CASE REPORT

An Unusual Appliance to intercept Cheek Biting Habit A Case

Report.
Dayanand Shirol1, Rahul Lodaya2,Chetan Bhat3,Sachin C. Gugwad4,Preetam Shah5

ABSTRACT
Recognition and elimination of an oral habit is of utmost
importance. Numerous articles emphasize the importance of
using prosthesis to prevent injuries related to cheek biting
habit in children with systemic disorders. This case report
describes the use of an unusual removable prosthesis to
prevent cheek biting habit in healthy 12-year-old girl who did
not have any of the commonly related conditions.
Keywords: Interception of cheek biting, cheek injuries,
deleterious oral habits, linea alba

patients who have developmental or medical problems,

such as psychological problems, congenital syndromes
or mental retardation; however, reports of oral injuries
in individuals unaffected by the above conditions are
scarce. Among the deleterious oral habits seen in
children the thumb/finger sucking, tongue thrusting
and bruxism are most common.3,4 Less commonly seen
are cheek biting and lip/nail biting habits. At times
dentists are in a dilemma as to which appliance to be
given to a patient with cheek biting/nail biting. This
article discusses a case report of such a child with cheek
biting habit who responded well to a simple removable
appliance to intercept the habit.

Case report
Introduction
Oral habits in children have concerned dentists for
many years. Dentists see in these habits the possibility
of harmful unbalanced pressures which may be brought
to bear upon the position of teeth and occlusion which
may become decidedly abnormal if habits are
continued for long periods of time. The dentists and
speech pathologists are interested more in oral
structural changes resulting from prolonged habit
patterns. The pediatrician and psychologist may place
more importance on the deeper seated behavioural
problems of the child, of which the oral habit may be
only a symptom. The parents appear to be more
concerned that a child with an oral habit is exhibiting an
act which is socially unacceptable. 1
The dentists rarely see children with deleterious oral
habits until the habits are well established. Oral and
peri-oral structures can be traumatized by self-injurious
oral habits.2 Because of this it is instructive to review
how the infant relates to his external environment
through his oral activities. Freud emphasized this by
delineating certain phases of childhood as oral and anal
periods. Others have spoken of the essential orality of
the child.1 Various articles have described prostheses
used to prevent self injuries to the oral tissues of
patients who have

A twelve-year old girl reported with complaint of mild

to moderate pain on the inner side of left cheek. History
revealed that pain is since two months, increasing
gradually and aggravates while eating. Behavior and
developmental milestones of the child was normal and
no abnormality found extraorally. Intraoral examination
revealed complete set of permanent dentition except
third molars. (Fig. 1) Two third of the crowns of
premolars and second molars were seen. A linear
elevation or welt like horizontal elevation was present
on the left buccal mucosa corresponding to the level of
occlusion of teeth, extending anteroposteriorly from
corner of mouth to second molar. The elevated part
had mild blanching and was tender on palpation. On
occlusion, the tissue was getting impinged between
upper and lower posteriors and this was causing
constant irritation to the mucosa. The occlusion showed
Class I molar relationship with no malposition in any of
the teeth. There was a persistent cheek biting during
mouth closure and the child was habituated to pull the
cheek mildly against the dentition. The left cheek
musculature was becoming slightly tense while
chewing. This habit was observed only on the left side.
No other relevant features were observed in relation to
soft and hard tissues, intraorally.
Counseling of the child and subsequent interception of
habit with mechanotherapy was

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2010 Int. Journal of Contemporary Dentistry

CASE REPORT

Fig 1. Intraoral photograph showing linea

Fig 3: The appliance seated in place

alba on left cheek mucosa

Fig 2: Removable habit breaking appliance with wire

and acrylic shield

habit with mechanotherapy was planned. Many articles
in the past have emphasized the importance of using
prosthesis to prevent such injuries. A removable crib
with buccal shield was prepared (Fig. 2).5 The
removable wire and the acrylic crib breaks up the biting
habit by completely separating the buccal mucosa
coming towards teeth (Fig. 3 & 4). The acrylic was
covering the premolars and molars on the buccal side.
The appliance was delivered to the child with
instructions on usage and caring for the same. She was
asked to wear the cribs for one month.
After one month, the mucosa showed reduction in the
linear elevation and the child had not experienced any
pain in the mucosa after started wearing the appliance
(Fig. 5). The child was asked to continue it for one more
month. At the end of two months (Fig. 6), the mucosa
showed complete healing to normal state and in turn
the child had discontinued the habit of pulling cheek
mucosa against the dentition during chewing and
closing the mouth.

