Case report: tongue and bite
Open bite and tongue thrustA case, carefully put into context
When swallowing, the tongue pushes forwards, and at the front the teeth do not meet. Here we show a documented course from an orthodontic practice over three months of FaceFormer training and put into context what a single case shows, what it does not show and when orthodontics is necessary. The title image is a symbolic image and does not show the patient from the case report.
The key points at a glance
- With an open bite, the upper and lower teeth do not meet at one point; with an anterior open bite, at the front at the incisors. Often the tongue pushes forwards when swallowing. This is called tongue thrust.
- The case report shows a patient whose open bite largely closed during three months of FaceFormer training. It is a single case. It illustrates how we see the connection; it does not provide proof.
- In our view, what moves the teeth in the long term is usually less the individual swallow than the permanent position of the tongue. If this pattern continues after braces, it works against the result, in our view one reason why teeth move back. The training addresses breathing, swallowing and head balance and does not replace an orthodontic examination.
Video
Open bite: from causes to solutions
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
The case
The starting situation: open bite with tongue thrust
The images come from the practice of Dr. Elizabeth Menzel, orthodontist. The patient has consented to publication.
Single case from an orthodontic practice; the images appear with her consent
Open bite in the incisor area, more pronounced on the left side, plus tongue thrust when swallowing
documented period with FaceFormer training according to the exercise instructions
from the front and from the side, at the start, after a few weeks and after three months
At the start, the incisors of the upper and lower jaw did not meet. A clear gap remained between them, larger on the left than on the right. This is an anterior open bite. In the lower jaw, the incisors were rotated and the canines were malpositioned.
How old the patient was and whether further orthodontic measures were under way is not evident from the documents available to us. We leave both open.
Image 2 shows what happened when swallowing. The tongue pushed forwards into the gap between the teeth. Such tongue thrust is considered one of the common functional factors in open bite.
Whether the tongue is the cause or the consequence has been debated in the field for decades. We show what research says about this further down.
Progress
Three months at a glance
The patient trained with the FaceFormer according to the exercise instructions. The images were taken at three points in time.
- At the start
Open bite, tongue at the front
The incisors do not meet, and when swallowing the tongue pushes between the teeth. The training begins.
- After a few weeks
The gap becomes smaller
The open area between the upper and lower incisors has become smaller, and in the lower jaw the teeth are gradually aligning.
- After three months
Largely closed at the front
The open bite in the front area is largely closed. The canines and premolars are approaching the intended interdigitation. The training is being continued.
In image 3, the open area between the incisors is already smaller, and the lower front teeth are straighter.
After three months, the upper incisors once again overlap the lower ones by a small amount. Whether this finding remains stable will only be shown by further follow-up.
The side view shows the interdigitation in the area of the canine and premolars after three months. Here the upper and lower teeth mesh with each other again.
An individual case shows one course. It does not show how often things go this way.Dr. Berndsen repeatedly observes similar courses in practice when the function is trained consistently. That is not a promise for the next case, because how much and how quickly a bite changes depends, among other things, on age, growth, severity and the regularity of training.
Fundamentals
What is an open bite?
In a normal bite, the upper incisors overlap the lower ones by a small amount. With an open bite, by contrast, a gap remains when you bring your back teeth together.
Orthodontists classify open bite by location and origin. If the gap is at the front, it is called an anterior open bite; if it is further back, a lateral open bite. For treatment, what matters most is whether the teeth are affected or whether the jaws themselves have grown this way. An orthodontic examination clarifies this.
Anterior open
At the front, the incisors do not meet. This is the best-known form, also in the case above.
Lateral open
A gap remains in the area of the back teeth, often on one side. Here too, the tongue can lie between the rows of teeth when swallowing.
Dental
Mainly the position of the teeth deviates, while the jaws have grown normally. In our view, function plays a major role here.
Skeletal
The jaws themselves have grown in such a way that a gap results at the front. Here orthodontic, and sometimes also surgical, planning is called for.
of 359 six-year-olds in a Brazilian birth cohort had an anterior open bite. The main risks were sucking habits between the first and fourth year of life and finger sucking at the age of six1
were evaluated by a systematic review from Ghent on children with dental malpositions. There, anterior open bite was associated with atypical swallowing and with distortions of certain sounds2
A small test in front of the mirror: bite loosely on your back teeth and pull your lips back. What do you see at the front?
