portions. This is a logical progression, from most to least visible and from greatest to least degree of voluntary control. Muscles are retrained in groups. Each exercise and assignment has a purpose and is therefore used only when needed. For example, masseter muscle strengthening receives attention only when the diagnostic evaluation reveals that muscle to be weak during swallowing. The purpose of each exercise is explained to the child and parent. Some exercises are designed to strengthen muscles; others are “feeling” exercises, aimed at establishing and making comfortable new posture and movement patterns. A great deal of emphasis is placed upon these new feelings. Whether the purpose be to strengthen or to habituate, it is important to give the patient plenty of time during the practice of each exercise (from 5 to 10 seconds each) to enable the procedure to gain results. Isometric principles are used extensively in therapy. Basically, the tongue learns to create a seal with the palate by pressing firmly against it. The patient thus replaces an anterior linguodental seal with a vertical linguopalatal seal. In most patients, one or more associated habits are also in need of modification, such as overuse of labial muscles, a labiodental seal, lack of good occlusion during swallowing, excessive lingual pressures against the anterior teeth during chewing, and abnormal preparatory lingual movements just prior to swallowing. These are corrected as warranted. The ease with which a child can be taught “how to” swallow correctly deceives some dentists into thinking they need only teach a patient “how,” tell him to do it always, and his habit will be changed. This, of course, is not true. The only way to overcome years of habit strength is to develop new habits. This is accomplished only by persistent and consistent practice. The exercises to be referred to are some of those found in the Zickefoose-Hanson manual.4 Other clinicians use different exercises and accomplish the same results. These work well for us, but we are constantly modifying them and replacing them with new procedures. The effectiveness of therapy diminishes as the clinician continues to use the same exercise at the same point in therapy, explaining it in the same words each time.
Lesson I 1. Practice in tongue-tip placement. The child alternates holding the end of a tongue depressor against the proper “spot” for the tongue tip with holding the tip of the tongue on that spot. 2. Tongue popping. An isometric exercise in which the child sucks the tongue against the roof of the mouth, observes the lingual frenum stretch, hold for 10 seconds, and then “pops” the tongue from the palate. 3. The masseter muscle is contracted and held tight for 10 seconds. 4. The tongue is held on the spot, and the lips remain closed for 5 minutes while the child goes about his regular activities. Lesson 2 1. Open and close. The tongue is sucked up, with the mouth held open for 5 seconds. The tongue remains sucked up as the mouth is slowly closed and held in this position for another 5 seconds. 2. Tongue and masseter. The tongue rests against the roof of the mouth while the masseter is contracted. again for 10 seconds. The child attends to the two concomitant sensations during the 10 seconds.
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3. Beginning swallow. A plastic straw placed behind the canines, with its ends protruding from the sidesof the mouth, lets the child know if the tip or underside of the tongue is moving forward as he “slurps” and swallows water. 4. A small orthodontic elastic is held by the tongue tip againstthe “spot” for 10 minutes following each practice, and the lips remain closed. Lesson 3
1. Tongue whistle. A whistle or “s” sound is practiced for 2 minutes each practice session,with emphasis on the sensationof having the sidesof the tongue resting againstthe upper gingivae, rather than againstthe teeth. 2. Elevation of the back of the tongue. The “k” sound is used to teach this movement. The child holds the back of the tongue up for 5 seconds,after which he either producesa “k” sound or swallows water. 3. Water trapping. The water is squirted into the concavity of the upper surface of the tongue and trapped there as the child positions tongue tip and sides properly. Attention to resting posturesof lips and tongue continues. Lesson 4
1. “Ka,” tip to spot. Combines elevation of back and tip of tongue. 2. Sip and trap. Trapping again, but the patient must get the water onto the tongue himself. Lip exercisesare introduced, and posture work continues. Lesson 5
1. Water trapping with mouth held open. A tongue depressorpositioned edgewisebetweenthe upper and lower first molars makes trapping more difficult. 2. Beginning quiet sucking. A straw againprovides the child with a cue if the tongue movesforward. Water is squirted into the mouth, the lips are closed, and the water is sucked posteriorly. This is the first exercise directed toward the very important movement of saliva from its low, anterior collection area to the back of the mouth for swallowing. 3. Swallowing soft foods. 4. Continuous drinking. The child learns to let gravity replace tongue action in drinking. Plus-minus work usually begins here, and continues for the next 4 weeks. The child is given a list of “reminder signals” from which he is to choose one for outside and one for indoors. For example, every time he seesa smile or hearsa bell ring, he is remindedto check his tongue and lip resting positions. Lesson 6
1. Chewing and swallowing foods. Chewing with proper lip and tongue action is taught. The patient observeschewing and swallowing (lips apart) in mirror. 2. Simulated saliva gathering. Same as Exercise 2, Lesson 5, but without the straw. Attention shifts from visual to kinesthetic cues. 3. Tongue drags. The tongue is sucked against the palate and slowly moved posteriorly. Lesson 7
Each lesson now includes attention to the four aspectsof oral behavior: swallowing of food, liquids, and saliva, and resting postures of the lips and tongue. Formal exercisesare no longer used, except with a few patients. More food is to be chewed and swallowed correctly. The child is to watch the mirror during meals. To provide more practice with saliva, the clinician has the child hold a sugarlessmint in the buccal cavity until it dissolves. He gathersand swallows saliva without letting the tongue leave the “spot.” Children who dentalize alveolar consonantshave usually reached the point where they can benefit most readily from speechtherapy beginning with this lesson. Lesson 8
In addition to the continuation of eating, drinking, and postural assignments,habit-strengtheningtechniques are begun. These include: Swallowing liquids while watching a television program or reading. Counting, by means of a hand-held tabulator, a specified number of saliva swahows each morning, afternoon, and evening. Thinking about swallowing correctly while going to sleep. Lesson 9
Most assignmentsin the previous lessonare continued. In addition, the child tries to awakenwith the tongue in the correct testing place and the lips closed by giving himself suggestionsabout swallowing right all night. He also begins to keep a daily chart of his swallowing and related behavior, either by listing approximate percentageof correct behavior or by using such terms as always righr, nearly always rig&, ect. The purposeof
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this is to encourage him to pay enough attention to all aspects of his oral behavior during the day to make these evaluations somewhat accurate and meaningful. He is told that it is his responsibility to know, at all times in the future whether he is continuing to use proper habits. Subsequent sessions. The parent may be asked to give suggestions to the child concerning swallowing or nose breathing while he is either sleeping or in a partially aroused state. The child is asked to count backward, starting with 100, as the clinician occasionally squirts water into the patient’s mouth. This reveals any subconscious nonswallowing tongue thrusts that may still be present. The child will almost always swallow properly but will disregard, for example, the gathering stage of the process.
