Ministry of Higher Education

And Scientific Research

University of Baghdad

College of Dentistry

BAD HABITS

A graduation project submitted to the council of the College

of Dentistry at the University of Baghdad, in partial

fulfillment of the requirements for the degree of bachelor in

dentistry

By

Ola Abdulhussain

Supervised by

Lecturer Dr. Ahmed Fadhil Faiq Aljarad

(B.D.S. M.Sc.)

May 2017

الرحيم الرحمن الله بسم

لنا علم ال سبحانك قالوا

أنت ك إن متنا عل ما إال

الحكيم العليم

العظيم الله صدق

البقرة )سورة آية

٣٢)

Acknowledgment

Firstly, I would like to thank Allah for giving me the ability to

understand and complete this project.

I also would like to thank my project supervisor Lecturer Dr. Ahmed

Fadhil Faiq Aljarad for his efforts and his great support which helped

me to improve my performance and knowledge.

Ola Abdulhussain

List of Content

Subjects Page no.Introduction 1Review of Literatures 21. Definition of habits 22. CLASSIFICATION OF HABITS 22.1 WILLIAM JAMES 22.2 KINGSLEY 22.3 FINN AND SIM 32.3.1 Compulsive Habits 32.3.2 Non-compulsive Habits 32.4 GRABER 32.5 Gurkeerat Singh 42.5.1 classification based on the cause the habit 42.5.2 Classification based on the origin of the habit 42.5.3 Classification based on the patient awareness to the habit 43. Etiological agents in the development of oral habits 43.1 Anatomical agents in the development of oral habits 53.2 Mechanical interferences affecting the development of oral habits

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3. 3 Pathological agents in the development of oral habits 63.4 Emotional agents in the development of oral habits 73.5 Imitation affecting the development of oral habits 73.6 Random behavior 73.7 Equilibrium theory 74.Types of bad habits 84.1 Digit – sucking habit 84.1.1 Defintion of digit – sucking habit 84.1.2 Types of digit sucking 84.1.3 Effect of digit – sucking 94.1.3.1 Effects of digit – sucking on Maxilla 104.1.3.2 Effects of digit – sucking on Mandible 104.1.3.3 Effects of digit – sucking on Inter-arch Relationship 104.1.3.4 Effects of digit – sucking on lip placement and function 104.1.3.5 Effects of digit – sucking on tongue placement and function

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4.1.3.6. Other Effects of digit – sucking habit 114.1.4. Diagnosis of digit – sucking 114.1.4.1 History of Digit Sucking 114.1.4.2 Extra-oral Examination of digit sucking 11

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4.1.4.3 Intraoral Examination of digit sucking 124.1.5 Treatment of digit – sucking habit 124.2 Tongue thrusting habit 134.2.1 Definition of tongue thrusting habit 134.2.2 Classification of tongue thrust 144.2.2.1 Backlund 144.2.2.2 Pickett’s 144.2.2.3 Moyers 144.2.3 Effects of tongue thrust on dento – facial structures 154.2.4 Diagnosis of tongue thrust 164.2.4.1 History 164.2.4.2 Examination 164.2.5 Management of tongue thrust 164.3 Mouth breathing habit 174.3.1 Definition of mouth breathing 174.3.2 Classification of mouth breathing 174.3.2.1Obstructive mouth breathing 174.3.2.2Habitual mouth breathing 174.3.2.3Anatomical mouth breathing 174.3.3 Effects of mouth breathing 174.3.3.1 Effects of mouth breathing on face 174.3.3.2Effects of mouth breathing on occlusion of teeth 184.3.4 Diagnosis of mouth breathing 184.3.5 Management of mouth breathing habit 194.4 Bruxism 194.4.1 Definition of bruxism 194.4.2 Etiology of bruxism 204.4.3 Signs and symptoms of bruxism 204.4.3.1 Signs and symptoms of bruxism On Teeth 204.4.3.2 Signs and symptoms of bruxism on Musculature 204.4.3.3 Signs and symptoms of bruxism on Tempro-mandibular joint

