American Journal

Of
ORTHODONTICS
(All rights reserved)

VOL. 42 NOVEMBER,1956 No. 11

Original Articles

ADVERSE MUSCLE FORCES-THEIR DIAGNOSTIC SIGNIFICANCE

W. J. TULLEY, B.D.S., F.D.S.R.C.S., LONDON, ENGLAND

PART from the work of Dr. Alfred Rogers, the role of the orofacial
A muscles received but brief mention in the orthodontic
1946. Research work on this subject was very limited.
literature up to
Brodie in the United
States and Rix, Ballard, and Gwynne-Evans in England have done much to
remedy this and have stimulated many others to undertake similar investiga-
tions.
Since its initial use by Moyers, the electromyograph is now being used as
a dental research tool, giving information which sometimes confirms and also
refutes certain theories of the masticatory musculature. This apparatus has
some serious limitations and it is not possible to produce a precise quantitative
study in the same way as with the cephalometric x-ray. It may, however, be
used in a serial study in the future if the results can be carefully interpreted.
Workers in this field who are studying the movements of the mandible in rela-
tion to various types of malocclusion should make a most valuable contribu-
tion to our knowledge.
In this article, however, I am concerned with the study of morphology
and function of the soft tissues which immediately surround the dental arches.
Rix17 and Brodie7 have pointed out that as the teeth erupt they reach a po-
sition in balance between the normal or abnormal lingual and labial muscle
From the Dental School, Guy’s Hospital, London S. E. 1, England.
Head before the flfty-second annual session of the American Association of Orthodontists,
Boston, Massachusetts. May 2. 1956.
801
forces (Fig. 1). It must be remcmberctl that the distribution and morphology
of the soft tissues show as wide a variation as do the type of facial skeleton
and the dental arch form. The six and shape of the soft Cssucs tlcvelol) as
part of the over-all growth pattern ant1 in our research work WV shoultl not
separate the growing facial skeleton from its investing musculature.
The circumoral muscles originate as prirnit~irc clcmcnts forming the upper
end of the slimentary canal and arc initially concerned with t,he vegctativc
function of feeding. The basic pattern of their behavior bccomcs cstablishetl
before birth and suckling movements havtl been shown t,o occur in utciro. As
the child grows older, learned activities [for example, speech ant1 facial cs-
prcssion) which arc represented in the conscious levels of the mind bccotn(i
superimposed on this vegetative role of the orofacial muscles, although they
are built upon the basic underlying coortlinating pattcm.” I?ccausc OF man’s

A. K.
Fig. l.-Tongue and lip position at rest. A. At birth, I3, after tooth eruption.

conscious control of these acquired activities, he differs from the lower ani-
mals and is particularly likely to establish faulty habits and uneconomical
use of his musculature in childhood, which adversely influence the developing
clentition.
The term “muscle habit” has a wide range of meaning and 1 would pre-
fer to restrict its use to an acquired abnormal behavior, which is capable of
re-education by the provision of a correct sensory appreciation. Tt is most,
important to distinguish between muscle habits and the more innate muscular
activities.
Brodie’l points out that, having treated a Class 11, Division 1 malocclusion,
we may give the lips a cha.nce to function normally, thus overcoming the habit
movements that could be secondary to the malocclusion and allow more nor-
mal development to continue. This is certainly an important point. In some
cases, however, there are an underlying abnormal morphology and beha,vior
\ r~lllnle 12 ADVER’SE MUSCLE FORCES 803
\ umber I I

of the lower lip and tongue which may be primary and not secondary to the
malocclusion and which tend to produce deterioration of incisor relationship
after treatment. It is important to distinguish between what has been called
il “mentalis habit” which can be eliminated (Fig. 2) and a particular pattern
of lip morphology and function which is part of the physical makeup of the
individual person (Fig. 3). Such lip positions are not habits, as they resist
re-educational attempts and make it impossible to change permanently the
axial inclinations of lower incisors.

~8ig. ,2.-A, “mentalis habit,” sucking in of lower lip in 4-year-old boy. B, One year later
after elimination of the habit with the Andresen appliance, (From Tulley, W. J. : D. Prac-
titionsr 2: 196, 1962.)