I have found it useful to put the child on a “maintenanceprogram” for the next several months. He is to chooseat least one activity, exercise,or assignmentfrom any of Lessons 5 through 9 to carry out eachday. He keepsa log of theseactivities and brings it with him on his recheck visits. How do you know whether therapy is effective? The orthodontist has repeatedopportunities to observe automatic tongue activity in patients who have completed therapy. While in the treatment chair, the patient will manifest habitual resting postures and saliva-handling procedures.The dental assistantand receptionistcan be easily trained to observe the patient in the waiting room as well as in the treatment room. If repeated re-referrals to the therapist fail to eliminate these evidences of tongue thrusting, the therapy is not successfulfor this patient. Of course, if the malocclusionis one that is probably related to abnormaloral habits and reappearsfollowing the removal of bands or retainer, the tongue thrust should be immediately suspectand the patient referredfor more oral habit therapy. This is the most reliable and most painful sign of regressionfor the orthodontistand the therapistas well. What can one do to ensure that one’s patients receive treatment from a qualified person? The International Association of Oral Myology has a certification program,
including rigid training requirements,a comprehensivewritted examination, and a demonstration of clinical competence.Training courses are offered by that organization in various geographicareas, according to need. Summary
A philosophy of the treatmentof tongue thrusting has been presented,along with a description of a therapy program. In geographic areas where such therapy has been provided over a number of years, it has been well accepted.Patients who do poorly in therapy coincide with those who have orthondtic relapse. Although tongue thrust may occasionally disappear spontaneouslyin patients receiving orthodontic treatment, the unpredictability of this outcome makes treatmenta wise preventive procedure. Oral myotherapy may be administeredby anyone who has the proper knowledge, training, and experience.Most therapistsprefer to wait until the child is about 9 yearsold to begin treatment. Poor risks for treatmentinclude patients with (1) long-standingnearnormal occlusions: (2) negative attitudes; (3) predominantly normal habit patterns; (4) mental or psychologicaldisorders;and (5) uncooperativeparents.A thoroughorthodontic evaluationshould precedetreatment,and any conditionswhich mitigate againstsuccessful therapy should be remediatedmedically, surgically, OF orthodontically before therapy begins. Usually, however, it is preferableto complete habit training before banding is begun. Eighty to 90 per cent of patients should complete treatment successfully and retain proper oral habits. The orthodontistshctuldbe wary of abbreviatedtraining programsand
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should readily send the patient back to the therapistthroughouttreatmentif any signs of relapseare detected.The role of the dentist in motivating the patient cannot be overemphasized.Whereassomepatientsare self-motivated,othersneedimmediatereinforcement throughout therapy, such as behavioral-modificationproceduresoffer. My approach to treatment entails a structured, yet flexible, program which uses learning theory principles. It requires a thorough diagnostic sessionplus at least nine weekly sessions,followed by recheck visits spacedgradually farther apart. Patients are seenperiodically throughoutorthodontictreatment.Follow-up studieshave proved this to be an effective approachto the remediationof tongue thrust. REFERENCES 1. Barrett, R., and Hanson, M: Oral myofunctional disorders, St. Louis, 1974, The C. V. Mosby Company. 2. Hanson, M.: Some suggestionsfor more effective therapy for tongue thrust, J. SpeechHear. Disord. 32: 75-79, 1967. 3. Hanson, T., and Hanson, M.: A follow-up study of a longitudinal researchon malocclusions and tongue thrust, Int. J. Oral Myol. 1: 1975. 4. Zickefoose, W., and Hanson, M.: Oral Myotherapy, Sacramento,Calif., 1974, The OMT Company. 1201 Behavioral ScienceBldg. (84112)
THE JOURNAL 80 YEARS AGO January, 1918 During the last two or three years several types of orthodontic appliances have been placed upon the market and widely advertised. One of the principal features recommending the appliance has been its ability to produce physiologic tooth movement. The term “physiologic tooth movement’ has been used by the manufacturers as a smooth-sounding advertising phrase which has led the public to use certain styles of appliances without stopping to consider what physiologic tooth movement really is. In fact, we find very liffle in orthodontic literature that explains what physiologic tooth movement consists of. In a description of a number of regulating appliances we also fail to find a positive statement as to why this or that particular appliance is capable of producing physiologic tooth movement to a greater extent than some other appliance. In fact, before we can be certain that any appliance produces a physiologic tooth movement, we must have some idea as to what constitutes such a movement. Without being particular in regard to what physiologic tooth movement means, we might say that it consists in the movement of the tooth according to natural or physiologic lines. In the development of the dental arch the physiologic tooth movement is the movement of the teeth during the process of eruption. It might also be said that the tipping or moving of teeth as the result of extraction destroying the proximal contact is to a certain extent a physiologic tooth movement produced by a change of conditions. However, we believe we can safely say that the eruption of a tooth is the result of physiologic development and consitutes in reality a physiologic tooth movement. In that case we have a normal action of all the tissues surrounding the tooth, which is physiologic. (Martin Dewey: EditorfalAppliances for Physiologic Tooth Movement, The International Journal of Orthodontia, predecessor of the American Journal of Orthodontics, 438-39, 1918.)
