Classification of Oral Habits

Oral habits can be classified based on various criteria, including their nature, impact, and the underlying motivations for the behavior. Below is a detailed classification of oral habits:

1. Based on Nature of the Habit

• Obsessive Habits (Deep Rooted):

  • International or Meaningful:
    • Examples: Nail biting, digit sucking, lip biting.
  • Masochistic (Self-Inflicting):
    • Examples: Gingival stripping (damaging the gums).
  • Unintentional (Empty):
    • Examples: Abnormal pillowing, chin propping.

• Non-Obsessive Habits (Easily Learned and Dropped):

  • Functional Habits:
    • Examples: Mouth breathing, tongue thrusting, bruxism (teeth grinding).

2. Based on Impact

• Useful Habits:
  • Habits that may have a positive or neutral effect on oral health.
• Harmful Habits:
  • Habits that can lead to dental issues, such as malocclusion, gingival damage, or tooth wear.

3. Based on Author Classifications

• James (1923):

  • a) Useful Habits
  • b) Harmful Habits

• Kingsley (1958):

  • a) Functional Oral Habits
  • b) Muscular Habits
  • c) Combined Habits

• Morris and Bohanna (1969):

  • a) Pressure Habits
  • b) Non-Pressure Habits
  • c) Biting Habits

• Klein (1971):

  • a) Empty Habits
  • b) Meaningful Habits

• Finn (1987):

  • I. a) Compulsive Habits
  • b) Non-Compulsive Habits
  • II. a) Primary Habits

4. Based on Functionality

• Functional Habits:
  • Habits that serve a purpose, such as aiding in speech or feeding.
• Dysfunctional Habits:
  • Habits that disrupt normal oral function or lead to negative consequences.

Transpalatal Arch

The transpalatal arch (TPA) is a fixed orthodontic appliance used primarily in the maxillary arch to maintain or regain space, particularly after the loss of a primary molar or in cases of unilateral space loss. It is designed to provide stability to the molars and prevent unwanted movement.

Indications

• Unilateral Loss of Space:
  • The transpalatal arch is particularly effective in cases where there is unilateral loss of space. It helps maintain the position of the remaining molar and prevents mesial movement of the adjacent teeth.
  • It can also be used to maintain the arch form and provide anchorage during orthodontic treatment.

Contraindications

• Bilateral Loss of Space:
  • The use of a transpalatal arch is contraindicated in cases of bilateral loss of space. In such situations, the appliance may not provide adequate support or stability, and other treatment options may be more appropriate.

Limitations/Disadvantages

• Tipping of Molars:
  • One of the primary limitations of the transpalatal arch is the potential for both molars to tip together. This tipping can occur if the arch is not properly designed or if there is insufficient anchorage.
  • Tipping can lead to changes in occlusion and may require additional orthodontic intervention to correct.

Frenectomy and Frenotomy

A frenectomy is a surgical procedure that involves the complete excision of the frenum and its periosteal attachment. This procedure is typically indicated when large, fleshy frenums are present and may interfere with oral health or function.

Indications for Frenectomy

The decision to perform a frenectomy or frenotomy should be based on the ability to maintain gingival health and the presence of specific clinical conditions. The following are key indications for treating a high frenum:

1. Persistent Gingival Inflammation:

   • A high frenum attachment associated with an area of persistent gingival inflammation that has not responded to root planing and good oral hygiene practices.

2. Progressive Recession:

   • A frenum associated with an area of gingival recession that is progressive, indicating that the frenum may be contributing to the loss of attached gingiva.

3. Midline Diastema:

   • A high maxillary frenum that is associated with a midline diastema (gap between the central incisors) that persists after the complete eruption of the permanent canines.

4. Mandibular Lingual Frenum:

   • A mandibular lingual frenum that inhibits the tongue from making contact with the maxillary central incisors, potentially interfering with the child’s ability to articulate sounds such as /t/, /d/, and /l/.
   • If the child has sufficient range of motion to raise the tongue to the roof of the mouth, surgery may not be indicated. Most children typically develop the ability to produce these sounds after the age of 6 or 7, and speech therapy may be recommended if issues persist.

