Art-4-4-2020
ORTHODONTICS AND DENTO-FACIAL ORTHOPEDICS www.stomaeduj.com
THE EFFECTS OF TONGUE PLATE AND TONGUE
Original Articles
APPLIANCE ON MAXILLARY DEFICIENCY IN GROWING
PATIENTS
Abdolreza Jamilian1a* , Ludovica Nucci2b , Ehsun Amini3c , Mitra Toliat1d, Shima Bagherzadeh Hamedani4e,
Felice Femiano2f
1
Department of Orthodontics, Faculty of Dentistry, Cranio Maxillofacial Research Center, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
2
Multidisciplinary Department of Medical-Surgical and Dental Specialties, Dental School, University of Campania Luigi Vanvitelli, Naples, Italy
3
Department of Oral and Maxillofacial Surgery, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4
Clinical Division of Orthodontics, Faculty of Dentistry, Medical University of Vienna, Vienna, Austria
a
DDS, MSc, PhD, Professor; e-mail: info@jamilian.net; ORCIDiD: https://orcid.org/0000-0002-8841-0447
b
DDS, Undergraduate Dental Student; e-mail: ludovica.nucci@virgilio.it; ORCIDiD: https://orcid.org/0000-0002-7174-7596
c
DDS, OMFS Resident; e-mail: Ehsun.amini@gmail.com
d
DDS; e-mail: Toliatmitra@gmail.com
e
DDS; e-mail: ajamilian@yahoo.com
f
DDS, PhD, Professor; e-mail: felice.femiano@unicampania.it; ORCIDiD: https://orcid.org/0000-0001-9341-2490
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(4).art.4
Objectives The purpose of this randomized trial study was to compare the effects of tongue plate and
tongue appliance in the treatment of Class III malocclusion with maxillary deficiency in growing patients.
Material and Methods 40 patients (19 males, 21 females) with maxillary deficiency were selected. 20
patients (9 boys, 11 girls) with the mean age of 9.3±1.2 were treated with tongue plate. 20 patients (10 boys,
10 girls) with the mean age of 10.1±0.7 were treated by tongue appliance. Lateral cephalograms obtained at
the beginning and end of the study were analyzed.
Results Paired t-tests and Wilcoxon test showed that SNA and ANB significantly increased in both groups. The
Mann-Whitney test showed that there were no statistically significant differences between the two groups
except for Jarabak ratio. Jarabak increased by 0.6±3.2° in the tongue appliance group and it decreased
0.4±1.6° in the tongue plate group (p<0.03).
Conclusion Both treatment modalities were successful in moving the maxilla forward. The crib of the tongue
appliance might bother the tongue and consequently parents are complaining about minor inflammation of
the tongue. The smooth surface of the tongue plate might therefore confer some advantages to this system
as compared to the tongue plate.
KEYWORDS
Class III Malocclusion; Tongue Plate; Growth Modification; Maxillary Deficiency; Tongue Appliance.
1. INTRODUCTION in Class III malocclusion with maxillary deficiency
in growing patients. Delaire[2] developed the
Skeletal Class III malocclusion is characterized by orthopedic face mask to stimulate maxillary growth.
mandibular prognathism, maxillary retrusion or a Reverse-pull headgear was also used to treat this
combination of both. Approximately, half of the discrepancy[3,4]. The use of ankylosed primary
skeletal Class III malocclusions are reported to result canines as anchorage for maxillary orthopedics is
from maxillary deficiency[1]. a viable alternative method[5,6]. Recently, tongue
A series of treatment approaches can be found appliance[7-10], tongue plate[11,12], miniplates[13,
in the literature regarding orthopedic treatment 14], bone-anchored maxillary protraction[15-17],
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Jamilian A, Nucci L, Amini E, Toliat M, Hamedani SB, Femiano F. The effects of tongue plate and tongue appliance on maxillary deficiency in
growing patients. Stoma Edu J. 2020;7(4):259-267.
Received: August 07, 2020; Revised: August 24, 2020; Accepted: August 28, 2020; Published: September 01, 2020
*Corresponding author: Professor Abdolreza Jamilian, DDS, MSc, PhD, Department of Orthodontics, Faculty of Dentistry, Cranio Maxillofacial
Research Center, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
Tel./Fax: 0098-22052228; e-mail: info@jamilian.net
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.
