Wednesday, October 31, 2012

LETTER: Tongue posture

Involvement of the tongue in development and treatment of malocclusion
Four articles in the October issue of the AJO-DO attracted my attention. All were related to the tongue. Lowe and Jacobson and Schendel discussed the competing advantages of appliances and surgery when correcting sleep apnea, while Ioi and colleagues assessed the ideal width of a smile. El-Dawlatly and co-workers discussed the dental and skeletal components of deep bites, and Cassis et al described the results of bonded spurs coupled with high pull chin cap therapy.  However only the last article mentioned the word ‘tongue’.
When I trained, the word tongue did not appear in my orthodontic text book. Even now, few clinicians rate the tongue as very important, although most might accept that wide palates tend to be associated with tongue-to-palate postures and many would link a low tongue posture to class III malocclusion; however, scientists would consider such thoughts no more than anecdotal.
In truth, few scientists are interested, because we cannot accurately assess long-term tongue posture, but that should not mean that we can dismiss these concepts entirely. When evidence is lacking or contradictory, it is sometimes better to rely on logic. With sleep apnea, the tongue often rests close to the pharyngeal wall, associated with a retruded maxilla. The evidence suggests that the longer sleep apnea appliances are worn the more retruded the maxilla becomes, while surgical correction tends to relapse in the long-term. Might changing tongue posture be more effective than both?
What supports the maxilla and why do the buccal corridors have such influence on the appearance? It is important to assess the nature of deep-bites, but surely more so to assess their cause. Mostafa and his team did not mention the tongue, but I have never seen a deep-bite where the tongue does not overlap the lingual cusps of the lower teeth.   Is this important?
Attractive faces have wide arches and pronounced malar processes, but despite the broad width these are usually associated with hollow cheeks. Perhaps the tongue is positioned in the palate with flat buccinator muscles. Perhaps we should pay more attention to tongue posture.
John Mew
London, UK


  1. Dr. Mew, You have been contributing to this Journal for a long time and I feel your work has gone largely unappreciated for too long. Your perception about the etiology of malocclusion - muscle-based as an adaptation to the modern environment - needs to be taken more seriously as the sequela of poor facial growth becomes more apparent to us. Thanks!

  2. I too agree with Dr.Mew. Tongue posture has been often neglected in our quest for etiological(muscle) basis of malocclusion. Perhaps, this silent phenomenal activity requires more attention than other tongue activities.We need more research towards this direction.

  3. "The man usually antagonize all what its unknown for him " , this is what our ancestors used to say ! Unfortunately this aphorism applies to clinical practice for most ortho. specialists ; most of us will treat the teeth, and maybe will seek the correct skeletal relationship also ( if the patient lucky ! ) but after completion of the treatment, the orthodontist will stands bewildered and very confused about what he must to do in front of the (insubordinate) tongue and its muscles that have not been tamed in order to get used to the new situation of the teeth and jaws ! And this is all because of not taking into consideration the real impact of the tongue on the case from the first moment of planing of the treatment
    All the best
    Dr.Dr. Yazan Jahjah

  4. Tongue posture may never have shown its profound influence on facial development more than in children with Trisomy 21 (Down Syndrome). These children can not only breathe better and hold their tongues in their mouths more easily after maxillary expansion (sometimes along with a few other structural therapies that may support such expansion), but some of them have experienced rapid growth in the year after expansion and also markedly improved cognition. I have seen this for myself in several examples to date and appreciate that there are more and more orthodontic specialists willing to help these children.

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