Surgical Considerations

• Keratinized Gingiva:

  • If a high frenum is associated with an area of no or minimal keratinized gingiva, a vestibular extension or graft may be used to augment the surgical procedure. This is important for ensuring stable long-term results.

• Frenotomy vs. Frenectomy:

  • In cases where a frenotomy or frenectomy does not create stable long-term results, alternative approaches may be considered. Bohannan indicated that if there is an adequate band of attached gingiva, high frenums and vestibular depth do not pose significant problems.

• Standard Approach:

  • The use of surgical procedures to eliminate the frenum pull is considered a standard approach when indicated. The goal is to improve gingival health and function while minimizing the risk of recurrence.

Causes:
The primary cause of CP is any factor that leads to decreased oxygen supply (hypoxia) to the developing brain. This can occur due to various reasons, including complications during pregnancy, childbirth, or immediately after birth.

Classification of Cerebral Palsy:

1. Based on Anatomical Involvement:

   • Monoplegia: One limb is affected.
   • Hemiplegia: One side of the body is affected.
   • Paraplegia: Both legs are affected.
   • Quadriplegia: All four limbs are affected.

2. Based on Neuromuscular Involvement:

   • Spasticity: Characterized by stiff and tight muscles; this is the most common type, seen in 70% of cases. Affected individuals may have limited head movement and a limp gait.
   • Athetosis: Involves involuntary, writhing movements, seen in 15% of cases. Symptoms include excessive head movement and drooling.
   • Ataxia: Affects balance and coordination, seen in 5% of cases. Individuals may exhibit a staggering gait and slow tremor-like movements.
   • Mixed: A combination of more than one type of cerebral palsy, seen in about 10% of cases.

1. Spastic Cerebral Palsy (70% of cases)

Characteristics:

• Limited Head Movement: Individuals have restrictions in moving their head due to increased muscle tone.
• Involvement of Cerebral Cortex: Indicates that the motor control areas of the brain (especially those concerning voluntary movement) are affected.
• Limping Gait with Circumduction of the Affected Leg: When walking, the patient often swings the affected leg around instead of lifting it normally, due to spasticity.
• Hypertonicity of Facial Muscles: Increased muscle tension in the facial region, contributing to a fixed or tense facial expression.
• Unilateral or Bilateral Manifestations: Symptoms can occur on one side of the body (hemiplegia) or affect both sides (diplegia or quadriplegia).
• Slow Jaw Movement: Reduced speed in moving the jaw, potentially leading to functional difficulties.
• Hypertonic Orbicularis Oris Muscles: Increased muscle tone around the mouth, affecting lip closure and movement.
• Mouth Breathing (75%): The individual may breathe through their mouth due to poor control of oral musculature.
• Spastic Tongue Thrust: The tongue pushes forward excessively, which can disrupt swallowing and speech.
• Class II Division II Malocclusion (75%): Dental alignment issue often characterized by a deep overbite and anterior teeth that are retroclined, sometimes accompanied by a unilateral crossbite.
• Speech Involvement: Difficulties with speech articulation due to muscle coordination problems.
• Constricted Mandibular Arch: The lower jaw may have a narrower configuration, complicating dental alignment and oral function.

2. Athetoid Cerebral Palsy (15% of cases)

Characteristics:

• Excessive Head Movement: Involuntary, uncontrolled movements lead to difficulties maintaining a stable head position.
• Involvement of Basal Ganglia: Damage to this area affects muscle tone and coordination, leading to issues like chorea (involuntary movements).
• Bull Neck Appearance: The neck may appear thicker and less defined, owing to abnormal muscle development or tone.
• Lack of Head Balance, Drawn Back: The head may be held in a retracted position, affecting posture and balance.
• Quick Jaw Movement: Involuntary rapid movements can lead to difficulty with oral control.
• Hypotonic Orbicularis Oris Muscles: Reduced muscle tone around the mouth can lead to drooling and lack of control of oral secretions.
• Grimacing and Drooling: Facial expressions may be exaggerated or inappropriate due to muscle tone issues, and there may be problems with managing saliva.
• Continuous Mouth Breathing: Patients may consistently breathe through their mouths rather than their noses.
• Tissue Biting: Increased risk of self-biting due to lack of muscle control.
• Tongue Protruding: The tongue may frequently stick out, complicating speech and intake of food.
• High and Narrow Palatal Vault: Changes in the oral cavity structures can lead to functional difficulties.
• Class II Division I Malocclusion (90%): Characterized by a deep bite and anterior open bite.
• Speech Involvement: Affected due to uncontrolled muscle movements.
• Muscle of Deglutition Involvement: Difficulties with swallowing due to affected muscles.
• Bruxism: Involuntary grinding or clenching of teeth.
• Auditory Organs May be Involved: Hearing impairments can coexist.