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Jamilian A, et al.
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Original Articles Table 1. Pre and post treatment measurements of the tongue plate and tongue appliance.
Cephalometric Groups Pre treatment Post treatment p value
measurement Mean ± SD Mean ± SD
SNA° Tongue Plate 76.0±1.7 78.4±1.7 0.001*
Tongue Appliance 75.9±2.8 77.4±2.7 0.001*
SNB° Tongue Plate 76.9±1.8 77.5±1.4 0.08
Tongue Appliance 77.2±2.9 77.2±2.9 1
ANB° Tongue Plate -0.9±1.1 0.7±1.6 0.001*
Tongue Appliance -1.4±1.7 0.2±1.4 0.001*
U1 to SN° Tongue Plate 99.9±6.1 103.7±5.3 0.02*
Tongue Appliance 98.6±6 99.9±7.2 0.3
ANS-PNS (mm) Tongue Plate 45.7±3.1 47±3 0.001*
Tongue Appliance 45.1±3.9 45.7±3.5 0.007*
Palatal-SN° Tongue Plate 10.9±3.4 10.4±4.1 0.2
Tongue Appliance 9.2±3 8.4±2.8 0.2
GoGn (mm) Tongue Plate 65±4 66.9±3.8 0.001*
Tongue Appliance 66.4±7.4 67.5±8 0.1
Jarabak R. (%) Tongue Plate 61.7±3.7 61.3±3.8 0.3
Tongue Appliance 61.7±3 62.3±4.4 0.5
U1 to Palatal° Tongue Plate 108.7±11.4 111.8±11.4 0.03*
Tongue Appliance 107.8±6.3 108.8±7.8 0.6
Inclination Angle Tongue Plate 81.4±3.4 83±4.3 0.05*
Tongue Appliance 83.6±3.2 85.9±5.8 0.07
GoGn-SN° Tongue Plate 35.9±5.4 36.4±4.9 0.3
Tongue Appliance 35.4±4.7 34.4±6.3 0.3
IMPA° Tongue Plate 92.3±6.2 87±6.5 0.001*
Tongue Appliance 88.2±6.6 83±5.5 0.001*
and miniscrew[18,19] have also been used to treat in the tongue plate and 2 patients in the tongue
maxillary deficiency. As known, the maxilla cannot appliance dropped out before final assessment. 40
be moved after growth cessation; therefore, the patients (19 males, 21 females) with skeletal Class
common belief is that the treatment of adult patients III malocclusion due to maxillary deficiency were
will eventually need surgery[20]. selected. Considering the previous studies, a sample
Both the tongue appliance and tongue plate have size of 40 patients was chosen for this study[21-23].
recently been introduced to literature and there is All subjects gave their informed written consent and
no previous comparison between the effects of the met the following inclusion criteria:
two; therefore, the aim of this study was to compare 1) Sella-Nasion-A (SNA) ≤ 80°, Sella-Nasion-B (SNB) ≤
the effects of the tongue plate and tongue appliance 80°, A-Nasion-B (ANB) ≤ 0°
in growing patients with class III malocclusion due to 2) Class III molar relationship
maxillary deficiency. 3) No mandibular shift
4) Concave facial profile
2. MATERIALS AND METHODS 5) Negative overjet
6) No congenital disease or endocrine disorders
In this retrospective study, the patient data were 7) No previous orthodontic treatment and surgical
handled according to the requirements and intervention.
