Submitted: 07 February, 2024 Accepted: 21 May, 2024 Published: 03 September, 2024 DOI:10.22514/jocpd.2024.

100

S Y S T E M AT I C R E V I E W

Orthodontic treatment in patients with atypical

swallowing and malocclusion: a systematic review
Alessio Danilo Inchingolo1, *, Angelo Michele Inchingolo1 , Merigrazia Campanelli1 ,
Vincenzo Carpentiere1 , Elisabetta de Ruvo1 , Laura Ferrante1 , Andrea Palermo2 ,
Francesco Inchingolo1, *, Gianna Dipalma1

1
Department of Interdisciplinary Abstract
Medicine, School of Medicine, University
of Bari “Aldo Moro”, 70124 Bari, Italy
This review aimed to analyze the correlation between atypical swallowing and
2
College of Medicine and Dentistry malocclusions and how this dysfunction can be treated. The Preferred Reporting
Birmingham, 35233 Birmingham, UK Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed
to conduct this systematic review, and the protocol was registered at International
*Correspondence
[email protected]
Prospective Register of Systematic Reviews (PROSPERO) with the CRD42024499707.
(Francesco Inchingolo); A thorough search was conducted on PubMed, Scopus and Web of Science to find
[email protected] papers that discussed myofunctional and orthodontic treatment for patients with atypical
(Alessio Danilo Inchingolo) swallowing and malocclusion from 01 January 2003 to 27 November 2023. The
search yielded 2554 articles, of which only 12 records were selected for qualitative
analysis. The analysis of these articles revealed that orofacial myofunctional therapy,
criab appliance, Habit corrector™, and soft tongue restrainers are potential therapies for
treating atypical swallowing and malocclusions. The tongue’s position affects muscle
behavior, leading to malocclusions that can be treated with various therapies, resulting
in effective clinical outcomes. However, more research is required to delve deeper into
the topic.

Keywords
Atypical swallowing; Tongue thrust; Deglutition; Swallowing; Atypical deglutition;
Malocclusion; Orthodontics; Speech therapy; Logopedic

1. Introduction (absent in physiological conditions) [20, 32–48]. Tongue

thrust, along with lip sucking, nail and digit sucking, and
Swallowing is a complex physiological process involving bo- mouth breathing, from an oral habit behavior that results in
lus, saliva and liquids moving from the oral cavity to the a learned pattern of muscular contractions [17, 49–53].
stomach [1–3]. This essential function requires a sophisti-
cated neuromuscular mechanism activated by nerve impulses There are two types of AS: primary and secondary [51, 54].
transmitted by the sensory receptors of the tongue and lips Primary AS has a psychological cause and occurs when a child
[4, 5]. In infants, the tongue is positioned between the bone swallows in an infantile manner during emotionally significant
bases [6–9], while in adults, the tip of the tongue is located moments [55]. In severe cases, psychotherapy may be neces-
at the level of the retro-incisor papilla [10–12]. The transition sary, mainly if the child develops habits such as thumb-sucking
usually occurs gradually over 15 months, coinciding with tooth [5, 56–58]. Secondary AS is caused by external factors [17]
eruption [7, 8]. However, infantile swallowing may sometimes such as thumb sucking, nail biting, bruxism, excessive use of
persist when children have orofacial malformations, digit habit a pacifier [18], prolonged artificial feeding and weaning, short
behavior, airway compromise, or allergies [13–24]. This frenulum, hypertrophic adenoids and tonsils, allergic rhinitis,
condition is known as atypical swallowing (AS), a pathological the abnormal posture of the head, lower jaw, and tongue [16,
condition that occurs when there is no transition from infantile 59–71]. This habit is often associated with malocclusions, par-
to adult swallowing [25–27]. In AS, the tongue’s posture ticularly skeletal problems such as open bite, ante-inclination
is altered (Fig. 1), with the tongue’s tip touching the front of the upper jaw, and post-inclination of the mandibular plane
teeth’ palatal surface or between the dental arches rather than [52, 72], as well as dental issues such as diastema, protrusion
the palate. Additionally, the back of the tongue is curved of the maxillary incisors, increased overjet, and decreased
downwards [28, 29], and the base touches the back of the palate overbite [73–75]. Due to its complex etiology, high incidence,
and the anterior pharyngeal wall [30, 31]. and resulting dental-skeletal problems, AS is of interest from
This condition results in reduced contraction of the jaw an orthodontic standpoint [76, 77]. This literature review
elevator muscles and increased activity of the perioral muscles assesses the relationship between AS and malocclusion and

This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).