Tongue
Tongue thrust: when the tongue presses against the teeth
Zungenvorschub, Zungenpressen, Zungenstoß or the English “tongue thrust” all describe the same picture. When swallowing, the tongue pushes forwards against or between the incisors.
In a physiological swallow, the tip of the tongue rests against a small ridge on the palate behind the upper incisors. From there, the tongue builds up pressure from front to back and pushes saliva or food into the throat. We call this starting point the tongue reference position.
If this contact is missing, the tongue looks for another support, and the teeth are what is available. In our view, tongue thrust is therefore as a rule not an isolated fault of the tongue, but a substitute solution. A low-lying tongue has to seal the swallow at the front against the teeth. How a normal swallow proceeds is described in the article Swallowing and swallowing disorders.
Dr. Klaus Berndsen, the developer of FaceFormer therapy, describes it in the video on the tongue like this: when swallowing, the tongue then presses forwards against the row of teeth, and we swallow many hundreds to a thousand times a day, also at night.
Tongue pressing is not a pathological finding in every case. In children under ten, swallowing with the tongue pushed forwards is, according to an older review, more the rule than the exception and is only loosely associated with dental malpositions there3. In our view, what matters is whether the pattern changes with the change of teeth.
The pattern deviates
Mouth breathing, a low-lying tongue or altered head balance often develop early, for example through a dummy, bottle or thumb.
The body compensates
The tongue braces itself against the teeth when swallowing, and the lips and chin help to seal. The nervous system stores this compensation as a pattern.
Form follows
For years, the tongue lies at the front between the teeth. In many of those affected, the bite remains open there or opens further.
The findings become visible
At the front the teeth do not meet, biting off is difficult, and sometimes sibilants sound unclear. Often only now is treatment started, and on the teeth.
Forces
What moves teeth: duration before strength
Teeth are not fixed rigidly in the jaw like posts in concrete. They stand where the forces around them balance out.
In 1978, the orthodontist William Proffit summarised what determines the position of the teeth. As the most important factors, he names the resting pressures of the tongue and lips and the forces in the periodontium. The same text states that breathing influences the posture of the head, jaw and tongue and thereby alters this equilibrium4.
The tongue presses from the inside, while the lips and cheeks hold against it from the outside. If the tongue lies at the front between the teeth, in our view there is an abutment there that prevents the incisors from meeting.
How the lips and lip closure are integrated into this equilibrium is described in the article Lip training.
a counterforce acted on a continuously growing rabbit tooth, and it remained almost ineffective5
were sufficient to achieve the same effect as a constantly applied force. The authors conclude that the duration of a force matters more than its strength5
A swallow lasts only a moment; even many hundreds of swallows add up to only a small part of the day. The permanent position of the tongue in between, by contrast, acts in one direction for hours. Proffit himself considered atypical swallowing to be an adaptation rather than a cause4. In our view, the swallow mainly shows where the tongue lies the rest of the time as well.
Like a fruit tree on a trellis
An espalier tree is not brought into shape with one strong jerk, but with ties that gently guide it in one direction over years. In our view, the permanent position of the tongue acts on the teeth in a similar way. The individual swallow is the brief jerk; the position in between is the tie.
Swallowing pattern
Form corrected, pattern remained
An open bite can be closed orthodontically. Whether the swallowing pattern changes along with it is another question.
At the University of Giessen in 1999, Kirsten Störmer and Hans Pancherz measured the electrical activity of the muscles around the mouth and of the masticatory muscles during swallowing. They compared people with an open bite and an atypical swallowing pattern with people who swallowed normally6.