Am. J. Orthod. .lanuar?; 1978
Fig. 7. Patient AR, a girl 15 years 9 months of age. The upper left and lower right second and lower right first deciduous molars had been extracted early. The space conditions have not been influenced by these early losses as crowding also is observed on the nonextraction sides. The bimaxillary crowding is due to mesiodistal tooth width that is larger than normal.
Fig. 8. Patient I.J., a girl 15 years 7 months of age. Early extraction of the upper right and left second, upper left first, and lower left second deciduous molars has not influenced space conditiona. Mesiodistal tooth width is small.
differences were found for variable 24 (ArW uj), indicating a wider arch in the group without lack of space, and for variable 27 (ToothW uj), and variable 34 (ToothW lj) .with higher values in the group with lack of space. All differences were significant at the 1 per cent level except for variables 11 (is-m%) and 27 (ToothW uj), which were sign&cant at the 5 per cent level. When children without lack of space,from the extraction and the control groups were
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compared,only one significant difference was found, namely, for variable 19 (NSL-NL), which showed a higher value in the children in the control group (P < 0.01). A corresponding comparison for children with luck of space also showed only one significant difference, in this casefor variable 30 (ArL lj), with a higher value in the children in the control group. The significance was at the 5 per cent level. Discussion
When the craniofacial morphology was comparedin children with and without early loss of deciduousmolars, the two groups did not differ very much. Although all linear measurementswere greaterin the control group, only one significant difference was found (pm-ss), which indicated a shorter maxilla in the extraction group. This finding supports the results of SeipeLzOwho found a diminished mesial growth of the dental arch in children with loss of permanentteeth. In the dental archesa significant difference for spacewas found only in the maxilla, which reflects a greater migration tendency after early losses in this jaw than in the mandible. This is in agreementwith the effect after extraction of permanentmolars.23For relative space, on the other hand, significant differencesexisted in both jaws, which can be explained by the fact that the sum of the mesiodistal tooth width was greater in the extraction group in both jaws, though at a significant level only in the maxilla. The differences found in arch length in both jaws and in arch width in the maxilla indicate a mesial migration of the molars or a combination of this and a distal movement of the incisors. A comparisonbetweenchildren with and without crowding in the extraction group, on the other hand, showedmany significant differences in both craniofacial and dental arch morphology (Table III). The same thing is true of the nonextraction group (Table II). Furthermore,it is evident from the tablesthat children with similar spaceconditions show similar facial and dental arch morphology. Early loss of deciduous molars thus has no general influence on space conditions. Reduction of space, resulting in crowding, is fairly common in children without extraction, and normal developmentmay occur in spite of early extraction (Figs. 3 to 8). This study shows that this difference occurs becausechildren with lack of space,irrespectiveof tooth extraction, have shorter and narrowerjaws, are less prognathic, and have greater mesiodistal tooth width than children without lack of space.On the other hand, neither the mandibular rotation nor the inclination of the incisors seemsto influence the spaceconditions to any appreciabledegree. REFERENCES 1. BjGrk, A.: The face in profile, Sven. TandGk. Tidskr. 40: Supp. 5B, pp. 32-33, 1947 2. Bjiirk, A.: Prediction of mandibular growth rotation, AM. J. ORTHOD. 55: 585-599, 1969. 3. BjGrk, A., and Skieller, V.: Facial development and tooth eruption, AM. J. ORTHOD. 62: 339-383, 1972. 4. Breakspear, E.K.: Further observations on early loss of deciduous molars, Dent. Pratt. Dent. Rec. 11: 233-252, 1961. 5. Broth, J.: Kefalometriske punkters reproduserbarhet, Specialistarbeide i kjeveortogedi, Oslo, 1975, Oslo Universitet. 6. Clinch, L.: A longitudinal study of the results of premature extraction of deciduous teeth between 3-4 and 13-14 years of age, Dent. Pratt. Dent. Rec. 9: 109-128, 1959. 7. Corelius, M., and Linder-Aronson, S.: The relationship between lower incisor inclination and various reference lines, Angle Orthod. 46: 11 l-1 17, 1976.
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and Thilander
Am. J. Orthd.
