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Understanding Oral Facial Habits by Dr. Daniel J. Grob

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Categories: Orthodontics;
Understanding Oral Facial Habits 

Often overlooked, oral habits can impact orthodontic care and are easily identified through quick screening

by Dr. Daniel J. Grob

The problem
If there is a topic in orthodontics where there is little agreement on the existence, treatment and relevance of an issue, it is oral habits.

Textbooks, discussions and publications pay it lip service, but little seems to be done to answer the basic questions surrounding this very important topic or, even more frustrating, what to do when you think an oral habit may be present and interfering with treatment.

When confronted with the topic, most dentists immediately assume you are talking about thumb sucking.

While this is an important issue, it is by far one of the least often encountered.

In fact, how many times have you received a referral from a general or pediatric dentist asking you to take responsibility for solving this stubborn behavior issue in a young patient?

Often, the parent and patient appear, the parent(s) are frustrated, and the child is looking over his or her shoulder, afraid to get involved in the discussion.

A search of the literature will turn up only a few articles that offer anecdotal discussions about the existence and influence of oral habits.

Kamdar1 defines a habit as “a repetitive action that is done automatically” and presents a patient case study for review.

In this report, he focuses on thumb sucking and resultant tongue thrusting that is corrected with various oral appliances. No attempt is made at a total Phase 1 or early treatment course of action.
His report confirms that when oral habits are discussed, dentists and orthodontists immediately think thumb sucking and tongue thrusting.

He also cites Proffit,2 who states that while tongue thrusting is a problem, resting tongue posture is probably responsible for long-term damage.

I have concluded over the past several years that more obvious habits are the ones least likely to cause trouble because they are addressed and, most of the time, can be eliminated or go away on their own.

Often, the habits that cause difficulty with orthodontic care are subtle and exert slow, light pressure, like the forces used to move teeth.

This is addressed by Ali3 in a review of habits as they relate to malocclusion. He divides habits into two classifications, one being an acquired oral habit or those that can be stopped with encouragement or by self, and two, compulsive habits that are the result of stress or emotional distress.

He reports up to 50% of children have a harmful oral habit, with thumb sucking the most prevalent (Fig. 1). To be fair, he also states that in most situations, this habit ceases around age 4 or so.

Other harmful habits with an associated effect on occlusion include:
  • Finger sucking
  • Mouth breathing
  • Lip chewing
  • Bruxism
  • Nail biting
  • Tongue thrusting, either simple or complex
As a prosthodontist, I liken the existence of oral habits as something that interferes with the natural “neutral zone” we need to establish to create a big, beautiful smile. Note the tongue muscles and facial muscles are in balance, resulting in the teeth standing up straight subject to favorable vertical loading (Fig. 2).
Understanding Oral Facial Habits
Fig. 1: A patient sucking their thumb.
Understanding Oral Facial Habits
Fig. 2: The neutral zone.


The study
At Valley Orthodontic Group, we had suspicions and concerns about this topic so we decided to run a totally unscientific poll by asking all new, recall and in-between patients to self-identify their habits in a simple exercise.

For three consecutive months, parents were handed a visual (the same visual we use to explain habits during the initial exam) and asked to check off the habits they thought pertained to their child (Fig. 3). Some of the information was confirmed or added by a quick clinical examination. What we found was interesting and probably counterintuitive.

The prevalence of habits in 174 patients are noted in Fig. 4. As you can see from this poll, thumb sucking is the least prevalent of the listed habits. As stated in the previous paper, most of the time it ceases by age 4, so we don’t get to see many of these patients.
Understanding Oral Facial Habits
Fig. 3: Habit visual.
Understanding Oral Facial Habits
Fig. 4: Chart of habits


In fact, a paper by Pearson4 somewhat justifies the habit in certain individuals and suggests thumb sucking is a natural response to several conditions. He shows sucking is in many instances a response to certain psychological events and, in most situations, will resolve with the events causing the habit.

Our poll numbers also show some patients had more than one habit.

The most common habit self-identified in our study was nail biting, followed closely by mouth breathing.

You might recall that Edward Angle5 in his 1907 textbook writes:
“Of all the various causes of malocclusion, mouth breathing is the most potent, constant and varied in its results.”

Bresolin6 concludes there are several harmful characteristics of mouth breathing, including:
  • Longer faces
  • Retrognathic jaws
  • Narrow palates with crossbites
Backlund7 found the link between oral habits and mouth breathing inconclusive.
Other habits identified in a significant number of patients included:
  • Bruxing
  • Lip biting
  • Tongue thrusting and tongue tie
Gottlieb,8 in a Journal of Clinical Orthodontics editorial, disputes the existence of habits at all and considers the behavior as a response to anatomical issues and therefore concludes they don’t meet the definition of a habit. He drifts into the chicken-egg argument and claims the tendency to “treat” these observations is pointless.

