A Cineradiographic Study of Deglutitive Tongue Movement and Nasopharyngeal Closure in Patients with Anterior Open Bite
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1 Originl Article A Cinerdiogrphic Study of Deglutitive Tongue Movement nd Nsophryngel Closure in Ptients with Anterior Open Bite Ttsuy Fujiki, DDS, PhD ; Teruko Tkno-Ymmoto, DDS, PhD b ; Hruhiro Noguchi, DDS, PhD ; Tkshi Ymshiro, DDS, PhD ; Guoqing Gun, DDS, PhD c ; Keiji Tnimoto, DDS, PhD d Abstrct: The purpose of this study ws to investigte the movement of the tip nd the dorsl surfce of the tongue during deglutition in ptients with nterior open bite using cinerdiogrphy. The subjects were 10 femle ptients with nterior open bites nd 10 femle controls with norml overbites. By cinerdiogrphy we estblished 7 stges of tongue movement nd bolus position during deglutition nd nlyzed the tongue position, tongue movement nd the time. The tongue-tip position ws more protrusive during deglutition in nterior open bite thn in the controls. After the hed of the bolus rrived t the opening of the esophgus, the rer prt of the dorsl surfce of the tongue demonstrted slower movement in ptients with nterior open bite thn in controls. The nsophrynx closed erlier in ptients with nterior open bite thn in controls. It is suggested tht nterior open bite ptients hd compenstory coordintion of tongue movement, soft plte movement nd phryngel constrictor muscle ctivity during deglutition. (Angle Orthod 2000;70: ) Key Words: Deglutition; Tongue; Open bite; Cinerdiogrphy INTRODUCTION Most ptients with nterior open bite hve tongue-tip protrusion during deglutition. 1 4 Some investigtors hve suggested tht such protrusion is cuse of the nterior open bite. 4 6 Others, however, hve suggested tht tonguetip protrusion during deglutition is result of functionl dpttion to n nterior open bite. 1 3 Thus, there hs been long-stnding controversy bout the reltionship between nterior open bite nd deglutition. 1 6 Deglutition is very bsic nd importnt function nd is complex ction involving multiple ntomicl struc Assistnt Professor, Deprtment of Orthodontics, Okym University Dentl School, Okym, Jpn. b Professor nd Chirmn, Deprtment of Orthodontics, Okym University Dentl School, Okym, Jpn. c Postdoctorl Reserch Fellow of Jpn Society for Promotion of Science (JSPS), Deprtment of Orthodontics, Okym University Dentl School, Okym, Jpn. d Professor nd Chirmn, Deprtment of Orl nd Mxillofcil Rdiology, Hiroshim University School of Dentistry, Hiroshim, Jpn. Corresponding uthor: Professor Teruko Tkno-Ymmoto, DDS, PhD, Deprtment of Orthodontics, Okym University Dentl School, Shikt-Cho, Okym City, Okym , Jpn (e-mil: t ymmo@dent.okym-u.c.jp). Accepted: Jnury Submitted: September by The EH Angle Eduction nd Reserch Foundtion, Inc. tures. 7,8 Tongue movement is prticulrly importnt in deglutition. However, in orthodontic prctice, pplinces such s the tongue crib 9,10 nd myofunctionl therpy 11,12 hve often been pplied with considertion of the tongue-tip position only, without considering the movement of the dorsl surfce of the tongue nd the tongue s deglutition function The purpose of the present study ws to investigte the movements of the tongue tip nd dorsl surfce of the tongue during deglutition in ptients with nterior open bite by use of cinerdiogrphy. Furthermore, during the swllowing ction in nterior open bite ptients bolus movement nd nsophryngel closure were evluted by time mesurement. MATERIALS AND METHODS Subjects The subjects were 10 femle ptients (ges 15 to 24) with nterior open bites nd 10 femle controls (ges 23 to 24) with norml overbites. The ptients with nterior open bite hd definite seprtion between the upper nd lower incisl edges when mesurements were mde reltive to the occlusl plne. 13 Cephlometric mesurements of the nterior open bite subjects showed n overbite rnging from 0.5 to 8.1 mm (men 2.9 mm) nd n overjet rnging 284
2 CINERADIOGRAPHY IN PATIENTS WITH ANTERIOR OPEN BITE 285 from 0.2 to 7.0 mm (men 3.0 mm). The controls hd n overbite rnging from 0.8 to 5.2 mm (men 2.8 mm) nd n overjet rnging from 1.6 to 5.0 mm (men 3.2 mm). Cinerdiogrphy A led mrker ws fixed t the tongue tip, nd brium pste (Fushimi Phrmceuticl Co Ltd, 100 wt/vol, Brytgensol, Kgw, Jpn) ws pplied to the nsl phrynx of ech subject. Ech subject ws seted on chir turned prllel to the fce of the imge intensifier nd her hed ws stbilized in cephlostt ttched to the chir. Ech subject ws sked to swllow 10 ml of liquid brium diluted 10% (wt/vol) with wter, while looking t her eyes in mirror in front of her. Cinerdiogrphic recordings were obtined t kev with 9-inch intensifier (Shimdzu Corportion, DIGITEX2400UX, Kyoto, Jpn) nd pproprite collimtion