With the atypical pattern, the muscles around the mouth worked harder and the masticatory muscles less during swallowing than in the comparison group6
were measured after the open bite had been closed orthodontically. No normalisation of the swallowing pattern was observed6
The groups were small, and an untreated comparison group was missing. As an indication, the finding fits our view: the teeth were moved, but the stored pattern continued.
with 4,377 participants were evaluated by the Cochrane review on retention after braces. It did not find a method that proved to be reliably superior; the evidence was low to very low13
of 31 treated patients who had had four premolars extracted still had a clinically acceptable lower front 20 years after the end of retention, in a long-term series from Seattle14
That teeth move back after brace treatment is considered the normal case in the profession, which is why a retention phase with a retainer follows13. But teeth do not move by themselves; they follow forces. In our view, relapse is therefore usually due to the fact that the function that shifted the teeth continues unchanged. A review from Milan describes the relationship as reciprocal and considers orthodontics together with functional training to be the best route7.
met the criteria in a systematic review. They showed associations between atypical swallowing and malpositions, including open bite, with very low certainty of evidence8
was the mean relapse of the open bite with additional functional training compared with orthodontics alone. The comparison group consisted of people who had already relapsed; allocation was not random9
The absence of a study does not mean the connection does not exist. It means it has not been tested.Research on the interplay of tongue and bite is sparse. That is why we describe how we see the connection and promise nothing that no study has shown.
Training
What the training addresses
FaceFormer training does not move teeth. It addresses the basic functions that, in our view, determine where the tongue lies: breathing, swallowing and head balance.
A swallowing pattern does not change through insight. It is displaced by a new one, and that requires precise, frequent repetition. That is why the training practises lip closure, nasal breathing, tongue reference position, the act of swallowing and head balance simultaneously in one sequence, instead of strengthening individual muscles in isolation.
The FaceFormer sits in the oral vestibule, in front of the teeth and behind the lips. The tip of the tongue rests against the reference point on the palate without touching the teeth. This way, the swallow regains its starting point at the front of the palate instead of at the front teeth.
In the basic exercise, the lips press the lip wedge together, the back teeth bite briefly, and then a swallow follows. The negative pressure in the mouth draws the tongue up to the palate. In the pull exercise, a gentle pull on the device is added.
For open bite, one detail is important. Swallowing takes place with brief contact of the back teeth and with the tongue against the palate. In our view, this leaves hardly any room for thrusting between the incisors.
- From day 1
Basic exercise
A few minutes three times a day with the FaceFormer ZERO. You increase the repetitions week by week.
- From around week 3
Pull exercise and night
The pull exercise is added. At night you wear the ZERO as a supplement to daytime training, as soon as the basic exercise is established.
- After a few weeks
Switching to the ONE
During the day you train with the FaceFormer ONE. It is the same size and shape as the ZERO, only made of firmer material. Children up to about ten years stay with the ZERO.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months until the new patterns run without thinking, followed by maintenance training.
Tooth positions change slowly, over months and often longer. The training has to continue until the new pattern holds up in everyday life, even without you thinking about it. You have to keep at it, and it can be worth it.
Do not end ongoing orthodontic treatment on your own initiative. The training is also possible with fixed braces; with brackets, dental wax helps. If you train with a practice, agree on the procedure together. The free FaceFormer app guides you through the basic exercises, and for children there is a separate plan under FaceFormer for children.
Limits
What this case shows and what it does not
A well-documented course is valuable. Nevertheless, a single case is not suitable as proof of an effect, and there are understandable reasons for this.
What it shows
In this patient, the open bite largely closed during three months of training. This is photographed and placed in time.
What it does not show
Whether the training was the cause, how often such a course succeeds and whether it remains stable. That requires many cases and a comparison group.
What remains open
Age, growth and possible further measures are not known to us. All three can change a bite.
Especially during growth, a bite also changes without treatment. A long-term observation followed untreated children who had an open bite at the age of five up to the age of twelve10.
with an open bite in the primary dentition still had an open bite at the age of twelve, without treatment. However, the overbite remained smaller in this group, and the authors saw an underlying growth pattern10
Another case has also been published. In 2021, Booth and Kinzinger described in the journal Kieferorthopädie the treatment of an open bite with a combination of high-pull headgear, an orthodontic appliance with traction via a head cap, and FaceFormer11. This is not the case shown here. It shows how orthodontics and training can work together, not how often this succeeds.
The only randomised study with the FaceFormer, the Hamburg study of 45 children, measured basic functions, not the bite. Both groups improved. With the FaceFormer, the tongue rested against the palate more often when swallowing, and mouth closure was achieved more quickly12. You can find all studies with their context under Studies and science.
