IFUNA View
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Official Journal of International Functional Association - IFUNA - www.ifuna.info Volume 2, Issue 2 - 2017
Editors
Prof. Barbara Bimler - Germany Editor in Chief Permanent Visiting Professor, University of Havana Medical School, Cuba Director of Bimler Laboratories Germany
Prof. Franco Magni -ITALY President of International Editorial Board Adjunct Professor of Orthodontics, University of Parma, Italy Past President of EOS (European Orthodontic Society) and SIDO (Italian Society of Orthodontics).
Prof. Bakr Rabie - Hong Kong Assistant to Editor in Chief Professor in Orthodontics Faculty of Dentistry The University of Hong Kong Hong Kong
Prof. Jose Duran von Arx - Spain Scientific Editor Professor and Chair Department of Orthodontics, University of Barcelona, Spain
Michael Gorbonos Editor President of IFUNA
Dr. William J. Clark - Scotland Editor Developed the Twin Block Technique and Trans Force Lingual Appliances Scotland
Prof. Leonid S. Persin - Russia Editor President of Russian Association of Orthodontics. Professor and Chair Department of Orthodontics, State University of Medicine Dentistry, Moscow Russian Republic
Prof. Wilma A. Simoes - Brazil Editor Professor and Director of Research Department of Functional Orthopedics at UNICSUL University, Brazil
Prof. Toshio Kubodera - MĂŠxico Editor Professor and Chair Department of Orthodontic University of UAEM, Toluca, Mexico
Dr. Michel Champagne- Canada Editor Editor of International Journal of Orthodontics, Quebec, Canada
Dr. Mario Pistoni -Argentina Editor President of Argentinian Association of Functional Jaw Orthopedics, Buenos Aires, Argentina
Prof. Ritsuki Ito - Japan Editor Visiting Professor at the University of Mexico, UAEM,Toluca, Mexico. Private Practice, Japan
Dr. Carlos de Salvador Planas Spain Editor Doctor in Medicine and Surgery President od Spanish Association of Pedro Planas (SAPP) Private Practice, Barcelona, Spain
Dr. Catalina Canalda - Spain Editor Specialist in Orthodontics and Cranio Mandibular Difsunctions Neuro Occlusal Rehabilitation by methodology of Prof. Pedro Planas Private Practice. Barcelona, Spain
Dr. Marie-Josephe Deshayes France Editor Club Telecrane International, Caen, France
Roger Price - USA Editor Consultant Respiratory Physiologist -Australia
Prof. Myroslava Drohomyretska - Ukraine Editor President of Ukrainian Orthodontic Association
Contents Page No.
Editorial Presentation of the Dental Museum Bimler Laboratories Presentation A new design for a new body 100 years of Hans Peter Bimler The Role of the Pediatric Dentist in the Cleft Palate and Craniofacial Team Reasons Why Orofacial Myology Has Been Slow Developing as a Profession Functional jaw orthopedics in the treatment of TMJ fractures in the growing patient How to upgrade from suction deglutition to swallowing deglutition trough cortical or subcortical networks To breath or not to breath by the nose: WHY? 122 Hippos – a life well lived The form – function spiral (FFS) Removable Orthodontic Appliances with High Retention. A new concept in the approach and treatment using removable orthodontic appliances From neural excitation to mechanotransduction
04 05 06 07 18 19 32 34 42 46 58 60 71 86
Michael Gorbonos A .B. Bimler A.B. Bimler Wilson Aragao A.B. Bimler Patrizia Defabianis & Eyal Botzer Sandra Coulson Patrizia Defabianis
Patrick Fellus Franco Magni & Peter Bimler Bridgette Preston Roger L. Price José Roberto Ramos
Patricia Valerio
All statements of opinion and of supposed fact are published on the authority of the writer under whose name they appear and are not to be regarded as views of the Ifuna. All rights reserved. ISSN: 2173-0172 Request for index Publisher: Ifuna View - E-mail: infuor@hotmail.com Visit the Ifuna online at www.ifuna.info As a president of the IFUNA I thank all the sponsors of our Scientific Association for several reasons: They help us in carrying out the research program that is so important for us all, they allow the Ifuna to publish the Electronic journal that is sent to more than 40.000 professional in the field and they are very special sponsors because they work with us as a great team in order to design and fabricate newer and better functional appliances for the total benefit of our patient. Thank you Dear Sponsors and welcome to work with us. The president of IFUNA: Dr. Michael Gorbonos. Atlantis Editorial Science & Technology S.L.L. C/ Alpujarras, 4 - Leganés (Madrid - Spain). Ph. +34 912 282 284 - e-mail: francisco@atlantiseditorial.com www.atlantiseditorial.com
IFUNA JOURNAL
Editorial On behalf of the International Functional Association, IFUNA, it is my great pleasure to welcome you to a second issue of the IFUNA Electronic Journal, The Journal is in English and is distributed electronically, at no charge including orthodontic associations, universities, orthodontists, dentists, orthodontic laboratories, medical doctors, chiropractors, therapists and many others. IFUNA has been created in 2007 in response to the demand and interest of a growing segment of our profession to build an international platform for the documentation, preservation and education of Functional Treatments - starting to treat at early age and treating the whole body. A new earlier orthodontic protocol and standard is warranted. We want to introduce a new concept for earlier orthodontic and orthopedic diagnosis and treatment from birth to age seven. Increasing the size of jaws and airway during early growth and development may reduce human disease. Early jaw treatment is relatively nonexistent for most children under six years of age today because early diagnosis is relatively nonexistent. “These new concepts may very well help orthodontists, paedodontists and dentists to move dental care into a future world of medical dentistry which includes the ability to work with such diverse concerns as airway development, bed wetting, ear disease, heart disease and longevity”. IFUNA is a non-profit organization and I personally invite you to become an IFUNA member. You can register on www.ifuna.info We dedicate this Ifuna Journal to Prof. José Duran von Arx from University Barcelona on his retirement from the University and wishing him many happy years ahead. We wish to invite you to our 10th International Congress together with AAOFM that celebrating 60 years which will take place on 20-23 September 2017 Buenos Aires, Argentina. I would like to thank Prof. Barbara Bimler, the editor, the contributors and Prof. Juan José Alió Sanz for publishing this issue. Michael Gorbonos President of IFUNA
