Contemporary Orthodontics

5th ed.

William R. Proffit, DDS, PhD

Kenan Distinguished Professor, Department of Orthodontics and Chairman

Emeritus, School of Dentistry, University of North Carolina, Chapel Hill, North
Carolina

Henry W. Fields, DDS, MS, MSD

Professor and Head, Section of Orthodontics, College of Dentistry, The Ohio

State University

Chief, Section of Orthodontics, Department of Dentistry, Columbus Children's

Hospital, Columbus, Ohio

David M. Sarver, DMD, MS

Private Practice of Orthodontics, Birmingham, Alabama

Adjunct Professor, Department of Orthodontics, School of Dentistry,

University of North Carolina, Chapel Hill, North Carolina

James L. Ackerman, DDS

Formerly Professor and Chairman, Department of Orthodontics, University of

Pennsylvania, Philadelphia, Pennsylvania

978-0-323-08317-1

3251 Riverport Lane

St. Louis, Missouri 63043

CONTEMPORARY ORTHODONTICS

ISBN: 978-0-323-08317-1

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Library of Congress Cataloging-in-Publication Data

Proffit, William R.

Contemporary orthodontics / William R. Proffit, Henry W. Fields Jr., David M. Sarver.

.5th ed.

p. ; cm.

Includes bibliographical references and index.

 ISBN 978-0-323-08317-1 (hardcover : alk. paper)

I. Fields, Henry W. II. Sarver, David M. III. Title.

[DNLM: 1. Orthodonticsmethods. WU 400]

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2012006984

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Sucking and Other Habits
Almost all normal children engage in non-nutritive sucking of a thumb or pacifier, and as a
general rule, sucking habits during the primary dentition years have little if any long-term
effect. If these habits persist beyond the time that the permanent teeth begin to erupt,
however, malocclusion characterized by flared and spaced maxillary incisors, lingually
positioned lower incisors, anterior open bite, and a narrow upper arch is the likely result
(Figure 5-34). The characteristic malocclusion associated with sucking arises from a
combination of direct pressure on the teeth and an alteration in the pattern of resting cheek
and lip pressures.

When a child places a thumb or finger between the teeth, it is usually positioned at an angle
so that it presses lingually against the lower incisors and labially against the upper incisors
(Figure 5-35). There can be considerable variation in which teeth are affected and how much.
From equilibrium theory, one would expect that how much the teeth are displaced would
correlate better with the number of hours per day of sucking than with the magnitude of the
pressure. Children who suck vigorously but intermittently may not displace the incisors much
if at all, whereas others,

FIGURE 5-34 In this pair of identical twins, one sucked

her thumb up to the time of orthodontic records at age 11
and the other did not. A, Occlusal relationships in the
thumbsucking girl and (B) her non-thumbsucking twin.
Note the increased overjet and forward displacement of
the dentition of the thumbsucker. C, Cephalometric
tracings of the two girls superimposed on the cranial base
of the two girls. As one would expect with identical twins,
the cranial base morphology is nearly identical. Note the
forward displacement of not only the maxillary dentition
but also the maxilla itself.
FIGURE 5-35 A child sucking their thumb usually places
it against the roof of the mouth, causing pressure that
pushes the lower incisors lingually and the upper incisors
labially. In addition, the jaw is positioned downward,
providing additional opportunity for posterior teeth to
erupt, and cheek pressure is increased while the tongue is
lowered vertically away from the maxillary posterior
teeth, altering the equilibrium that controls width
dimensions. If the thumb is placed on one side instead of in
the midline, the symmetry of the arch may be affected.

particularly those who sleep with a thumb or finger between the teeth all night, can cause a
significant malocclusion.

The anterior open bite associated with thumbsucking arises by a combination of interference
with normal eruption of incisors and excessive eruption of posterior teeth. When a thumb or
finger is placed between the anterior teeth, the mandible must be positioned downward to
accommodate it. The interposed thumb directly impedes incisor eruption. At the same time,
the separation of the jaws alters the vertical equilibrium on the posterior teeth, and as a result,
there is more eruption of posterior teeth than might otherwise have occurred. Because of the
geometry of the jaws, 1 mm of elongation posteriorly opens the bite about 2 mm anteriorly,
so this can be a powerful contributor to the development of anterior open bite (Figure 5-36).