J Clin Pediatr Dent. 2024 vol.48(5), 14-26 ©2024 The Author(s). Published by MRE Press. www.jocpd.com
 15

F I G U R E 1. Tongue posture. (A) The physiologically correct resting position. (B) The normal swallowing position. (C) The
atypical swallowing position.

possible therapies [78–96]. 2. Materials and methods

The literature proposes various therapeutic approaches for
the early treatment of anterior open bites, which can have a This systematic review was conducted according to Preferred
dental or dentoalveolar origin or be of a skeletal type [97, 98]. Reporting Items for Systematic Reviews and Meta-Analyses
In most cases, both dental and skeletal characteristics are (PRISMA) guidelines. The protocol was registered with
present. Therapeutic modalities for early correction of an PROSPERO under CRD42024499707.
anterior open bite include functional, fixed, and removable A PubMed, Scopus and Web of Science search was con-
appliances [99–101]. Functional, fixed, and removable appli- ducted to find papers in English that matched the topic of my-
ances aim to prevent mechanical factors such as thumb-sucking ofunctional and orthodontic treatment in patients with AS and
or tongue thrusting from keeping the bite open and limit ex- malocclusion, ranging from 01 January 2003, to 27 November
cessive vertical growth of the craniofacial skeleton [102–105]. 2023. The search strategy utilized the following Boolean
Various orthodontic devices are available to treat AS. These keywords: (“atypical swallowing” OR “tongue thrust” OR
devices include the Fraenkel and Bionator, devices for eruption “deglutition” OR “swallowing” OR “Atypical deglutition”)
guidance, elastodontic appliances (Fig. 2), lingual spurs, fixed AND (“malocclusion” OR “orthodontics” OR “Speech ther-
lingual or palatal grids, speech therapy and myofunctional apy” OR “logopedic”) (Table 1).
therapy (MFT) [72, 106, 107]. The following criteria were considered for inclusion in the
study: (1) studies that examined the treatment of myofunc-
tional and orthodontic problems in patients with AS and den-
tal malocclusion; (2) randomized clinical trials, retrospective
studies, and case reports; (3) only English language studies;
and (4) full text.
Papers that did not meet these criteria were excluded. The
review was conducted using the PICOS criteria:
• Participants: Children of both genders without patholo-
gies or syndromes with AS and malocclusion who received
orthodontic treatment.
• Interventions: Orthodontic and myofunctional treatment.
• Comparisons: Pre- and post-treatment analysis of patients
F I G U R E 2. Elastodontic device for open bite. with AS and dental malocclusion.
• Outcomes: Treatment with orthodontic devices leads to a
more physiological lingual posture.
• Study: Randomized clinical trials, retrospective studies,
and case reports.

TA B L E 1. Database search indicators.

KEYWORDS: A: atypical swallowing; B: tongue thrust; C: deglutition; D: swallowing; E:
Atypical deglutition; F: malocclusion; G: orthodontics. H: speech therapy; I: logopedic.
Articles screening strategy
Boolean Indicators: (A OR B OR C OR D OR E) AND (F OR G OR H OR I)
Timespan: 01 January 2003 to 27 November 2023
Electronic databases: PubMed, Scopus, WOS
WOS: Web Of Science.
16

The study excluded animal and in vitro studies, off-topic - Bias due to post-exposure intervention.
works, reviews, letters, comments and non-English language - Bias due to missing data.
studies. - Bias arising from the measurement of the outcome.
Two reviewers, MC and VC, independently searched the - Bias in the selection of the reported results.
databases to gather relevant studies. These studies were then
evaluated based on specific selection criteria to rate their qual- 3. Results
ity. The chosen articles were saved in Zotero (version 6.0.15).
In case of any disagreements among the three authors, they An electronic database search found 2554 articles, including
were resolved through discussion with a senior reviewer (FI). 1183 from Scopus, 867 from PubMed, and 504 from Web of
Two reviewers, RF and EI, evaluated the quality of the Science. No articles were found through a manual search.
included papers using a tool called ROBINS. This tool is After removing duplicates, 1876 studies were screened by
designed to assess the risk of bias in non-randomized studies evaluating their title and abstracts, focusing on myofunctional
that compare the health effects of two or more interventions. and orthodontic treatment for patients with AS and malocclu-
They evaluated seven points and assigned a degree of bias to sion. Of the screened articles, 1863 did not meet the inclusion
each one. In case of a disagreement, a third reviewer (FI) until criteria (1857 were off-topic, and 6 were reviews), leaving 13
an agreement was reached. records to be selected. One non-retrieved record was excluded,
Here are the domains evaluated in the ROBINS tool: and 12 were chosen for qualitative analysis after reviewing
- Bias due to confounding. eligibility criteria. Fig. 3 illustrates the selection process, and
- Bias arising from the measurement of exposure. Table 2 summarizes the selected records.
- Bias in the selection of participants in the study.