3. Ataxic Cerebral Palsy (5% of cases)

Characteristics:

• Slow Tremor-like Head Movement: Unsteady, gradual movements of the head, indicative of coordination issues.
• Involvement of Cerebellum: The cerebellum, which regulates balance and motor control, is impacted.
• Lack of Balance Leading to Staggering Gait: Individuals may have difficulty maintaining equilibrium, leading to a wide-based and unsteady gait.
• Hypotonic Orbicularis Oris Muscles: Reduced muscle tone leading to difficulties with oral closure and control.
• Slow Jaw Movement: The jaw may move slower, affecting chewing and speech.
• Speech Involvement: Communication may be affected due to poor coordination of the speech muscles.
• Visual Organ May be Involved (Nystagmus): Involuntary eye movements may occur, affecting visual stability.
• Varied Type of Malocclusion: Dental alignment issues can vary widely in this population.

4. Mixed:
Mixed cerebral palsy involves a combination of the above types, where the individual may exhibit spasticity, athetosis, and ataxia to varying degrees.

Dental Considerations for Mixed CP:
- Dental care for patients with mixed CP is highly individualized and depends on the specific combination and severity of symptoms.
- The dentist must consider the unique challenges that arise from the combination of muscle tone issues, coordination problems, and potential for involvement of facial muscles.
- A multidisciplinary approach, including occupational therapy and speech therapy, may be necessary to address oral function and hygiene.
- The use of sedation or general anesthesia might be considered for extensive dental treatments due to the difficulty in managing the patient's movements and ensuring safety during procedures.

Associated Symptoms:
Children with CP may exhibit persistent reflexes such as the asymmetric tonic neck reflex, which can influence their dental treatment. Other symptoms may include mental retardation, seizure disorders, speech difficulties, and joint contractures.

Dental Problems:
Children with cerebral palsy often experience specific dental challenges:

• They may have a higher incidence of dental caries (tooth decay) due to difficulty in maintaining oral hygiene and dietary preferences.
• There is a greater likelihood of periodontal disease, often exacerbated by medications like phenytoin, which can lead to gum overgrowth and dental issues.

Dental Treatment Considerations:
When managing dental care for children with cerebral palsy, dentists need to consider:

• Patient Stability: The child’s head should be stabilized, and their back should be elevated to minimize swallowing difficulties.
• Physical Restraints: These can help manage uncontrolled movements during treatment.
• Use of Mouth Props and Finger Splints: These tools can assist in controlling involuntary jaw movements.
• Gentle Handling: Avoid abrupt movements to prevent triggering the startle reflex.
• Local Anesthesia (LA): Administered with caution, ensuring stabilization to prevent sudden movements.
• Premedication: Medications may be given to alleviate muscle hypertonicity, manage anxiety, and reduce involuntary movements.
• General Anesthesia (GA): Reserved for cases that are too challenging to manage with other methods.

Veau Classification of Clefts

The classification of clefts, particularly of the lip and palate, is essential for understanding the severity and implications of these congenital conditions. Veau proposed one of the most widely used classification systems for clefts of the lip and palate, which helps guide treatment and management strategies.

Classification of Clefts of the Lip

Veau classified clefts of the lip into four distinct classes:

1. Class I:

   • Description: A unilateral notching of the vermilion that does not extend into the lip.
   • Implications: This is the least severe form and typically requires minimal intervention.

