A critical appraisal of tongue-thrusting

W. J. Tulley,
London, England

Ph.D.,

F.D.S., D. Orth.,

R.C.S.

any of the present-day views on tongue-thrusting are reflected in the early writings of very able clinicians, and their work has to some extent been ignored. Like many other present-day views on orthodontics, they have gone through a full cycle, and in the conclusion to this article it will be sepn t,hat there has been an overconcentration on the effect of the soft tissues on malocclusion. One of the earliest writings is that of Lcf~ulon,~ published in 1839, in which it is obvious that he appreciated t,hat among the causes of irregularities of teeth wcrc sounds of speech in which the tongue strikes against the upper anterior teeth, pushing them forward. An article by Desirabode, published in 1843, is the first traceable refercncc to the fact that the lips on the outside and the tongue on the inside of the mouth constitute a balance of forces that may retain the teeth in their position. In 1859, Bridgeman introduced the lateral pressure theory and described irregularities of the teeth due to visincreme~ati (external muscle forces, as that of the lips and cheeks), visestensionis (internal muscle forces, as that of the tongue), and wisoccZusioS (occlusal forces). Kingsley,4 in 1879, made a considerable study of speech sounds but did not relate movements of the soft tissues to dental arch form. At the turn of the century, Angle5 recognized the problems of the muscular environment of the dental arches but would not accept the fact that in certain cases t,hey might form an insurmountable difficulty in treatment. In the appendix to the seventh edition of Malocclusion of the Teeth, Angle states : We are just beginning to realize how common and varied are the vicious habits of the lips and tongue, how powerful and persistent they are to overcome. Norman Bennett6 showed a clear understanding of the problem when, in 1914, he wrote: The muscles of mastication produce conditions of vertical and lateral stress, the USC of the tongue in mastication and speech reacts upon the teeth internally, and the lips and cheeks in their every movement, even of
640

Tongue-thrusting

641

transient emotion, bring pressure to bear externally. Many of these forces are too slight and of insufficient duration to produce any definite movement of the teeth, but others are constantly acting; with the mouth shut and the teeth closed the buccal cavity is obliterated, and the teeth are compressed between the tongue and the lips and cheeks. Very little experience in the movement of teeth by mechanical means is enough to show that even quite a small force acting continuously will produce a considerable movement, and it becomes clear that the teeth in their arches are but passive objects kept in a state of equilibrium under the influence of the muscles that react on them directly and indirectly. Bennett discussed Sim Wallaces theory that tongue size is dependent on tongue function and that this is a dominant factor in determining the size of the dental arches, but he rather dismissed the tongue as an all-important factor in arch development. Brash,? in his Dental Board lectures, did not place emphasis on the effect of the soft tissues of the tongue and lips on the dental arches, but he went so far as to state: The growth of the tongue and the mandible are no doubt correlated, but it is improbable that the tongue exercises any important mechanical influence on the general form and size of the mandible or in moulding the form of the growing palate. Friel,* having studied muscle activity, was convinced that it was static function, and not dynamic function, which molded the dental arches in their position of linguofacial balance and this, as we shall see, has been reaffirmed. Van Thai was concerned with speech in relation to malocclusion. She deduced that malocclusion was not the cause of various types of speech defect. Froeschels10 found that lisping and open-bite originated from the same abnorexmality of tongue control. Rogcrs11 was a strong exponent of myofunctional ercises calc&ted to harness muscle forces in order to treat malocclusions. This scheme had a following, but it was based on the concept of function dictating form and was not widely accepted. A simple definition of tongue-thrust might be stated as follows: The forward movement of the tongue tip between the teeth to meet the lower lip in drglutition and in sounds of speech so that the tongue becomes interdental. This does not include consideration of forward tongue posture, which is much more important. The papers which initiated intensive research on problems of tongue behavior in the past two decades were those of Rixl and Ballard and GwynneEvans.14 Similar observations were made on tongue behavior and speech. Rixl! I3 drew attention to tongue activity which seemed to retain infantile characteristics, wit,h the tongue showing great affinity for lower lip contact. He based his thesis on the belief that this represented a delay in maturation of behavior. Ballard and Gwynne-Evans I4 looked at the subject from the genetic point of view, stressing the familial patterns of behavior. Brodie regarded the whole facial pattern from the general morphologic point of view and was less interested in the tongue and its behavior as a single factor. I was privileged to work with Rix, Ballard, and Gwynne-Evans in 1948

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Am.