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Presentation of the Dental Museum near Leipzig www. Dentalmuseum.eu
In 2000, after 10 years of struggle and hassle, the DENTAL MUSEUM finally opened to the public. It should come as no surprise that the ‘hassle’ was overcome by Andreas Haesler, the Director, heart, soul and driver of this extraordinary success story. The DENTAL MUSEUM houses one of the largest collections of historical dental memorabilia from all over the world. It is not only a Museum it is also a Center of Science. Pictured here is one of the four buildings. The Library houses an incredible wealth of material drawn from over 180 collections of catalogues, journals, doctoral theses and other papers. The other collections are equally impressive. What makes this Museum unique is the space available, which allows for the display of almost everything on offer. There is even the ‘Camion for Children’s Dental Check-up’, dating back to the Communist German era. This is a treasure trove for film and television companies looking for specialized properties – such as in the 2015 remake of the classic “The Diary of Anne Frank”.During the German occupation of the Netherlands Anne Frank lived for a while in the same room as a Dentist, and his office was faithfully recreated with the original equipment – courtesy of the DENTAL MUSEUM. Don’t avoid Dentists – visit their Museum – It is an attraction rather than an extraction
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Bimler Laboratories Presentation In 1953, the Bimler Laboratories were founded, a couple of years after the first publication of the “Gebissformer”, as the Bimler appliance was called originally. It was the result of the “minimax” principle, striving for the maximum effect with the minimum effort. This was due mainly to the general shortcoming of almost everything in Central Europe after WW II, not just of orthodontists but also of materials like wire and acrylic, only the patients were plentiful. In order to cope with the growing interest in his treatment method and demand in his appliance, Dr. Hans Peter Bimler together with his father and his brother developed a construction system of prefabricated parts in different sizes for the fast and easy assembly of the “Gebissformer”. This proved popular first on the national and later on the international level.
Soon, special instruments were offered like pliers and articulators to provide the suitable basic tools for construction and manipulation. Until today, we take it as a compliment that they are copied in certain countries. The Bimler Laboratories are also a listed as publishing company since 1992. The first movie, however, dates back to 1939 when it was shown at the EOS congress of that year, showing a youthful Dr. Bimler taking a special double exposure x-ray radiography “Roentenophotogramm” of his teenage girl friend and later wife Erika. This 16mm movie can be seen at the Dental Museum also presented in this journal. www.bimler.com - bimler@germanynet.de
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A new design for a new body Prof. Wilson Aragão Brasil
“The head is the region of the human body where a number of independent func-
tions are performed: breath, smell, taste, chewing, vision, hearing, balance and neuronal integration.”(Melvin Moss)¹
“…and the balance of all these functions is directly related to the spatial position of the
temporomandibular joints – TMJ.” (Wilson Aragão).²
The HBTC is a treatment protocol wich reaches all parts of the human body, from the
head, integrating all encephalic nerves and their functions, like breathing, chewing, swallowing, smell, taste, hearing, balance and vision.
For human beings, breathing, both inhaling and exhaling, must be completely performed
by nose.
When someone breathes through the nose, the air is filtered by the nasal cavities struc-
tures, which are surrounded by the turbines where the air has to make turns to reach the nasalpharynx due to the sinusoidal path.
Air is also filtered by the cilia, which retain dirt and also the nasal mucus, that traps dirt that
crashed into the sinusoidal structure.
The diameter of the nasal cavities structure decreases so that the nasopharynx diameter
reaches about ten percent of the diameter of the nasal cavity opening. This means air filtration is properly done.
Air temperature is equalized by nostrils, so that, no matter where, wether at a -10° C/ 14° F
or a 40° C/ 104° F temperature, the human being lungs receives air at 36° C/ 96.8° F.
Temperature equalization is performed by the structure of the nasal fossae. This structure
has a very intense blood supply controlled by the CNS and may present vasoconstriction or vasodilatation. It also has muscles that open or close the nasal fossae according to temperature.
Humidification of the air that goes into the lung is provided by the lacrimal fluid (tear film),
which flows out the eyes, from the nasolacrimal duct to the height of the lower turbines, where air is aspirated into the lungs.
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Humidification is very important, because the air exchange in the alveoli should take place
at about 95% humidity.Âł
Concerning to moisture, it is important to emphasize that lacrimal fluid contains ap-
proximately 94 chemical elements, such as immunoglobulins (IgA, IgE, IgG, IgM), which are sucked in and then distributed throughout body by breathing and blood flow, what makes immune system function in a proper way. Another tear film element, the dipalmitoylphospha-
tidylcholine (DPPC), is very important for the formation of the surfactant liquid in the lung alveoli.2
Finally, the pressurized air goes to the lungs. As nasal ducts become narrower and sinusoidal in shape, air flows faster, increasing pres-
sure. So, when air reaches nasopharynx, its speed is faster than when it entered nostrils. That is how pressure is achieved by nasal breathing.