F I G U R E 3. Below are the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow
diagram and indicators of database search.
 TA B L E 2. Descriptive summary of items selection.
Authors Study Number of patients Average age/gender Treatment and duration Outcomes
design
MFT to correct AS.
Di vecchio et Clinical trial 370 --- This study outlines a clinical protocol using the
9–12 months
al. [108] 2019 Froggy Mouth, a myofunctional device created to
correct AS.
13 years MFT to correct AS.
Manzoor et Case report 1 The treatment involves identifying and removing
Male (M) 6 months
al. [109] the root cause, performing retraining exercises,
2023 and using mechanical restraints if necessary.
9–11 years MFT to correct AS.
Quinzi et al. Clinical trial 40 Evaluate the impact of a functional device on
16 M–24 female (F) 6 months
[110] 2020 facial expressions and lip strength in individuals
with AS.
15–23 years MFT to correct AS.
Begnoni et al. Clinical trial 15 The effects of MFT on muscle function and
7 M, 8 F 10 weeks
[111] 2020 behavior in a group of patients with AS who have
completed their second dentition.
7.1–10.6 years
Van Dyck et Clinical trial 22 The study group was subjected to orofacial OMT can help improve tongue posture. Any
11 M, 11 F
al. [112] 2016 myofunctional therapy (OMT), and tongue interaction between OMT and expansion can
elevation was measured with the Iowa Oral have a positive impact.
Performance Instrument (IOPI) system—a
6-month treatment.
Taslan et al. Clinical trial 19 7–12 years A study was conducted on 13 children using a The crib appliance conditioned tongue pressure,
[113] 2010 crib appliance to measure tongue pressure during and the study group showed a significant open
rest and swallowing over 12 months, utilizing a bite closure by the end of the treatment.
diaphragm-type pressure transducer.
9 years
Anoop et al. Case report 1 A soft tongue restraint was inserted, and the With good patient compliance, a soft tongue
F
[114] 2020 patient was recalled for monthly follow-up restrainer can correct an open bite by allowing
treatment for six months. the upper front teeth to erupt.
Group 1:
6.37 years
50
10 M, 15 F;
Condò et al. Clinical trial Group 1 = 25 All patients were treated with the Habit Early treatment with Habit Corrector™ produced
Group 2:
[115] 2012 Group 2 = 25 Corrector™ for 12 months due to their AS, which better results in patients with primary dentition
9.19 years
caused an anterior dentoalveolar open bite. and the first phase of mixed dentition than in the
12 M, 13 F
late phase.

17
 18
TA B L E 2. Continued.
Authors Study Number of patients Average age/gender Treatment and duration Outcomes
design

Lim et al. Retrospective 28 The patients underwent 18.14 ± 9.04 months of Bio-exercise and removable orthodontic
[116] 2022 study 8.41 ± 1.45-year-old, BioEx therapy, which included lip and tongue appliances effectively increased tongue length
13M, 15F training and tongue elevators. and height between T0 and T1 .
5–17 years
Saccomanno Clinical trial 23 All patients showed AS, and 16 underwent rapid Orthodontic therapy is highly effective in treating
10 M, 13 F
et al. [117] palatal expansion treatment followed by speech bad habits when combined with speech therapy.
2012 therapy, while 7 patients received only speech Muscle analysis using a dynamometer and
therapy. surface electromyography has yielded significant
results.
9.46 ± 1.60 years
Ciavarella et Retrospective 24 The patients who had hyper-divergent Class II Radiographs before and after treatment revealed a
16 M, 8 F
al. [118] 2014 study malocclusion with mandibular retrusion and AS significant increase in tongue length and height,
were treated with swallowing occlusal contact improving tongue position and airway space.
intercept appliance for 24 months.
MFT group:
45 8.4 years
MFT group = 19 15 M, 4 F
Korbmacher Clinical trial The MFT group received treatment from The FFT group exhibited a notable enhancement
FFT (Face Former FFT group:
et al. [119] speech/language pathologists, while the FFT in the palatal tongue position during swallowing,
Therapy) group = 26 8.3 years
2004 group underwent tongue and lip exercises using a and the improvement was statistically significant.
17 M, 9F
training device called Face Former (Akkuphon®,
Unna, Germany) for 6 months.