J. Orthodontics June 19F9

when their concepts were first put forward, The late James Whillis, Professor of Anatomy at Guys Hospital, became intensely interested in this subject and realized that there was a lack of informat,ion conccming hot,11 normal and abnormal tongue behavior. A rcscarch unit was set up in t,he Medical School at Guys Hospital to study the normal ant1 abnormal behavior of the orofacial musculature. The long-term resubs of this study will be reported Iatcr in this article. This study modified the earlier views expressed by Rix, Ballard, and Gwynne-Evans. The general conclusions arc that, although some of the abnormal patterns of activity of the tongue might be described as being similar to the infantile behavior, t lure is 110 cvidcnce to show that these activities are due to dclaJ- in maturation. There is no stat,istical evidence to prove that bottle-focding is responsible for encouraging il dclav in maturation of orofacial bc~havior. It was also shown that, cxcrciscs could not 1~ used to bring about basic changes in behavior on a perIllil.ll~Ilt basis. In the early 1950s many of the csponents of multibanded techniqurs with cscellcnt, control of tooth movement recognized that thcrc wcrc: a few cases in which the behavior of the tongue and lips formed a pattern of activity t,hat, canscd relapse. Other authorities, such as Straub,lG gave the impression that tongue problems were very extensive and that re-cdnca,tion of orofacial brharior by trained speech therapists was necessary for many orthodontic procedurcs. S~KXY~~ therapists and speech pathologists became increasingly in volvctl. 111~confusion of thinking on the subject prompted a poem by Professor Bloomer entitled The Inverted, Pcrvcrtcd, Reverted Swallow. In the same paper Bloomcr17 sums up the general view when he states: Some orthodonists and speech therapists are happy in their common endeavors in training patients to swallow. Others from both professions look on with a measure of disapproval. The concern represents not an antithesis to cooperation but an uneasiness about prescribing cookbook treatment programs for problems in which the dynamics of cause and effect are not yet understood. A few of t,hc ways in which these problems have been examined arc as follows : Electronlyography. Moyersls investigated functional movements of the orofacia.1 musculature using the electromyograph. Since then, Tulley,l Marx,?O ant1 many others have contributed. Although the labial musculature can be studied in this way, and an important contribut,ion has been rnade to our nnderstanding of lip posture, it is quite impossible to study the tongue musculature by electromyography. Ueasurenze,I.t of intraoral pressuws. Wit,11 the introduction of small transducers, intraoral pressures can be measured more accurately than with other methods previously described. Winder+ was probably the first in this field, and he has been followed by many othrr investigators who have confirmed that the tongue is probably more important than the surrounding musculature in its effect. I,eaF and Iluffinghamz3 showed that the speed and intensity of the rapid movements of the tongue in speech and swallowing were probably not so

Tongue-thrusting

643

significant as the resting posture, which will be seen to confirm many clinical observations. Cinefhoroscopy. Ardran and Kemp,Z4 Cleall,Z Tulley,G and others have shown that this technique has limitations in terms of speed and is only two dimensional. It does not lend itself to serial studies because, although the dosage is small using image intensifiers, it is difficult to pcrsuadc patients that it is clinically necessary. Cephalometric head films. Peats7 and others have shown the possible differences between the relaxed and habitual postures of the tongue and this, iu turn, has made some contribution to our knowledge. However, this technique is subject to variation. Newophysiologic experiments. BosmaZ8 and his co-workers, Grossman,? Berry, and liawcus,l have carried out various neurologic tests on the behavior of the tongue. So far, the use of stereognostic test,s has indicated very considcrable individual differences in lingual scnsorimotor factors, and I am sure that this work will continue. Serid cinephotog,ruphy. This is difficult to a,nalyzc scientifically, but, it tloes highlight the individual variations. Although cint~photography cannot display the intraoral movements of the tongue, work by Vhillis32 and ot,hcr film studies carried out by the Veterans Organization have shown tongue movements through surgical defects in the fact. This longitudinal approach has proved to be of great value, as will be seen later. It is now much more certain that facial form will dictate function rather than that function dictates form, as was formerly believed. In an effort to clarify some of the confusion over itongL~e-tlllllst. The author has undertaken two experiments : (1) an epidemiologic investigation of the incidence of abnormal tongue function and posture and (2) a longitudinal study using tine films of patients, with or without orthodontic treatment, some of them extending OCR 3 period of 20 years
Epidemiologic investigations

