A Critical Appraisal of Tongue-thrusting-Tulley

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A critical appraisal of tongue-thrusting

W. J . Tul ley , Ph.D. , F.D.S. , D. Or th. , R.C.S.

London, England

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

the early writings of very able clinicians, and their work has to some extentbeen 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 irregulari ties 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 (occlusa l 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, Anglestates : “We are just beginning to real ize how common and varied are the

vic ious 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 U S C of the tongue in mastication and speech reacts upon

the teeth internally, and the lips and cheeks in their every movement, even of

64 0



Tongue-thrusting 64 1

transient emotion, bring pressure to bear externally. Many of these forces are

too slight and of insuffic ient 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 direct ly and in-

directly.”

Bennett discussed Sim Wallace’s 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 wide ly 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 l ip 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 Simila r observations were made on tongue behavior and speech. Rixl”! I3

drew attention to tongue activi ty which seemed to retain infantile charac-

teris tics, 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



642 Tulle?/ Am. J. Orthodontics

June 19F9

when their concepts were first put forward, The late James Whi llis, Professor

of Anatomy at Guy ’s 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 Guy’s 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

conc lusions arc that, although some of the abnormal patterns of act ivity of the

tongue might be described as being similar to the infantile behavior, t lure is

11 0 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,

cxc rciscs could not 1~ used to bring about basic changes in behavior on a per-Il l i l .l l~Ilt basis.

In the early 1950’s many of the csponents of multibanded techniqurs with

cscellcnt, control of tooth movement recognized that thcrc wcr’c: a few cases

in which the behavior of the tongue and lips formed a pattern of act ivity 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~~herapists and speech pathologists became increasingly in

volvctl.

‘1’11~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,?Oant1 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 w ill be seen to confirm many clinical

observations.

Cinefhoroscopy. Ardran and Kemp,Z4 Cleall,Z” Tulley,‘G and others have

shown that th is technique has limitations in terms of speed and is only two

dimensional. It does not lend itsel f to ser ial 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 li’awcus,“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 surg ical defects in the fact. This longitudinal approach

has proved to be of great value, as wi ll 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-tlll’llst.” The author has undertaken

two experiments : (1) an epidemiologic investigation of the incidence of abnormal

tongue function and posture and (2) a longitudina l study using tine films of

patients, with or without orthodontic treatment, some of them extending OCR

3 period of 20 years

Epidemiologic invest igat ions

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

selected from all socia l 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 tonguein production of t,he ‘ls” sounds in speech, were set aside for further invcstiga-

tion. The tongue had to be suffic iently 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 wi th 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 (1 I’g. 1) These figures put tongue-thrusting

in its true perspoct,ive.

longi tudina l t ine 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 clin ician:

Tongue-thrush~g US CL abit. The fact that this w ill not be seen very com-

monly past the age of 11 years is a reason for delaying treatment where the

facia l 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 wi ll be treated quick ly when the labial seg-

ment is put into its correct position. It is quite unnecessary for these childrento be sent for any form of x-educational therapy. Placement of the teeth in



Tongue-thrusti?lg 645

A

B

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 relationsh ip 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 markedin the sibilant sounds of speech and may often be seen in siblings and in one



646 Tulley Am . J. OrthodoltticsJune 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 theincisor relationship (Fig. 4). In contrast to the simple tongue-thrusting habit,

it wi ll 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 Bri tish 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 excess ive 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

l i l l j i>ll scgmcnts in goo~l relationship so that the lower lip can COll l ( ’ to seal On

t11c labiai SllI+iIW ;,f the upper i&+isor t Wtll. Ptlilny palients wit,11 ClaSS II,

Fig. 3. Fam i l ia l (endogenous) tongue behavior in two members of a fami ly . Note in -

terarch tongue posi t ion. A, With Class I I dental base. B , With Class I I I dental base.



Tongue-thrusting 647

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

is not like ly 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

pl’esenting a difficult problem (Fig. 6). It is the one in which tongue-thrust,

;Intl more tspcc ially tongue posture taken into conjunction with t,hc adrc~e

skclc tal form, wi ll 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 dn c 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

1 iic macroglossia is ext,rcmely ri lre.

A

B

Fig. 4. A, Tongue position in “s” sound before orthodontic treatment. B, One yearlater

then 3 was no interarch spacing during “s” sound. Three months active treatment 01dy.



648 Tulley Am. J. OrthodonticsJune 1969

Fig. 5. A typical example of anter ior open-bi te and forward posture of tongue wi thpoor fac ial pattern.

Fig. 6. An addi t ional example of a typical fac ial type wi th forward tongue posture and

with a Class I I I dental base relat ionship. Prognosis for maintain ing the open-bi te in a

closed condi t ion is poor.



l’ongue-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 skele tal 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.

R E F E R E N C E S

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650 l’ulley A,,r. J. OrthodonticsJune 1969

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A Critical Appraisal of Tongue-thrusting-Tulley