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Year : 2019  |  Volume : 37  |  Issue : 2  |  Page : 167-171

Tongue position assessment during oral phase deglutition in children with anterior open bite and normal vertical overbite

1 Department of Orthodontics, Cooperative University of Colombia, Medellín, Colombia
2 Department of Phonoaudiology, Cooperative University of Colombia, Medellín, Colombia
3 Department of Statistic, Universidad Pontificia, Bolivariana, Medellín, Colombia

Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Paola Botero-Mariaca
Department of Orthodontics, Cooperative University of Colombia, Medellin
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_333_18

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Introduction: Tongue position during deglutition presents great variability and can be assessed clinically or with different techniques. Aim: This study aims to determine tongue position during deglutition in children aged 8–16 years with anterior open bite (AOB) and normal vertical overbite (NVO) using a fluorescein technique. Settings and Design: A cross-sectional analytical study was conducted to assess tongue contact points during the oral phase of deglutition. Subjects and Methods: A total of 132 children with AOB and 132 children with NVO were included in this study. The difference between tongue contacts in both groups was performed, and the association between tongue position and anterior occlusion was establish. Statistical Analysis Used: Normal distribution analysis, Parson's Chi-square test (P < 0.05). Results: In AOB, about 28.8% showed tongue contact on the palatal surface of the incisors during the oral phase, 25.8% at the gingival margin, and 22% on the palatal rugae. Regarding NVO, 53% showed contact on the palatal rugae, 28.8% at the gingival margin, and 13.6% at the palatal surface. Conclusion: AOB group presented a higher prevalence of impaired tongue positions compared to NVO controls. The palatal surface was the most frequent contact point in the AOB, whereas tongue showed contact points at the palatal rugae in NVO.

Keywords: Deglutition, open bite, overlap, tongue thrust

How to cite this article:
Gonzalez P, Martínez MB, Sierra V, Rueda ZV, Botero-Mariaca P. Tongue position assessment during oral phase deglutition in children with anterior open bite and normal vertical overbite. J Indian Soc Pedod Prev Dent 2019;37:167-71

How to cite this URL:
Gonzalez P, Martínez MB, Sierra V, Rueda ZV, Botero-Mariaca P. Tongue position assessment during oral phase deglutition in children with anterior open bite and normal vertical overbite. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2022 Aug 14];37:167-71. Available from: http://www.jisppd.com/text.asp?2019/37/2/167/261352

   Introduction Top

The tongue is considered a muscular organ involved in speech, mastication, deglutition, and sucking that produces forces directly or indirectly on hard oral tissues and teeth both during function and at rest.[1],[2] Those pressures have been associated with modulation of dental arch development and dentofacial structures.[3],[4],[5],[6] Tongue thrust during swallowing is considered to be resulting front of a previously established anterior open bite (AOB) caused by deleterious oral habits;[2],[7],[8] therefore, the tongue is considered to have a secondary role in the etiology of AOB.[5],[6]

Deglutition assessment methods have been oriented by a qualitative approach, like visual examination; and therefore, an exact tongue position during deglutition has been difficult to determine. Several studies reported quantitative two-dimensional (2D) methods such as cineradiography, electromyography, electropalatography, cine magnetic resonance, and videofluoroscopy,[4],[5],[6],[7],[8],[9],[10],[11],[12] with the disadvantage of a 2D evaluation that inhibits an accurate view of tongue position from a coronal plane. Payne technique is considered a 3D method in which the use of radiation is avoided, and a discriminative tongue position can be established.[13]

Although it is accepted in the literature that tongue positions forward when AOB is present, the results of the different studies are heterogeneous because of the different techniques used to establish tongue position during normal deglutition and the difficulty to discriminate the exact structure where pressure is applied. For example, some studies have determined the presence of lingual apex contact on the palatal rugae, and others reported contacts on the lingual side of the dentoalveolar area.[4],[10],[13]

Prevalence and severity of AOB have been associated to racial origin and dental development. A higher prevalence of AOB in African Americans than in Caucasians (ratio of 4:1) is reported in North America.[7],[14],[15],[16] AOB prevalence rate in Caucasian populations (2%–4.7%)[2],[16] is lower than in Latin America (2.7%–9%).[17],[18] Regarding the dentition type of AOB is more prevalent in deciduous and early mixed dentition (11%), with a decrease during late mixed dentition (4.2% and 6.2%). A 2.5%–8.7% rate has been reported in the permanent dentition.[18]

Uncertainties about differences in tongue position between different types of malocclusions still remain, mainly between AOB and normal vertical overbite (NVO). In addition, tongue position discrimination has not been demonstrated due to differences in the instrument used to perform the assessment.[10],[18],[19] The aim of the present study was to determine tongue position in AOB and NVO in children aged 8–16 years using a fluorescein technique.

