A critical appraisal of tongue-thrusting

W. J. Tulley, Ph.D., F.D.S., D. Orth., R.C.S.

London, England

M any of the present-day views on tongue-thrusting are reflected in

the early writings of very able clinicians, and their work has to some extent
been ignored. Like many other present-day views on orthodontics, they have
gone through a full cycle, and in the conclusion to this article it will be sepn
t,hat there has been an overconcentration on the effect of the soft tissues on
malocclusion.
One of the earliest writings is that of Lcf~ulon,~ published in 1839, in which
it is obvious that he appreciated t,hat among the causes of irregularities of teeth
wcrc sounds of speech in which the tongue strikes against the upper anterior
teeth, pushing them forward.
An article by Desirabode, published in 1843, is the first traceable refercncc
to the fact that the lips on the outside and the tongue on the inside of the mouth
constitute a balance of forces that may retain the teeth in their position. In
1859, Bridgeman introduced the lateral pressure theory and described ir-
regularities of the teeth due to visincreme~ati (external muscle forces, as that
of the lips and cheeks), visestensionis (internal muscle forces, as that of the
tongue), and wisoccZusioS (occlusal forces).
Kingsley,4 in 1879, made a considerable study of speech sounds but did not
relate movements of the soft tissues to dental arch form.
At the turn of the century, Angle5 recognized the problems of the muscular
environment of the dental arches but would not accept the fact that in certain
cases t,hey might form an insurmountable difficulty in treatment. In the
appendix to the seventh edition of Malocclusion of the Teeth, Angle
states : We are just beginning to realize how common and varied are the
vicious habits of the lips and tongue, how powerful and persistent they are to
overcome.
Norman Bennett6 showed a clear understanding of the problem when, in
1914, he wrote: The muscles of mastication produce conditions of vertical
and lateral stress, the USC of the tongue in mastication and speech reacts upon
the teeth internally, and the lips and cheeks in their every movement, even of
640
 Tongue-thrusting 641

transient emotion, bring pressure to bear externally. Many of these forces are
too slight and of insufficient duration to produce any definite movement of the
teeth, but others are constantly acting; with the mouth shut and the teeth
closed the buccal cavity is obliterated, and the teeth are compressed between
the tongue and the lips and cheeks. Very little experience in the movement of
teeth by mechanical means is enough to show that even quite a small force
acting continuously will produce a considerable movement, and it becomes clear
that the teeth in their arches are but passive objects kept in a state of equi-
librium under the influence of the muscles that react on them directly and in-
directly.
Bennett discussed Sim Wallaces theory that tongue size is dependent on
tongue function and that this is a dominant factor in determining the size of
the dental arches, but he rather dismissed the tongue as an all-important factor
in arch development.
Brash,? in his Dental Board lectures, did not place emphasis on the effect
of the soft tissues of the tongue and lips on the dental arches, but he went so
far as to state: The growth of the tongue and the mandible are no doubt cor-
related, but it is improbable that the tongue exercises any important mechanical
influence on the general form and size of the mandible or in moulding the form
of the growing palate.
Friel,* having studied muscle activity, was convinced that it was static
function, and not dynamic function, which molded the dental arches in their
position of linguofacial balance and this, as we shall see, has been reaffirmed.
Van Thai was concerned with speech in relation to malocclusion. She de-
duced that malocclusion was not the cause of various types of speech defect.
Froeschels10 found that lisping and open-bite originated from the same abnor-
mality of tongue control. Rogcrs11 was a strong exponent of myofunctional ex-
ercises calc&ted to harness muscle forces in order to treat malocclusions.
This scheme had a following, but it was based on the concept of function dic-
tating form and was not widely accepted.
A simple definition of tongue-thrust might be stated as follows: The for-
ward movement of the tongue tip between the teeth to meet the lower lip in
drglutition and in sounds of speech so that the tongue becomes interdental.
This does not include consideration of forward tongue posture, which is much
more important.
The papers which initiated intensive research on problems of tongue be-
havior in the past two decades were those of Rixl and Ballard and Gwynne-
Evans.14 Similar observations were made on tongue behavior and speech. Rixl! I3
drew attention to tongue activity which seemed to retain infantile charac-
teristics, wit,h the tongue showing great affinity for lower lip contact. He based
his thesis on the belief that this represented a delay in maturation of behavior.
Ballard and Gwynne-Evans I4 looked at the subject from the genetic point of
view, stressing the familial patterns of behavior. Brodie regarded the whole
facial pattern from the general morphologic point of view and was less in-
terested in the tongue and its behavior as a single factor.
I was privileged to work with Rix, Ballard, and Gwynne-Evans in 1948
 Am. J. Orthodontics
642 Tulle?/ June 19F9