This case illustrates how we see the connection. It cannot be transferred to others, and no particular result can be promised.
Orthodontics
When an open bite belongs in a practice
Which form is present and what is necessary is clarified by a dental or orthodontic practice. These signs are a good reason to go.
Gap at the front or side
The teeth do not meet at one point, even when you bite firmly.
Biting off is difficult
Pasta or a lettuce leaf can hardly be bitten off with the incisors.
Sibilants sound unclear
With s, z or sh, the tongue pushes between the teeth.
The bite is changing
The gap is getting larger, or teeth are visibly shifting.
The jaw joint is making itself felt
Clicking, pain or restricted mouth opening are added. More on this in the article on craniomandibular dysfunction (TMD).
In children, an early look is worthwhile. In the primary and mixed dentition, an open bite often still closes during growth, as the observation above shows. If it persists, the orthodontic practice clarifies whether and when treatment makes sense. How children train with the FaceFormer is described in FaceFormer for children.
In adults, growth is complete. A dental open bite is usually treated orthodontically. If it is skeletal and severe, jaw surgery may be necessary. In our view, the function nevertheless belongs in the planning before and after, because an operation changes the shape, not the pattern of breathing, swallowing and head balance that guides the tongue. If the tongue continues to work forwards afterwards, the old pattern works against the new result. More on this under Jaw surgery and BiMax.
The training does not replace an orthodontic examination and treatment planning. Why teeth can move back after braces and what the function has to do with it is described in the article Retainers and relapse.
Everyday life
What you can observe in everyday life
The tongue between swallows
Check a few times a day where the tip of your tongue is. It belongs behind the upper incisors against the palate, not against or between the teeth.
Swallowing with tooth contact
When swallowing, the back teeth touch briefly and the lips stay relaxed. If the chin tenses as well, the mouth is working against the tongue instead of with it.
Nose instead of mouth
Nasal breathing keeps the mouth closed and the tongue up. More on this under Deviated nasal septum. Taping the mouth shut at night is not a substitute; see Mouth taping.
Sucking habits in children
Prolonged sucking on a dummy or finger is considered the most important risk factor for open bite in childhood. Support your child gently and without pressure in breaking the habit.
Do not train pressing
Pressing the tongue forcefully against the palate is not the goal. Why is explained in the article on Mewing.
Questions
Frequently asked
What is an open bite?
With an open bite, the upper and lower teeth do not meet at one point, even when the back teeth are together. With an anterior open bite, a gap remains at the front between the incisors; with a lateral open bite, in the area of the back teeth. Whether the teeth or the jaws themselves are affected is clarified by an orthodontic examination.
Tongue thrust and tongue pressing: why does the tongue press against the teeth?
Both terms describe the tongue pushing forwards against or between the incisors when swallowing, instead of bracing itself against the palate. Often the tip of the tongue lacks contact with the palate, for example with mouth breathing or after long-standing sucking habits. In our view, this is as a rule a substitute solution that runs unconsciously and is therefore more likely to change through training than through good intentions.
Can tongue pressing cause an open bite?
A connection has been described, but its direction is disputed in the field. In our view, what matters is less the brief swallow than the permanent position of the tongue in between. If it lies at the front between the teeth for years, it acts like an abutment that prevents the incisors from meeting.
Does an anterior open bite in children grow out?
In the primary and mixed dentition, it often still closes during growth. In a long-term observation of 14 untreated children with an open bite at the age of five, only one still had an open bite at the age of twelve. Nevertheless, have it checked early, especially if sucking habits are present or the gap remains.
Can an open bite be treated without surgery?
That depends on the form. A dental open bite is usually treated orthodontically. If it is skeletal and severe, jaw surgery may be necessary in adults; the orthodontic examination clarifies this. In our view, the function belongs in the planning before and after such a procedure, because an operation changes the shape, not the pattern that guides the tongue forwards.
Can FaceFormer training close an open bite?
That cannot be promised. The case report shows a course, not proof. The training aims to restore breathing, swallowing and head balance to a physiological state and, in our view, thereby creates a precondition for a malposition to be able to regress. It does not replace an orthodontic examination.