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4.4.4 Diagnosis of Nocturnal Bruxism 214.4.5 Management of bruxism 215. Myobrace for bad habits 225.1 Myobrace for Kids 225.2 Myobrace for Teens 23References 25

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List of Figures

Figure title Page no.Figure 1: Infantile swallow; note the placement of the tongue at rest and its position just before the act of swallowing. The tongue comes in between the gum pads to obtain the vacuum required to suck

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Figure 2 : Ectopically erupting central incisor resulting in the tongue being placed at the sight 7

Figure 3 : Anterior tongue thrust habit due to the congenitally missing permanent maxillary lateral incisors 7

Figure 4 : Nasal blockage as seen on an OPG 8Figure 5 : Digit-sucking habit 9Figure 6 :The maxillary and mandibular arches in the vertical and horizontally placed digit suckers 11

Figure 7: Abnormal placement of the tongue/tongue thrust swallow 15

Figure 8: Anterior tongue thrust in an adult 16Figure 9 :Lateral tongue thrust 16Figure 10: Simple tongue thrust 16Figure 11 : Complex tongue thrust 16Figure 12 : Effect of mouth breathing on gums and occlusion 19Figure 13 : myobrace for kids 24Figure 14 : myobrace for teens 25

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Introduction

Oral habits in children are a prime concern for the dentist, be it an

orthodontist, pedodontist or a general practitioner. The neonate uses its mouth

as a primary device for exploring the environment and his survival depends on

instinctive sucking when his lips and tongue are stimulated. By random

movements, infants discover their hands and toes, and use these to continue

stimulation of the mouth and related structures.

Normal habits grow out of these early developmental stages

smoothly. Occasionally, a retained infantile pattern can cause an evident oral

habit.

Finn (1975) says that habits cause concern because they cause Oral

structural changes, Harmful, unbalanced pressures bear upon the immature,

highly malleable alveolar ridges and bring about potential changes in position of

teeth and occlusion, also behavioral problems and Socially unacceptable act.

The prevalence of oral habits in high school girls and primary school

students have been reported to be 87.9 and 30%, respectively (Yassaei et al.,

2004). Quashie-Williams et al. (2007) found 34.1% of children with an oral

habit in his study.

The aim of this present study was to review different oral habits and

their management as a guide to parents and dentists.

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Review of Literatures

1. Definition of habits William James in 1923 defined habits as a new pathway of discharge

formed in the brain by which certain incoming currents lead to escape. While

Maslow in 1949 defined habits as a formed reaction that is resistant to change,

whether useful or harmful, depending on the degree to which it interferes with

the child’s physical, emotional and social functions. While Dorland in 1963

defined habits as fixed or constant practice established by frequent repetition.

2. CLASSIFICATION OF HABITS Over time various authors have classified habits in differing ways

which include the following:

2.1 WILLIAM JAMES

William James in 1923 classified habits into: Useful Habits and

Harmful Habits. Useful Habits Include habits of normal function, e.g.

correct tongue posture, respiration and deglutition. while Harmful Habits

Includes all habits which exert pressures/stresses against teeth and dental arches

and also mouth breathing, lip biting and lip sucking.

2.2 KINGSLEY Based on the nature of the habits, Kingsley in 1956 classified habits as:

• Functional oral habit, e.g. mouth breathing.

• Muscular habits Tongue thrusting, cheek/lip biting.

• Combined muscular habits Thumb and finger sucking.

• Postural habits Chin-propping

• Face leaning on hand

• Abnormal pillowing.

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2.3 FINN AND SIM Finn and Sim in 1975 classified habits into: Compulsive oral habits and

non-compulsive oral habits.

2.3.1 Compulsive Habits An oral habit is compulsive when it has acquired a fixation in the child

to the extent that he retreats to the practice of this habit whenever his security is

threatened by events which occur in his world. They express deep-seated

emotional need and attempts to correct them may cause increased anxiety.