2. Class II:

   • Description: A unilateral notching of the vermilion border, with the cleft extending into the lip but not involving the floor of the nose.
   • Implications: Surgical repair is usually necessary to restore the lip's appearance and function.

3. Class III:

   • Description: A unilateral clefting of the vermilion border of the lip that extends into the floor of the nose.
   • Implications: This more severe form may require more complex surgical intervention to address both the lip and nasal deformity.

4. Class IV:

   • Description: Any bilateral clefting of the lip, which can be either incomplete notching or complete clefting.
   • Implications: This is the most severe form and typically necessitates extensive surgical repair and multidisciplinary management.

Classification of Clefts of the Palate

Veau also divided palatal clefts into four classes:

1. Class I:

   • Description: Involves only the soft palate.
   • Implications: Surgical intervention is often required to improve function and speech.

2. Class II:

   • Description: Involves both the soft and hard palates but does not include the alveolar process.
   • Implications: Repair is necessary to restore normal anatomy and function.

3. Class III:

   • Description: Involves both the soft and hard palates and the alveolar process on one side of the pre-maxillary area.
   • Implications: This condition may require more complex surgical management due to the involvement of the alveolar process.

4. Class IV:

   • Description: Involves both the soft and hard palates and continues through the alveolus on both sides of the premaxilla, leaving it free and often mobile.
   • Implications: This is the most severe form of palatal clefting and typically requires extensive surgical intervention and ongoing management.

Submucous Clefts

• Definition: Veau did not include submucous clefts of the palate in his classification system.
• Diagnosis: Submucous clefts may be diagnosed through physical findings, including:
  • Bifid Uvula: A split or forked uvula.
  • Palpable Notching: Notching at the posterior portion of the hard palate.
  • Zona Pellucida: A thin, translucent membrane observed in the midline of the hard palate.
• Associated Conditions: Submucous clefts may be associated with:
  • Incomplete velopharyngeal mechanism, which can lead to speech issues.
  • Eustachian tube dysfunction, increasing the risk of otitis media and hearing problems.

Eruption Gingivitis

• Eruption gingivitis is a transitory form of gingivitis observed in young children during the eruption of primary teeth. It is characterized by localized inflammation of the gingiva that typically subsides once the teeth have fully emerged into the oral cavity.

Characteristics

• Age Group:

  • Eruption gingivitis is most commonly seen in young children, particularly during the eruption of primary teeth. However, a significant increase in the incidence of gingivitis is often noted in the 6-7 year age group when permanent teeth begin to erupt.

• Mechanism:

  • The increase in gingivitis during this period is attributed to several factors:
    • Lack of Protection: During the early stages of active eruption, the gingival margin does not receive protection from the coronal contour of the tooth, making it more susceptible to irritation and inflammation.
    • Food Impingement: The continual impingement of food on the gingiva can exacerbate the inflammatory process, leading to gingival irritation.

Contributing Factors

• Accumulation of Debris:
  • Food debris, material alba, and bacterial plaque often accumulate around and beneath the free gingival tissue. This accumulation can partially cover the crown of the erupting tooth, contributing to inflammation.
• Common Associations:
  • Eruption gingivitis is most frequently associated with the eruption of the first and second permanent molars. The inflammation can be painful and may lead to complications such as:
    • Pericoronitis: Inflammation of the soft tissue surrounding the crown of a partially erupted tooth.
    • Pericoronal Abscess: A localized collection of pus in the pericoronal area, which can result from the inflammatory process.

Clinical Management

• Oral Hygiene:

  • Emphasizing the importance of good oral hygiene practices is crucial during this period. Parents should be encouraged to assist their children in maintaining proper brushing and flossing techniques to minimize plaque accumulation.

• Professional Care:

  • Regular dental check-ups are important to monitor the eruption process and manage any signs of gingivitis or associated complications. Professional cleanings may be necessary to remove plaque and debris.

• Symptomatic Relief:

  • If the child experiences pain or discomfort, topical analgesics or anti-inflammatory medications may be recommended to alleviate symptoms.