Pig. X.-Father and two sons with similar lower lip morphology and tension. (Not a
mentalis habit.)

Turning attention to the tongue, many habits are ascribed to this organ-
for example, tongue lolling, tongue thrusting, biting, and sucking. The tongue
readily fills any open-bite created by finger- or thumb-sucking and such habits
804 TULLEP

Fig. 4.-Persistent contact of lower lip and tongue at rest. in swallowing, and in speech.
(From Cwynne-Evans, E., and Tulley. W. J.: II. I+m&itioner 6: 222, 1955.)

Fig. 5.-Father and dauqhter with similar tongue resting positions and open-bite, Roth
have pronounced lisp. (From Pringle : D. Practitioner 6: 297, 1955.)
may bc climinatcd with mechanical treatment of the malocclusion. The rest-
ing position of the tongue is important. The question is: How oft,en is its
resting position primary or secondary to dental arch form? There is a pcr-
nicious and basic behavior of the tongue described by Rix and Ballard which
is certainly not a habit. In this, the tongue rests constantly against the lower
lip and thrusts or spreads forward to meet the contracting lower lip in swal-
lowing and speech (Figs. 4 and 5). This tongue position is reminiscent of the
neonatal t,ongue-lip contact’” (Figs. 1 and 4). Lisping speech accompanies
this behavior and may be found in several members of the family. The speech
therapist, may overcome the lisp but fails to change the basic pattern of tongue
behavior. This is a poor prognostic sign in cases where an attempt is being
made t,o t,rctat an open-bite.

Fig. B.-Normal activity of tongue and lips in the Arst stage of swallowing. Teeth are
together, lips relatively passive, tongue bulges into the palate and backward into mm-pharynx.
(From Pringle: D. Practitioner 6: 297. 1955.)

Atypical behavior in the first stage of swallowing described by Rix” in

J946 has occupied a prominent part in the Critish orthodontic literature. The
term “habit” should not be used to describe this, as swallowing is a basic
vegetative function below the conscious levels of the mind. Rix17 and Whilli9
pointed out tha.t the teeth arc usually placed in light or firm contact during
swallowing at the time when the mylohyoid muscle contracts. The tongue
bulges into the palate, centrifugally against the teeth and backward into the
oropharynx (Fig. 6). After the age of 5 to 7 years, this is the usual behavior
during swallowing of hard foods after they have been masticated, and it oc-
curs frequently during the day and night in the act of “basic swallowing”
which redistributes saliva and removes excess. Exceptions occur when suc-
culent and juicy foods are swallowed; then the teeth are not placed in con-
tact. Rix observed that a high percentage of children with malocclusions
always swallowed with the teeth apart. The tongue in these cases was not
acting in a rigid-walled cavity. The tongue space was increased and this
meant that t,he tongue was not thrust strongly against the t,eeth and tlcvclop-
ing palatal vault and did not. balance adequately the external forces of the
cheeks and lips contract,ing in many varyin g degrees to effect an anterior seal
(Fig. 7).

Fig. 7.-A, Marked lip contraction in “teeth apart” swallows. (Extracted from cinefilm.)
B, Diagram showing excessive lip activity and tongue pressure not counteracting this. The
“blunt tongue” swaIlow.

An account of the various theories that have been put forward as to the
origin of this atypical swallowing behavior must, of necessity, bc brief but
these theories are included as they shed some light on the clinical aspect. Rix,
in his original paper, suggested that the “teeth apart” swallow was a residual
infantile behavior and that maturation might be delayed in the presence of
\-ul,:me 42 BDVERSE MURCLE FORCES 807
‘V,,mbcr I I

upper respiratory obstruction and infection. Hc pointed out that with nasal
obstruction the “teeth together” swallowing is uncomfortable and that if
upper respiratory troubles were dealt with early the behavior might tend to
change. However, Gwynne-Evans and Ballard, in 1948, believed it to be an
infantile patt,ern of behavior due to some delay in maturation of ncuromus-
cular behavior at the cortical level and not related to upper respiratory in-
fections. They thought that a change could be encouraged by exercises and
appliances, such as the Andrcsen appliance, designed to provide the correct
sensory appreciation of the tongue acting in a rigid-walled cavity. The rc-
sults of this attempt at re-education were disappointing. Recent papers by
thcsc authors have shown some modification in the original theories, but Ris
maintains that there is a similarity between certain types of “teeth apart”
swallow and the infantile suckling behavior. Hc has shown that changes may

