Protocol for Fabrication and Utilization of a Novel Chairside Technique for Interception of Tongue Thrusting Habit

Abstract

The importance of early interception of the tongue-thrusting habit need not be overemphasized. Among several habit-breaking appliances, few chairside methods are available among the gamut of habit-breaking appliances available. So, a novel chairside appliance technique was employed with the use of routinely used armamentarium like Begg's bracket, lock pin, and flowable composite. This paper describes the technique and its application alongside rapid maxillary expansion (RME) appliance in a 10-year-old female patient. The chairside technique was found to be simple and acceptable to the patient. This clinical technique was employed for the fabrication of a modified habit-breaking appliance for interception of tongue thrusting habit in a 10-year-old female patient with skeletal class III maxillomandibular relationship undergoing alternate rapid maxillary expansion and constriction (ALTRAMEC) and facemask therapy for correction of skeletal class III malocclusion. Incorporation of spikes in the bonded RME framework would have significantly affected the patient's compliance. This novel design strategically helped to reduce the wire framework and provide an easy chairside procedure using simple orthodontic armamentarium for habit interception, especially in patients who are already subjected to RME appliance or who refrain from such evidently visible habit-breaking appliance.

How to cite this article

Wali DV, Sawant H, Jawdekar A, et al. Protocol for Fabrication and Utilization of a Novel Chairside Technique for Interception of Tongue Thrusting Habit. Int J Clin Pediatr Dent 2026;19(2):250–254.

Introduction

Habits like tongue thrusting lead to the development of various malocclusions.¹ The orthodontic literature is enriched with numerous appliances for interception of such habits.² However, the efficacy of this appliance hinges on the patient's compliance.³ Traditional appliances like tongue crib are at times discomforting to the patient and are associated with speech-related problems and development of frequent ulcerations.⁴ Also, the display of such prominent vertical spikes poses stigma to some patients, who thereby defer from continued wear of the appliance.⁵

Fabrication

• Begg's brackets were used in the construction of this appliance for interception of tongue thrusting habit (Fig. 1).

• The lock pins were inserted into the vertical slots extraorally (Fig. 2).

• The lock pins were bent toward the lingual side with a bird beak plier (Fig. 3).

• The lock pins inserted into the vertical slot were tied with ligature ties (Fig. 4).

• The tip of the lock pins was covered with flowable composite to prevent lacerations to the tip of the tongue (Fig. 5).

• The lingual surface of lower incisors was etched with 37% phosphoric acid, followed by priming with 3M UNITEK bonding agent and placement of Begg's bracket on the lingual surface of lower anteriors just above the cingulum of lower incisors using bracket positioning tweezers (Fig. 6).

Figs 1A and B:

Begg's brackets and lock pin

Fig. 2:

Insertion of lock pins into the vertical slots of Begg's brackets

Figs 3A and B:

Bending of lock pins toward the lingual side using a bird beak plier

Figs 4A and B:

Ligature ties used to secure the lock pins into the vertical slot of Begg's brackets

Fig. 5:

Tip of the lock pins covered with flowable composite

Figs 6A and B:

Placement of Begg's bracket on lingual surface of lower anteriors

Advantages

• The strategic position just above the cingulum of lower anteriors has helped to minimize the visibility of the habit-breaking appliance.

• Wire bending and fabrication of spikes have been eliminated as it is a completely chairside modification of routinely used orthodontic armamentarium.

• The placement of an additional ligature tie securing the lock pins in the vertical bracket slot will help to prevent movement of the lock pins in the slot while eating slimy and sticky foodstuffs and will also prevent movement of the lock pins when subjected to rotatory or vibratory motions during tooth brushing.

• The entire modification of the Begg's bracket was performed chairside, and only bonding was carried out intraorally to reduce operatory chairside time.

Clinical Application

Presented below is a case in which this novel technique for fabrication of a tongue thrusting appliance was employed. The aforementioned case presents didactic issues encompassing a myriad of skeletal class III malocclusion with anterior open bite due to persistent tongue thrusting habit. Incorporation of a traditional tongue crib along with bonded rapid maxillary expansion (RME) would have highly affected the patient's compliance and would have also accentuated the complexity of the design of the appliance. Taking cognizance of the fact that the patient had to use a key for alternate constriction and expansion as per the protocol of alternate rapid maxillary expansion and constriction (ALTRAMEC), it was prudent to fabricate a design that would less interfere during activation to prevent any accidental ingestion of the key or untoward breakage of the appliance. Hence, a modification of routinely used orthodontic armamentarium was done to retrain the tongue to its normal position along with some tongue training exercises. Previous literature has extensively described the etiology, clinical features, and management of tongue-thrusting habits, emphasizing their association with orofacial muscle imbalance, abnormal swallowing patterns, and the role of both myofunctional therapy and habit-breaking appliances in treatment.^6–9 Similar such design has been enlisted in the literature but had several disadvantages because of tongue lacerations and frequent ulcerations and has been selectively modified by incorporating new elements in the design.¹⁰

Discussion

This novel technique for interception of tongue thrusting habit is of use to best cater to the needs of the operator's valuable chairside time and patient's compliance. Habit-breaking protocol for tongue thrusting habit comprises a wide array of methods encompassing noninvasive approaches like tongue training exercises to the use of a fixed tongue crib. The level of tongue position is important in assessing tongue function and deciding an appropriate habit-breaking appliance for the same. High tongue position can be better treated with a fixed tongue crib on the palatal side. Composite spikes are also routinely available for interception of the habit. However, they are subjected to dietary restrictions for their continued usage for interception of tongue thrusting habit.