MFT: myofunctional therapy; AS: atypical swallowing; IOPI: Iowa Oral Performance Instrument.
 19

The level of risk of bias in the studies included in the analysis malocclusions such as overlapping, rotation, or spacing. This
is presented in Fig. 4. Most studies indicate a high risk of problem can occur mainly during childhood and adolescence,
confounding bias, while the risk of measurement bias is low. critical periods for dental arch development. Identifying and
The selection of participants in most studies has a low risk of correcting inappropriate lingual posture early on prevents or
bias, while the bias due to post-exposure cannot be calculated treats malocclusion. This can be achieved through myofunc-
due to the high heterogeneity. The risk of bias due to missing tional therapies, orthodontic devices, and other strategies that
data is low in many studies. The measurement bias of the promote correct lingual posture and better dental occlusion
outcome is low, but the selection bias of the reported results [29, 120]. AS is prevalent among both adults and children [77,
is high in most studies. Finally, the analysis indicates that six 121]. This literature review aims to evaluate the relationship
studies have a low risk of bias, 10 have a high risk of bias, two between AS and malocclusion and possible therapies.
have a very high risk of bias, and the remaining studies have a
In 2019, Di Vecchio et al. [108] assessed the treatment
questionable risk of bias.
of swallowing through orthodontic appliances combined with
speech therapy [108, 122–124]. They introduced a clinical
4. Discussion protocol that uses the innovative myofunctional device, Froggy
Mouth (Fig. 5), designed to correct AS. The device was used
Incorrect tongue posture can have a significant impact on mal- for 15 minutes daily for 9–12 months on 370 young patients.
occlusion development. When the tongue is not positioned cor- After this period, correction of the AS was observed. In 2020,
rectly, it can affect the alignment of teeth and facial structures. Quinzi et al. [110] also studied the effects of the Froggy
For instance, a tongue continuously pressing against the teeth Mouth device on 40 patients with AS. They also looked at
can push the dental arches into incorrect positions, leading to lip strength and altered facial expressions. The myofunctional

F I G U R E 4. Bias assessment.
20

device proved effective in treating AS and correcting facial

expressions and lip incompetence [110, 125–127].

F I G U R E 6. A tongue crib appliance with an acrylic ball

is needed for AS correction.

F I G U R E 5. Froggy mouth device.

In 2015, Van Dyck et al. [112] analyzed OMT for the early
treatment of anterior open bite. The study included 22 patients
randomly divided into two groups, with one group receiving
OMT and the other not. The therapy improved tongue posture,
but no significant differences were found in the expansion [98,
112, 128–130].
Manzoor et al. [109], in 2023, proposed a device to correct
the AS of a 13-year-old boy with a class I occlusion and open
bite [125, 131–133]. The apparatus comprises a two-band
grid (Fig. 6) with an acrylic ball in the center welded onto the
molars. The ball keeps the tongue away from the front teeth. F I G U R E 7. Example of tongue crib appliance.
After 6 months of therapy, the open bite was resolved.
Begnoni et al. [111] (2020) studied 15 patients with AS
treated with myofunctional devices. Electromyography was
used to analyze the therapy’s effects on patients between the
ages of 15 and 23—using standardized protocols led to a sig-
nificant improvement in the functionality of the oral muscles
[111, 134–136].
Taslan et al. [113] (2015) controlled tongue pressure with
a diaphragm-type pressure transducer in a study group of 13
children during 12 months of treatment with a crib appliance
(Fig. 7) and in a control group of 6 children. Patients with
AS have lower tongue strength. Pressure tongue results are
conditioned by crib treatment [30, 43, 67]. Open bite closure
has significant and significant value for the study group [30,
43, 66]. F I G U R E 8. Soft tongue restrainer.
In 2020, Anoop and colleagues demonstrated that the soft
tongue restrainer (Fig. 8) had better compliance than crib
appliances (Fig. 7). They also showed that the upper front Habit Corrector™ (Fig. 9) in treating AS with open bite. The
teeth could be successfully supra-erupted to close an open bite, study examined patients in primary dentition, the first phase
resulting in positive clinical outcomes. However, it should be of mixed dentition, and the late phase. Habit Corrector™ is
noted that this study was a case report conducted on a 9-year- a removable appliance designed to correct dental and skeletal
old girl, and therefore, the results may not be generalized to malocclusions in children [9, 141–143]. The study found that
other populations [52, 114, 137–140]. early treatment with Habit Corrector™ during the last phase
of primary dentition and the first phase of mixed dentition was
Condò et al. [115] conducted a study to evaluate the ef-
more effective in restoring physiological occlusion and growth
fectiveness of an orthodontic and endodontic appliance called
 21