Fig. 8.-Diagram showing electromyographic results. A, Teeth together in swallowing,

strong masseteric contraction, and slight lip activity. B, Teeth apart in swallowing. very
little masseteric activity, strong lip activity. C.R.T., Cathode ray tube.

occur with orthodontic treatment. Gwynne-Evans holds the view that the
atypical swallowing behavior, with its peristaltic-like contraction of the cir-
cumoral muscles, is an expression of a “visceral type” of behavior, the muscles
of the fact occupying a developmental position between the somatic muscu-
lature controlled by the central nervous system and the visceral musculature
controlled by the autonomic nervous system. Ballard now believes that these
patterns of behavior are inherent and very resistant to change.
Using the electromyograph as evidence, I have studied a group of students
between 20 and 30 years of age.2” By recording from the masseter, it is pos-
sible to determine whether or not the teeth are placed together in swallowing.
The masseter muscle norrnally contracts strongly during the phase of the
 B.

Fig. 9.-Examples of chewing and swallowing crackrrs in the normal way, with teeth
together. (Electromyographic recor,ds.) A, Note strong masseteric contraction in swallow-
ing. B, Note alteration of circumoral and masscteric contraction in chewing. strong mas-
seteric activity in swallowing.

Fig. IO.-Examples of cases with malocclusion, swallowing without strong masseteric contrac-
tion but with excessive lip activity. (Electromyographic records. )
Volume 42
Nrrnber II
ADVERSE MUSCLE FORCES 809

mylohyoid contraction to hold the teeth in firm contact. By recording simul-

tancously from the group of circumoral muscles, it is also possible to illus-
trate the amount of lip activity (Fig. 8). Typical records for the “teeth to-
gether” swallow arc shown in Fig. 9. The masseterie contraction is marked
and the circumoral contraction is minimal. In Fig. 10, whcrc the teeth are
apart in swallowing, the masseteric contraction is slight compared with the
circumoral activity. The results of these investigations show that the “teeth
apart ’ ’ swallow is present in a large number of adults, particularly if they
hart any dcgrcc of malocclusion.

A. B.

Pig. Il.-Varying incisor inclinations resulting from abnormal soft tissue forces. A,. Close
adaptation of incisors with tendency to retroclination. B, Dispersal of incisor relatmns.

It is impossible to cover all aspects of atypical swallowing behavior here,

but among the whole range of variations described by Rix’$ in 1953, two
sharply contrasting types are recognizable :
S. Nondispersing behavior of tongue:
Those cases in which the tongue does not come forward to exert any
force on the lingual surface of upper and lower incisors. The lips
may or may not contract excessively. The upper and lower in-
cisors are upright or retroclincd (Fig. 11, A).
2. Dispersing behavior of tongue:
Those cases in which the actions of tongue and lips are associated
with a dispersal of upper and lower incisor relations (%‘ig. 11, l3).
In the film study, variations of these two themes are shown. Fig. 7 illus-
trates the effect of excessive contraction of the circumoral muscles in swallow-
ing, which must be a contributory factor in the lack of centrifugal devclop-
ment of the dental arches that is found in some Class I cases. The lips may
not be sealed at rest, but contract excessively when active. There is a par-
ticular type of Class I malocclusion with retroclination of upper and lowei
incisors and a deep overbite which is associated with the nondispersing action
of the tongue. The constricting effect of the lips is not counterbalanced by a.
forward spread of the tongue, which stays back in the mouth.
 810 TULLEY

Fig. lZ.-Soft tissue morphology and swallowing activity in Class II, Divisiotl 2 mal-
occlusion. Teeth well apart in sw4lowing. tongue does not thrust forward. lower lip acting
high on labial surface of l/l. (From Pringle : n. PractitioneT 6: 297, 1955.)