With that, I would like to explain the typical day in an orthodontic practice, which may include:
  • Exams with treatment plan
  • Banding and bonding
  • Struggles
  • Retention
  • Relapse
What if variables, previously unknown, could explain the struggles with treatment, failure of retention and, of course, outright relapse so some stability might also actually be increased?
Stability has been a struggle since the founding of orthodontics.

Little9 disrupted the orthodontic profession in the 1980s with papers showing that a good number of patients had relapse crowding after removing permanent teeth. (Remember, removing permanent teeth is supposed to prevent relapse and enhance stability.)

In summary he stated that:
  • Long-term stability was variable
  • No characteristics were predictive of crowding
  • Arch length decreases with time
  • Success was around 20 to 30%
  • Long-term retention was essential
This, as well as other articles on relapse, points to the extraction/non-extraction decision or overzealous expansion as a cause for relapse.

This constant battle fails to recognize the other influences on relapse and stability. Namely, the four influences on malocclusion and stability noted in the Orthotown “Treatment by Twelves” article by Grob10 listing:
  • Hereditary jaw relationships
  • Teeth eruption, size and shapes
  • Temporomandibular joint function
  • The soft tissue envelope, including the lips, cheeks and tongue
I also propose we look at the jaw bones in two distinct varieties. Namely, the skeletal bones that are determined for the most part by heredity, which can’t be changed, and the smile bones that are susceptible to internal and external forces.

The smile bones would be classified as the alveolar bone housing above the mucogingival junction and are susceptible to slow gradual pressure such as orthodontic care with light wires or plastic (Fig. 5).

They would also be susceptible to light gentle forces present in subtle oral habits.

These bones would be responsible for the relative lack of size to support all the teeth and are mentioned by Rose.11

So, during a typical clinical exam, how does one identify the presence of habits in a patient?
There are some subtle signs that will lead one to conclude habits are present, or to at least ask the patient and parent more probing questions.

I complete one of the simplest methods of identification during the very first clinic exam while looking at the dentition, tongue and lips.

After looking at the dorsal and ventral surface of the tongue for obvious or not-so-obvious ties and restrictions, I ask the patient to bite down and swallow. I lightly grab the lower lip and ask the patient to repeat (Fig. 6).

A pull back on the lips while swallowing is almost always an indication of some tongue-muscle-lip imbalance. Following that exercise, I show visuals of proper tongue placement during swallowing and the resulting balance of the teeth positioned within the “neutral zone” (Fig. 7).
Understanding Oral Facial Habits
Fig. 5: Smile bone jawbone junction.
Understanding Oral Facial Habits
Fig. 6: Patient swallowing.
Understanding Oral Facial Habits
Fig. 7: Swallow spot.


What if, despite identifying habits in the exam and treatment, one is still left with signs and symptoms of oral habits? And, more importantly, what clinical signs and symptoms can be used to help treat the patient?

Clinical signs and symptoms
One of my more recent challenges was a teenage girl who was thought to have a Class 2 division 1 subdivision malocclusion. We bonded the dentition and told the family elastics and perhaps a Forsus corrector would be used to correct the rather “standard-looking” Class 2 molar and bicuspid relationship. Several months later, following Forsus, elastics and Carriere mechanics, the unilateral problem persisted. Careful evaluation indicated a tongue/lip muscle imbalance was present. Placing “tongue tamers,” like those described by Voudouris,12 got the patient to position the tongue on the roof of the mouth during rest, swallowing and with elastics. This allowed for the light forces with Pitts self-ligating braces with heat-activated wire to expand the arches and settle the occlusion into Class 1 (Figs. 8–11).
Understanding Oral Facial Habits
 
Understanding Oral Facial Habits
Understanding Oral Facial Habits
Understanding Oral Facial Habits
Figs. 8–11: Sequential photos of the patient.

A tip-off to the presence of oral habits can come during basic intraoral photographs. When the anterior dentition is viewed with the teeth together, poor alignment should be even on both the right and left. When you see one side predominate another, you can almost be certain there is an external influence (Fig. 12).

When the occlusal plane is tipped for no apparent reason, one may consider an oral habit.
In this situation, finger and nail biting was the culprit (Fig. 13).
Understanding Oral Facial Habits
Fig. 12: Single incisor crooked.
Understanding Oral Facial Habits
Fig. 13: Tipped occlusal plane.


