Guest Editorial
The influence of the tongue on dentofacial growth
John Mew
In 1907, Edward Angle1 said this about the tongue:
‘‘… there are as many variations as there are cases
met with, resulting and corresponding with variations in
the malocclusion’’. At the time, these were recognized
as wise words, and in 1918 A.P.Rogers2 created
a series of exercises intended to train the tongue and
lips. Unfortunately, few clinicians, either then or since,
have been very successful in influencing the action or
position of the tongue and, possibly as a result, soft
tissue training or Myofunctional Therapy, as it is
currently referred to, is hardly used in current
Orthodontic practice. It is not easy to understand
why, as orthodontists both then and now accept that
the teeth and alveolus are in a position of balance
between the soft tissues. I think the probable reason is
that training the soft tissues is not considered to be
part of an orthodontist’s job and, in addition, it is
tedious and unreliable. Might that attitude change?
In fact, there is much evidence to suggest that
unusual function of the soft tissues in general, and the
tongue in particular, are related to malocclusion. Rare
cases of aglossia show major collapse of the dental
arches and Harvold3 showed that the surgical removal
of part of a monkey’s tongue caused a related
reduction of arch size. Malocclusion is frequently
associated with unusual form or function of the soft
tissues which may range from a simple sucking habit
to a ’full fan’ tongue thrust with only the posterior
molars in contact. It seems that most of the speciality
are of the opinion that the soft tissues respond to the
shape of the hard tissues rather than the reverse,
although there is little evidence to support this.
That a relationship does indeed exist between them
can easily be verified by putting a blob of acid-etched
resin on the buccal surface of an unopposed molar
tooth and watching it move lingually. This alone must
suggest that the oral soft tissues have the power to
change alveolar form. Cases of muscular-dystrophy
demonstrate bizarre mandibular shapes and, if the IX
John Mew, Head of the London School of Facial Orthotropics
London, UK
Published Online:
G 2015 by The EH Angle Education and Research Foundation,
Inc.
715
or XI nerves are damaged, major changes will be seen
in the dental skeleton.
It is difficult to measure tongue function and almost
impossible to measure its posture. Sadly, in today’s
scientific world if something cannot be measured, it is
at risk of being ignored. Why, we should ask, are
orthodontists so sure that the tongue, which is 95%
muscle, is not an important factor in malocclusion?
The issue was raised in the UK by Rix4 in 1946 who
noticed that many patients with malocclusion had
tongue-between-tooth swallows and several orthodon-
tists including Ballard5 and Tully6 emphasized the
influence of the tongue and lips. However despite this
revival of interest, the topic of oral function and posture
subsequently faded in the UK and elsewhere. Cur-
rently, I see few references to the tongue in The Angle
Orthodontist, and often its influence does not appear to
have been considered. Indeed the word ‘tongue’ rarely
appears, even when discussing issues such as the
inclination of the incisor teeth and open bites.
Research provides us with information about exper-
imental situations and, on this basis, we form our
theories and hypotheses. However, this information is
always specific to the particular conditions of the
research and cannot necessarily be extended to
a wider population. To act on the basis of research,
we have to use logic. For instance, there is good
evidence to suggest that the faster you drive over
a cross road, the less likely you are to hit another
vehicle; however, you would be wise to apply some
logic to the evidence before you act on it.
Denied significant research about tongue posture,
can we apply logic to the miscellaneous information
that does exist concerning the tongue? Several papers
suggest that malocclusion is reduced when the mouth
is closed 7-9 and I know of no evidence to the contrary.
Equally, there is a lot of evidence to suggest that there
is a higher ratio of malocclusion when the tongue is
away from the palate, especially if it is postured
between-the-teeth or low.10-15 Often this is of the open
bite or Class III type and, again, I know of no evidence
to the contrary. I have never seen a case of anterior or
lateral open bite where the tongue does not flow into
the space. Clearly this is either coincidental or one
facilitates or precipitates the other. It is commonly
assumed that the tongue moves to fill a space created
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by adverse growth or defective eruption; however, I
know of no evidence to confirm that either is causative.