The act serves as a bulwark against society or a safety valve when

emotional pressures are too much to bear. Various etiologies often implicated

are:

• Rapid feeding patterns

• Too little feeding at a time

• Too much tension during feeding

• Bottle-feeding

• Insecurity brought by a lack of love and tenderness by the mother.

2.3.2 Non-compulsive HabitsNon-compulsive habits are the ones that are easily added or dropped

from the child’s behavior pattern as he matures. Continual behavior

modification causes release of undesirable habits and addition of new socially

acceptable ones. No abnormal response results from attempts to retrain the child

to form a pattern of behavior consistent with his increased level of maturity.

2.4 GRABER Graber in 1976 classified all habits under extrinsic factors of

general causes of malocclusion which include the following :

Thumb/digit sucking

Tongue thrusting

Lip/nail biting, bobby pin opening and mouth breathing

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2.5 Gurkeerat Singh

Gurkeerat Singh in 2007 classified habits as following :

2.5.1 Classification based on the cause the habit Habits classified based on the cause of the habit into : Physiologic

Habits which required for normal physiologic functioning, e.g. nasal breathing,

sucking during infancy. Pathologic Habits Those that are pursued due to

pathologic reasons e.g. mouth breathing due to deviated nasal septum (DNS)/

enlarge adenoids.

2.5.2 Classification based on the origin of the habit Habits classified based on the origin of the habit into : Retained Habits

which Those that are carried over from childhood into adulthood. Cultivated

Habits which Those that are cultivated during socioactive life of an individual.

2.5.3 Classification based on the patient awareness to the habit Habits classified based on the patient awareness to the habit into:

Unconscious Habits Which are sustained by unconscious behavior. Simple

attenuation of sensory feedback mechanism aid in cessation. Conscious Habits

which involve choice or need, making treatment more difficult and complex.

3. Etiological agents in the development of oral habits There are seven etiological agents involved in the development of oral

habits which include the following: (Gurkeerat Singh, 2007)

anatomical

mechanical interferences

pathological

emotional

imitation

random behavior

equilibrium theory

3.1 Anatomical agents in the development of oral habits

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For example, posture of the tongue. Infantile swallow occurs due to a

large tongue in a small oral cavity coupled with anterior open bite of gum pads .

Figure 1 :Infantile swallow; note the placement of the tongue at rest and its position just

before the act of swallowing. The tongue comes in between the gum pads to obtain the

vacuum required to suck

3.2 Mechanical interferences affecting the development of oral

habits Mechanical interferences lead to undesirable oral habits, e.g. in a child

with normal breathing and swallowing, if permanent incisors erupt ectopically ,

then to achieve a proper anterior seal/ vacuum when swallowing, the child must

thrust the tongue and resultant mouth breathing occurs due to loss of lip seal.

Again if the succedaneous teeth are missing, an abnormal habit can develop.

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Figure 2 : Ectopically erupting central incisor resulting in the tongue being placed at the sight

Figure 3 : Anterior tongue thrust habit due to the congenitally missing permanent maxillary

lateral incisors

3. 3 Pathological agents in the development of oral habits Certain conditions of oral and perioral structures can cause an

undesirable oral habit, e.g. tonsillitis, DNS, hypertrophy of inferior nasal

turbinates (can cause mouth breathing)

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Figure 4 : Nasal blockage as seen on an OPG

3.4 Emotional agents in the development of oral habits Upset children regress towards infancy, assume infantile postures, e.g.

digit sucking which gives the child a feeling of security.

3.5 Imitation affecting the development of oral habits Young children are extremely observant and sensitive to environment

and highly affected by parents and siblings. The child may imitate jaw

positions/speech disorders of parents.

3.6 Random behaviorBehavior appears purposeless if not completely accidental.

3.7 Equilibrium theory Weinstein et al in 1963 observed: “An object subjected to an unequal

force will get accelerated and thereby will move to a different position in space.