so tht lterl imge of the entire mouth nd phrynx could be obtined. The cinerdiogrphic imge ws recorded on 35 mm imging film (Fuji Film, MI- CF, Tokyo, Jpn) t 30 or 60 frmes per second. These swllowing events were recorded 3 times. The cinerdiogrphic imge ws nlyzed in slow motion nd by single-frme nlysis using the plybck cpbility of Cinengio-projecter (ELK, CAP35B, Aichi, Jpn). We estblished the following 7 stges of deglutition: stge 1, contct of the tongue tip with the mxillry incisors nd/or the pltl mucos; stge 2, loss of contct of the dorsl tongue with the soft plte; stge 3, pssge of the bolus hed cross the posterior/inferior mrgin of the rmus of the mndible; stge 4, pssge of the bolus hed through the opening of the esophgus; stge 5, pssge of the bolus til through the point below the posterior nsl spine (PNS); stge 6, pssge of the bolus til cross the posterior/inferior mrgin of the rmus of the mndible; nd stge 7, pssge of the bolus til through the opening of the esophgus. By modifiction of orl nd phryngel trnsit times, 14 we mesured the times between ech stge nd the times from ech stge to closure of the nsophrynx. Furthermore, cinerdiogrphic imges were trced, nd the liner mesurements were nlyzed t severl stges (Figure 1). As deglutitive tongue movements were highly vrible mong different individuls, 8 the dt ws recorded 3 times in ech subject nd verged. One investigtor performed ll of the trcings nd mesurements. To evlute intr-exminer error in trcing nd mesurements, 1 frme of cinerdiogrphy ws trced nd mesured twice during deglutition in ech subject on 2 seprte occsions t lest 1 month prt. The method error ws determined by Dhlberg s formul, ME d 2 /2n where n is the number of subjects nd d is the difference between 2 mesurements of pir. The method error did not exceed The dt of liner nd time mesurements were compred between the ptients with nterior open bite nd the FIGURE 1. Stndrd points nd liner mesurements. Stndrd points were AP, the boundry point between the upper centrl incisor nd pltl mucos; E, the point nerest to tongue bse in the contct region between tongue nd pltl mucos; ANS, the most nterior point of the mxill t the level of the plte; PNS, the most posterior point on the bony hrd plte; MP, the point t which the line crossing t right ngle to the pltl plne (through ANS nd PNS) through the middle point between ANS nd PNS intersects the pltl mucos; MT, the point t which the line crossing t right ngle to the pltl plne through the middle point between ANS nd PNS intersects the dorsl tongue; MS, the point t which the line crossing t right ngle to the pltl plne through the middle point between ANS nd PNS intersects the stndrd plne (pssing the edge of the mxillry incisor nd prllel to the pltl plne); PP, the point t which the line crossing t right ngle to the pltl plne through PNS intersects the pltl mucos; PT, the point t which the line crossing t right ngle to the pltl plne through PNS intersects the dorsl tongue; PS, the point t which the line crossing t right ngle to the pltl plne through PNS intersects the stndrd plne; Me, the lowest point on the symphysel outline of the chin; C1, the front most point of the tls; D, the point t which the line through Me nd C1 intersects the dorsl tongue; I, the edge point of the mxillry incisor; nd Ti, the tongue-tip point. Liner mesurements were the following: () Contct of tongue nd plte, AP E/AP PP; (b) Front prt of dorsl tongue, MP-MT/MP-MS; (c) Middle prt of dorsl tongue, PP-PT/PP-PS; (d) Rer prt of dorsl tongue, C1-D/C1-Me; nd (e) Tongue tip, P -Ti/PS-I. AP E nd AP PP re distnces on the pltl mucos. MP-MT, MP-MS, PP- PT, PP-PS, C1-D, C1-Me, nd PS-I re stright distnces. P -Ti is the shortest distnce from the line crossing t right ngle to the pltl plne through PNS to Ti. controls by the Mnn-Whitney U-test. The chnges in vlues of liner mesurements were compred between severl stges in ech subject by the Wilcoxon signed rnk test. RESULTS The vlues of liner mesurements The liner mesurement of tongue tip in ptients with nterior open bite ws mm/mm t the stge t which the dorsl surfce of the tongue lost contct with the soft plte (stge 2), mm/mm t the stge of the bolus hed pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 3) nd mm/mm t the stge of the hed of the bolus pssing through the opening of the esophgus (stge 4) (Tbles 1 through 3). These dt were significntly greter for the ptients with nterior open bite thn for the controls. Thus, the tongue-tip position in the ptients with nterior open bite ws more protrusive thn tht of the controls. The other vlues of liner mesurements were not significntly different between ptients with nterior open bite nd controls (Tbles 1 through 3).