8. Hasund, A., and Remme. T. W.: Prognati og ansiktsharmoni i relasjon till tannbuenes plassforhold pa norske barn mellom 3-7 Hr (with English summary), Nor. Tannlaegeforln. Tid. 77: 319-338, 1967. 9. Linder-Aronson, S.: The effect of premature loss of deciduous teeth: A biometric study in 14. and ISyear-olds, Acta Odontol. Stand. 18: 101-122, 1960. 10. Lund&m, A.: The significance of early loss of deciduous teeth in the etiology of malocclusion. AM. J. ORTHOD. 41: 819-826, 1955. 11. Lund&m, A.: Tooth size and occlusion in twins, Basel, 1948, S. Karger, pp. 55-59. 12. Meredith, H. V., and Knott, V. B.: Childhood changes of head, face and dentition: A collection of research reports, Iowa Orthodontic Society, 1973. 13. Moorrees, C., Gron, A. -M., Lebret, L., Yen, P.. and Frohlich, F.: Growth studies of the dentition: A review, AM. J. ORTHOD. 55: 600-616, 1969. 14. Norderval, K., Wisth, P. J., and Bde, 0. E.: Mandibular anterior crowding in relation to tooth size and craniofacial morphology, Stand. J. Dent. Res. 83: 267-273, 1975. 15. Richardson, M.: The relationship between the relative amount of space present in the deciduous dental arch and the rate and degree of space closure subsequent to the extraction of the deciduous molar, Dent. Pratt. Dent. Rec. 16: 111-118, 1965. 16. Riinnerman, A.: Early extraction of deciduous molars and canines: Its incidence and influence on spacing, Trans. Eur. Orthod. Sot., pp. 153- 168, 1965. 17. Rijnnerman, A., Effect of early loss of primary molars on tooth eruption and space conditions: A longitudinal study, Acta Odontol. Stand. (In press.) 18. Ronnerman, A., and Thilander, B.: A longitudinal study on the effect of unilateral extraction of primary molars, Stand. J. Dent. Res. 87: 306-316, 1977. 19. Sagne, S.: The jaws and teeth of a medieval population in southern Sweden, OSSA 3: Supp. 1, pp. 68-72, 1976. 20. Seipel, C. M.: Variation of tooth position, Sven. TandU. Tidskr. 39: Supp. p. 119, 1946. 21. Siersbaek-Nielsen, S., and Helm, S.: Trangstilling i den permanente dentition efter tidligt tab af temporaere molarer og hjometaender (with English summary), Tandlaegebladet (Dan. Dent. J.) 77: 600-610, 1973. 22. Solow, B.: The pattern of craniofacial associations, Acta Odont. Stand. 24: Supp. 46, pp. 25-27,42, 1966. 23. Thilander, B., and Skagius, S.: Orthodontic sequelae of extraction of permanent first molars: A longitudinal study, Trans. Eur. Orthod. Sot., pp. 429-442, 1970. S-400 33 Gdieborg
Oval myofunctional
therapy
Marvin L. Hanson, Ph.D. Salt Lake City, Utah
R
ather than an attempt to presentvarious approachesto the treatment of oral habit disordersor to rationalize or defend a single approach,the presentarticle represents an effort to describe my personal philosophy and procedures.I acknowledgethe early training receivedfrom Richard Barrett as the foundation of this philosophy; the tutelageof George A. Kopp also contributed greatly to my understandingof the nature of habits and their modification, and the years of close association with William Zickefoose helped shapethe approachto remediation that I proposeto set forth in this article. An earlier article2reviewed sometwenty-odd principles that I consideredimportant in administering effective therapy for tongue thrust. I believe that most of these principles are still valid and recommendthem for your reading. I attempt the extremely difficult task of putting myself in the position of the orthodontist who, for the benefit of his patients, must ask himself many questions about tongue thrust. It is difficult for me to be objective. I steppedinto the office of Boyd V. Sheets back in 1958 and found him working on a researchproject. When I askedhim about the nature of the research,he answered:“It has to do with tongue thrust.” I heard no more about it until 1963, when my departmentsent me to Tucson to learn tongue-thrusttherapy from Mr. Barrett, becausethere were patientsin Pocatello, Idaho, who neededtreatment. I moved to Salt Lake City the next year and found the orthodontistseagerto have me see their patients. There seemedto be little doubt in any of their minds regardingthe necessity for such treatment; they had tried to ignore the behavior for years and were continually confronted with relapses.Experimentationwith cribs and rakes proved ineffective, and they were anxious to give therapy a try. Over the years, our relationshiphasbeenmutually beneficial, from all the feedbackthat reachesme and in Salt Lake City nearly all the thirty or more orthodontists routinely refer their patients with tongue thrust for therapy before initiating orthodontic treatment. In this area, at least, such therapy appearsto have stood the test of time. The questions which follow, along with their answers, representa close association with orthodontists, generaldentists, and pedodontistsover a number of years. While we wait for more definitive answersfrom researchregardingthe role of the tongue in malocclusion, we do the best we can with therapy, borrowing from learning theorists, clinical psychologists, speechpathologists,and othersin an attemptto give the orthodontic patient the best treatment available, Should speech therapy ever be given? One of the best argumentsI am confronted with is the patient who experiencesorthodontic relapse. Recently, two such patients, a teenFrom the Division of Speech Pathology and Audiology, Department of Communication, University of Utah.
