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Modified Palatal Crib Appliance for Habit Correction: A Case Report

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Digit sucking is the most commonly seen oral habit & one of the most common learned patterns of behaviours seen in children of preschool age and is a habit of concern as it is an important etiological factor in the development of malocclusion, a secondary tongue thrust develops leading to the exaggeration of the condition. To plan an appropriate treatment it is important to understand the etiology, which includes psychological, physiological and anatomical and planning for behavior eradication is critical for the positive outcomes. Starting from counselling to appliance therapy, ample treatment modalities have been reported in the literature. Many appliances have been developed for habit correction and have been modified depending on the patient compliance. Palatal crib is one such appliance for treating digit sucking habit & tongue thrusting. This case report describes a 12-year-old girl who reported to our department with a history of digit sucking habit which was intervened using modified palatal crib appliance.
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Journal of Dental & Oro-facial Research Vol 13 Issue 02 Aug 2017 JDOR
RUAS 61
Modified Palatal Crib Appliance for Habit Correction:
A Case Report
*Shwetha G.1, Ashmitha K. Shetty2, Usha R.3 and Pushpalatha C.4
*Corresponding Author Email: gshwetha247@gmail.com
Contributors:
1Assistant Professor,
2,4 Reader,3 Lecturer,
Department of Pedodontics and
Preventive Dentistry, Faculty of
Dental Sciences, M.S. Ramaiah
University of Applied Sciences,
Bengaluru - 560054
Abstract
Digit sucking is the most commonly seen oral habit & one of the most common
learned patterns of behaviours seen in children of preschool age and is a habit of
concern as it is an important etiological factor in the development of malocclusion,
a secondary tongue thrust develops leading to the exaggeration of the condition. To
plan an appropriate treatment it is important to understand the etiology, which
includes psychological, physiological and anatomical and planning for behavior
eradication is critical for the positive outcomes. Starting from counselling to
appliance therapy, ample treatment modalities have been reported in the literature.
Many appliances have been developed for habit correction and have been modified
depending on the patient compliance. Palatal crib is one such appliance for treating
digit sucking habit & tongue thrusting. This case report describes a 12-year-old girl
who reported to our department with a history of digit sucking habit which was
intervened using modified palatal crib appliance.
Keywords: Modified Palatal Crib, Habit Breaking Appliance, Digit Sucking Habit,
Tongue Thrusting Habit
Introduction
Habit is defined as a fixed practice produced by a
constant repetition of an act1. Oral habits are
common in children. These habits include: non-
nutritive sucking habits (thumb/finger/pacifier),
tongue-thrusting, tongue sucking, lip or nail
biting habits & bruxism. Non-nutritive sucking
habit comprises the use of pacifiers, blankets and
digit sucking. The term digit sucking is
synonymous with finger sucking or thumb
sucking. It is defined as the placement of the
thumb or one or more fingers in various depths
into the mouth. The prevalence of this habit as
reported by investigators ranges from 1.7% to
47%2. This habit develops early in life around 29
weeks of age and continues from infancy through
primary, mixed and permanent dentition. If the
habit continues into the mixed dentition a
malocclusion may develop3.Proffit and Mason
defined tongue-thrusting habit as the protrusion
of the tongue against or in between the anterior
dentition with excessive circumoral muscle
activity during swallowing. They also stated that
one or more of the following conditions should
exist to define the thrust: first, the tongue should
move forward to contact the lower lip during
swallowing. Secondly, the forward movement of
the tongue between the anterior teeth during
speech may be observed. Finally, a forward
positioning of the tongue with the tip of the
tongue positioned between or against the anterior
teeth at rest.4
Various side-effects of these habits are anterior
open bite, increased overjet, labial inclination of
upper incisors & lingual inclination of lower
incisors, Posterior cross bite. Spontaneous
correction of the dental changes occurs if the
habit ceases before the age of 5 years and thus do
not require any treatment.5,6 The treatment
approaches for these habits should be carried out
in the following stages7
1. Direct counselling of the patient
2. Reminder therapy
3. Rewards concept
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4. Orthodontic appliance treatment.
This paper describes the clinical case report of a
12-year-old girl whose habit was corrected using
a modified palatal crib appliance.