A. B. C’.
Fig. 13.-Types of Class II, Division 1 Malocclusion. A, With normal skeletal relation-
ship with occlusion Class II, Division 1. “Teeth apart” swallow with lower lip contraction
and tongue thrust. B, With Class 11 skeletal relationship (mandibular retrusion). “Teeth
apart” swallow with strong tongue thrust. C, Class II, Division 1 with “teeth together”
§wallow, lower lip not active-its position secondary to the jaw relationship. (From Pringle :
D. Pmctitioner 6: 297. 1955.)
Volume 42 ADVERSF: MUSCLE FORCES 811
Number I I

A similar type of behavior may be found in Class II, Division 2 maloc-

clusions and Rix refers to this as the “blunt tongue” swallow (Fig. 12). With
the tongue held back between the arches in this way, a cross-bite is rarely
seen. It does not necessarily follow that the lip activity is excessive, but there
is no forward tongue pressure on the incisor segments. Improvement in the
axial inclinations of incisors will depend on the possibility of modifying these
atypical forces.
In Class II, Division 1 malocclusions the action of the t,ongue and lower
lip may be responsible for the dispersal of the incisor relationship (E’ig. 13).
When this action is strongly adverse, the stability of the end result may be
jeopardized. If the relative position of the lower lip is changed by retraction
of the upper incisors, it may act on their labial surfaces to retain these teeth
but produce secondary effects on the lower incisors causing them to imbri-
cate.‘”

P‘ig. 14.-Maturation of facial expression accompanying orthodontic treatment. A, Age 9 :

B, age 23. (From Pringle: D. Prnctitiorcer 6: 297, 1955.)

Having explained some of the differences between muscular habits and

more fundamental innate muscle forces, there is another aspect to discuss
from the prognostic viewpoint, that is, the question of whether all these ab-
normal forces remain resistant to change because of their innate biologic back-
ground.
Ballard” has presented a rather pessimistic picture of the immutability of
some types of behavior. I agree with him up to a point, but we all see re-
markable changes taking place in the faces of our child patients as they grow
older (Fig. 14). We also notice remarkable changes in children when we do
no more than observe them. This is true of the child with lack of lip seal
where there is no interference of the incisors between the lips. In many of
t.hese cases the children arc not mouth breathers and improvement occurs
unless there is a major discrepancy between the length of the upper lip and
t,hat of the teeth and alveolus.
 TULLEY

The answer to many of these changes lies in the fulfillment of the growth
potential not only of the skclet,on, but of the soft tissues also, ant1 in thtl
maturation of the facial musculature which t,akes on the adult ‘~mask. ” With
the increasing worries of raising a family and of income tax, wc do not es-
pect to SW the same lax lip positions of childhood. With the tlesircl of th(l
young lady to appear attractive, WC (10 not SW the same “deadpan’ ’ face of
the preadolescent.
It is most important, in making a prognosis, to tlccide whether the MOI*-
phology and function of the soft tissues constitute such a dominant fa.ctor.
taken into consideration with the facial skeleton and the dentition, as to fornl
part of a tlcfinite facial type that cannot, t)c a.ppreciably changed (compare
L4 and B in Fig. 15).
J.W. TEETH IN OCCLUSION

A. B.

Fig. 15.-Diametrically opposite clinical types with associated facial skeleton! soft
tissue morphology and atypical behavior. A, Concave face with excessive retroclinatlon of
incisors and tense, active lips. No tongue thrust. B, Convex face with bimaxillary protru-
sion. proclined upper and lower incisors, flaccid lips, and thrusting tongue. From Pringle :
D. Practitioner 6: 297, 1955.)

In order to survey some of these problems, Gwynne-Evans and I arc

carrying out a serial study of treated and untreated cases using cinrfilm. This
is a study which must continue for a considerable time. Three main factors
are illustrated in the film :
1. Muscular habits than can be eliminated.
2. Modification in behavior with growth a.nd maturation, with special
referrnce to swallowing.
3. Fundamental patterns that arc unchangeable in both morphology
and function.
All these factors have to be taken into consideration in making a diag-
nosis and prognosis, and much of this can bc decided only on clinical experi-
ence. If, however, paGents are kept under observation and simple guiding
treatment for a time a.nd arc followed with serial cephalograms, as advocated
by Broadbent, a better assessment can be made of the need for active treat-
ment and its ultimate stable success.
 MUSCLE FORCES 813