While chewing, the condyle in the balance side moves downwards, forwards and inwards,
following the trajectory provided by the lower beam of the lateral pterygoid muscle, and this
movement is detected by the proprioceptors of position and motion of the TMJ joint capsule and is transmitted to the brain for analysis, while the exteroceptors in the oral mucosa, cheeks and tongue inform the cerebral cortex where food is, and if it is placed by the tongue between teeth, to be properly chewed.
Meanwhile, the condyle on the chewing side (work side) is moved to the side and slightly
backwards by the masseter and temporalis muscles, within the limits of elasticity of the TMJ
joint capsule, which it is also informed to the brain by movement and position proprioceptors within the TMJ joint capsule.
Whenever one chews unilaterally on the right or left side, a hypertrophy of masseter, ster-
nocleidomastoid and supra and infra hyoid muscles takes place on the same side.
Due to unilateral chewing and its consequent hyperthrophy of the masticatory muscles, the
supra and infra hyoid muscles, and muscles of the shoulder girdle, the body gets out of its proper axis, what leads to serious results on all body joints and internal organs.
With the hypertrophy of these muscle groups, the collar bone is taken up by the hypertro-
phy of the muscular segment to the collar bone to mastoid bone. The shoulder blade comes forward and upward by hypertrophied omo hyoid muscle.
As a result of muscle actions, muscle fascia of the chewing side elevates all structures,
such as pelvis, which is lifted and rotated forward, resulting in a transference of the body weight to the leg of the opposite side.
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On the chewing side, the internal structures of the thorax and abdomen are pulled up. In humans, if unilateral chewing takes place on the left side, heart and kidneys are the affected organs. In women, besides all already mentioned, its remarkable the stretching of the ovary in this side.2 Concerning to the chewing opposite side, body compression is quite noticeable. If someone chews left, the kidney on the right side is compressed, what will affect the ability of filtering the blood and possibly lead to the development of kidney stones after some years. It may also cause an appendicitis crisis due to the decreased blood flow to the appendix, a poorly nourished blood organ, and may occur as a consequence of ischaemia and necrosis.2 In Women, polycystic ovaries may occur, by stretching on the chewing side and compression on the no-chewing side, because ovaries are extremely sensitive organs. There are very obvious signs of unilateral chewing on the outer side of the body. The shoulders are uneven. when the shoulder level on the chewing side is higher, the distance between shoulder and neck is smaller on the chewing side.2 Backwards, a cervical vertebrae scoliosis may evolve at the chewing side, due to trapezius muscle upwards and forwards movements. With the shoulder, trapezius muscle raises and takes spine from C1 to C12 to the chewing side. In a profile view, if one chews left, at the right profile view a kyphosis is seen due to the left shoulder is higher and forth.2 The front side of the body will stretch due to the fascia. At chewing side, chest gets higher than at the other side. This change in men is not very clear; however, in women it produces an unpleasant lifting effect, which is always on the chewing side.2 In front view and standing position, its remarkable that, at the chewing side, this persons hand stands higher than the other one. Due to the unilateral chewing, the pelvic girdle will get higher and rotated forward, making the body weight rest on the leg the other side.2 In a panoramic radiograph, this position of the pelvic girdle may lead to a ‘shorter leg’ diagnosis. And this makes misdiagnosis very common, leading to prescriptions of insoles to com-
pensate these ‘shorter legs’ and thereby perpetuating pathology. Also because unilateral
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chewing, it will be noticed joint problems in the leg opposite to chew. The most common are kneee problems.2
Tongue has 17 muscles, eight on each side and one in the middle. These muscles are
inserted at various levels such as the palate, the hyoid bone and jaw, and on both sides of these structures.
Swallowing problems may also occur when a person chews unilaterally, since the tongue
muscles only work this side of the masticatory, while the othermuscles are not triggered and
track the movement by inertia, because they are together. Then tongue muscles of chewing
side are hypertrophied, while the no-chewing side ones get baggy, with consequences such as the palate increase on chewing side, in comparison to the width measures of the median
raphe. As already mentioned, there is an increase in the inserts ossification and also a change of structures spatial position, such as the soft palate, and also the hyoid bone and jaw.2
By swallowing with closed lips, tongue removes air from nasopharynx and oropharynx
and sends pressure mostly to paranasal sinus. If patient chews unilaterally, swalling creates a much stronger pressure on the chewing side and therefore this pressure will be stronger in the paranasal sinus of the chewing side.2
Olfaction is carried to the brain by the encephalic nerve I, olfactory nerve, and has connec-
tions with the limbic system, hypothalamus and reticular formation.
During feeding proccess, the olfactory nerve is mainly responsible for the experience of
flavor variations according to the different kinds of food, since tongue can only capture basic tastes.
Taste is perceived by special afferent encephalic nerves: V-Trigeminal, VII-Facial, IX-Glos-
sopharyngeal, with a small role played by the X-Vagus.
Since this activity has already been described by other scientific papers, I will not go fur-
ther than showing that unilateral chewing promotes the movement of the bolus only on chew-
ing side of the tongue. Therefore, after long time not using nerve endings in taste buds on the no-chewing side, these buds gradually lose their taste efficiency until complete inactivity. The hearing in human beings is connected to the cochlear nerve for transmission to the
CNS. But it is much more related to the functional performance of the biological units related to the middle ear.