Hence, any object subjected to a set of forces remains in place if forces are

balanced”. In dentition, small imbalance of forces maintained for a long time (6

years) can upset the equilibrium. This depends upon the duration of the habit.

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4.Types of bad habits 4.1 Digit – sucking habit

4.1.1 Defintion of digit – sucking habit Gellin in 1978 Defines digit-sucking as placement of thumb or one

or more fingers in varying depths into the mouth. While Moyers defines it as

Repeated and forceful sucking of thumb with associated strong buccal and lip

contractions. Practically all children take up this habit, but eventually

discontinue it spontaneously with age and maturation, as growth unfolds.

Figure 5 : Digit-sucking habit

4.1.2 Types of digit sucking : Active: In this type, there is a heavy force by the muscles during the

sucking and if this habit continues for a long period, the position of

permanent teeth and the shape of mandible will be affected (Johnson and

Larson, 1993).

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Passive: In this type, the child puts his/her finger in mouth, but because

there is no force on teeth and mandible, so this habit is not associated

with skeletal changes (Gale and Ager, 1979).

4.1.3 Effect of digit - sucking Dentofacial changes associated with digit – sucking habit can affect :

Maxilla , mandible , inter-arch relationship , lip placement and function , tongue

placement and function , and other effects.

4.1.3.1 Effects of digit – sucking on Maxilla Digit – sucking habit can cause proclination of maxillary incisors

when a child places a thumb/finger between the teeth, it is usually positioned at

an angle so that it presses against the lingual palatal surface of the upper

incisors and the lingual surface of the lower incisors. This direct pressure causes

displacement of incisors. Digit – sucking can cause increased arch length ,

increased anterior placement of apical base of maxilla , increase in SNA angle ,

increased clinical crown length of maxillary incisors , increased counter

clockwise rotation of occlusal plane and decreased width of palate. Left/right

side of anterior maxillary arch is usually deformed with deformation related to

whether the right or left thumb is sucked.

4.1.3.2 Effects of digit – sucking on Mandible Digit - sucking habit can cause proclination of mandibular incisors

and increased mandibular inter-molar width with More distal position of point B

in which the Mandible is more distally placed relative to the maxilla. The Mandibular incisors experience a lingual and apical force.

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Figure 6 :The maxillary and mandibular arches in the vertical and horizontally placed digit

suckers

4.1.3.3 Effects of digit – sucking on Inter-arch Relationship Digit – sucking habit can cause decreased inter-incisal angle and

increased overjet and decreased overbite with posterior cross-bite ,If the thumb

is placed between the upper and lower teeth, tongue is lowered, which decreases

the pressure exerted by the tongue against the lingual aspect of upper posterior

teeth, at the same time, cheek pressure against these teeth is increased as

buccinators contracts during sucking. Cheek pressures are greatest at the corner

of the mouth, therefore, maxillary arch tends to become V-shaped with more

constriction across the canines than molars. Hence, the maxillary arch becomes

narrower than the mandibular arch.

4.1.3.4 Effects of digit – sucking on lip placement and function Digit – sucking habit can cause Lip incompetence ,Hypotonic upper

lip and Hyperactive lower lip since it must be elevated by contractions of

orbicularis oris and mentalis muscle to a position between malposed incisors

during swallowing.

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4.1.3.5 Effects of digit – sucking on tongue placement and

function Digit – sucking habit can cause tongue thrust , Lip to tongue rest

position and lower tongue position in which Tongue is displaced inferiorly

towards the floor of mouth and laterally between posterior teeth.

4.1.3.6 Other Effects of digit – sucking habit Digit – sucking habit can affects psychological health and cause risk of

malpositioning of the teeth and jaws with deformation of digits and speech

defects (lisping).

4.1.4 Diagnosis of digit - sucking The diagnosis of digit - sucking consists of the following diagnostic

procedures:

4.1.4.1 History of Digit Sucking Information on whether the child has had a history of digit sucking is

obtained from the parents. When there is a positive answer, one should inquire

about:

Frequency: Number of times/day habit is practiced.