Flaring is not a normal eruption side effect. In this situation, spacing and flaring in an otherwise normal jaw situation tips the astute clinician off to the fact some oral habit is present (Fig. 14).
Open bites are encountered on a regular basis. And while the argument is the tongue goes into the opening because it is there, many open bites are a result of tongue pressure at rest (Fig. 15).
During treatment, clinicians often have difficulty “finishing” the occlusal treatment to perfection and symmetry. In this instance, clinicians should look to the existence of oral habits to help explain and treat the problem area.
Understanding Oral Facial Habits
Fig. 14: Flaring with spaces.
Understanding Oral Facial Habits
Fig. 15: Open bite.


The patient in Figs. 16–18 had a lateral incisor that would not align because of repeated re-bracketing and adjustment. Finally, a tongue tamer was placed, and we were able to finish treatment.
Understanding Oral Facial Habits
Figs. 16–18: Single lateral.
Understanding Oral Facial Habits
Understanding Oral Facial Habits


To help show how malocclusion may not be a result of heredity, let’s turn to a family of three children I recently examined. The process started with the youngest sibling, who was evaluated for crowding. We determined she was a mouth breather and referred her for T and A surgery. Her clinical manifestations were narrow arches with lack of room for teeth (Fig. 19).

Following my rather thorough examination, one of the older brothers was evaluated and determined to have a digit sucking habit. While not as crowded as the first child, signs of uneven crooked teeth and occlusal tipping were noted (Fig. 20).

Lastly, the oldest brother was brought in for treatment and it was determined that he had no habits. His dentition showed signs of crowding, but the occlusion was rather even, symmetrical and tight (Fig. 21).
Understanding Oral Facial Habits
Fig. 19: Airway issues resulting from a narrow smile and crowding.
Understanding Oral Facial Habits
Fig. 20: Digit habit resulting in tipping, crowding and an open bite.
Understanding Oral Facial Habits
Fig. 21: No apparent habits and presented with some minor alignment issues.


Oral habits, based on our research as well as anecdotal experience, are present in practically one-half of all orthodontic patients. Many times, they do not matter clinically, but when they do, they can leave the patient, parent and orthodontist confused and frustrated.

Discussion
In addition to identifying habits early and treating them during procedures with tongue tamers and appliances, some clinicians advocate for therapy to reduce the impact of tongue and cheek muscle imbalance. Wasson13 explains that traditional myofunctional therapy may be too complicated, expensive and inconsistent for many and proposes a technique for balancing the pressures from the tongue and cheeks. Called neuromuscular facilitation, this process, developed by Falk, operates at the subcortical level. Wasson urges orthodontists to try the technique and suggests the rewards are worth the investment in training and time.

Conclusions
Oral facial habits are a little understood, partially ignored phenomenon that comes into play in everyday orthodontic practice. Examples have been shown to validate that paying attention to the face muscle balance between the cheeks and tongue is extremely important.
A basic screening technique has been proposed to help identify these issues and assist in smooth treatment of malocclusions. 

References
1. Kamdar, RJ. Damaging Oral Habits. Journal of Intl Oral Health 2015;7:85-87
2. Proffit, W. Contemporary Orthodontics. 4th Edition. CV Mosby;147
3. Ali, F. Oral habits in relation to malocclusion: A review. Intl Journal of Health Sciences 5:230-238
4. Pearson, GH. The psychology of finger sucking, tongue sucking and other oral habits. Read before the NSO March 1948
5. Angle. Textbook of Malocclusion. 1907
6. Bresolin, D. Mouth breathing in allergic children: Its relationship to dentofacial development. AJO/DO 83:4 334-340
7. Backlund, E. Facial Growth and the Significance of Oral Habits, Mouthbreathing and Soft Tissues for Malocclusion: A study on children around the age of 10. Acta Odont Scandia 21:367
8. Gottlieb, E.L. The Editors Corner. JCO 1970;06:299
9. Little, RM. An evaluation of changes in mandibular anterior alignment from 10 to 20 years post retention. AJO/DO May 1988;93:423-880
10. Grob, D. Treatment by Twelves. Orthotown. October 2013
11. Rose, JC. Origins of dental crowding and malocclusions: An anthropological perspective. Compendium. June 2009
12. Voudouris, J. Tongue tamers for rapid open bite closure. JCO June 2022
13. Wasson, JL. Correction of tongue thrust swallowing habits. JCO 1989;1:27

Author Bio
Dr. Daniel J. Grob Dr. Daniel J. Grob completed his dental, orthodontic and prosthodontic schooling at the Marquette University School of Dentistry. He has practiced in Tucson and Phoenix, Arizona, for more than four decades. Grob is a diplomate of the American Board of Orthodontics, a member of the American Association of Orthodontics and the American Dental Association, and the former editorial director of Orthotown magazine. Grob is a member of the Orthotown editorial advisory board.
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