When humans speak, their own voice is heard through the Eustachian Tubes, which must
be permeable and have its opening to nasopharynx working properly. Besides, the structures
must be running the same on both sides, with harmonic and synchronous bilateral chewing,
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breathing, nasal and nasopharyngeal under sub atmospheric pressure to allow the proper
function of the middle ear and correct mechanical transmission to the cochlea, sending the correct signals to the brain.
When lips are inadequate sealed, atmospheric pressure environment gradually invades the
region of oro and nasopharynx, reaches Eustachian tube and middle ear and finally gets to the
mastoids. When air pressure reaches all these regions, gravity law also acts on them, making middle ear bones percussion be interpreted as sound.
Stapedius, the muscle that moves ear bones, is one of the most sensitive in human body.
For proper function, this muscle demands a sub atmospheric pressure in the middle ear region. But when atmospheric pressure invades middle ear, this muscle has to work against at-
mospheric pressure and therefore against Law of Gravity. Although Stapedius muscle works
at any circumstance, when it does it against Gravity, its effort is interpreted by the brain as noise: the so-called tinitus.
The cochlear nerve is responsible for balance and hearing in human body, so that these
two senses are intrinsically linked. As consequence, absolute absence of sound and sound above audible decibel limits lead to loss of balance.
Balance is tied to spatial position of the eyeballs and it is co-rulled by impulses of the
nerves that control eye movements, the encephalic nerves III, IV and IV.
All these functions are carried to the thalamus and cortex by the trigeminal nuclei. Vision is part of head activities. It is carried to the brain by encephalic nerve II, the ‘optical
nerve’.
To achieve an adequate view, eyes must present movements which are controlled by three
encephalic nerves, the II, IV and VI pairs respectively, and the VIII encephalic nerve too. These couples make all the movement needed to see in almost all directions.
But if someone chews unilaterally and/ or is a ‘mouth breather’, eyeballs position is altered
due to the replacement of the muscles responsible for the eyeballs movement. This occurs
because there is a fascia surrounding facial muscles, from neck to the occiput. In unilateral
chewing, the activity of these fasciae is altered , and as result a change of the spatial position of the eyeballs takes place.
After some years of unilateral chewing, with the bi pupillary changes, the information trans-
mitted through the encephalic nerve that make eyeballs move gets changed, which changes
the information that comes from the eighth encephalic nerve to the brain, causing imbalance episodes, interpreted as labyrinthitis.
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Figure 1. Before AFR treatment.
Figure 2. After 02 months AFR treatment.
The integration of all these neuronal activities described above is carried to the thalamus
and then to the brain by encephalic nerves, but the direct activity of all encephalic nerves,
except the I and II (Olfactory and Optical nerves), is driven to Thalamus by encephalic nerve V (Trigeminal nerve). So, taking this into account, all the functional activities described earlier end up being conducted by the Trigeminal – for good or evil.
The treatment system I call ‘Human Body Total Care (HBTC)’ comprises three intraoral
devices called AFR (Aragao’s Function Regulator) + breathing exercises + chewing exer-
cises. It can treat systemic diseases, and may be or not associated with other medical, dental, physiotherapy professional procedures.
The AFR devices promote the proper position of the temporomandibular joints (TMJ) within
the Glenoid cavity, without compression of the bilaminar zone, where nerves and vessels (arterioles, veins) are located.
Due to the compression of the bilaminar zone, the unilateral chewing initially causes edema,
with all the characteristic table of inflammation. If compression remains, changes will occur either in other areas, such as glenoid cavity wall or in the jaws condyle, caused by ischemia.
This compression also exists on the Auriculo-temporal nerve, a branch of the Trigeminal,
which innervates this region.
The treatment promoved by the HBTC method is done by the AFR (Aragao’s Functions
Regulator), and is effective because when the AFR is placed in the buccal vestibule of the patient, and his/her lips close, the following occurs:
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The structures of the TMJ on both sides are moved into a good position, both TMJ space
on the same level (no stretching or compression of the joint capsule or the bilaminar zone, no projection of the mandibule).
Accordingly to the lips sealing, swalling occurs, and resulting from swallowing, the oro-
nasofaryngeal space is submitted to sub atmospheric pressure, the ideal working condition for these structures, particularly neuronal receptors V, VII, IX and X encephalic nerves, respectively Trigeminal, Facial, Glossopharyngeal and Vagus nerves.
Under such condictions, all nociceptive signaling of TMJ to the Trigeminal nucleus turns to
a non- nociceptive signal, in order that neural signaling of all encephalic nerves V, VII, IX and X which come from oronasofaryngeal space gradually become normal.
Due to the use of the AFR under the conditions above, the reticular formation, the hypo-
thalamus and limbic system, now receive and send signals to the trigeminal sensory nuclei, gradually modulating the functions of these areas.
All motor functions, particularly motor neurons, improve significantly their function through
the use of AFR.
It is described bellow how AFR works on the treatment of systemic diseases, according to
the disease groups as follows: •
Chronic pain.
•
Headaches, migraines, fibromyalgia.
•
Muscle aches, backache, joint pain and spine pain.
Primary headache disorders include migraine, tension-type headache, cluster headache
and other trigeminal autonomic cephalalgias. These disorders are neurovascular in origin, whereby a neurologic mechanism triggers a vascular response.