   Subjects and Methods Top

A cross-sectional analytical study was performed in children between 8 and 16 years of age, from public educational institutions during August 2012–June 2013. The University Ethics Committee approved this research, and six institutions endorsed the study, after authorization granted by Secretary of Education and School Directors.

Procedures were explained to parent or student guardians before informed consent was provided. In addition, if a child accepted participation in the study, he/she signed the informed consent form.

Children with the presence and absence of AOB, with full anterior incisors erupted, and patients without posterior crossbite were included. Exclusion criteria included schoolchildren who had a mental syndrome or systemic disease that altered their normal skeletal development, children who had or are receiving interceptive orthodontic treatment, children that did not consent oral cavity examination, children with previous and/or current speech therapy treatment and patients with thumb sucking and lip interposition habits.

AOB definition considered for the study was the following: anterior teeth that do not reach the line of occlusion and no antagonist contact by at least 1 mm, measured between upper and lower incisors incisal edges. NVO accepted definition was: individual had incisal edges of the mandibular incisors in contact with the palatal surfaces of the maxillary incisors, with approximately one-third of the crowns of the lower incisors covered. The presence of oral habits was determined by clinical examination and parent's reference.

Prior to the collection and assessment of children, a standardization of the handling data collection instruments was made; a pilot test was performed for intra- and inter-observer calibration for clinical analysis and Payne technique application on five undergraduate and postgraduate students from a local university (Kappa index = 0.95 for interobserver and 0.99 for intraobserver).

Payne technique was performed in a dark room. First, each child was told to stick out the tongue, and saliva excess was removed with a gauze, then fluorescein was applied on the tongue beginning with the right side edge and passing continuously and without pause along the front until the left side edge was reached. Immediately, the participant was asked to swallow only once, and then open the mouth. It was emphasized that the participant must not talk during the procedure. An approximation was made with a Payne lamp to observe tongue contact points during the oral phase of deglutition. Contact points observed were represented in a graph with the data collection format designed. The selected variables were gingival margin contact, contact in the middle area of the palatal surface of upper teeth, contact with the palatal rugae, contact with the lingual surface of lower teeth, and presence or absence of tongue protrusion.

To identify children with AOB and NVO for the recruitment process, a clinical evaluation was carried out.

A normal distribution analysis was performed, and data were normally distributed. To verify that there was a difference between tongue contacts points during the oral phase of deglutition in AOB patients compared with NVO, Pearson's Chi-square test was performed. P < 0.05 was considered statistically significant. Data analysis was performed using the SPSS statistical package (version 21.0, International Business Machines Corporation (IBM), New York, United States). The sample was divided into two groups according with age to identify whether age had some influence in tongue contacts. The first group compromised students from 8 to 12 years of age and the second students between 13 and 16 years of age.

   Results Top

A total of 7500 students of 13,999 who met the inclusion and exclusion criteria were evaluated. From them, 132 students with AOB (prevalence: 1.76%; 95% confidence interval 1.46–2.06) were identified; 56.1% were female and 43.9% were male. One-hundred and thirty-two students with NVO were selected. The magnitude of ABO was on average 3.5 mm (standard deviation 2.0 mm). [Table 1] shows the distributions of the frequencies of AOB and NVO by gender and age.
Table 1: Frequencies of anterior open bite and normal vertical overbite expressed by sex and age

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Regarding the 132 students with AOB, 28.8% presented tongue contact points during the oral phase of deglutition at the palatal surface of upper incisors [Figure 1], 25.8% at the gingival margin, and 22% at the palatine rugae. In 18.2% of the students, the tongue was protruding, and in 5.3% of the students, the tongue contacted the lower teeth. With respect to the 132 students with NVO, 53% showed tongue contact during the oral phase of deglutition at the palatal rugae [Figure 2], 28.8% at the gingival margin, and 13.6% at the palatal surface. In 2.3% of the students, the tongue was protruded and contacted lower teeth [Table 2].
Figure 1: Payne technique photography of a patient with anterior open bite and tongue position against the palatal surface of the upper incisors

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Figure 2: Payne technique photography of a patient with normal vertical overbite and tongue position at the palatal rugae

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Table 2: Prevalence of anterior open bite and normal vertical overbite with different variables

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Evaluating swallowing tongue contacts in relation to age, students between 8 and 12 years of age presented 47% tongue contact on the palatal rugae, followed by the gingival margin with 21.2%. About 35.4% of students between 13 and 16 years of age presented tongue contact in the gingival margin in differences between both groups were statistically significant for tongue contacts on the palatal rugae and lower incisors [Table 3].
Table 3: Frequencies of tongue contacts according to group age