3 286 FUJIKI, TAKANO-YAMAMOTO, NOGUCHI, YAMASHIRO, GUAN, TANIMOTO TABLE 1. Liner Mesurements t Stge 2 Stge 2 Control Anterior Open Bite Contct of tongue nd plte Front prt of dorsl tongue Middle prt of dorsl tongue Rer prt of dorsl tongue Tongue tip Vlues re mens SD (mm/mm). ** P.01; nterior open bite ptients vs controls. TABLE 2. Liner Mesurements t Stge ** Stge 3 Control Anterior Open Bite Contct of tongue nd plte Front prt of dorsl tongue Middle prt of dorsl tongue Rer prt of dorsl tongue Tongue tip Vlues re mens SD (mm/mm). * P.05; nterior open bite ptients vs controls. TABLE 3. Liner Mesurements t Stge * Stge 4 Control Anterior Open Bite Contct of tongue nd plte Front prt of dorsl tongue Middle prt of dorsl tongue Rer prt of dorsl tongue Tongue tip Vlues re mens SD (mm/mm). * P.05; nterior open bite ptients vs controls * Chnges in vlues of liner mesurements In both nterior open bite ptients nd controls, the degree of contct between tongue nd plte ws significntly lrger t: (A) the stge of the hed of the bolus pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 3) thn t the stge of the dorsl tongue losing contct with the soft plte (stge 2) nd, (B) the stge of the bolus hed going through the opening of esophgus (stge 4) thn t the stge of the bolus hed pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 3) (Figure 2). In ptients with nterior open bite nd in controls, the front prt of the dorsl surfce of the tongue ws significntly smller: (A) t the stge of the bolus hed pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 3) thn t the stge of the dorsl tongue losing contct with the soft plte (stge 2), nd (B) t the stge of the bolus hed going through the opening of the esophgus (stge 4) thn t the stge of the bolus hed pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 3) (Figure 2b). In ptients with nterior open bite nd in controls, the middle prt of the dorsl tongue ws significntly smller t the stge of the bolus hed going through the opening of the esophgus (stge 4) thn t the stge of the bolus hed pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 3) (Figure 2c). In ptients with nterior open bite nd in controls, the rer prt of the dorsl tongue ws significntly lrger t the stge of the bolus hed pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 3) thn t the stge of the dorsl tongue losing contct with the soft plte (stge 2), nd significntly smller t the stge of the bolus til pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 6) thn t the stge of the bolus til going through the point below the PNS (stge 5). Furthermore, the rer prt of the dorsl tongue in controls ws significntly smller t the stge of the bolus til going through the point below the PNS (stge 5) thn t the stge of the bolus hed going through the opening of the esophgus (stge 4), lthough ptients with nterior open bite showed no chnge for this period (Figure 2d). In other words, in the ptients with nterior open bite the vlue of the rer prt of the dorsl surfce of the tongue begn to decrese in size fter the stge of the bolus til going through the point below the PNS (stge 5), but in the controls the vlue of the rer prt of the tongue begn to decrese fter the stge of the bolus hed going through the opening of esophgus (stge 4). These findings indicte tht the rer prt of the dorsl tongue in the nterior open bite ptients hd slower movement thn in controls fter the stge of the bolus hed going through the opening of the esophgus (stge 4). Vlues of time mesurements There ws no significnt difference between ptients with nterior open bite nd controls for the time between ech stge (Tble 4). The times of nsophryngel closure in the ptients with nterior open bite were months from the stge of the dorsl tongue losing contct with the soft plte (stge 2), months from the stge of the bolus hed pssing cross the posterior/inferior mrgin of the rmus of the mndible (stge 3), months from the stge of the bolus hed going through the opening of the esophgus (stge 4), nd months from the stge of the bolus til pssing through the point below PNS (stge 5) (Tble 5). These times were significntly smller for the ptients with nterior open bite thn for the controls. Thus, nsophryngel closure ws erlier in ptients with nterior open bite thn in controls. DISCUSSION Recently, Schwestk-Polly et l 15 showed tht n orthodontic pplince with spikes influenced tongue movement during swllowing in ptient with nterior open bite. Furthermore, Yshiro nd Tkd 16 indicted tht the electromyogrphic pttern of genioglossus muscle c-