when their concepts were first put forward, The late James Whillis, Professor
of Anatomy at Guys Hospital, became intensely interested in this subject and
realized that there was a lack of informat,ion conccming hot,11 normal and ab-
normal tongue behavior.
A rcscarch unit was set up in t,he Medical School at Guys Hospital to study
the normal ant1 abnormal behavior of the orofacial musculature. The long-term
resubs of this study will be reported Iatcr in this article. This study modified
the earlier views expressed by Rix, Ballard, and Gwynne-Evans. The general
conclusions arc that, although some of the abnormal patterns of activity of the
tongue might be described as being similar to the infantile behavior, t lure is
110 cvidcnce to show that these activities are due to dclaJ- in maturation. There
is no stat,istical evidence to prove that bottle-focding is responsible for encour-
aging il dclav in maturation of orofacial bc~havior. It was also shown that,
cxcrciscs could not 1~ used to bring about basic changes in behavior on a per-
Illil.ll~Ilt basis.
In the early 1950s many of the csponents of multibanded techniqurs with
cscellcnt, control of tooth movement recognized that thcrc wcrc: a few cases
in which the behavior of the tongue and lips formed a pattern of activity t,hat,
canscd relapse. Other authorities, such as Straub,lG gave the impression that
tongue problems were very extensive and that re-cdnca,tion of orofacial br-
harior by trained speech therapists was necessary for many orthodontic pro-
cedurcs. S~KXY~~therapists and speech pathologists became increasingly in
volvctl.
111~confusion of thinking on the subject prompted a poem by Professor
Bloomer entitled The Inverted, Pcrvcrtcd, Reverted Swallow. In the same
paper Bloomcr17 sums up the general view when he states: Some ortho-
donists and speech therapists are happy in their common endeavors in training
patients to swallow. Others from both professions look on with a measure of
disapproval. The concern represents not an antithesis to cooperation but an
uneasiness about prescribing cookbook treatment programs for problems in
which the dynamics of cause and effect are not yet understood.
A few of t,hc ways in which these problems have been examined arc as
follows :
Electronlyography. Moyersls investigated functional movements of the oro-
facia.1 musculature using the electromyograph. Since then, Tulley,l Marx,?O
ant1 many others have contributed. Although the labial musculature can be
studied in this way, and an important contribut,ion has been rnade to our nnder-
standing of lip posture, it is quite impossible to study the tongue musculature
by electromyography.
Ueasurenze,I.t of intraoral pressuws. Wit,11 the introduction of small trans-
ducers, intraoral pressures can be measured more accurately than with other
methods previously described. Winder+ was probably the first in this field,
and he has been followed by many othrr investigators who have confirmed that
the tongue is probably more important than the surrounding musculature in
its effect. I,eaF and Iluffinghamz3 showed that the speed and intensity of the
rapid movements of the tongue in speech and swallowing were probably not so
 Tongue-thrusting 643