Duration: Amount of time spent on habit.

Intensity: Amount of force applied to the teeth during sucking.

4.1.4.2 Extra-oral Examination of digit sucking Casual examination of the upper extremities can reveal considerable

information about the digit used for digit sucking habit.

Cleaner digit

Redness, wrinkling or chapped and blistered due to regular sucking.

Dishpan thumb—clean thumb with short nails.

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Fibrous/roughened wart like callus on superior aspect of the digit,

ulceration, corn formation.

Rarely finger deformity seen.

Short upper lip

Higher incidence of middle ear infections, blocked Eustachian tubes,

enlarged tonsils and mouth breathing.

4.1.4.3 Intraoral Examination of digit sucking Intraoraly , we should examine the oral cavity for correct size and

position of the tongue at rest, tongue action during swallowing. In case of

serve finger or thumb sucking habits, where the digit applied an anterior

superior vector to the upper dentition and palate, will have flared and proclined

maxillary anteriors with diastemas and retroclined mandibular anteriors.

Other intraoral symptoms will include a high probability of buccal

crossbite, particularly in those children who suck their digits with a

pronounced contriction of their buccal musculature and a tendency to narrow

palates. Also we should observe the symmetry of incisal position of upper

central and lateral incisors. Asymmetry indicates that the child sucks the right

or left thumb or finger by preference. Measure dimensions of over-et and open

bite if present.

4.1.5 Treatment of digit – sucking habit

Dental changes due to finger sucking do not need any treatment if the

habit stopped before the 5 years of age and as soon as giving up the habit, dental

changes will be corrected spontaneously (Warren and Bishara, 2001; Proffit and

Fields, 2000; Warren and Bishara , 2002). At the time of permanent anterior

teeth eruption and if the child is motivated to stop the sucking habit, it is time to

start the treatment as follows (Proffit and Fields, 2000): Direct interview with

child if he/she is mature enough to understand (Maguire, 2000; Proffit and

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Fields, 2000). Encouragement: This can give the child more pride and self

confidence (Maguire, 2000; Bishara, 2001).

Reward system (Maguire, 2000). Reminder therapy (Maguire,

2000; Proffit and Fields, 2000). Orthodontic appliance: The final stage in

treatment is the use of orthodontic appliance whether fixed or removable, which

can play the role of reminder and can reduce the willing of finger sucking. For

long-term habits or unwilling patient, the fixed intra oral appliance is the most

effective inhibitor. In the case of using fixed or removable appliance, we should

alarm the parents about potential problems in speaking or eating during the first

24 to 48 h, which are usual and self correcting. After active phase of treatment,

the appliance should remain in place for more 3 to 6 month to minimize the

relapse potential (Maguire, 2000).

4.2 Tongue thrusting habit Tongue thrusting is the most controversial of all oral habits.

Considerable attention has been paid at various times to the tongue and tongue

habits as possible factors in malocclusion .

4.2.1 Definition of tongue thrusting habit Proffit defined tongue thrusting habit as placement of the tongue tip

forward between incisors during swallowing , this anterior tongue position may

be termed as tongue thrust, deviate swallow, visual swallow or infantile

swallow. Tongue thrust is actually a ‘misnomer’ as it means that tongue is

forcefully thrusted forward whereas actually. The tongue is only placed

forward.

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Figure 7: Abnormal placement of the tongue/tongue thrust swallow

4.2.2 Classification of tongue thrust

4.2.2.1 Backlund Backlund in 1963 classified tongue thrust into : Anterior tongue thrust

which is forceful anterior thrust. And posterior tongue thrust which is

Lateral thrusting in case of missing teeth.

4.2.2.2 Pickett’s

Pickett’s in 1966 classified tongue thrust into : Adaptive tongue

thrust in which tongue adapts to an open bite caused by missing teeth/thumb

sucking. And transitory tongue thrust in which tongue is put forward only for

a short period. Forceful and rapid. Habitual tongue thrust which is due to

postural problem, a habit or presence of open bite.