This proposed novel technique was used in the aforementioned case report, which presented a myriad of etiologies contributing to the complexity of malocclusion, including tongue thrusting habit, vertical growth pattern, associated mouth breathing habit, constricted maxillary arch, and skeletal class III jaw relationship. Thorough planning and meticulous execution of each aspect of treatment planning will help to reduce the risk of relapse. This case encompassed functional problems accentuating the severity of skeletal and dental malocclusion. The discrepancies, interestingly, were in all three planes: anteroposterior, transverse, and vertical plane, but the root cause analysis lies in its functional part. Failure to address any of these could lead to inefficacy in achieving the final results.

The management of anterior open bite often involves a multifaceted approach that combines habit-breaking appliances and functional therapy. A palatal crib, in conjunction with the overnight use of an oral screen, can effectively aid in anterior open bite closure by discouraging tongue thrust and promoting proper tongue posture.¹¹ The importance of correcting the swallowing pattern cannot be overstated, as improper swallowing habits often exacerbate open bite issues.¹ Incorporating targeted swallowing exercises and tongue posture correction helps retrain the oral musculature for optimal function.¹² Habit-breaking appliance programs, combined with tongue placement exercises and the use of tongue spots, further assist in addressing maladaptive oral behaviors.¹³ However, care must be taken during reprogramming, as improper techniques or incomplete correction can lead to lateral tongue thrust, potentially causing secondary issues such as posterior crossbite.¹⁴ Therefore, a holistic and carefully monitored approach is essential to achieve stable and functional results in managing anterior open bite.

Successful implementation of the ALTRAMEC protocol and protraction with facemask (Figs 7 and 8), with judicious use of a modified tongue crib, has helped reduce accentuation of skeletal class III malocclusion.¹⁵ Failure of early intervention of developing class III malocclusion results in untoward growth of the mandible, as the mandibular arch is no longer withheld in the constraints of the maxillary arch.¹⁶ Developing class III malocclusion, if not intervened early, necessitates Le Fort advancement or bilateral sagittal split osteotomy (BSSO) during the adult phase. Thorough planning and meticulous execution of interceptive orthodontics can help prevent invasive surgical procedures, which require hospitalization, monitored care, and risk factors pertaining to orthognathic surgery.¹⁷ Mandibular setback with BSSO is commonly associated with increased relapse, as the pharyngeal airway has an inherent tendency to be a bit compromised after mandibular setback.¹⁸ Such complex cases present a myriad of issues, which affect the patient's confidence and perception of esthetics among peers. Taking cognizance of the invasiveness of postpubertal surgical procedures and cost-effectiveness, it becomes prudent to identify developing class III malocclusions, which can also be considered an orthodontic emergency.¹⁹

Figs 7A and B:

Correction of skeletal class III malocclusion with ALTRAMEC and protraction of maxilla with facemask

Figs 8A and B:

Comparative evaluation of pre- and posttreatment extra oral profile photographs

Growth factor is also one of the factors that affects treatment mechanics. Hyperdivergent growth pattern with tongue thrusting habit accentuates open bite.¹ Careful chairside and radiographic evaluation should be implemented to assess growth pattern affecting the prognosis of any malocclusion.²⁰

Lip morphology is yet another factor that needs to be appropriately addressed for optimum relation. Short and flaccid upper lip, lips with gull-wing lip morphology, and hypotonicity of lips with failure to achieve lip seal need to be addressed. Such lip morphology is commonly associated with the development of mouth-breathing habit. Anterior tongue thrust is found to be commonly associated with mouth-breathing habit to create anterior seal instead of lip closure.²¹ Taking cognizance of the aforementioned fact, it becomes prudent to augment the use of oral screen during night in conjunction with habit-breaking appliance for tongue thrusting to ensure adequate functionality and minimize risk of relapse.

The current case report does not address the entire treatment for correction, as the patient did not report after a few months of active interception due to migration issues.

Future Scope

Use of ball pen refills has been used as an alternative for shims used for activation of FORSUS fatigue-resistant device.²² Ball pen stopper instead of flowable composite could be used as it provides a snug fit to the L-pin. However, this is subject to ethical clearance. Hence appropriate consents need to be procured from various authorizing bodies prior to implementation of these. This would further help to reduce chairside time. Hence similarly such modification could also be used, as flowable composite may chip off to some extent when subjected to the brunt of masticatory forces.

Orcid

Diksha V Wali https://orcid.org/0009-0007-8125-0069

Hitesh Sawant https://orcid.org/0000-0002-3907-5427

Ashwin Jawdekar https://orcid.org/0000-0002-9948-9007

Parag V Gangurde https://orcid.org/0000-0002-8521-8687