significant as the resting posture, which will be seen to confirm many clinical
observations.
Cinefhoroscopy. Ardran and Kemp,Z4 Cleall,Z Tulley,G and others have
shown that this technique has limitations in terms of speed and is only two
dimensional. It does not lend itself to serial studies because, although the dosage
is small using image intensifiers, it is difficult to pcrsuadc patients that it is
clinically necessary.
Cephalometric head films. Peats7 and others have shown the possible dif-
ferences between the relaxed and habitual postures of the tongue and this,
iu turn, has made some contribution to our knowledge. However, this technique
is subject to variation.
Newophysiologic experiments. BosmaZ8 and his co-workers, Grossman,?
Berry, and liawcus,l have carried out various neurologic tests on the behavior
of the tongue. So far, the use of stereognostic test,s has indicated very considcr-
able individual differences in lingual scnsorimotor factors, and I am sure that
this work will continue.
Serid cinephotog,ruphy. This is difficult to a,nalyzc scientifically, but, it
tloes highlight the individual variations. Although cint~photography cannot
display the intraoral movements of the tongue, work by Vhillis32 and ot,hcr
film studies carried out by the Veterans Organization have shown tongue
movements through surgical defects in the fact. This longitudinal approach
has proved to be of great value, as will be seen later.
It is now much more certain that facial form will dictate function rather
than that function dictates form, as was formerly believed. In an effort to
clarify some of the confusion over itongL~e-tlllllst. The author has undertaken
two experiments : (1) an epidemiologic investigation of the incidence of abnormal
tongue function and posture and (2) a longitudinal study using tine films of
patients, with or without orthodontic treatment, some of them extending OCR
3 period of 20 years

Epidemiologic investigations

In this investigation 1,500 Il-year-old school children, a random sample

selected from all social groups in southeast and east London, were examined.
Those who had circumoral contraction in swallowing with forward movements of
the tongue and those in whom there was also a forward movement of the tongue
in production of t,he ls sounds in speech, were set aside for further invcstiga-
tion. The tongue had to be sufficiently forward to have the tip placed either
interdentally or under the upper incisal edge.
As by far the most common reference on tongue-thrusting is associated with
Class II, Division 1 malocclusion, 329 of the children (22 per cent of the total
sample) were shown to have some degree of this malocclusion, but only 141
(less than one half) were assessed as requiring orthodontic treatment. Only
43 of the 329 children showed evidence of adverse tongue and lip behavior
which might jeopardize permanent correction of the incisor relationship.
Examining the total sample for the more pronounced type of tongue-thrust,
only 40 of the total sample (2.7 per cent) had the type of tongue behavior
Fig. 1. Examples of tongue-thrust with good occlusion

shown in Fig. 1, and only half of this group hat1 any degree of malocclusion
deserving of treatment. ln fact, 12 of the children with tongue-thrust, and lisp-
ing speech had excellent occlusions (1qg.
I 1) These figures put tongue-thrusting
in its true perspoct,ive.
longitudinal tine studies

By examining some 50 patients over a period of nearly 20 years, I have

been able to confirm my previous findings and those of Ballard on the
nature of tongue-thrust. It is possible t,o break down tongue-thrusting into
main categories, but thcrc is also some overlap and it is difficult to produce
a good classification. Investigations over the past 20 years have enabled us to
rnake the following classification, which is not claimed to bc ideal but repre-
sents an attcrnpt to he helpful to the clinician:
Tongue-thrush~g US CLhabit. The fact that this will not be seen very com-
monly past the age of 11 years is a reason for delaying treatment where the
facial pattern is good and there is merely a slight open-bite and increased
ovcrjet with a Class I or Class II relationship (Fig. 2). These patients with
a persistent tongue-thrust habit will be treated quickly when the labial seg-
ment is put into its correct position. It is quite unnecessary for these children
to be sent for any form of x-educational therapy. Placement of the teeth in
 Tongue-thrusti?lg 645

Fig. 2. A, Example of facial maturation. A habit tongue-thrust was present in associa-

tion with thumb-sucking up to 7 years of age. The incisor relationship developed normally
and the open-bite closed. No active treatment. B, Models from 4 to 19 years.

correct position and the very presence of the appliance will be sufficient.
Although the psychologic aspects of this subject have been ignored, it is inter-
esting to note that I have seen cases in which the lisping speech has returned
for a short time when the child is under stress.
Tongue-thrusting which is possibly endogenous or in&e. In the epidemio-
logic investigation previously described, a familial pattern was evident in 30
per cent of the small group of children who had tongue-thrusting behavior
(Fig. 3). This needs further investigation, and it may be that there is an ob-
scure central variation. This kind of tongue-thrusting is particularly marked
in the sibilant sounds of speech and may often be seen in siblings and in one
646 Tulley Am. J. Orthodolttics
June 1969