Can I train with the FaceFormer while wearing braces?
Yes. The training is possible alongside fixed braces; with brackets, dental wax helps. Do not end ongoing orthodontic treatment on your own initiative. If you train with a practice, agree on the procedure together.
Does the training also help with a crossbite or an edge-to-edge bite?
Crossbite and edge-to-edge bite, like open bite, are dental and jaw malalignments in which a muscular imbalance often plays a part: the tongue lies low or pushes forward, and the lower jaw is guided to one side or forward. This is where FaceFormer training comes in. It trains the tongue reference position, lip closure and the swallowing sequence, thereby creating the precondition for the teeth and jaws to sit in a more stable muscular balance. This also explains why a malalignment can return after braces or surgery: the function that shifted it is often still there. Train alongside orthodontic treatment and discuss your progress with your practice.
More articles from the knowledge section
More experiences
Where to go next
Sources
- Peres KG, Barros AJ, Peres MA, Victora CG (2007). Effects of breastfeeding and sucking habits on malocclusion in a birth cohort study. Revista de Saúde Pública 41(3):343-350. PMID 17515986. Source
- Thijs Z, Bruneel L, De Pauw G, Van Lierde KM (2022). Oral Myofunctional and Articulation Disorders in Children with Malocclusions: A Systematic Review. Folia Phoniatrica et Logopaedica 74(1):1-16. PMID 34107494. Source
- Lebrun Y (1985). Tongue thrust, tongue tip position at rest, and sigmatism: a review. Journal of Communication Disorders 18(4):305-312. PMID 3894438. Source
- Proffit WR (1978). Equilibrium theory revisited: factors influencing position of the teeth. The Angle Orthodontist 48(3):175-186. PMID 280125. Proffit WR, Sellers KT (1986). The effect of intermittent forces on eruption of the rabbit incisor. Journal of Dental Research 65(2):118-122. PMID 3455965. Source
- Störmer K, Pancherz H (1999). Electromyography of the perioral and masticatory muscles in orthodontic patients with atypical swallowing. Journal of Orofacial Orthopedics 60(1):13-23. PMID 10028785. Source
- Maspero C, Prevedello C, Giannini L, Galbiati G, Farronato G (2014). Atypical swallowing: a review. Minerva Stomatologica 63(6):217-227. PMID 25267151. Source
- Gonçalves FM, Taveira KVM, Araujo CM et al. (2023). Association between atypical swallowing and malocclusions: a systematic review. Dental Press Journal of Orthodontics 27(6):e2221285. PMID 36995845. Source
- Smithpeter J, Covell D (2010). Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. American Journal of Orthodontics and Dentofacial Orthopedics 137(5):605-614. PMID 20451779. Source
- Klocke A, Nanda RS, Kahl-Nieke B (2002). Anterior open bite in the deciduous dentition: longitudinal follow-up and craniofacial growth considerations. American Journal of Orthodontics and Dentofacial Orthopedics 122(4):353-358. PMID 12411879. Source
- Booth D, Kinzinger G (2021). Behandlung eines offenen Bisses mit einer Kombination aus Highpull-Headgear und Face Former [Treatment of an open bite with a combination of high-pull headgear and Face Former]. Kieferorthopädie 35:9-14. Quintessenz. Case report, not listed in PubMed. Source
- Korbmacher HM, Schwan M, Berndsen S, Bull J, Kahl-Nieke B (2004). Evaluation of a new concept of myofunctional therapy in children. International Journal of Orofacial Myology 30:39-52. PMID 15832861. Hamburg study; co-author Sabine Berndsen is a co-developer of the FaceFormer. Source
- Martin C, Littlewood SJ, Millett DT, Doubleday B, Bearn D, Worthington HV, Limones A (2023). Retention procedures for stabilising tooth position after treatment with orthodontic braces. Cochrane Database of Systematic Reviews 5:CD002283. PMID 37219527. Source
- Little RM, Riedel RA, Årtun J (1988). An evaluation of changes in mandibular anterior alignment from 10 to 20 years postretention. American Journal of Orthodontics and Dentofacial Orthopedics 93(5):423-428. PMID 3163221. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