In this investigation 1,500 Il-year-old school children, a random sample selected from all social groups in southeast and east London, were examined. Those who had circumoral contraction in swallowing with forward movements of the tongue and those in whom there was also a forward movement of the tongue in production of t,he ls sounds in speech, were set aside for further invcstigation. The tongue had to be sufficiently forward to have the tip placed either interdentally or under the upper incisal edge. As by far the most common reference on tongue-thrusting is associated with Class II, Division 1 malocclusion, 329 of the children (22 per cent of the total sample) were shown to have some degree of this malocclusion, but only 141 (less than one half) were assessed as requiring orthodontic treatment. Only 43 of the 329 children showed evidence of adverse tongue and lip behavior which might jeopardize permanent correction of the incisor relationship. Examining the total sample for the more pronounced type of tongue-thrust, only 40 of the total sample (2.7 per cent) had the type of tongue behavior

Fig.

1.

Examples

of tongue-thrust

with

good

occlusion

shown in Fig. 1, and only half of this group hat1 any degree of malocclusion deserving of treatment. ln fact, 12 of the children with tongue-thrust, and lisping speech had excellent occlusions (1qg. 1) These figures put tongue-thrusting I in its true perspoct,ive.
longitudinal tine studies

By examining some 50 patients over a period of nearly 20 years, I have been able to confirm my previous findings and those of Ballard on the nature of tongue-thrust. It is possible t,o break down tongue-thrusting into main categories, but thcrc is also some overlap and it is difficult to produce a good classification. Investigations over the past 20 years have enabled us to rnake the following classification, which is not claimed to bc ideal but represents an attcrnpt to he helpful to the clinician: Tongue-thrush~g US CLhabit. The fact that this will not be seen very commonly past the age of 11 years is a reason for delaying treatment where the facial pattern is good and there is merely a slight open-bite and increased ovcrjet with a Class I or Class II relationship (Fig. 2). These patients with a persistent tongue-thrust habit will be treated quickly when the labial segment is put into its correct position. It is quite unnecessary for these children to be sent for any form of x-educational therapy. Placement of the teeth in

Tongue-thrusti?lg

645

Fig. tion and

2. A, Example of facial maturation. A habit tongue-thrust was present with thumb-sucking up to 7 years of age. The incisor relationship developed the open-bite closed. No active treatment. B, Models from 4 to 19 years.

in

associanormally

correct position and the very presence of the appliance will be sufficient. Although the psychologic aspects of this subject have been ignored, it is interesting to note that I have seen cases in which the lisping speech has returned for a short time when the child is under stress. Tongue-thrusting which is possibly endogenous or in&e. In the epidemiologic investigation previously described, a familial pattern was evident in 30 per cent of the small group of children who had tongue-thrusting behavior (Fig. 3). This needs further investigation, and it may be that there is an obscure central variation. This kind of tongue-thrusting is particularly marked in the sibilant sounds of speech and may often be seen in siblings and in one

646

Tulley

Am.

J. Orthodolttics June 1969

of the parents. It can occur when there is a perfectly normal occlusion if there is a good facial skeletal pattern, and then it is of little significance to the orthodont,ist. If it occurs where there is an adverse facial pattern, it may be a dorninant feature and may place severe limitations on the improvement of the incisor relationship (Fig. 4). In contrast to the simple tongue-thrusting habit, it will not respond to any kind of therapy. Tongue-thrust us UTL crduptive behnzGr. The majority of problems which are of concern to the orthodontist fall into this category. In the British Isles and part,s of the United States many patients arc unable to effect an anterior oral seal with the lips at rest. This does not mean that there is any mouth breathing. The resting posture of the tongue is more important than its functional movements. The type of deglutit,ion in which thcrc is a tongue-thrust and excessi\-c circumoral contraction is due to the fact that there has to be excessive contra+ tion of the labial musculature in cases where the lips arc incompetent ant1 the tongue comes forward to complete the anterior oral seal. This tongue-thrust swa.110~ can change ynitc dramatically if orthodontic t~reatment can ~)lacc the lillji>ll scgmcnts in goo~l relationship so that the lower lip can COlll( to seal On t11c labiai SllI+iIW ;,f the upper i&+isor t Wtll. Ptlilny palients wit,11 ClaSS II,

Fig. terarch

3.