The characteristics of headaches vary. Migraine, for instance, is described as a disabling
throbbing, pulsating, or beating pain, whereas tension-type headache is characterized as a non-disabling dull, steady, aching pain.
Dental profession has become increasingly active in managing some of these pain disor-
ders; however, the major burden of managing most of these disorders still lies with the medical community.
Besides the convergence of the peripheral input, the trigeminal nuclei also receive extensive
neuronal and interneuronal connections from sites throughout the CNS, including the motor cor-
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tex, which also sends afferents to other cranial nerve nuclei and reticular formation structures, the limbic system, and the hypothalamus. The nuclei are also rich in receptors for the spectrum of neurotransmitters through which sensory input and motor behaviors are modulated. In addition, second-order nociceptive neurons from subnucleus caudalis arborize throughout the reticular formation and limbic structures and connect to the subnucleus interpolaris, subnucleus oralis and main sensory nucleus. These nuclei also receive descending motor input from cortex and circuits which are related to pain interpretation. These ascending secondorder neuronal and descending corticospinal connections show that nociception, before and after it is interpreted as pain, affects ongoing behavior. It is remarkable that all the CNS input is also carried by second-order neurons from the dorsal horn of the spinal cord. Therefore, potential pain input from regions outside trigeminal receptive fields may excite CNS structures that intensively communicate with trigeminal nuclei and modulate their functions. Due to unilateral chewing, muscular shortening results in muscle fasciae stretching and consequent elevation of all viscerae on chewing side. Symptons such as “atypical thoracic pains” are triggered as mediastinum area gets smaller and compressed. Chronic pains are treated by AFR (Aragao’s Functions Regulator), since its placement into
buccal vestibule causes lips sealing, with the following results:
SLEEP DISORDERS Systemic diseases such as sleep apnea, snoring, insomnia, bruxism, panic disorder (night terrors) and mouth breather syndrome most often have mouth breathing and/or unilateral chewing as common denominator. The main cause of mouth breathing is the lack of register on the Central Nervous System (CNS) of the breathing through the nose on the first year of extra uterine life, that is, the new born starts breathing through the mouth early on the first year of life.² But the picture above described is unusual, because children as a rule breathe through nose when breastfed, what is correct and must be done for one year, at least. While nose breathing, the air that goes during inhaling to lungs through nasal cavities is added to the lachrymal fluid (tear film), which flows into the nasolachrymal duct at the height of the middle turbines. Lachrymal fluid contains more than 94 chemical elements, and plays a great role on several inner lung metabolic exchanges, from inner alveolar pressure to auto-immunizing elements production, providing the individual with higher tolerance to allergenic elements².
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Mouth breathers cannot chew bilaterally, alternating dental arch sides, because by moving the bolus from one side to another, it can be inhaled through the trachea, causing shock and cough to expel the food. So, to be able of breathing through mouth, one must perform unilateral chewing. Brain oxygenation becomes inefficient as result of mouth breathing, and therefore it may get harmed as a whole. Quality and quantity of neurotransmitters become inadequate, as those which form the sleep inductor melatonin, causing insomnia. In relation to cognition and behavior, mouth breathing children are unquiet and have to be in constant agitation in search for more oxygen. Although dispersive and agitated, when these children are forced to stand still, they get
sleepy and cannot pay attention to classes at school, and as result they are often diagnosed with Attention Deficit Disorder (ADD) and unnecessarily medicated.
Mouth breathing for many years causes cerebral hypoxia. Particularly in early childhood, it can induce hypoxia in the limbic system region, thus causing daytime panic attacks and sleep episodes of night terrors.²
Figure 3. Before AFR Treatment.
Figure 4. After 01 year AFR treatment.
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In the treatment with the AFR, the first relationship is observed basal patient’s bone and
determining the type indicated for AFR.
Then, the patient shall be told to exercise slow and deep breathing with sealed lips, for 10
minutes per hour, awake.²
By this means, breath will be adjusted according to the buffering capacity of blood, and it
will also regulate heart activity, blood stream pressure, the amounts of oxygen-hemoglobin and erythrocytes, the hemoglobin-oxygen affinity, hematopoiesis, the excretory functions of the kidneys, intestinal tract and transpiration.
The variations of the values of these constants are picked up by internal or direct by inter-
ceptors the respiratory center by the action of the blood.The perception of decreased rate of oxygen is due to hemorreceptors located in the carotid and aortic bodies. These receptors have the innervation of the Vagus and Glossopharyngeal nerves.The periodic nature of inhala-
tion and exhalation is controlled by neurons located in the bridge and the medullae. They are named respiratory centers. Today recognize three main groups of neurons.4
My hypothesis concerning to sleep apnea is that when someone sleeps and breathes
through mouth in supine position, the tongue, while free from the action of sub atmospheric pressure provided by lip seal, contacts the oropharynx region, which is innervated by the
Glossopharyngeal and Vagus nerves, and this contact activates the pneumotaxic center on
the brain, then causing inhaling stop. This contact is the usual signal for swallowing, but not
in this circunstance, because the phenomenon here described means sleep apnea, causing saturation of CO2, heart’s activity increase and lung stop.
Chemoreceptors are the elements that bring inhaling back. They are the central and periph-
eral chemoreceptors (carotid and aortic bodies), the most important being the carotid bodies,
which are primarily responsible for all the increased ventilation in response to arterial hypoxemia. In addition to these components, other parts of the brain influence the alteration of respira-
tory pattern: the limbic system and hypothalamus in emotional states such as fear or anger.