recommendations of the Declaration of Helsinki. An unstratified subject allocation sequence was
The ethical approval was obtained from SBUMS generated by a computer program; random
Local Research Ethics Committees. The informed numbers were generated and their assignment
written consent was obtained from the patient and was concealed from the clinician until the time of
a parent or guardian. A CONSORT diagram showing the appointment at which the appliance was to
the flow of patients through the trial is provided be placed. The treating clinician was blinded from
in Fig1. Sixty-eight patients were enrolled in this the randomization procedure, but because of clear
research. 23 patients were excluded due to not differences in appliance design, blinding was not
meeting the inclusion criteria. Three of the patients possible during the treatment period. A table of
260 Stoma Edu J. 2020;7(4): 259-267 pISSN 2360-2406; eISSN 2502-0285
The effects of tongue plate andCONSORT
tongue appliance
2019 Flow Diagram
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Original Articles
Enrollment Assessed for eligibility (n= 68)
Excluded (n= 23)
Not meeting inclusion criteria (n= 23 )
Declined to participate (n= 0 )
Other reasons (n= 0 )
Randomized (n= 45)
Allocation
Allocated to intervention tongue plate (n= 23) Allocated to intervention in tongue appliance
Received allocated intervention (n=23) (n= 22)
Did not receive allocated intervention (give Received allocated intervention (n=22)
reasons) (n= 0 ) Did not receive allocated intervention (give
reasons) (n= 0)
Follow-Up
Lost to follow-up (Did not attend) (n=3) Lost to follow-up (Did not attend) (n=2)
Discontinued intervention (give reasons) (n=0) Discontinued intervention (give reasons) (n=0)
Analysis
Analysed (n=20) Analysed (n=20)
Excluded from analysis (give reasons) (n=0) Excluded from analysis (give reasons) (n=0)
Figure 1. Consort.
Figure 2. Right view of pretreatment of a tongue plate patient. Figure 3. Left view of pretreatment of a tongue plate patient.
random numbers was used to divide the patients into Figs. 2-8. 20 patients (10 boys, 10 girls) with the mean
two equal groups. A CONSORT diagram showing the age of 10.1±0.7 were treated by tongue appliance.
flow of patients through the trial is provided in Fig. 1. A tightly fitting and well retained upper removable
The patients were randomly assigned to two equal appliance was fabricated with Adams clasps on the
groups using a standard random number table. The upper first permanent molars and two C clasps were
tongue appliance has some C clasps on the upper placed on the upper permanent central or lateral
permanent central or lateral incisors or deciduous incisors or deciduous canines. Long tongue cribs
canines. An acrylic plate was mounted posterior to were placed in the inter-canine area in an effort to
the upper incisors. The patient was instructed to wear restrict the tongue. These cribs were long enough
the appliance full-time except for eating, contact to cage the tongue and were adjusted to avoid
sports and tooth brushing. The active treatment time traumatizing the floor of the mouth.
lasted for 24 months. The patient was examined and The patients were instructed to wear the appliance
progress was observed after each monthly visit. Pre full-time except for eating, contact sports and tooth
and post photographs and cephalometric images brushing. The active treatment time lasted for 17±3
of one of the tongue plate patients can be seen in months. The patients were examined and progress
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Original Articles Table 2. Comparison of cephalometric changes between tongue plate and tongue appliance.
Cephalometric mea- Tongue Plate Tongue Appliance p Value
surement X±SD X±SD
SNA (°) 2.4±1.5 1.5±1.4 0.2
SNB (°) 0.6±1.4 0±2 0.8
ANB (°) 1.6±1 1.6±1.6 0.6
U1 to SN (°) 3.8±6.3 1.3±5.5 0.2
ANS-PNS (mm) 1.3±1.3 0.6±0.9 0.1
Palatal-SN (°) -0.5±3.4 -0.8±2.9 0.6
GoGn (mm) 1.9±1.3 1.1±1.5 0.09
Jarabak R. (%) -0.4±1.6 0.6±3.2 0.03
U1 to Palatal (°) 3.1±5.5 1±7.6 0.3
Inclination Angle 1.6±4.1 2.3±5.4 0.8
GoGn-SN (°) 0.5±1.8 -1±4.2 0.09
IMPA (°) -5.3±3 -5.2±7.2 0.7
*Statistical significance was set at p<0.05
Figure 5. Tongue plate in situe.
Figure 4. Pretreatment cephalometric of a patient with tongue plate.
was observed after each monthly visit. Pre and post
photographs and cephalometric images of one of
Figure 6. Right view of posttreatment of the same tongue plate patient.
the tongue appliance patients can be seen in Figs.
9-14. Lateral cephalograms, OPGs, photos, and study the subnasale), inclination angle (the angle formed
casts of patients of both groups were taken before between a perpendicular line to soft tissue nasion
(T1) and after (T2) treatment. and the palatal plane), and Jarabak ratio (the ratio
SNA, SNB, ANB, GoGn-Sn (mandibular plane angle), between the posterior and anterior face heights;
Upper 1 to SN (angle between long axis upper central S–Go/N–Me) of each patient were measured before
incisor and anterior cranial base), IMPA (angle and after treatment.
between the long axis of the lower central incisor The reliability of the measurements was determined
and mandibular plane), Nasolabial angle (the angle by randomly selecting 16 cephalograms at the
formed between the lines tangent to the columella beginning and end of the treatment from each group.
and the upper lip vermillion and intersecting at They were traced twice on two separate occasions
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Original Articles
Figure 7. Left view of posttreatment of the same tongue plate patient.