Familial tongue

(endogenous) position. A, With

tongue Class

behavior II dental

in base.

two

members B, With Class

of III

family. dental

Note base.

in-

Tongue-thrusting

647

Division 1 malocclusion may exhibit tongue-thrust prior to treatment, but this is not likely to be a primary problem after treatment. An adaptive tongue behavior, in which the tongue is not only forward in functional movement but postured forward over the lower incisors at rest to seal with the lower lip, is a very important problem. This posture is associated with an adverse skeletal pattern in which there is a high Frankfort-ma.ndibulal plane angle. In the epidemiologic survey, the type of facial pattern found in only 0.6 per cent of the child population has always been recognized by orthodontists ils plesenting a difficult problem (Fig. 6). It is the one in which tongue-thrust, ;Intl more tspccially tongue posture taken into conjunction with t,hc adrc~e skclctal form, will produce an anterior open-bite which is very resistant to I rc~atmcnt. This may be associated with a Class I, II, or III malocclusion. Pathologic n?zd ~/rossl~~aO?lornlnl tompc 1>roble,lzs. Just as the common malocdclusions arc not due to pathologic abnormalities, the common variations in tongue function should not be look4 upon as bein g dnc to pathologic entities, and it is very unlikely that any degree of dysdiadochokincsia has any relc~ancc to the cliscussion. There is no doubt that tongue size plays some part, but :I 1riic macroglossia is ext,rcmely rilre.

Fig. 4. A, then 3 was

Tongue position in s sound before orthodontic no interarch spacing during s sound. Three

treatment. months active

B, One treatment

year

later 01dy.

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Tulley

Am. J. Orthodontics June 1969

Fig.
poor

5.

typical pattern.

example

of

anterior

open-bite

and

forward

posture

of

tongue

with

facial

Fig.
with closed

6. a

An Class

additional III dental is poor.

example base

of

a typical

facial Prognosis

type for

with

forward

tongue the

posture open-bite

and in a

relationship.

maintaining

condition

longue-thrusting
Summary and conclusions

649

An attempt has been made here to place the problem of tongue behavior in its true perspective by indicating that only a very small percentage of orthodontic problems are ultimately complicated by it. In a limited number of cases with poor facial pattern associated with forward tongue posture at rest, an anterior open-bite may not be permanently reduced, whatever the method of treatment. This clinical type is very unfavorable for treatment but 08ccurs in only about 0.6 per cent of the population. Early treatment is undesirable, as the whole problem may look much worse during the early mixed-dentition phase. A classification of tongue-thrusting has been attempted. It is better to place the emphasis on the morphology of the skeletal and soft-tissue structures which demand abnormal posture and activity, rather than on the more transient and rapid movements of the tongue in speech and deglutition.
REFERENCES

1. Lefoulon, P. J.: Orthopedic dentaire, Gaz. d. HBp., p. 111, 1839. 2. Desirabodc, M.: Complete elements of the science and art of the dentist, 1843, American Liljrary of Dental Science. 3. Bridgeman, M.: Lateral pressure, Tr. Odont. Sot. London, p. 160, 1859. 4. Kingsley, N. TV. : Oral deformities, New York, 1879, D. Appleton & Co. 5. Angle, E. H.: Malowlusion of the t&h, ed. 7, Philadelphia, 1907, S. S. White Dental Mfg. Co. 6. Bennett, Sir N.: Science and practice of dental surgery, London, 1914, Oxford University Press, vol. 1. of irregulariks and malocclusion of the teeth, London, 1929, 7. Brash, J. C.: The aetiology Dental Board of the United Kingdom. 8. hriel, E. S.: An investigation into the relation of function and form (malocclusion), Krit. I). J. 47: 353, 1926. 9. Van Thai, J. H.: Tongue thrusting in relat,ion to sigmatism, J. College Speech Therapist
18: 1, 1935.