Case Report
A 12-year-old girl accompanied by her mother
reported to the Department of Pedodontics and
Preventive Dentistry, Ramaiah University of
Applied Sciences Bengaluru, with a chief
complaint of digit sucking habit since she was 2
years old. A detailed history was recorded;
mother revealed that the child is practicing digit
sucking habit regularly for 8-9 hrs/day during
waking hours, also reported that the patient had
speech problems and was undergoing speech
therapy. On examination callous formation was
seen over the right middle and ring finger and
places her digits up to her 1st phalanges.[fig.1] As
duration and intensity of digit sucking was
intense, the child presented with anterior open
bite with simple tongue thrusting. [fig.2] & was
in mixed dentition stage and reversible pulpitis
wrt 85 which was restored using GIC type II. All
the other methods of habit cessation attempted
had failed in this patient. Thus appliance therapy
was planned. A fixed habit breaking appliance,
i.e., a palatal crib was planned and modification
was done to the palatal crib as the patient had
speech problems. Accordingly the first molars
were banded, and alginate impression was made.
The crib was fabricated on the cast using a 0.8mm
stainless steel wire8, then the joints of the crib
were soldered, and over the crib small round
beads were placed using silver solder [fig.3]. In
the next appointment, the appliance cementation
was done using GIC type I [fig.4] The patient
reported again after 2 weeks, mother gave a
positive feedback about the regression of the
habit. There were observable changes on the
nger, while follow-up check-up after 3 months
showed a marked reduction in the habit and the
callous formation on the digit had resolved
completely. Patient was asked to wear appliance
for at least 6 months after the reversal of habit to
avoid relapse of the habit, post-treatment follow-
up showed no relapse. After that period of 6
months, the appliance was removed.
Discussion
The habit of sucking the finger (or thumb) is
considered to be performed for oral gratification
and psychological reassurance. Severe digit
sucking can lead to proclination of maxillary
anteriors, constriction of the maxilla,
retroclination of the mandibular incisors,
increased overjet and anterior openbite9.
Usually, in cases with anterior open bite due to
thumb sucking, a secondary tongue thrust
develops leading to the exaggeration of the
condition. The line of treatment for the prolonged
digit sucking involves positive reinforcements,
developing a desire in the patient to quit the habit,
reminders and appliances which act as a
mechanical barrier as well as physical reminders.
Appliances consisting of cribs in the anterior
region are found to be very effective as reminders
as well as physical restrainers10-13.
In the present case the patient had digit sucking
habit along with tongue thrusting and also
reported to have difficulties during speech. To
plan an appropriate treatment it is important to
understand the etiology that includes
psychological, physiological and anatomical and
planning for behaviour eradication for the
positive outcomes.
Counselling to appliance therapy, ample
treatment modalities have been reported in the
literature, we planned to counsel the patient first
but there was no change in the habit. Hence we
planned to give an appliance to break both the
habits, but considering the speech problem, we
planned to modify the palatal crib appliance so
that there is no interference with the speech.
Pathophysiology of Finger-sucking Damage to
Occlusion
Several studies have been conducted to
understand the pathophysiology of finger-
sucking damage to the occlusion.
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Fig. 1 Digits showing callous formation
Fig. 2 Patient showing anterior open bite with
simple tongue thrusting
A study by Ahlgren to examine the activity of the
mentalis, buccinator and lip muscles during non-
nutritive sucking habits using Electromyography
(EMG) found more electromyographic activity in
the lip and mentalis muscles than in the
buccinator muscle.14
Fig. 3 Fabrication of the modified palatal crib
appliance
Fig. 4 Cementation of the appliance
Proffit stated that the anterior open bite
malocclusion seen in thumb-sucking individuals
is caused by interference to eruption of the
incisors accompanied by eruption of the posterior
teeth. He indicated that the possible cause for the
posterior crossbite malocclusion is a combination
of lower tongue position and increased cheek
activity during sucking.15 On the contrary to what
Proffit hypothesized, Larsson and Ronnerman in
a comparative study in children aged between 9-
13years with prolonged finger sucking habit and
children without habit found that modelling of the
alveolar process was probable cause for open bite
and not the arrested eruption of the incisors. Once
the habit is stopped the inhibition of the vertical
growth of the anterior maxillary process might
self-correct, permanent effects on occlusion is
anticipated and self-correction might not occur if
the child continues the finger-sucking habit after
pubertal growth.16 Possible factors leading to
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retention of this abnormal malocclusion include
abnormal tongue and lip functions.