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Am.J Onhod Jutwnn 197 8
aged boy and a teen-agedgirl, were referred for therapy following relapse.The girl had seemedlike a good, conscientiouspatient, but her bite, which had been closed down completely, had reopened2 m m . in a period of 3 months.Her orthodontistassuredme that in her casethe only explanationhe could find for the relapsewas the tonguethrust, which he had observedin full bloom at the time of her last visit to him. The boy had receivedtongue-thrusttherapytwice previosly and had admittedly cooperated as poorly with the two therapistsas he did with his orthodontist, who had finally given up becauseof the patient’s unwillingnessto wear his positioner. His orthodontist, who, by the way, prefershypnotherapyfor tonguethrust, also insistedthat even if the boy were to wear the positionerfaithfully, retention would not be possibleunlesshe overcame his tongue thrust. The tongue was clearly pushing forcefully, during rest and during swallowing, againstthe bilateral spaceswhich reappearedfollowing removal of bands. This pattern, recurring in countless casesin the past, wherein orthodontic relapse seemedto be repeatedlyassociatedwith tongue habits, has resulted in widespreadacceptanceof oral myofunctional therapy as a preventive measure.A question associated with this first decision is: “Is the tongue thrust likely to disappearspontaneously,either becauseof natural maturationalprocesses,or becauseof the orthodontic alteration of its environment?” The best answer that can be given at the present time is: “Possibly. Sometimes.” Another possibility is that the alteredenvironment,especiallyin the caseof a correctedoverjet, which is the most common type of orthodontic problem referred for tongue-thrusttherapy, m ight encouragethe continuanceof the thrusting pattern by decreasingthe anteroposteriordimensionof the oral cavity.3 Until more definitive knowledge is available, the decisionto completeorthodontic treatmentwhen a tongue thrust is presentis a seriousgamble. Who should provide the speech therapy? Dental assistants,dental hygienists, speech pathologists,generaldentists, orthodontists,and physical therapistshave been trained to do the work. The clinician, whatever his academictraining m ight be, should know the anatomy and physiology involved; understandhuman behavior, normal and abnormal; have training and experiencein motivation; and have substantialtraining and experience in oral myotherapy.No amount of reading can preparehim to treat patients successfully. He needsextensiveobservationof effective clinicians and, eventually, feedbackconceming his own efforts at therapy. Training standardsare now being proposedby the Intemational Association of Oral Myology. Efforts of this organizationare directed toward the upgradingof such training through standardizationand through affiliation with university training programs. At what age should therapy be given. 7 The decision is, of course, dependentupon many variablesand must be made separatelyfor each patient. Most clinicians shy away from treating 4- and Syear-old children, becausesuch young children are not ready to accept the responsibility of carrying out assignments.If the child is unusually mature, intelligent, and motivatable, and the clinician proceedsat the child’s level with patience, successis sometimesforthcoming. Important preventive procedurescan be taken at this age, primarily concernedwith promoting easy nasal breathing. The 6- to &year-old patient is usually receptiveto suggestionsand tries hard. “Scanning” (the trying out of all kinds of behavior)is easierat this agethan later, becauseof the constantly changing oral environmentthe tongue has in which to function. Even at this
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age, however, significant self-correction occurs, and many children would be treated unnecessarily. Most clinicians prefer to wait until the child is about 9 years old before beginning treatment. At that age he is mature enough and is motivated socially to work to achieve nice teeth. The approachof orthodontic treatment provides extra motivation for him. I have had good success,as have most clinicians, with adults, and do not hesitateto accept them as patients. The extra years of habit strength seem to be compensatedfor by the strong motivation found in most adult patients. When should therapy for tongue thrust not be administered?
1. When the malocclusion has been stable for several months or years and is not seriousenoughto warrant orthodontic correction. In this case, the patient and parentsare cautionedto watch carefully for signs of changesin the severityof the malocclusionand to arrange for a re-evaluation in the event the teeth begin to move away from normal occlusion. 2. When the patient demonstrates,either through a history of failure in speechtherapy, resistanceto therapy, or unwillingnessto comply with practice requirementsas they are explained to him, a poor attitude toward the remediationof his problem. 3. When lingual behavior is inconsistent, and normal (nonthrusting) patterns predominate. 4. In patients with severemental retardation,brain damage,or behavioraldisorders. 5. When parentsor other responsiblepersonscannot, or will not, observethe child and provide feedbackto him and to the therapist concerninghis performance. What steps should precede treatment for tongue thrust?
1. An orthodontic evaluation. 2. A thorough evaluation of the oral myofunctional disorder by a qualified person. 3. Elimination or ameliorationof any untoward condition through medical treatment or surgery. This includeslarge, chronically inflamedtonsils and adenoids;restrictednasal passages;severeankyloglossia;and chronic allergies which impede nose breathing. 4. In certain cases, orthodontic treatment for such conditions as extremely narrow maxillary arch, severelingual cross-bite,extremeoverjet making habituationof closed-lip posture difficult, and large anterior maxillary diastemas.When either of the last two problemsis present,I prefer to postponespeechtherapyuntil relatively rapid orthodontic treatmenthas significantly lessenedthe severity of the diastemaor overjet. What results can one expect? If the clinician is conscientiousand effective, from 80 to 90 per cent of the patientshe seesshouldcompletetherapysatisfactorilyand retain proper tongue habits and occlusion. This successrate representsa meanof posttreatmentstudies that have been conductedin the United States.Most of the 10 to 20 per cent who do not succeedare those who do not comply with assignmentsand do not completetraining. If the orthodontist, the parents,and the myotherapistdo not work togetherto detect signs of relapse,especiallyduring the retentionperiod, the successrate will decreaseconsiderably, Treatmentshould not be consideredcompleteduntil at least 1 year following removal of the retainer or positioner. How long should treatment take? The few clinicians who use hypnotherapyonly see the patient in from two to six sessions,usually a week apart. At the other extreme are therapistswho routinely give twenty or more weekly lessons.Most treatment, though,
62 Hanson consists of from seven to ten weekly sessions, followed by variably spaced rechecks which persist through orthodontic treatment. The program ordinarily requires nine weekly visits, with return visits after 2 weeks, then 3 weeks, then 4. The patient is then seen at 2-month intervals three or four times, then every 6 months until bands are to be removed. It is important that he be examined whenever his oral environment is being significantly altered, that is, when bands are attached or removed and a retainer or positioner is placed or discontinued. My patients are seen, albeit infrequently, for from 4 to 6 years. The total number of visits in this period of time is from sixteen to twenty or more. What concomitant problems need attention? Any habits or conditions which facilitate a forward posturing of the tongue may contribute to the total oral habit pattern. Mouth breathing fosters a habitual low, forward positioning of the tongue. Dentalization of the linguo-alveolar speech sounds ( “t,” “d,” “n,” “1,” “s,” “z,“) promotes habitual anteriorization, even during nonspeech periods. Thumb- or finger-sucking prevents normal linguopalatal contact during swallowing. Enlarged tonsils are definitely linked with the perpetuation of the “infantile” swallow pattern. How can the patient be motivated to modifjl oral habits.7 The best motivator is the orthodontist, who explains to the patient that teeth in malocclusion over a period of several years tend to return to that state following orthodontic treatment if acted upon by adverse muscle forces. Most orthodontists in the Salt Lake City area refuse to treat a tonguethruster until they receive a report from the oral myoiogist indicating that proper patterns have been established. When the patient is so informed, he receives his most important motivational influence. The myotherapist confirms what the child has learned from the orthodontist. He explains that therapy is enjoyable, but that practice requirements must be met if treatment is to be continued. These instructions are given to the patient*: You probably swahow once a minute all day long, and you continue to swallow while you are asleep. All these swallows have to be done correctly and automatically. The only way for you to reach this goal is for you to accept all responsibility for remembering to carry out the assignment. During the first few weeks there must be three practice sessions each day. These should be held at specific times. If during the entire week you miss more than one practice session you are to phone the therapist’s office and tell him you have missed practices. You then may be asked to continue the same assignment for an extra week before coming for your next visit.