Figure 10. Pretreatment cephalometric of a patient with tongue
appliance.
Figure 8. Posttreatment cephalometric of the same patient with tongue
plate.
Figure 11. Frontal view of the tongue appliance .
Figure 9. Frontal view of pretreatment of a tongue appliance patient.
Figure 12. Palatal view of the tongue appliance.
after a two-week interval. A paired t-test showed no of statistical significance was set at p<05. Paired
statistically significant differences between the two T-tests were used for intra group evaluation if the
measurements. distribution was normal; otherwise, the Wilcoxon
An intraclass correlation coefficient was also test was used. The Mann-Whitney test was used to
calculated to assess test/retest reliability. The level compare the data between the two groups.
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Original Articles
Figure 13. Frontal view of posttreatment of the same tongue appliance
patient. Figure 15. The mark of the tongue appliance on the tongue.
4. DISCUSSION
Various techniques and appliances are being used
to treat the maxillary deficiency including modified
protraction appliance, reverse-pull headgear,
facemask, Class III activator, and reverse chin cup
[7,8,24-35]. The face mask therapy has become a
common technique used to correct the developing
Class III malocclusion [36,37]. A search in literature
will reveal ample research about the face masks
and their effects on the nasomaxillary complex.
In addition, the experimental studies constantly
demonstrate pronounced forward movement of the
maxilla due to the heavy and continuous protraction
forces of the face masks [38-40]. However, one of
the problems with the face masks is their bulky size
and shape, which makes it a discouraging choice for
children. Especially patients who wear glasses will
be more susceptible to discomfort. This discomfort
along with the embarrassment caused by the large
size for children, especially at school in front of other
peers, might reduce patient compliance. The chin
part of the face mask will result in the backward
Figure 14. Pretreatment cephalometric of the same patient with tongue rotation of the mandible and increase in the anterior
appliance. facial height. Recently, tongue plate and tongue
appliance were used to overcome the above-
mentioned disadvantages. In both appliances a
considerable pressure will be transmitted to the
3. RESULTS
deficient maxilla. The mechanism of the force is
provided in the following ways:
The results of this study showed that SNA and ANB
1. The pressure of the Tongue during swallowing
increased by 2.4±1.5° (p<0.001) and 1.6±1° (p<0.001)
might reach 5 pounds in each swallowing. The
in the tongue plate group. SNA and ANB also
frequency of swallowing is about 500 to 1200 times
increased in the tongue appliance group by 1.5±1.4°
in 24 hours. This intermittent force is transferred
(p<0.001) and 1.6±1.6° (p<0.001), respectively. The
through the tongue appliance to the deficient
SNB did not show any significant changes in either
nasomaxillary complex.
of the groups. U1 to SN increased from 99.9±6.1° to
2. The tongue generates a considerable force in its
103.7±5.3° in the tongue plate group (p<0.02) and it
rest position while caged behind the cribs or plate.
increased from 98.6 ±6° to 99.9 ±7.2° in the tongue
These forces are transmitted by the tongue to the
appliance group (p<0.3).
palatal cribs or plate and finally to the nasomaxillary
The Mann-Whitney test showed that there were
complex consequently pushing the maxilla to a
no statistically significant differences between the
forward position. The more anterior function and
cephalometric data of the two groups; except for
position of the tongue, the greater the force will
the Jarabak ratio. The Jarabak ratio decreased by
be. The more posterior the crib or plate, the greater
-0.4±1.6 in the tongue plate group; yet, it increased
the force will be. The application of face masks
by 0.6±3.2 in the tongue appliance group (p<0.03).
might cause unfavorable effects on the mandible.