Two main practical points emerge from this discussion. First, it is ap-
prcciatctl that with the multi-band technique the experienced orthodontist
can move teeth where he will and in rnany cases achieve stability, a sign that
t,hr muscle forces may be adaptable. However, if we are honest, we all have
a percentage of cases that are not stable even with prolonged retention. It is
toward a better understanding of these that this study is directed.
There is no doubt that Angle recognized these problcrns but would not
accept the fact that in certain cases they were insurmountable. In the ap-
pendix to the seventh edition of his Mwlocclusion of the Teeth, he st,ates: “We
arc just beginning to realize how common and varied are the vicious habits
of the lips and tongue, how powerful and persistent they are in causing and
rna.intaining malocclusion, how difficult they are to overcome.
“The period of retention of the teeth after they have been moved into
normal occlusion is one of the most important in treatrnent and so complicated
and persistent are the delicate forces that tend to derangement of the estab-
lished occlusion as to necessitate the most thoughtful consideration of the
problems involved and a degree of skill in overcoming them which much cx-
prricnce alone can develop, even among those with talent for the work.”
The second point is that I do not believe that swallowing behavior can
be changed by exercises alone unless it would have modified anyway with
routine treatment. Jt may be possible to train a child to swallow properly
when in the office and by conscious effort he will repeat it correctly every
time he comes, but he does not think every time he swallows during the day
and night,.

The role of the circumoral muscles in influencing tooth position has been
discussed. Emphasis has been placed on the necessity to distinguish between
bad muscular habits, which can be eliminated with treatment and exercises,
and the more innate behavior which may resist change. It is this subtle dif-
Sercnce which is so important in assessing stability of repositioned teeth. A
serial study by cinefilm has shown examples of habit elimination and the pcr-
sistencc of more basic behavior.’
My thanks are due Mr. R. E. Rix and Mr. K. E. Pringle, for their help and encour-
agement; Mr. E. Gwynne-Evans, with whom I have been privileged to work in the Upper
Respiratory Research United, Guy’s Hospital Medical School; Miss Treadgold, Mrs.
Rawlins, and Miss Whiteley, for the illustrations, and Mr. Colewell, for the acrylic ntodels.

REFERENCES

1. Angle, Edward H.: Malocclusion of the Teeth, Appendix to 7th edition, Philadelphia,
1907, S. S. White Dental Mfg. Co.
2. Ballard, C. F., and Gwynne-Evans, E.: Upper Respiratory Musculature and Ortho-
dontics, D. Record 68: 1, 1947.
3. Ballard, C. F.: Some Basis for Aetiology and Diagnosis in Orthodontics, Tr. European
Orthodont. Sot.. D. 27. 1948.
4. Ballard, C. F.: The *Facial Musculature and Anomalies of the Dento Alveolar Stmc-
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Brodie, A. G.: Facial Patterns, Angle Orthodontist 16: 1, 1946.
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9. Brodie, A. G.: Anatomy and Physiology of Head and Neck Musculat,ure, A&I. .J.
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Il. Brodie, A. 0.: Muscular Factors in the ljiagnosis and Treatment of JIaloeclusion,
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20. Rix, R. E.: Objectives, Presidential Aclclrers, Tr. European Orthodont. Sot., p. 13,
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21. Rogers, Alfred P.: Evolution, Development anal Application of Myofunctional Therapy
in Orthodontics. AM. .J. ORTIIOMNTICS ANI) ORAL HCRG. 25: 1. 1939.
22. Tulley, WT. J.: The Stu,lv of Anatomv in Relation to Dentistry, &it. 1). ,I. 92: 1, 1952.
23. Tullev, TV. J.: Methods of Recording Behaviour Patterns of the Orofacial Muscles
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24. Tuller. W. .J.: Proanosis and Treatment Plannine <j in Orthodontics, Brit. I). .I. 97:
55, 1954. -
25. Walther, D. P.: Skeletal Form and the Behaviour Patt,ern of Certain Orofacial
Muscles, Tr. European Orthodont. Roe., p. 55, 1954.
26. Whillis, .J. W.: Movements of the Tongue in Deglutition, Tr. Hrit. Sot. Stully Ortho-
dontics, p. 121, 1946.