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   Discussion Top

Payne technique is a noninvasive method considered an easy and straightforward deglutition test. This technique verifies conditions for suitable lingual support, thrust, or tongue interposition,[20],[21],[22],[23] showing tongue contacts during deglutition after the first swallow on command. It is a low-cost technique that may be easily implemented by an orthodontist, which allows a clear functional test to establish an appropriate treatment. Literature suggests that deglutition evaluation should be performed during unconscious swallowing; therefore, results cannot be influenced by patient's consciousness, which can modify tongue contacts. Results obtained through Payne technique were similar to those reported by cineradiography,[19] suggesting that it is a reliable method.[6],[12],[13],[14],[15],[16],[17],[18],[19],[23] Although Payne technique did not assess the behavior of the dorsal surface of the tongue during function; the dorsal portion of the tongue has not been related to changes in tooth positions. Tongue position during deglutition in patients with AOB has a variable location pattern [Table 2], which can cause to a difficulty in detecting an altered position using only visual examination thus leading to a misdiagnosis. Tongue position at the palatal surface of the upper incisors and the protruding tongue between the incisors is associated with AOB, while tongue contacts on the palatal rugae are associated with NVO.[6] An altered position during tongue function leads to an imbalance between oral tissue forces and may produce tooth changes in both vertical and anteroposterior position.

Although there is controversy in the literature regarding whether tongue thrust is the cause or the consequence of AOB, most authors agree that patients with AOB protrude the tongue forward during deglutition.[9],[19] However, some studies that suggested tongue thrust as an etiologic factor of AOB[2] did not have an adequate methodology.

Tongue protrusion during deglutition can be the result of functional adaptation of an AOB[8],[20] as stated by Machado et al., who suggested that forward lingual resting position interferes with normal anterior teeth eruption, causing AOB.[6] Fujiki et al. investigated tongue tip and dorsal surface movement during deglutition, in patients with AOB versus patients with NVO using cineradiography.[19] They observed that tongue tip position protruded more during deglutition in AOB patients than in the controls and that the rear part of the dorsal surface of the tongue demonstrated slower movement in patients with AOB than in controls.[19] However, their results cannot be compared with the present study.

In our study, 78.1% of AOB patients showed impaired tongue contact during deglutition that consisted in contact on the palatal surface of the upper incisors, contact at the gingival margin, lower teeth contact, or tongue protrusion. Meanwhile, only 44.7% of NVO patients presented impaired tongue positions. Considering that, NVO patients showed a substantial percentage of impaired tongue position without leading to AOB, so compensatory dental or skeletal mechanisms may be acting in NVO patients with impaired tongue position. It would be interesting to determine those mechanisms in future studies.

The present study could not establish lingual position as an etiologic factor, but it demonstrated that tongue position is impaired in patients with occlusal alterations in the anterior area. Fujiki et al. reported that tongue thrust is a physiological adaptation to achieve anterior seal in patients with AOB.[4] For future studies, it should be consider other potentially related factors, such as thumb sucking, pacifier use, oral breathing, and the lip interposition habit should be considered.[21],[22]

Designing treatments for malocclusions such as AOB is challenging, either when determining the type of therapy needed or aiming at avoiding recurrence.[21],[24],[25],[26] Several studies have reported relapses in AOB, which can range between 0.25 and 3 mm and can be found in 35%–78% of patients who have already undergone orthodontic treatment.[15],[27] The reported tongue positions in AOB patients should be taken into account for the design and subsequent development of therapeutic devices.

In the present study, age did not show a significant influence in tongue contacts when the groups where compared. Tongue position during deglutition maturates at the age of 4 years and goes from an infantile swallowing to a mature deglutition during normal growth.[3] In the present study, students were between 8 and 16 years old, which could be a factor in diminishing developmental influence on tongue contacts during deglutition.

The cross-sectional design of the present study cannot establish the etiology of the AOB; so, case–control design where the potentially related factors are considered is advisable. Another limitation of the present study was that the breathing function was not evaluated and it could have influenced tongue position; nonetheless, the association between oral breathing and AOB in the literature is scarce.[3],[6]

   Conclusion Top

Is can be concluded thar cases with AOB presented impaired tongue positions when compared with NVO. In the former, the tongue position had a higher frequency of contact points at the palatal surface, while in the control group, the tongue position presented more contacts at the palatal rugae.

Tongue position in both groups of patients varied greatly; therefore, an objective evaluation of tongue position during the clinical examination is recommended because no specific position can be assumed.

Financial support and sponsorship

This study was supported by Universidad Cooperativa De Colombia grant number A21-R03.

Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]

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