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In other words, backward and downward rotation the tongue plate is better than with the tongue
Original Articles
of the mandible is one of the unfavorable effects appliance due to the smooth surface area of the
of such extra oral appliances. These effects are tongue plate and lack of irritation of the cribs.
very unsatisfactory in vertically growing patients. The treatment used in this study was meant to correct
However, the tongue appliance and tongue plate a skeletal problem as part of growth modification
used in this study had no adverse effects on the and further treatment was done by using fixed
mandible. Another advantage of the tongue appliances.
appliance and tongue plate over the other extra oral
appliances is that it is less conspicuous and needs less 5. CONCLUSION
patient compliance. The tongue appliance, tongue
plate and facemask lingualize the lower incisors by Both treatment modalities were successful in moving
different mechanisms. The tongue appliance and the maxilla forward. The crib of the tongue appliance
tongue plate lingualize the lower incisors due to might bother the tongue and consequently parents
the elimination of the tongue pressure on them. are complaining about minor inflammation of the
However, the facemask lingualizes the lower incisors tongue. The smooth surface of the tongue plate
due to chin cup pressure. The neutral zone is the might therefore confer some advantages to this
area where the displacing forces of the lips and system as compared to the tongue plate.
tongue are in balance. The presence of the tongue
appliance and tongue plate in the mouth alters CONFLICT OF INTEREST
the neutral zone. In other words, since the tongue The authors declare no conflict of interest.
is caged by the crib or plate it does not exert any
forces on the lower incisors thus, they are retroclined AUTHOR CONTRIBUTIONS
due to the pressure of the lips. After the appliances
are removed, the tongue pressure on the lower AJ: was responsible for the study concept, study design,
incisors will result in their proclination. The force of data interpretation, critical revision, writing and revising the
the tongue transfers to the nasomaxillary complex report and final approval of the article. LN: administration,
and that is why the inclination angle is increased data interpretation, recruitment, statistical analysis. EA: was
in both groups. In this study, both appliances were responsible for data gathering. MT: was responsible for data
successful in forward movement of the maxilla. One interpretation, critical revision and final approval of the article.
of the advantages of the tongue plate is that unlike SB: was responsible for literature review. FF: was responsible for
the tongue appliance it does not leave any marks drafting, data interpretation, critical revision and final approval of
on the tongue of the patient. The tongue appliance the article.
might bother the tongue and consequently parents
are complaining about minor inflammation of ACKNOWLEDGMENTS
the tongue. As can be seen in Fig. 15, the tongue
appliance has left marks on the patient's tongue.
None.
It seems that the cooperation of the patient with
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266 Stoma Edu J. 2020;7(4): 259-267 pISSN 2360-2406; eISSN 2502-0285
The effects of tongue plate and tongue appliance
www.stomaeduj.com
Original Articles
Abdolreza JAMILIAN
DDS, MSc, PhD, Professor
Department of Orthodontics
Faculty of Dentistry
Cranio Maxillofacial Research Center
Tehran Medical Sciences
Islamic Azad University
Tehran, Iran
CV
Professor Abdolreza Jamilian is an Orthodontic researcher and specialist. He received his DDS (1991), MSc in Orthodontics
(1998), and Fellowship of Orthognathic Surgery & Craniofacial Syndroms (2010) from the Shahid Beheshti University in Tehran,
Iran. He obtained his European Board of Orthodontics in 2013. He is a professor at the Islamic Azad University, Tehran. He
practices in orthodontics. He has lectured in several international congresses and has been a consultant for various journals.
He has published over 200 original, peer reviewed research and review articles, 15 book chapters and more than 300 scientific
communications. He holds 3 patents with the United States Patent and Trademark Office.
Research interests: Class 3 malocclusion, Cleft lip and palate, Orthognathic surgery.
Questions
1. Which one has been used to treat maxillary deficiency?
qa. Fixed tongue appliance;
qb. Tongue plate;
qc. Tongue appliance;
qd. All of them.
2. Which one is an extra oral appliance?
qa. Reverse chin cup;
qb. Tongue appliance;
qc. Fixed tongue appliance;
qd. Tongue plate.
3. Which one does the patient wear easily during daily activities?
qa. Reverse chin cup;
qb. Tongue plate;
qc. Face mask;
qd. Chin cap.
4. Which one has no effect on the patients’ vertical growth pattern?
qa. Face mask;
qb. Chin cap;
qc. Reverse chin cup;
qd. Tongue plate.
Stoma Edu J. 2020;7(4): 259-267 pISSN 2360-2406; eISSN 2502-0285 267