On the evidence available, I think it is unsafe to
ignore the influence of the tongue and there are many,
including myself, who go to great efforts to train the
tongue to contact the palate both at rest and during
swallowing. Myofunctional therapy has yet to prove
itself as a viable technique and many orthodontists will
need more evidence before they will accept it. Others
will see it for what it is: an intermittently successful way
of improving soft tissue posture. That it often fails is
probably due to lack of technique rather than failure of
principle and, as techniques improve, its need is likely
to become more widely recognized.
Over time, clinical experience works on the minds of
enthusiastic young clinicians, many of whom grow to
realize that the soft tissues are in ultimate control. For
instance, most orthodontists think of Charles Tweed as
a ‘four on the floor’ man, dedicated to mechanics. This
is why he was severely criticized in his time by many
members of the American Association of Orthodon-
tists. He was an active student in Angle’s school,
constantly creating new ideas, often contradicting
Angle himself. Not many people know that, in his later
years, he rejected much of his own previous work. He
decided that early treatment was essential and only
accepted mixed dentition cases in his practice. Not
long before he died, he pronounced, ‘‘Knowledge will
gradually replace harsh mechanics, and in the not-too-
distant future the vast majority of orthodontic treatment
will be carried out during the mixed dentition period of
growth and development prior to the difficult age of
adolescence.’’ Has that time come yet?
REFERENCES
1. Angle EH. Treatment of Malocclusion of the Teeth. SS
White. 1907; p 109.
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2. Rogers AP. Exercises for the Development of the Muscles of
the Face, with a View to Increasing their Functional Activity.
Dent. Cosmos. 1918;60:857–897.
3. Harvold EP. The Role of Function in the Aetiology &
Treatment of Malocclusion. Am J Orthod. 1968;54:883.
4. Rix RE. Deglutition and the Teeth. Dent Rec. 1946;66:103.
5. Ballard CF. A Consideration of the Physiological Back-
ground of Mandibular Posture & Movement. Dent Practi-
tioner. 1955;6:80.
6. Tulley WJ. Clinical Types. Dent Practitioner. 1956;6:
225–235.
7. Trotman C, McNamara JA Jr, Dibbets, J, Th van der Weele
L. Association of lip posture and the dimensions of the
tonsils and sagittal airway with facial morphology. Angle
Orthod. 1997;67:425–432.
8. Linder-Aronson S, Woodside DG, Hellsing G, Emerson W.
Normalisation of incisor position after adenoidectomy.
Am J Orthod Dentofacial Orthop. 1993;103:412–427.
9. Melsen B, Attina, L, Suntueri M, Attina, A. Relationships
between Swallowing Pattern Mode of respiration and
Developing Maloccluson. Angle Orthod. 1987;57:113–119.
10. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate
Experiments on Oral Respiration. AJO. 1981;79:359–372.
11. Ogaard B. Larsson E, Runa-Lindsten R. The effect of
sucking habits, cohort, sex, inter-canine arch widths and
breast or bottle feeding on posterior cross-bite in Norwegian
and Swedish 3 year old children. Am J Orthod Dentofacial
Orthop. 1994;106:161–166.
12. Fujiki T, Inoue M, Miyawaki S, Nagasaki T, Tanimoto K,
Takano-Yamamoto T. Relationship between maxillofacial
morphology and deglutitive tongue movement in patients
with anterior open bite. Am J Orthod Dentofacial Orthop.
2004;125:160–167.
13. Gorgulu S, Sagdl D, Akin E, Karacay S, Bulakbasr N,
Tongue movements in patients with skeletal Class mal-
occlusions evaluated with real-time balanced turbo field
echo cine magnetic resonance imaging. Am J Orthod
Dentofacial Orthop. 2011;139:e405–e414.
14. Primozic J, Farcnik F. Perinetti G, Richmond S and Ovsenik
M. The association of tongue posture with the dentoalveolar
maxillary and mandibular morphology in Class III malocclu-
sion: a controlled study. Eur J Orthod. 2013;35:388–393.
15. Volk J, Kadivec M, Music MM, Ovsenlk M. Three-dimen-
sional ultrasound diagnostics of tongue posture in children
with unilateral posterior crossbite. Am J Orthod Dentofacial
Orthop. 2010;138:608–612.