4.2.2.3 Moyers

Moyers in 1970 classified tongue trust into : Simple tongue thrust in

which teeth are together. And Complex tongue thrust in which teeth are apart

and buccal occlusion is deranged. Also Retained Infantile swallow which means

persistence of infantile swallow even after permanent teeth appear.

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Figure 8: Anterior tongue thrust in an adult

Figure 9 :Lateral tongue thrust

Figure 10: Simple tongue thrust

Figure 11 : Complex tongue thrust

4.2.3 Effects of tongue thrust on dento – facial structures Tongue thrust can cause open – bite (anterior and posterior) and

proclination of upper anterior teeth with Protrusion of anterior segments of both

arches with spaces between incisors and canines. Narrow and constricted

maxillary arch—posterior cross-bite.

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4.2.4 Diagnosis of tongue thrust

4.2.4.1 History We should take history o rule out any upper respiratory tract

infections, digit sucking habit, neuromuscular problems, swallow pattern in

siblings and parents to check for the hereditary factor is done.

4.2.4.2 Examination We should examine tongue posture at rest using lateral cephlograms or

by seating patient upright, here tongue assumes a lower posture at rest with the

tip touching the cingulum/lingual fossae. Tongue activity during swallowing –

Whether tongue thrust is simple/complex, anterior or lateral.

4.2.5 Management of tongue thrust Different methods have been attempted to correct the tongue thrust

habit with variable success. The American Academy of Pediatric Dentistry

states that the management of the tongue thrust may include “myofunctional

therapy, simple habit control,

habit-breaking appliances, orthodontics and possible surgery” (American

Academy of Pediatric Dentistry Council on Clinical Affairs, 2005). Training of

correct swallow and posture of the tongue.

These exercises help in toning up respective muscles thereby

eliminating tongue thrust.

• Myofunctional exercises: The patient can be guided regarding the correct

posture of the tongue during swallowing by various exercises. The child is

asked to place the tip of the tongue in the rugae areas for 5 min and is asked to

swallow

• Orthodontic elastics and sugarless fruit drop exercises

• 4S exercises: Spot, salivating, squeezing the spot and swallowing

• 2S exercise: It includes identifying - spot and squeeze

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4.3 Mouth breathing habit

4.3.1 Definition of mouth breathing CHOPRA in 1951 Defined mouth breathing as habitual respiration

through the mouth instead of the nose. CHACKER in 1961 Defined mouth

breathing as a prolonged or continued exposure of the tissues of anterior areas

of mouth to the drying effects of inspired air. While Sassouni in 1971 Defined

it as, habitual respiration through the mouth instead of the nose. While Merle

in 1980 Used the term oro-nasal breathing instead of mouth breathing.

4.3.2 Classification of mouth breathingSIM and FINN classified mouth breathing into: Obstructive mouth breathing,

habitual mouth breathing and anatomical mouth breathing

4.3.2.1Obstructive mouth breathing Children with an increased resistance to or a complete obstruction of

the normal flow of air through the nasal passages. Seen in ectomorphous

individuals with long narrow faces and nasopharyngeal passages

4.3.2.2Habitual mouth breathing Child who continually breathes through the mouth by force of habit,

although the obstruction has been removed.

4.3.2.3Anatomical mouth breathingChild with short upper lip does not permit closure without undue effort.

4.3.3 Effects of mouth breathing

4.3.3.1 Effects of mouth breathing on face Mouth breathing can cause lips slack and stay open and short upper lip

with moulding action of upper lip on incisors is lost thereby resulting in

proclination and spacing. While Lower lip become heavy and everted.

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4.3.3.2Effects of mouth breathing on occlusion of teeth Mouth breathing can cause proclination of anteriors and distal relation of

mandible to maxilla while lower anteriors elongate and touch the palatal tissues.

Upon gingival tissues Constant wetting and drying of the gingiva causes

irritation, saliva about the exposed gingiva tends to accumulate debris resulting

in an increase in bacterial population.