Fig 4: The appliance seated in place with

teeth in occlusion

Fig 5: After one month of therapy

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2010 Int. Journal of Contemporary Dentistry

10

CASE REPORT
References
1. Finn Sidney B., Clinical Pedodontics, 4th Ed.,
W.B. Saunders Company, 1998.
2. Romero M, Vicente A, Bravo LA, Prevention of
habitual cheek biting: a case report, Special
Care Dentistry. 2005 Jul-Aug;25(4):214-6
3. McDonald, Avery, Dean, Dentistry for the child
and adolescent, 8th Ed., Mosby publication,
2004.
4. Shetty SR, Munshi AK., Oral habits in children--a
prevalence study, J Indian Society of
Pedodontic & Preventive Dentistry. 1998
Jun;16(2):61-6.

Fig 6. After six months of therapy

Discussion
Many authors have described oral habits in their own
perception. It would be a frequent or constant practice
or acquired tendency, which has been fixed by frequent
repetition(Butterswort, 1961) or learned patterns of
muscular
contractions(Mathewson,
1982).
All
researchers have stressed upon constant practice and
frequent repetition. In this child, the habit might be
stress-induced or have started as a result of
counteraction to the irritation in the gums due to the
erupting premolars and second molars on left side;
eventually this repetition has lead to a habitual act.
Such areas of recurring, mild mechanical trauma or
irritation from malposed teeth may become altered as
Frictional keratosis - the oral counterpart of a callus on
the skin. This linea alba is considered to be a variation
of normal anatomy but is called frictional keratosis,
chronic cheek bite keratosis or morsicatio buccarum
when it becomes pronounced. There is usually a
clenching or bruxing habit and the most severe lesions
are found in persons with the habit of constantly
pushing the cheeks between the teeth with a finger
while gently biting on the buccal tissues.
Various articles have described the use of appliances to
prevent habits related-injuries to the oral tissues of
patients who have systemic disorders. This child did not
have any of the commonly related conditions.
Oral screen or vestibular screen is the widely
mentioned treatment of choice for interception of
cheek biting habit. However, Graber5 suggested the use
of a removable acrylic crib which acts as a barrier
between teeth and cheek covering only the posterior
teeth. Due to the less bulky nature of such unusual
appliance and comfortable fit in the left buccal
vestibule the patient compliance was good. Such
appliance is of great help even in cases with posterior
tongue thrusting wherein the acrylic shield will cover
the lingual surfaces of teeth.

11

5. Graber T.M. Orthodontics- Principles and

Practice, Third Ed., W.B. Saunders Company,
1996.
About the Authors:
1)Dr. Dayanand Shirol . M.D.S
Reader, Dept. Of Pedodontics, Bharati
Vidyapeeth Deemed University Dental
College & Hospital, Pune
2)Dr. Rahul Lodaya . M.D.S
Reader, Dept. Of Pedodontics, Bharati
Vidyapeeth Deemed University Dental
College & Hospital, Pune
3)Dr. Chetan Bhat . M.D.S
Reader, Dept. Of Pedodontics, Bharati
Vidyapeeth Deemed University Dental
College & Hospital, Pune
4)Dr. Sachin Gugawad . M.D.S
Senior Lecturer, Dept. Of Pedodontics,
Bharati Vidyapeeth Deemed University
Dental College & Hospital, Pune
5)Dr. Preetam Shah . M.D.S
Professor, Dept. Of Pedodontics, Bharati
Vidyapeeth Deemed University Dental
College & Hospital, Pune
Correspondence Address:
Dr. Dayanand Shirol

E-mail dayanandshirol@gmail.com

IJCD NOVEMBER, 2010 1(2)

2010 Int. Journal of Contemporary Dentistry