of the parents. It can occur when there is a perfectly normal occlusion if there
is a good facial skeletal pattern, and then it is of little significance to the ortho-
dont,ist. If it occurs where there is an adverse facial pattern, it may be a dorn-
inant feature and may place severe limitations on the improvement of the
incisor relationship (Fig. 4). In contrast to the simple tongue-thrusting habit,
it will not respond to any kind of therapy.
Tongue-thrust us UTL crduptive behnzGr. The majority of problems which
are of concern to the orthodontist fall into this category. In the British Isles
and part,s of the United States many patients arc unable to effect an anterior
oral seal with the lips at rest. This does not mean that there is any mouth
breathing. The resting posture of the tongue is more important than its func-
tional movements.
The type of deglutit,ion in which thcrc is a tongue-thrust and excessi\-c
circumoral contraction is due to the fact that there has to be excessive contra+
tion of the labial musculature in cases where the lips arc incompetent ant1
the tongue comes forward to complete the anterior oral seal. This tongue-thrust
swa.110~ can change ynitc dramatically if orthodontic t~reatment can ~)lacc the
lillji>ll scgmcnts in goo~l relationship so that the lower lip can COlll( to seal On
t11c labiai SllI+iIW ;,f the upper i&+isor t Wtll. Ptlilny palients wit,11 ClaSS II,

Fig. 3. Familial (endogenous) tongue behavior in two members of a family. Note in-
terarch tongue position. A, With Class II dental base. B, With Class III dental base.
 Tongue-thrusting 647

Division 1 malocclusion may exhibit tongue-thrust prior to treatment, but this

is not likely to be a primary problem after treatment.
An adaptive tongue behavior, in which the tongue is not only forward in
functional movement but postured forward over the lower incisors at rest to
seal with the lower lip, is a very important problem. This posture is associated
with an adverse skeletal pattern in which there is a high Frankfort-ma.ndibulal
plane angle.
In the epidemiologic survey, the type of facial pattern found in only 0.6 per
cent of the child population has always been recognized by orthodontists ils
plesenting a difficult problem (Fig. 6). It is the one in which tongue-thrust,
;Intl more tspccially tongue posture taken into conjunction with t,hc adrc~e
skclctal form, will produce an anterior open-bite which is very resistant to
I rc~atmcnt. This may be associated with a Class I, II, or III malocclusion.
Pathologic n?zd ~/rossl~~aO?lornlnl tompc 1>roble,lzs. Just as the common mal-
ocdclusions arc not due to pathologic abnormalities, the common variations in
tongue function should not be look4 upon as bein g dnc to pathologic entities,
and it is very unlikely that any degree of dysdiadochokincsia has any relc~ancc
to the cliscussion. There is no doubt that tongue size plays some part, but :I
1riic macroglossia is ext,rcmely rilre.

Fig. 4. A, Tongue position in s sound before orthodontic treatment. B, One year later
then 3 was no interarch spacing during s sound. Three months active treatment 01dy.
648 Tulley Am. J. Orthodontics
June 1969

Fig. 5. A typical example of anterior open-bite and forward posture of tongue with
poor facial pattern.

Fig. 6. An additional example of a typical facial type with forward tongue posture and
with a Class III dental base relationship. Prognosis for maintaining the open-bite in a
closed condition is poor.
 longue-thrusting 649

Summary and conclusions

An attempt has been made here to place the problem of tongue behavior in
its true perspective by indicating that only a very small percentage of ortho-
dontic problems are ultimately complicated by it.
In a limited number of cases with poor facial pattern associated with for-
ward tongue posture at rest, an anterior open-bite may not be permanently
reduced, whatever the method of treatment. This clinical type is very unfa-
vorable for treatment but 08ccurs in only about 0.6 per cent of the population.
Early treatment is undesirable, as the whole problem may look much worse
during the early mixed-dentition phase.
A classification of tongue-thrusting has been attempted. It is better to place
the emphasis on the morphology of the skeletal and soft-tissue structures which
demand abnormal posture and activity, rather than on the more transient and
rapid movements of the tongue in speech and deglutition.
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June 1969

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