Figure 12 : Effect of mouth breathing on gums and occlusion

4.3.4 Diagnosis of mouth breathing There is no single test for mouth breathing. A doctor might diagnose

mouth breathing during a physical examination when looking at the nostrils or

during a visit to find out what’s causing persistent nasal congestion. They may

ask questions about sleep, snoring, sinus problems, and difficulty breathing.

A dentist may diagnose mouth breathing during a routine dental

examination if you have bad breath, frequent cavities, or gum disease. If a

dentist or doctor notices swollen tonsils, nasal polyps, and other conditions, they

may refer you to a specialist, like an ear, nose, and throat (ENT) doctor for

further evaluation.

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4.3.5 Management of mouth breathing habit Management of mouth breathing should include the following :ENT

referral For management of nasopharyngeal obstruction . Prevention and

interception: It usually ceases at puberty or after it due to increase in size of

passage during period of rapid growth. Mouth breathing can be intercepted by

use of an oral screen.

We should do Myofunctional therapy by holding pencil between the

lips during day time , and tape the lips together with surgical tape in habitual

mouth breathing during night time . Patients with short hypotonic upper lip

should stretch the upper lip to maintain lip seal or stretch in downward direction

towards the chin.

We should do button pull exercise by which a button of 1½” diameter

is taken and a thread is passed through the button hold. The patient is asked to

place the button behind the lip and pull the thread, while restricting it from

being pulled out by using lip pressure.

We can instruct the patient to blow under the upper lip and hold under

tension to a slow count of 4 repeat 25 times a day , also draw upper lip over the

upper incisors and hold under tension for a count of 10.

4.4 Bruxism

4.4.1 Definition of bruxism Rubina in 1986 defines Bruxism as the term used to indicate the non

functional contact of the teeth which may include clenching, grinding and

tapping of the teeth. While Ramjford in 1961 defines Bruxism as nocturnal,

subconscious activity but can occur during the day or night and may be

performed consciously or subconsciously. It is a conscious activity when

parafunctional activities are included in it.

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4.4.2 Etiology of bruxismNadler in 1957 gave the following causes of Bruxism.

• Local factors

• Systemic factors

• Psychological factors

• Occupational factors.

4.4.3 Signs and symptoms of bruxism

4.4.3.1 Signs and symptoms of bruxism On Teeth Bruxism can cause tooth mobility Seen due to occlusal trauma of

bruxism. Spread of gingivitis to deeper structure and alveolar bone loss with

dull percussion sounds and soreness to biting stress . Also non functional

pattern of occlusal wear and increased sensitivity from excessive abrasion of

enamel with atypical facets—Shiny, uneven, occlusal wear with sharp edges,

abrasion on incisal edges of upper and lower incisors.

Other features of bruxism include Pulp exposure and abscess and

fractures of crown/restorations and root fractures.

Tooth wear from bruxism can be found in both primary and permanent

dentitions. During grinding some forces are directed laterally, thus loading the

tooth horizontally rather than axially.

4.4.3.2 Signs and symptoms of bruxism on Musculature Bruxism can cause muscular facial pain and muscle tiredness or

tightness and fatigue on rising in morning and tenderness of jaw muscles to

palpation with compensatory hypertrophy of muscles and muscular

incoordination. Also locking of jaws with difficulty in opening mouth for a long

time.

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4.4.3.3 Signs and symptoms of bruxism on Tempro-mandibular

joint Bruxism can cause pain, osteoarthritis, crepitus/clicking, restricted jaw

movements, jaw deviations. The disc may become worn or perforated and wear

patterns are often correlated with condylar remodeling.

4.4.4 Diagnosis of Nocturnal Bruxism History and clinical examination is usually sufficient to diagnose

bruxism. Ask the patient to move the mandible in lateral and/ or protrusive

positions until wear facets on mandibular and maxillary arches correspond.