Effects of Tongue-thrust on Occlusion and
Speech: The effects of tongue-thrust on occlusion
have been the subject of controversy. Tongue-
thrust habit may be a contributing or a
maintaining factor in malocclusion, lisping or
both. Tongue-thrusting has been associated with
speech problems, like anterior lisp and
articulatory problems with some consonants such
as S, Z, T, D, L, and N17,18. Depending on the
severity of malocclusion and the child’s
compensative ability, the open bite may result in
articulation errors19. Tulley in a survey examined
over 1,500 11-year-old school children for a
tongue-thrust habit found that some children
displayed lisping in their speech though they had
an excellent occlusion20.
Relationship between Tongue-thrust and Thumb-
Sucking: All open bites are accompanied by a
tongue-thrust. In cases of the thumb-sucking
habit, spontaneous correction of the open bite
usually occurs after the elimination of habit
except in cases where there are other associated
habits. Other habits could include tongue-
thrusting, mouth breathing and hyperactive
perioral muscles21. In a case control study of 723
children aged 10-11 years, it was found that
children with thumbsucking habit showed an
increased tendency of tongue-thrust swallow and
teeth apart swallow compared to the control
group22. da Silva Filho et al in a study found the
difference that, in thumb-sucking subjects the
anterior open bite was circular in contour, in
tongue-thrust swallow it was diffuse or
rectangular in shape21.
Conclusion
Prolonged finger-sucking habit is a risk factor in
malocclusion predominantly anterior open bite. A
posterior crossbite might be associated with the
finger-sucking habit, but it occurs more with
prolonged pacifier use. It was found that the
longer the habit, the more the associated damage
to the primary and permanent dentition. Methods
for habit intervention include counselling,
positive reinforcement, a calendar with rewards,
an adhesive bandage, bitter nail polish, long
sleeves and appliance therapy. It is recommended
to start with the least invasive methods before
using habit breaking appliances. Some children
need additional help to stop the habit and in that
case habit-breaking appliances are indicated.
Habit-breaking appliances are either fixed or
removable. One of the fixed appliances used to
break the habit is the palatal crib appliance.
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... It is believed that the behavior of sucking one's finger (or thumb) is carried out for psychological comfort and oral enjoyment. Severe digit sucking can result in mandibular incisor retroclination and maxillary anterior proclination, constriction of the maxilla, increased overjet, and AOB [8]. ...
... Positive reinforcement, encouraging the patient to break the habit, equipment that functions as a mechanical barrier, and tactile reminders are all part of the treatment plan for extended digit sucking. Crib appliances in the anterior region are proven to be quite useful both as physical restraints and as reminders [8]. ...
Article
Full-text available
The most prevalent oral habit and one of the most often habitual behavioral patterns in preschool-aged children is thumb-sucking. This behavior is crucial to the development of malocclusion and must be addressed carefully since it may cause a secondary tongue thrust that worsens the issue. Developing an effective treatment plan requires determining the underlying cause, which may include psychological, physiological, and or anatomical factors. Overall prevention of behavior needs to be planned for successful outcomes. One such device for treating tongue-thrusting and thumb-sucking habits is the palatal crib. The present case shows the possible effectiveness of palatal crib use in conjunction with myofunctional therapy for a child whose diagnosis involves habitually holding the tongue low and sucking the thumb that causes an anterior open bite (AOB). An 11-year-old boy with flared and spaced upper and lower incisors also had an AOB. Myofunctional therapy was combined with palatal cribs to help the tongue reposition itself and discourage the habit of sucking. The AOB was successfully corrected with an appropriate overjet and overbite after a total of three months of treatment.
Article
This study assessed the relationship between nonnutritive sucking habits, facial morphology, and malocclusion in 3 planes of space (transverse, vertical, and anteroposterior) in 330 Brazilian children (4 years of age) attending state schools in the city of Recife, Brazil. The data were collected by interviews with the children's mothers or minders and by clinical examinations carried out by a calibrated examiner (K = 1). The chi-square test, Fisher's exact test, and multivariate analysis were used for statistical analysis. The prevalence of malocclusion in the sample was 49.7%, according to occlusal classification, and 28.5% of the children had 2 or 3 factors contributing to their malocclusion. Posterior crossbite was detected in 12.1%, anterior open bite in 36.4%, and increased overjet in 29.7%. A significant association was found between malocclusion and sucking habits (P < .001). Most of the children had a high facial skeletal pattern, although no association was found between facial morphology and malocclusion. The results draw attention to the magnitude of the problem in childhood and emphasize the need for longitudinal studies to support clinical practice guidelines for the target population.