The child whose parents are well motivated is more willing to cooperate. The parents are involved early in treatment. In order for the clinician to have insight into the child’s oral behavior, the father and mother are asked to observe him carefully for a week or more and to write comments concerning chewing, lip and tongue resting postures. and mouth or nose breathing. Adults and adolescents can usually dedieate themselves wholeheartedly to the task of relearning oral sensorimotor patterns when motivated by goals of better appearance and dental health. Younger patients, though, often need more immediate goals and rewards. The enthusiasm of the clinician following a demonstration of improvement after a week of good practice is very important. Frequent smiles, nods of approval, and verbaI rewards from parents help a great deal. In addition to these things, however, I have found the application of proven behavioral modification principles to be very effective. Behavioral modification is an approach involving (1) the establishment of a base line (a thorough knowledge of the child’s present behavior); (2) a program of detailed steps
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leading toward well-defined goals (each step dependsupon skills learned in previous steps);and (3) a systemof reinforcementor rewards.Baseline is determinedthrough the efforts of the clinician and parents, along with self-observationsof the child. The reinforcementtechniquesapplied include the following: The practice chart. Child and parenttogethermaintain a recordof practices, with a box provided for eachexerciseor assignmentin eachlesson.The chart is brought to therapyeach week. A “plus-minus” system. This can be appliedto any aspectof training, but we use it principally for work on proper resting posturesof the tongue and lips. Whenthepatient(on his honor for a given period of time-15, 20 or 30 minutes) has kept his tongue and lips in their proper positions for this time, he so informs a parent and placesa plus (+) on a chart on the wall. When the parent seesthat the patient’s lips have been closed for the given period of time, he should tell the child and place a plus on the chart. Any time the parent seesthe child with the lips in an open position at rest, or with the tongue forward at rest, he signals him and placesa minus (-) on the chart. Each time someoneplacesa mark on the chart he must inform the other. At the end of eachweek, the marks are tallied and rewardsor punishments(tasks,restrictionson hours, etc.) are meted out, according to the previous agreements. Some clinicians prefer to use only positive reinforcement,without punishment. In either case,during the first week of this program,the patientis rewarded if he earns more pluses than minuses. During the secondweek, he must earn twice as many pluses as minusesto earn a reward, three times as many in the third week, and four times as many during the fourth week. If the child succeeds in getting “plus” weeksfour times in a row, he is given a “bigger” reward for having done so, also accordingto previous agreementwith the parents. Written comments are entered in the child’s manual or notebook, commending him for good work. Special privileges in the therapy room are awarded for specific achievements. The child may be allowed, for example,to spin a dial and receive a toy or prize of some sort according to the number indicated by the pointer. Many clinicians have an “honor board,” a bulletin board on which are placed the photographsof patientswhen they reach a certain stageor degreeof competencein therapy. What are the objectives of treatment ? The principal aim is the elimination of all abnormallingual or labial pressuresagainstthe teeth. This encompasses rest positionsof the tongue and lips; automatic swallows of food, liquid, and saliva; speech;and related habits, such as biting the lower lip, digit-sucking, bruxism, and tongue-sucking.Treatment cannotbe consideredsuccessfuluntil all aspectsof the problemhave beencorrected at a subconsciouslevel. A consequentend product should be the arrestof progressof a related malocclusion and, in some cases,a 1 to 2 mm. improvementin malocclusion. Such improvementis sometimesseenwithin 4 months after the first therapysession.Very rarely doestherapy for tongue thrust obviate orthodontic treatment. Viewed from a different perspective,the aim of therapyshouldbe the establishmentof physiologically efficient oral habits. Proper function should be producedwith the least possibleexpenditureof energy and without negativeeffects on structure. What is the nature of therapy? The $rst assignment I make concerns resting postures
64 Hanson of lips and tongue.’ The child is provided with “reminder
cards” which he is to place around the home, on loose-leaf notebooks, in his locker, and to use as bookmarks at school. His parents are asked to give a simple signal, without accompanying verbal reminders, when they see him with his lips resting in an open position. They record the number of times they use this signal daily. At the fifth or sixth lesson, this attention to resting postures takes the form of the plus-minus system discussed earlier. I consider this to be the most important part of therapy. Parents are made responsible for providing feedback to the patient during and following all orthodontic and oral habit treatment. The establishment of new muscle habit patterns progresses in phases, from the anterior to the posterior portions. This is a logical progression, from most to least visible and from greatest to least degree of voluntary control. Muscles are retrained in groups. Each exercise and assignment has a purpose and is therefore used only when needed. For example, masseter muscle strengthening receives attention only when the diagnostic evaluation reveals that muscle to be weak during swallowing. The purpose of each exercise is explained to the child and parent. Some exercises are designed to strengthen muscles; others are “feeling” exercises, aimed at establishing and making comfortable new posture and movement patterns. A great deal of emphasis is placed upon these new feelings. Whether the purpose be to strengthen or to habituate, it is important to give the patient plenty of time during the practice of each exercise (from 5 to 10 seconds each) to enable the procedure to gain results. Isometric principles are used extensively in therapy. Basically, the tongue learns to create a seal with the palate by pressing firmly against it. The patient thus replaces an anterior linguodental seal with a vertical linguopalatal seal. In most patients, one or more associated habits are also in need of modification, such as overuse of labial muscles, a labiodental seal, lack of good occlusion during swallowing, excessive lingual pressures against the anterior teeth during chewing, and abnormal preparatory lingual movements just prior to swallowing. These are corrected as warranted. The ease with which a child can be taught “how to” swallow correctly deceives some dentists into thinking they need only teach a patient “how,” tell him to do it always, and his habit will be changed. This, of course, is not true. The only way to overcome years of habit strength is to develop new habits. This is accomplished only by persistent and consistent practice. The exercises to be referred to are some of those found in the Zickefoose-Hanson manual.4 Other clinicians use different exercises and accomplish the same results. These work well for us, but we are constantly modifying them and replacing them with new procedures. The effectiveness of therapy diminishes as the clinician continues to use the same exercise at the same point in therapy, explaining it in the same words each time.