Then ask the patient to purposely clench/grind the maxillary teeth until

symptoms, similar to patients complaints are noted. Nocturnal bruxism is more

influenced by emotional stress level and sleep patterns rather than tooth

contacts. Thus, it responds poorly to patient education, relaxation and

biofeedback techniques, and occlusal alterations. It can be effectively reduced

with occlusal appliance therapy, e.g. muscle relaxation appliance.

The muscle relaxation appliance is used to treat muscle hyperactivity

and conditions associated with it like bruxism. It is fabricated for the maxillary

arch and provides an occlusal relationship considered optimal for the patient

when it is in place .

4.4.5 Management of bruxism To manage bruxism we should determine the underlying cause and

eliminate it. Then do psychotherapy which includes counselling, hypnosis,

conditioning, relaxation exercises, and biofeedback (patient is made aware of

tension level in their jaw muscles and are trained to relax these muscles).

Drugs like vapocoolants (ethyl chloride) for pain in the TMJ area, local

anaesthetic injections into TMJ for muscles, tranquilizers and sedatives, muscle

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relaxants are used. Do Occlusal adjustments to bring the jaws to normal relaxed

state of physiologic movements. Bite planes also help. Bite planes/occlusal

splints/ bite guards An occlusal guard is usually made of acrylic resin and is

designed to cover the occlusal surface and/ or incisal edges of teeth.

We should restore the lost vertical dimension—cast crowns/stainless

steel crowns with electro galvanic stimulation for muscle relaxation.

Ultrasound Provides analgesic effect for masticatory pain. TENS

Transcutaneous electrical nerve stimulation: Local analgesic for pain related to

temporomandibular joint. Transcutaneous electrical stimulation of skin over

major sensory nerves is sometimes undertaken.

5. Myobrace for bad habits The Myobrace System is suitable for a wide variety of orthodontic

concerns, with a range of solutions available for most patients. It is designed to

work most effectively for patients from five to fifteen years of age, and is most

effective in early childhood while the child is still developing. The optimal

patient age group is six to ten years of age.

5.1 Myobrace for Kids 3 out of every 4 children have crowded teeth and incorrectly

developing jaws. These problems are evident from as early as 4 years of age.

The optimal treatment age using the Myobrace System is from six to

ten years of age, when the child is still developing.  Treatment works best when

combined with arch development and Myolay if necessary.

Modern research has shown that mouth breathing, tongue thrusting,

reverse swallowing and thumb sucking are the real causes of incorrect jaw

development, crowded teeth and other orthodontic problems.

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Quite often Dentists or Orthodontists do not recommend any treatment

before the age of 13; rather advising patients and parents to wait until all

permanent teeth are present, and to then treat with braces and extractions. But

braces and extractions do not address the real causes of crooked teeth and quite

often once they are removed, the teeth crowd up again.

Myobrace for Kids targets the underlying causes of crooked teeth as

soon as the problems are evident, while the child's biological adaptability is at

their peak. Improving these poor myofunctional habits at an early age allows for

the child to have good dental alignment and improved jaw growth.

Figure 13 : myobrace for kids

5.2 Myobrace for Teens Once the permanent teeth are present in the teenage years, the

Myobrace System becomes less effective than if treatment was started during

childhood. Treatment with the Myobrace System can still work at this age when

combined with arch expansion. The longer you've had poor myofunctional

habits, the more difficult they are to correct. Old habits die hard, and so the

sooner treatment is started the better the results may be. Additional alignment

with braces may be required.

The Myobrace for Teens is a no-braces alternative to straightening

teeth. Treatment involves using a series of removable orthodontic appliances

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combined with daily exercises to train the oral muscles and produce straighter

teeth and a healthier smile.

Myobrace treatment is simple. It does not involve wearing braces or

using complex and uncomfortable dental appliances 24 hours a day, seven days

a week. Wearing a Myobrace appliance for one to two hours each day and while

sleeping, combined with a few simple yet effective exercises each day is all it

takes for a real change to occur.

Figure 14 : myobrace for teens

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