4 CINERADIOGRAPHY IN PATIENTS WITH ANTERIOR OPEN BITE 287 FIGURE 2. Chnges in vlues of liner mesurements t stges 2, 3, 4, 5, nd 6. () contct of tongue nd plte; (b) front prt of dorsl tongue; (c) middle prt of dorsl tongue; (d) rer prt of dorsl tongue; nd (e) tongue tip. Vlues re men SD (mm/mm) in nterior open bite ptients,, nd controls. *P.05, **P.01 Stge 2 vs stge 3, stge 3 vs stge 4, stge 4 vs stge 5, nd stge 5 vs stge 6. TABLE 4. The Time between 7 Stges Stge Control Anterior Open Bite Vlues re mens SD (ms) tivity during deglutition dpted for orthodontic chnge of occlusl form for the nterior open bite. Although these reports 15,16 showed only 1 cse, it ws obvious tht occlusl form nd deglutitive tongue movement were relted to ech other. Deglutitive tongue movements re importnt in swllowing events. 7,17,18 In norml swllowing, the tongue tip nd sides re in contct with the lveolr ridge, nd the center TABLE 5. The Time from Ech Stge to Nsophryngel Closure Stge Control Anterior Open Bite Vlues re mens SD (ms). * P.05; nterior open bite ptients vs controls * * * * portion of the tongue sequentilly elevtes from front to bck. 14 However, in most nterior open bite ptients, the tongue tip protrudes without contct with the lveolr ridge during deglutition. 1 4 Khrils et l 17 suggested tht it ws importnt for tongue tip nd sides to sel ginst the lveolr ridge during deglutition nd tht the sel ws relted to the motions of the center portion of the tongue during
5 288 FUJIKI, TAKANO-YAMAMOTO, NOGUCHI, YAMASHIRO, GUAN, TANIMOTO deglutition. In the present study, the nterior open bite ptients not only hd tongue-tip protrusion, but lso slower movement in the rer prt of the dorsl tongue fter the stge of the bolus hed going through the opening of the esophgus. The movements of the rer prt of the dorsl surfce of the tongue my hve chnged with tongue-tip protrusion during deglutition. Tongue movements during deglutition re ctully only up nd down movements of ech region on the tongue. 17 These tongue movements cuse bolus propulsion. 7,17,18 In this study, the rer prt of dorsl tongue in ptients with nterior open bite showed slower movement thn the controls fter the stge of the bolus hed going through the opening of the esophgus. Therefore, we speculte tht bolus movement in ptients with nterior open bite becomes slower thn norml fter the stge of the bolus hed going through the opening of the esophgus. However, the time of bolus movement between stges ws not significntly different between the controls nd nterior open bite ptients. Bolus propulsion is lso ided by phryngel constrictors, 7,17,18 hypophryngel suction, 18 nd upper esophgel sphincter opening 19 ; lthough the tongue movement is the min propulsion for bolus trnsport. 7,18 Tken together, the present findings suggest tht bolus propulsion in ptients with nterior open bite is mde minly by phryngel constrictors, hypophryngel suction, nd upper esophgel sphincter opening. Nsophryngel closure during deglutition consists of both elevtion of the soft plte nd dduction of the superior phryngel constrictor muscle. 20 The pttern of nsophryngel closure during deglutition is different from tht in speech 21 nd belching. 20 In our study, the nsophrynx closed significntly erlier in the ptients with nterior open bite thn in the controls. Therefore, the pttern of nsophryngel closure during deglutition in nterior open bite ptients my be different from tht in controls in terms of coordintion of the soft plte nd the superior phryngel constrictor muscle. The phryngel constrictor muscle is involved not only in nsophryngel closure, 20 but lso in bolus propulsion during deglutition. 