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To describe tongue pressure changes before, during, and after crib appliance therapy in mixed dentition open bite cases. A crib appliance was applied to each of the 13 patients in the study group. The control group consisted of six patients. Tongue pressures were measured using a diaphragm-type pressure transducer during rest position and swallowing in changing intervals for 12 months in both groups. Tongue pressures were performed on the upper first molar, upper and lower central incisors, and on the middle spur of the crib appliance. In the study group, the initial resting tongue pressure on the upper molar increased after appliance insertion and was followed by a decreasing trend for 12 months. The resting tongue pressures on the upper and lower incisors remained lower than initial values at the end of 12 months. Swallowing pressures returned to initial values at the end of 12 months, and the changes were insignificant. The resting and swallowing tongue pressures on the middle spur of the crib appliance decreased gradually during the 10 months (P < .05). Pressure changes in the control group were insignificant for all measurements. Open bite values in the study group increased significantly by the end of 12 months. Measurements performed on the crib confirm the tongue adaptation to environmental changes. Resting tongue pressures at the 12th month remained lower than the initial values. These findings indicate adaptive behavior of the tongue to open bite closure and the new position of the incisors.
Article
The relationship between sucking habits, swallowing patterns and the prevalence of different malocclusion symptoms was analyzed in 725 Danish children. The swallowing pattern was classified as normal, simple tongue-thrust or complex tongue-thrust swallow. The malocclusion frequency was registered on the basis of a method described by Bjork, Krebs and Solow and information on previous and persisting habits was obtained through questionnaires to the children's parents. The findings indicated that previous sucking habits had a significant influence on the type of swallow. Finger- or thumbsucking and dummysucking all resulted in an increased tendency to tongue-thrust swallow and teeth-apart swallow. Tongue-thrust swallow was highly related to an increase in the frequency of distal occlusion, extreme maxillary overjet and open bite. However, the relationship between sucking habits and the development of malocclusion cannot be explained entirely by the influence on the swallowing pattern, since children with sucking habits also exhibited increased frequency of malocclusion, independent of swallowing pattern.
Article
Recommendations about patient selection for myofunctional therapy and treatment timing are made. Whether tongue thrust is a habit or an innate behavior pattern and whether it is related to open bite malocclusions and incisor protrusion are discussed. Tongue thrust may be a delayed transition stage in some children. Therapy is not indicated in the absence of speech or dental problems, or before puberty. The article reviews oral form and function interactions pertinent to tongue thrust and provides guidelines for patient selection for myofunctional therapy. Certain anatomic conditions predispose normal children to anterior tongue positioning, which disappears during puberty. In these children the tongue thrust is a normal, if delayed, transition stage. In other children, it is a necessary adaptation. Myofunctional therapy is not indicated in the absence of speech or dental problems and is not indicated, in our view, before puberty. If tongue thrust and an associated malocclusion persist to puberty, tongue therapy may be indicated. The therapy then is more effective when combined with orthodontic treatment to reposition teeth, rather than being done before orthodontics. Speech therapy can modify speech errors in tongue-thrusters and reposition the tongue tip posteriorly.
Article
Excellent results were obtained by using the classical palatal crib for the patient, who is appraised as having morphological, functional and psychological changes resulting from finger and/or pacifier sucking habits.
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A nonpunitive fixed appliance utilizing a Teflon (E.I. du Pont de Nemours and Co., Inc., Wilmington, DE) roller is described. The appliance is used in conjunction with a program of positive reinforcement in managing thumb sucking in children 7-13 years of age. It has been used successfully in 24 children, with no cases requiring reinsertion.
Article
Continuing finger-sucking often leads to an anterior open bite. The object of the present study was to attempt to illustrate whether this open bite is caused by an arrested eruption of incisors or primarily by inhibited growth of the alveolar processes. A comparison is made between 9-, 11- and 13-year-old children with continuing finger-sucking habits or who ceased finger-sucking only after 8 years of age, and children of the same ages without sucking habits in respect of the clinical crown length of central and lateral incisors in the upper and lower jaws. In all measurements the clinical crown length among children in the finger-sucking groups was greater than among children in the control groups (Table 1). The anterior open bite of the finger-suckers was therefore probably not caused by arrested eruption of incisors but rather by inhibited vertical growth of the anterior part of the alveolar processes.