Lesson I 1. Practice in tongue-tip placement. The child alternates holding the end of a tongue depressor against the proper “spot” for the tongue tip with holding the tip of the tongue on that spot. 2. Tongue popping. An isometric exercise in which the child sucks the tongue against the roof of the mouth, observes the lingual frenum stretch, hold for 10 seconds, and then “pops” the tongue from the palate. 3. The masseter muscle is contracted and held tight for 10 seconds. 4. The tongue is held on the spot, and the lips remain closed for 5 minutes while the child goes about his regular activities. Lesson 2 1. Open and close. The tongue is sucked up, with the mouth held open for 5 seconds. The tongue remains sucked up as the mouth is slowly closed and held in this position for another 5 seconds. 2. Tongue and masseter. The tongue rests against the roof of the mouth while the masseter is contracted. again for 10 seconds. The child attends to the two concomitant sensations during the 10 seconds.
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3. Beginning swallow. A plastic straw placed behind the canines, with its ends protruding from the sidesof the mouth, lets the child know if the tip or underside of the tongue is moving forward as he “slurps” and swallows water. 4. A small orthodontic elastic is held by the tongue tip againstthe “spot” for 10 minutes following each practice, and the lips remain closed. Lesson 3
1. Tongue whistle. A whistle or “s” sound is practiced for 2 minutes each practice session,with emphasis on the sensationof having the sidesof the tongue resting againstthe upper gingivae, rather than againstthe teeth. 2. Elevation of the back of the tongue. The “k” sound is used to teach this movement. The child holds the back of the tongue up for 5 seconds,after which he either producesa “k” sound or swallows water. 3. Water trapping. The water is squirted into the concavity of the upper surface of the tongue and trapped there as the child positions tongue tip and sides properly. Attention to resting posturesof lips and tongue continues. Lesson 4
1. “Ka,” tip to spot. Combines elevation of back and tip of tongue. 2. Sip and trap. Trapping again, but the patient must get the water onto the tongue himself. Lip exercisesare introduced, and posture work continues. Lesson 5
1. Water trapping with mouth held open. A tongue depressorpositioned edgewisebetweenthe upper and lower first molars makes trapping more difficult. 2. Beginning quiet sucking. A straw againprovides the child with a cue if the tongue movesforward. Water is squirted into the mouth, the lips are closed, and the water is sucked posteriorly. This is the first exercise directed toward the very important movement of saliva from its low, anterior collection area to the back of the mouth for swallowing. 3. Swallowing soft foods. 4. Continuous drinking. The child learns to let gravity replace tongue action in drinking. Plus-minus work usually begins here, and continues for the next 4 weeks. The child is given a list of “reminder signals” from which he is to choose one for outside and one for indoors. For example, every time he seesa smile or hearsa bell ring, he is remindedto check his tongue and lip resting positions. Lesson 6
1. Chewing and swallowing foods. Chewing with proper lip and tongue action is taught. The patient observeschewing and swallowing (lips apart) in mirror. 2. Simulated saliva gathering. Same as Exercise 2, Lesson 5, but without the straw. Attention shifts from visual to kinesthetic cues. 3. Tongue drags. The tongue is sucked against the palate and slowly moved posteriorly. Lesson 7
Each lesson now includes attention to the four aspectsof oral behavior: swallowing of food, liquids, and saliva, and resting postures of the lips and tongue. Formal exercisesare no longer used, except with a few patients. More food is to be chewed and swallowed correctly. The child is to watch the mirror during meals. To provide more practice with saliva, the clinician has the child hold a sugarlessmint in the buccal cavity until it dissolves. He gathersand swallows saliva without letting the tongue leave the “spot.” Children who dentalize alveolar consonantshave usually reached the point where they can benefit most readily from speechtherapy beginning with this lesson. Lesson 8
In addition to the continuation of eating, drinking, and postural assignments,habit-strengtheningtechniques are begun. These include: Swallowing liquids while watching a television program or reading. Counting, by means of a hand-held tabulator, a specified number of saliva swahows each morning, afternoon, and evening. Thinking about swallowing correctly while going to sleep. Lesson 9
Most assignmentsin the previous lessonare continued. In addition, the child tries to awakenwith the tongue in the correct testing place and the lips closed by giving himself suggestionsabout swallowing right all night. He also begins to keep a daily chart of his swallowing and related behavior, either by listing approximate percentageof correct behavior or by using such terms as always righr, nearly always rig&, ect. The purposeof
66 Hanson
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this is to encourage him to pay enough attention to all aspects of his oral behavior during the day to make these evaluations somewhat accurate and meaningful. He is told that it is his responsibility to know, at all times in the future whether he is continuing to use proper habits. Subsequent sessions. The parent may be asked to give suggestions to the child concerning swallowing or nose breathing while he is either sleeping or in a partially aroused state. The child is asked to count backward, starting with 100, as the clinician occasionally squirts water into the patient’s mouth. This reveals any subconscious nonswallowing tongue thrusts that may still be present. The child will almost always swallow properly but will disregard, for example, the gathering stage of the process.