10. Frocschels, E.: Sigmatismen und Zahnstellung, Ztschr. Stomatol. 35: 232, 1937. 1 1. Rogers, A. P.: Evolution, development and application of myofunctional therapy in orthodontics, Ax J. ORTHODOXTICS S; ORAL SURG. 25: 1, 1939. 12. Ris, R. E.: Deglutition and the teeth, D. Record 66: 103-108, 19% 13. Rix, B. E.: Deglutition, Tr. European Orthodont. Sot., p. 13, 1948. 14. Ballard, C. F., and Gwynne-Evans, E.: The upper respiratory musculature and orthodontics, I. Brit. Sot. Orthodont. p. 160, 1947. 15. Brodie, A. G.: Facial patterns-A theme on variations, Angle Orthodontist 16: 75, 1946. 16. Straub, W. J.: Malfunction of the tongue, Ax J. ORTHODONTICS 46: 404-424, 1960. 17. Bloomer, H. H.: Speech defects in relation to orthodontics, AM. J. ORTIIODONTICS 49: 920-929, 1963. 18. Moyers, R. E.: An electromyographic analysis of certain muscles involved in temporomandibular movement, AIVI. J. ORTIIODONTICS 36: 481, 1950. 19. Tulley, W. J.: Methods of recording bchaviour patterns of the orofacial muscles using the electomyograph, D. record 73: 741, 1953. 20. Marx, R.: The use of integrators in electromyographic investigations of orthodontic problems, Tr. European Orthodont. Sot., p. 318, 1963. 21. Winders, R. V.: A study in the development of an electronic technique to measure the forces exerted on the dentition by the perioral and lingual musculature, Ahr. J. ORTHO. DONTICS 42: 645-657, 1956. 22. Lear, C.: Personal communication, 1962.

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lulley
pressures. E. H.: The Unpublished mechanism Ph.D. of thesis,

A,,r.

J. Orthodontics

June

1969

23. LuWngham, J. K.: Intraoral 1966. 24. drdran, G. M., and Kemp,
44: 1038, 1954.

University Proc. Roy.

of London, Hoc. Med. thesis, 10:

54:

swallowing,

13. Clcall, J. F.: Dcglutition-A study of form and function. University of New Zealand, 1964. 26. Tullry, TV. J. : Cineradiographic studies of tongue I)ehaviour, 1959. 27. Peat, .J. Ii.: ;Z ccphalometric study of tongue t)osition, AM.
3.51, 1968.

Unpublished 1).
J.

D.D.S.

Lrac~titionor

135,
x9-

OIlT11ol)0rl~ICS

28. Bosma, J. F.: Deglutition: Pharyngeal stage, Physiol. rev. 37: July, 1957. 29. Grossman, R. C.: Methods for evaluating oral surface tension, J. D. Rcs. 43: 301, 19ti4. 30. Berry, I). C., and Mahood, M.: Oral stercognosis and oral abilit,p in relation to prosthetic treatment, Brit. D. J. 120: 179, 1%X. 31. Fawcus, X.: An investigation iuto lingwitl scanwry motor skills in children and adults with normal speech, I). Practitioner 17: SO, 1Wi. 32. Whillis, J.: Movements of the tongue in dcglutition, Tr. Brit. Sot. Orthodout., p. 121, 194G. of the incisors, Tr. Brit. S0c. 33. Ris, 1~. E.: Some observations upon the: c~trvironmc~rlt
Ortllodorlt., 34. p. is, 1953.

Ballard, C. I?.: The significance of soft tissue morpholo~> )I 7 in treatmcnt~ planning, Tr. European Orthodont. Sot., p. l-k, 1953. 35. Tullq, IV. J. : The tongue: That unruly member, 1). Practitioner orthodontic results, !I. Practit,ioner 36. lullel~ . , 11;. .I.: Long-term The morphologic Irasis of prognosis determining 37. Hallard, C. F.: Practitioner 18: 63. 1967.

diagnosis,

prognosis

and

15: 27, 19ti4. 12: 253-260 19(X trcatmcnt pkming,

I),