Since fear is a stimulator of the limbic system, and it is reported that the lack of O2 and in-
crease of CO2 level brought by sleep apnea are lethal, the limbic system manages to recover inhaling, the carotid body excites the inspiratory center, re-inflate lungs and so heart activity returns to normal.
But for obese people, in addition to a long term mouth-breathing, lack of physical activity
extends from day to day, and each apnea episode is followed by a violent tachycardia, leading
to a respiratory rate of chocking and prolonged wheezing, until heart cannot stand any more, thus causing an infarction.
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In my treatment protocol, patient is instructed to use the AFR, make the exercise of lip closure in slow, deep breathing. The patient is also referred to a cardiologist to check heart condition, to a speech therapist for training the oropharynx and larynx muscles, and to a nutritionist for proper diet recommendation, besides getting the advice for at least a 40 minutes daily walk at accelerated speed, but no running. Snoring treatment demands the same recommended exercises for sleep apnea therapy. After two months of using AFR and exercises, snoring will disappear. After using the AFR for 6 (six) months, the signs and symptoms of insomnia, mouth breathing and even burnout syndrome get better, as well as panic disorder, if the patient is accompanied by psychoanalyst treatment.
REFERENCES 1.
Moss ML – The primacy of functional matrices in orofacial growth. Dent. Pratic Tit.Vol.19, n. 2, p.65-73, 1968.
2. Aragão W. Regulador de Función Aragão – Tratamiento de las enfermedades sistémicas a partir del sistema estomatognático. Editorial Ripano, Madrid, 2008.
3. Guyton AC – Neurociência básica – Anatomia e Fisiologia. Rio de Janeiro: Guanabara Koogan, 1993. 4. Lent R – Cem bilhões de neurônios. Rio de Janeiro, Ed Atheneu, 2001.
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100th Birthday of Dr. med. Hans Peter Bimler
On December 12th 2016, the day for the 100th birthday of the German orthodontist Dr. med. Hans Peter Bimler, the special exhibition to his memory was inaugurated in the Dental Museum in Colditz-Zschadrass, south of Leipzig in the east of Germany. Our pictures show the Director Andreas Haesler with the special guest Rick Ito from Japan in front of a photograph of Bimler. The lively party lasted all afternoon and through the evening. On Friday, July 14 - 2017 we want to meet again there for a little scientific conference – if you are inte-rested, safe the date and contact us for more information: Dr. Barbara Bimler: bimler@germanynet.de www.dentalmuseum.eu
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The Role of the Pediatric Dentist in the Cleft Palate and Craniofacial Team Prof. Patrizia Defabianis. Dr. Eyal Botzer Israel
Orofacial clefts are the most common oro-facial anomaly in newborn infants and the second
commonest congenital abnormality, affecting approximately one in every 800 births world-
wide. It is a non “life-threatening� abnormality, which can have significant effect on maternal
bonding and include cleft lip with or without cleft palate (CL/P) or isolated cleft palate (CP), the former being more frequent than the latter. Submucous clefts are rarer (1/1200 births).
Clefs differ with respect to embryology, etiology, candidate genes, associated abnormali-
ties, and recurrence risk; they can occur in isolation or as a part of a broad range of syn-
dromes1. Depending on their exact location, these growth disturbances result in different defects and can be divided into three main types: isolated cleft Palate (Fig. 1); unilateral cleft lip with or without cleft palate (Fig. 2); bilateral cleft lip with or without cleft palate (Fig. 3).
Nowadays there is still disagreement about technique, timing and sequence in treatment
planning. Successful treatment requires a multidisciplinary approach, but there is no consen-
sus in sequence due to lack of randomized clinical trials comparing outcomes and effects of timing2,3. Several approaches have been published on early management of the alveolar seg-
ments and the dislocated pre-maxilla and nowadays we are more and more confronted with
a world-wide tendency in favor of the all-in-one operation to close clefts of the lip, alveolus and palate. Unfortunately, surgical methods widely vary from center to center; every center has its own protocols with no fixed rules about the order in which individual cleft sections are closed and/or at what age. Anyway, long-term treatment is required with not always satisfac-
tory outcome as it is well-known that all types and timings of surgical repair are detrimental to maxillary growth. Usually the first surgery of the lip and nose at the age of 3 months or so, surgical closure of the palate at the age of 9-12 months, when some protocols defer the clo-
Figure 1. Isolated cleft palate.
Figure 2. Unilatera Cleft lip and Palate.
Figure 3. Bilateral Cleft lip and Palate.
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sure of the hard palate till the age of 4 years. The next stage is surgery for pharyngeal function at age 4 and up only when necessary.
The alveolar cleft is closed by bone graft before the eruption of teeth into the cleft site
meaning ages 7-11 years. Orthognathic surgery may be considered at the end of growth when needed.
Additional surgeries such as reshaping of the nose or removal of excess lip tissue can be
considered depending on the situation of any single patient.
Due to the prevalence of this malformation, there is no doubt that every dentist or ortho-
dontist will encounter a cleft patient during his or her professional life. Better knowledge of the treatment phases and possibilities including functional therapy options will improve the dental and overall care delivered to these patients around the world.
Care of a newborn with cleft lip and palate requires a multidisciplinary team and every
medical center that treats craniofacial defects should have a multidisciplinary team including a plastic surgeon, a speech and language pathologist (SLP), an Ear Nose and Throat surgeon (ENT), a maxillofacial surgeon and an orthodontist. However, a more comprehensive team should include a social worker, a pediatrician, a psychologist or a child psychiatrist, a pediatric dentist and a prosthodontist.