I have found it useful to put the child on a “maintenanceprogram” for the next several months. He is to chooseat least one activity, exercise,or assignmentfrom any of Lessons 5 through 9 to carry out eachday. He keepsa log of theseactivities and brings it with him on his recheck visits. How do you know whether therapy is effective? The orthodontist has repeatedopportunities to observe automatic tongue activity in patients who have completed therapy. While in the treatment chair, the patient will manifest habitual resting postures and saliva-handling procedures.The dental assistantand receptionistcan be easily trained to observe the patient in the waiting room as well as in the treatment room. If repeated re-referrals to the therapist fail to eliminate these evidences of tongue thrusting, the therapy is not successfulfor this patient. Of course, if the malocclusionis one that is probably related to abnormaloral habits and reappearsfollowing the removal of bands or retainer, the tongue thrust should be immediately suspectand the patient referredfor more oral habit therapy. This is the most reliable and most painful sign of regressionfor the orthodontistand the therapistas well. What can one do to ensure that one’s patients receive treatment from a qualified person? The International Association of Oral Myology has a certification program,
including rigid training requirements,a comprehensivewritted examination, and a demonstration of clinical competence.Training courses are offered by that organization in various geographicareas, according to need. Summary
A philosophy of the treatmentof tongue thrusting has been presented,along with a description of a therapy program. In geographic areas where such therapy has been provided over a number of years, it has been well accepted.Patients who do poorly in therapy coincide with those who have orthondtic relapse. Although tongue thrust may occasionally disappear spontaneouslyin patients receiving orthodontic treatment, the unpredictability of this outcome makes treatmenta wise preventive procedure. Oral myotherapy may be administeredby anyone who has the proper knowledge, training, and experience.Most therapistsprefer to wait until the child is about 9 yearsold to begin treatment. Poor risks for treatmentinclude patients with (1) long-standingnearnormal occlusions: (2) negative attitudes; (3) predominantly normal habit patterns; (4) mental or psychologicaldisorders;and (5) uncooperativeparents.A thoroughorthodontic evaluationshould precedetreatment,and any conditionswhich mitigate againstsuccessful therapy should be remediatedmedically, surgically, OF orthodontically before therapy begins. Usually, however, it is preferableto complete habit training before banding is begun. Eighty to 90 per cent of patients should complete treatment successfully and retain proper oral habits. The orthodontistshctuldbe wary of abbreviatedtraining programsand
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should readily send the patient back to the therapistthroughouttreatmentif any signs of relapseare detected.The role of the dentist in motivating the patient cannot be overemphasized.Whereassomepatientsare self-motivated,othersneedimmediatereinforcement throughout therapy, such as behavioral-modificationproceduresoffer. My approach to treatment entails a structured, yet flexible, program which uses learning theory principles. It requires a thorough diagnostic sessionplus at least nine weekly sessions,followed by recheck visits spacedgradually farther apart. Patients are seenperiodically throughoutorthodontictreatment.Follow-up studieshave proved this to be an effective approachto the remediationof tongue thrust. REFERENCES 1. Barrett, R., and Hanson, M: Oral myofunctional disorders, St. Louis, 1974, The C. V. Mosby Company. 2. Hanson, M.: Some suggestionsfor more effective therapy for tongue thrust, J. SpeechHear. Disord. 32: 75-79, 1967. 3. Hanson, T., and Hanson, M.: A follow-up study of a longitudinal researchon malocclusions and tongue thrust, Int. J. Oral Myol. 1: 1975. 4. Zickefoose, W., and Hanson, M.: Oral Myotherapy, Sacramento,Calif., 1974, The OMT Company. 1201 Behavioral ScienceBldg. (84112)
THE JOURNAL 80 YEARS AGO January, 1918 During the last two or three years several types of orthodontic appliances have been placed upon the market and widely advertised. One of the principal features recommending the appliance has been its ability to produce physiologic tooth movement. The term “physiologic tooth movement’ has been used by the manufacturers as a smooth-sounding advertising phrase which has led the public to use certain styles of appliances without stopping to consider what physiologic tooth movement really is. In fact, we find very liffle in orthodontic literature that explains what physiologic tooth movement consists of. In a description of a number of regulating appliances we also fail to find a positive statement as to why this or that particular appliance is capable of producing physiologic tooth movement to a greater extent than some other appliance. In fact, before we can be certain that any appliance produces a physiologic tooth movement, we must have some idea as to what constitutes such a movement. Without being particular in regard to what physiologic tooth movement means, we might say that it consists in the movement of the tooth according to natural or physiologic lines. In the development of the dental arch the physiologic tooth movement is the movement of the teeth during the process of eruption. It might also be said that the tipping or moving of teeth as the result of extraction destroying the proximal contact is to a certain extent a physiologic tooth movement produced by a change of conditions. However, we believe we can safely say that the eruption of a tooth is the result of physiologic development and consitutes in reality a physiologic tooth movement. In that case we have a normal action of all the tissues surrounding the tooth, which is physiologic. (Martin Dewey: EditorfalAppliances for Physiologic Tooth Movement, The International Journal of Orthodontia, predecessor of the American Journal of Orthodontics, 438-39, 1918.)