Although negative pressure is created within the mouth during sucking, there is no reason to
believe that this is responsible for the constriction of the maxillary arch that usually
accompanies sucking habits. Instead, arch form is affected by an alteration in the balance
between cheek and tongue pressures. If the thumb is placed between the teeth, the tongue
must be lowered, which decreases pressure by the tongue against the lingual of upper
posterior teeth. At the same time, cheek pressure against these teeth is increased as the
buccinator muscle contracts during sucking (Figure 5-37). Cheek pressures are greatest at the
corners of the mouth, and this probably explains why the maxillary arch

FIGURE 5-36 Cephalometric tracing showing the effects

of posterior eruption on the extent of anterior opening.
The only difference between the red and black tracings is
that the first molars have been elongated 2 mm in the red
tracing. Note that the result is 4 mm of separation of the
incisors because of the geometry of the jaw.

FIGURE 5-37 Diagrammatic representation of soft tissue

pressures in the molar region in a child with a sucking
habit. As the tongue is lowered and the cheeks contract
during sucking, the pressure balance against the upper
teeth is altered, and the upper but not the lower molars
are displaced lingually.

tends to become V-shaped, with more constriction across the canines than the molars. A child
who sucks vigorously is more likely to have a narrow upper arch than one who just places the
thumb between the teeth.

Mild displacement of the primary incisor teeth is often noted in a 3- or 4-year-old

thumbsucker, but if sucking stops at this stage, normal lip and cheek pressures soon restore
the teeth to their usual positions. If the habit persists after the permanent incisors begin to
erupt, orthodontic treatment may be necessary to overcome the resulting tooth displacements.
The constricted maxillary arch is the aspect of the malocclusion least likely to correct
spontaneously. In many children with a history of thumbsucking, if the maxillary arch is
expanded transversely, both the incisor protrusion and anterior open bite will improve
spontaneously (see Chapter 12). There is no point in beginning orthodontic therapy, of
course, until the habit has stopped.

Whether a habit can serve in the same way as an orthodontic appliance to change the position
of the teeth has been the subject of controversy since at least the first century ad, when Celsus
recommended that a child with a crooked tooth be instructed to apply finger pressure against
it to move it to its proper position. From our present understanding of equilibrium, we would
expect that this might work, but only if the child kept finger pressure against the tooth for 6
hours or more per day.

This concept also makes it easier to understand how playing a musical instrument might
relate to the development of a malocclusion. In the past, many clinicians have suspected that
playing a wind instrument might affect the position of the anterior teeth, and some have
prescribed musical instruments as part of orthodontic therapy. Playing a clarinet, for instance,
might lead to increased overjet because of the way the reeds are placed between the incisors,
and this instrument could be considered both a potential cause of a Class II malocclusion and
a therapeutic device for treatment of Class III. String instruments like the violin and viola
require a specific head and jaw posture that affects tongue versus lip/cheek pressures and
could produce asymmetries in arch form. Although the expected types of displacement of
teeth are seen in professional musicians,31 even in this group the effects are not dramatic, and
little or no effect is observed in most children.32 It seems quite likely that the duration of
tongue and lip pressures associated with playing the instrument is too short to make any
difference, except in the most devoted musician.

Can habits affect development of the jaws? In Edward Angle's era, a sleeping habit in
which the weight of the head rested on the chin once was thought to be a major cause of
Class II malocclusion. Facial asymmetries have been attributed to always sleeping on one
side of the face or even to leaning habits, as when an inattentive child leans the side of his
face against one hand to doze without falling out of the classroom chair. It is not nearly as
easy to distort the facial skeleton as these views implied. Sucking habits often exceed the
time threshold necessary to produce an effect on the teeth, but even prolonged sucking has
little impact on the underlying form of the jaws. On close analysis, most other habits have
such a short duration that dental effects, much less skeletal effects, are unlikely.