7,17,18 In our study, bolus propulsion in the nterior open bite ptients might hve occurred minly by the ction of the phryngel constrictor muscle, hypophryngel suction, nd upper esophgel sphincter opening; however, the min bolus propulsion in the controls ws tongue movement. Therefore, erlier closure of nsophrynx during deglutition my indicte compenstory function by the phryngel constrictor muscle for bolus propulsion in ptients with nterior open bite. During deglutition, ptients with nterior open bite showed tongue-tip protrusion, slower movement of rer prt of dorsl tongue, nd erlier closure of nsophrynx. These coordinted motions of tongue, soft plte, nd phryngel constrictor muscle my be compenstory or dptive functions in the cse of nterior open bite. Further investigtion is necessry to determine whether the compenstory or dptive functions shown during deglutition in our study chnge with the improvement of the nterior open bite by orthodontic tretment. CONCLUSIONS Anterior open bite ptients showed tongue-tip protrusion, slower movement of rer prt of dorsl tongue, nd erlier closure of nsophrynx compred with controls during deglutition. These results suggest tht ptients with nterior open bite hd compenstory coordintion of tongue nd soft plte movements during deglutition. ACKNOWLEDGMENTS This work ws supported by Grnt-In-Aid for Scientific Reserch from the Ministry of Eduction, Science nd Culture of Jpn ( , ). REFERENCES 1. Subtelny JD, Subtelny JD. Orl hbits study in form, function, nd therpy. Angle Orthod. 1973;43: Subtelny JD. Mlocclusions, orthodontic corrections, nd orofcil muscle dpttion. Angle Orthod. 1970;40: Clell JF. Deglutition: study of form nd function. Am J Orthod. 1965;51: Tulley WJ. Adverse muscle forces their dignostic significnce. Am J Orthod. 1956;42: Kydd WL, Akmine JS, Mendel RA, Krus BS. Tongue nd lip forces exerted during deglutiton in subjects with nd without n nterior open bite. J Dent Res. 1963;42: Hovell JH. Recent dvnces in orthodontics. Brit Dent J. 1955; 98: Ergun GA, Khrils PJ, Lin S, Logemnn JA, Hrig JM. Shpe, volume, nd content of the deglutitive phryngel chmber imged by ultrfst computerized tomogrphy. Gstroenterology. 1993;105: Gy T, Rendell JK, Spiro J, Mosier K, Lurie AG. Coordintion of orl cvity nd lryngel movements during swllowing. J Appl Physiol. 1994;77: Cuebs JO. Nonsurgicl tretment of skeletl verticl discrepncy with significnt open bite. Am J Orthod Dentfcil Orthop. 1997;112: Hung GJ, Justus R, Kennedy DB, Kokich VG. Stbility of nterior openbite treted with crib therpy. Angle Orthod. 1990;60: Andrinopoulos MV, Hnson ML. Tongue-thrust nd the stbility of overjet correction. Angle Orthod. 1987;57: Hrden J, Rydell CM. A study of chnges in swllowing hbit resulting from tongue thrust therpy recommended by R.H. Brrett. Int J Orthod. 1984;22: Subtelny JD, Skud M. Open-bite: dignosis nd tretment. Am J Orthod. 1964;50: Logemnn JA. Mnul for the Videofluorogrphic Study of Swllowing. 2nd ed. Austin, Tex: Pro-ed; Schwestk-Polly R, Engelke W, Hoch G. Electromgnetic rticulogrphy s method for detecting the influence of spikes on tongue movement. Eur J Orthod. 1995;17: Yshiro K, Tkd K. Tongue muscle ctivity fter orthodontic tretment of nterior open bite: cse report. Am J Orthod Dentofcil Orthop. 1999;115: Khrils PJ, Lin S, Logemnn JA, Ergun GA, Fcchini F. Deglu-
6 CINERADIOGRAPHY IN PATIENTS WITH ANTERIOR OPEN BITE titive tongue ction: volume ccommodtion nd bolus propulsion. Gstroenterology. 1993;104: Dejeger E, Pelemns W, Ponette E, Vntrppen G. Effect of body position on deglutition. Dig Dis Sci. 1994;39: Cook IJ, Dodds WJ, Dnts RO, et l. Opening mechnisms of the humn upper esophgel sphincter. Am J Physiol. 1989;257: G748 G Du K, Shker R, Ren J, Arndorfer R, Hofmnn C. Mechnism nd timing of nsophryngel closure during swllowing nd belching. Am J Physiol. 1995;268:G1037 G Shprintzen RJ, Lencione RM, McCll GN, Skolnick ML. A threedimensionl cinefluoroscopic nlysis of velophryngel closure during speech nd nonspeech ctivities in normls. Cleft Plte J. 1974;11:
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