compared to the late phase of mixed dentition [11, 115, 144, treatment on cephalometric evaluation revealed an increase in
145]. tongue length and height, supporting the repositioning of the
tongue from a lower posture to a physiological position onto
the palatal spot [118, 157, 158].

F I G U R E 9. Habit Corrector device. F I G U R E 1 0. Face Former device used in FFT.

All treatment approaches aim to strengthen orofacial tissues,

promote nasal breathing, and establish a normal swallowing
pattern [146–149]. In young children, Face Former Therapy
(FFT) is more effective than MFT in treating functional dis-
orders such as AS and tongue thrust. The training device
(Face Former, Akkuphon®, Unna, Germany) used in FFT
resulted in a statistically significant improvement in palatal
tongue position while swallowing (Fig. 10). The FFT group
achieved habitual mouth closure in less time than the MFT
group [119, 150].
Lim et al. [116] demonstrated the importance of retraining
the tongue muscles to learn the most physiologically har-
monious resting position and stabilizing that position with
tongue elevators and lip and tongue exercises [116, 151, 152].
Orofacial myofunctional disorders are diseases or behaviors
that adversely impact oral posture and activities. Throughout F I G U R E 11. Swallowing occlusal contact intercept
history, interest has focused on horizontal behaviors, partic- appliance.
ularly tongue thrusts [48, 84–86]. The lateral cephalograms
were analyzed for tongue posture changes before and after The following discussion focuses on different therapies and
treatment, and the results showed that tongue elevators com- devices used to treat AS and their implications for correcting
bined with lip and tongue exercises increased the tonicity of malocclusion. Various studies have examined the effectiveness
the tongue muscles, resulting in a more normalized tongue. of other devices, such as the “Froggy Mouth,” lingual grills,
Additionally, tongue length and height increased statistically lingual restraints, and eruption guides, in correcting AS and
significantly between pre- and post-treatment [116]. related problems. These therapies have significantly improved
Saccomanno et al. [117] treated AS patients with incorrect lingual posture, oral muscle strength, and occlusion param-
tongue positioning and palate contraction with rapid palatal eters. Additionally, combined orthodontics and myofunc-
expansion followed by speech therapy [117, 130]. Short lin- tional therapy have shown promising results in treating AS
gual fraenum, hypertrophy of adenoids, tonsils, turbinates, and improving orofacial function. However, further research is
and allergic rhinitis were all removed as potential limitations necessary to evaluate the long-term efficacy of these therapies
to therapy effectiveness. The orbicular muscle force was and to identify the best treatment for patients with AS and
measured using a dynamometer before and after treatment, malocclusion.
tongue thrust was assessed using fluorescein coloring, and
the orofacial muscles were electromyographically examined. 5. Conclusions
Orthodontic therapy and myofunctional treatment produced
significant results in muscle analysis using a dynamometer and Abnormal swallowing, also known as atypical swallowing,
surface electromyography [117, 153–156]. occurs when the tongue or other muscles in the mouth are
Ciavarella et al. [118] demonstrated that using a swallowing not positioned correctly during the swallowing process. This
occlusal contact intercept appliance (Fig. 11) for 16 hours per can include the tongue touching the front teeth instead of the
day for 24 months in AS patients improved tongue position and roof of the mouth or excessive movement of the tongue during
the superior posterior airway space, resulting in enhanced deg- swallowing. These abnormal muscle movements can apply
lutition, phonation, and respiratory function. The data pre-post constant or undue pressure on the teeth and surrounding struc-
22

tures during swallowing, which can affect the development and CONFLICT OF INTEREST
alignment of the teeth. This can lead to malocclusions such as
The authors declare no conflict of interest.
overlapping, spacing, rotation, or tooth misalignment. There-
fore, atypical swallowing can potentially cause malocclusions
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