All team members should accompany the infant during the years to adulthood, as a healthy
body and a healthy mind person.
TREATMENT PHASE 1: INFANCY (0-6 MONTHS) Isolated Cleft palate Cleft palate appears often as part of the "Pierre Robin sequence”. Due to posterior tongue
position (“Glossoptosis”) airway and breathing difficulty may develop thus leading to feeding
difficulties and then created “vicious circle": no sufficient caloric intake resulting in decreased muscular tone, the tongue falls backwards even more and the respiratory difficulties are worsened and so on….
In the past it was the dentist’s role to install an obturator - feeding plate that allowed more
efficient feeding, thereby increasing the newborn’s caloric intake and preventing the glos-
soptosis. One of the first feeding plates that also helped the tongue position was the “Hotz Plate” (fig. 4, 5).
Today, there are special feeding bottles which allow almost all newborns with a cleft to feed
without the feeding plate.
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Figure 4. Hotz plate.
Figure 5. Hotz palte inserted and the forward tongue position.
In severe cases where the mandible is severely retrognatic and airway is impaired, there is
a range of treatments to secure the airway such as “Nasal Airway� insertion or even tracheotomy or Distraction Osteogenesis to advance the mandible and open the airway. Cleft lip and palate
Infants with cleft lip and palate often present a cleft of the alveolar bone, and as a result,
the bone segments are distorted in different directions and there is a soft tissue gap. Dur-
ing development in the womb, certain tissue structures do not fuse. It is very important to
underline that cleft always results in a deficiency of tissue and not in a mere displacement of
normal tissue and are characterized by an important anatomical disruption of the lip muscles, in particular of the orbicularis muscle. In unilateral cleft lip and palate (UCLP), the orbicularis
muscle is interrupted and diverted: its fibers are atrophic and run upwards and parallel to the edge of the cleft, and are inserted at the base of the columella medially and at the nasal wing laterally (see fig. 2). The more severe the cleft, the more difficult it is to achieve pleasant postoperative results due to the presence of abnormal maxillary growth vectors: during oral func-
tion (feeding, crying, smiling etc.) the columella on the non- affected side and the nasal wing on the cleft side are stretched in opposite directions, increasing so the width of the cleft. The defect affects the external portion of the upper lip, the alveolar ridge, the hard and soft pal-
ate; the nasal floor communicates with the oral cavity, the maxilla on cleft side is hypoplasic,
the columella is displaced to the normal side and the nasal wing on the cleft side is displaced laterally, posteriorly, and inferiorly increasing so nasal deformity. The loss of facial symmetry,
the disruption of the bone segments, the interruption of the muscles that contribute to further displacement of the margins of the cleft and the increasing deformity of the nasal structures,
are the main features in these patients. The nasal septum is deviated to the healthy side, the
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chin is deviated to the affected side, the columella is stretched and this results in the dis-
placement of the tip of the nose. In these conditions, mechanics of facial growth is seriously
affected and results in an asymmetry of the premaxilla (which is tilted up toward the cleft side), and a deviation of the nasal septum (which bulges towards the cleft side). In bilateral cleft lip and palate (BCLP) the orbicularis oris muscles run parallel to the edge of the cleft and inserts into the alar margin. The lip and the alveolar ridge are absent under both nostrils and the cen-
tral portion of the lip, alveolar ridge, and the premaxilla are positioned abnormally. In these
patients the columella is very short, the deformities of the nose are generally important due
to the stretching of the alar cartilages during oral function, and the tip of the nose is directly
attached to the lip. Generally speaking, these patients may develop airway distress because of the tongue lodging in the palatal defect further increasing the cleft width.
The role of the pediatric dentist or the orthodontist is to prepare the infant for his lip and
nose surgery, so the alveolar bone segments are aligned and the soft tissues are located in good proximity and the plastic surgeon can perform surgery with no tension in the soft tis-
sues and minimal scarring. Some surgeons are performing a Gingivo Periost Plasty (GPP) consisting in a bony connection of the alveolar segments thus reducing the need for bone
grafting at an older age. The process of approximating the alveolar bone segments is called Pre-Surgical Orthopedics (PSO). The effect of PSO on maxillary arch has been a subject of
debate for many years, but controversy regarding the effect of PSO on its growth still exists.
Advocates of PSO claim that the pre-surgical orthopedic plate molds the alveolar segments into a better arch form and prevents the tongue from positioning in the cleft, improving so the
dentomaxillary development4-7. Opponents of this therapy claim that lip surgery alone has the same effect and that the pre-surgical orthopedic plate is only an expensive appliance used to comfort the parents by starting treatment at the earliest possible moment8-12.
Before PSO started, the surgeons had been removing the Premaxilla surgically. Only in the
19th Century did they start to conserve the Premaxilla, either by back sliding of the premaxilla or by surgical Lip Adhesion. In the 20th century started combination of PSO and surgery.
In1844 Hullihen used adhesive tape binding to retract the premaxilla. In 1927 Brophy used
a silver wire through both the ends of the cleft alveolus to approximate the segments and in 1951 McNeil used a series of “non fitting” intraoral acrylic plates to mold the alveolar seg-
ments into the desired position – very similar to todays’ Invisalign method. Following McNeil’s work, Latham and Millard developed metal devices “ the Latham appliance” that is retained to the palate by pins and bends the alveolar segments toward each other. This appliance “won”
many opponents mainly due to its invasiveness and also because of the fact that almost all
patients undergoing GPP presented an anterior X-bite and Class 3 occlusal relations. In the beginnings of the 1980. Grayson and Cutting from the Institute of Reconstructive Plastic Sur-
gery of the New York University developed a modified technique for alveolar molding, they
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Figure 6. Active plate held with elastics to the cheeks.
Figure 7. Original slide courtesy of Dr. Barry Grayson: areas of grinding and adding soft lining to the molding plate.
used an acrylic plate as the Hotz plat that was modifies once a week with adding soft lining material on one side or the alveolar segment and grinding the inner part of the plate on the opposite side of the bone in order to redirect the alveolar segments’ position and growth towards the desired position (Fig. 6, 7). There are 2 types of PSO: 1. Active plate- The plate does not fit the alveolar bone shape and molds the segments by applying a gentle force. In this technique there is high control over the force vectors but there is a possible growth interference 2. Passive plate-The plate only prevents collapse of the alveolar segments. Usually combined with Lip Adhesion and it probably does not interfere with growth. When moving the bone to the desired position, the soft tissues that are above are being approximated too, thus the plastic surgeon is able to operate on an easier and stress-free
Figure 8. Soft tissues before PSO.
Figure 9. Soft tissues after PSO.
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tissue. In fact, many plastic surgeons prefer this preparation before surgery (Figs. 8, 9, 10). Nasal Molding Another problem described in literature is that surgical reconstruction of the nasal structures may hinder the nasal airway to such an extent that Figure 10. Hard tissues before and after PSO. the patient breath through the mouth as well13. Sometimes, surgical procedures increase nasal resistance to the degree that the child would start breathing through the mouth. Indeed, nasal asymmetry, columellar deficiency, and deformation of nasal cartilages are important factors contributing to an increased nasal resistance. This might result in a variable degree of growth deficiency14,15. Dr. Barry Grayson and his colleagues at NYU, developed a technique that corrects the deformation of nasal cartilage and distorted nose of the cleft lip patients this treatment is called NAM – Naso Alveolar Molding16. The background to NAM are the findings of the Japanese group led by Kiyoshi Matsuo which shows that auricular cartilage can be shaped and molded in newborns (Fig. 11). The newborn’s cartilages have some degree of plasticity immediately after birth for a limited time. By molding the nasal cartilages, we can significantly improve the esthetic outcome of the cleft patient. In the NAM treatment, a stent is added to the active PSO plate. Its aim is to effectively reshape the nasal cartilage and mold the maxillary arch before primary surgery. NAM components consist in the use of an orthodontic wire from the palatal prosthesis with an acrylic bulb positioned inside the nose, underneath the apex of the alar cartilage, as the nasal stent. The aim of this procedure is to elevate the wing and the
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Figure 11. Auricular cartilage before and after molding.
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tip of the nose during the 3 to 6 months prior to surgical repair, thus inducing improved rounding of the nostril on the cleft-side and reduced alar flattening following primary nasoplasty17,18. The stent is inserted into the deformed nostril and with gentle force application, the nose shape is corrected and the nasal columella is elongated to the proper length. The NAM treatment lasts 3-5 months with weekly visits before the first lip surgery. (Figs. 12, 13, 14, 15).
Figure 12. The Change in the nasal stent size during treatment.
Figure 13. Change in the nose in a unilateral cleft lip and palate.
Figure 14. Change in the nose and colunella in a bilateral cleft lip and palate.
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Figure 15. Lateral view of a bilateral cleft without NAM and with NAM.
Nasal alveolar molding has been shown to be an effective method to normalize the anatomy of the nose and maxillary arch and to minimize asymmetry by lengthening the columella, reshaping the nasal cartilages, and molding the alveolar processes. Furthermore, it provides aesthetic and functional benefits of nasal tip and alar symmetry. In bilateral cases, it successfully helps in retracting the premaxilla posteriorly, lengthening the deficient columella and favor the repositioning of the apex of the alar cartilages toward the tip of the nose. There is a simple version of Nasal Molding that was developed at the Tel Aviv Medical Center for incomplete cleft lip case, where the nose is deformed but there is bony support at the nostril floor. A simple use of Nasal Oxygen Cannula that is cut in its anterior part to allow breathing and inserted into the nose. The deformed nostril can be molded by adding soft dental lining material and the cannula is retained to the cheeks by adhesives (Fig. 16). Neonatal Teeth Neonatal teeth are a very frequent finding in a cleft lip patient. The tooth buds are very close to the surface and erupt soon after birth. Most of the times these are the lateral decidu-
Figure 16. Modified Oxygen nasal cannula for Nasal Molding.
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ous teeth and in most cases extraction of the tooth is indicated because the tooth may interfere with the lip surgery and the GPP.
TREATMENT PHASE 2: TODDLERS (AGES 6-36 MONTHS) Retention Plates Sometimes, a retention plate is needed to prevent the alveolar segments from collapsing
after surgery.
Toddlers with retention plates should be monitored regularly to allow expansion and growth
of the palate and allow the teeth to erupt. Prevention
At this age we must begin prevention of dental caries. Infants with cleft lip and palate are at
high risk to develop tooth decay for many reasons. First of all, often teeth are affected by more or less severe enamel defects (enamel hypoplasia etc.) due to invasive surgical procedures,
while lip surgical scares and dental malposition (rotation etc.) make oral hygiene procedures difficult to perform.
TREATMENT PHASE 3: AGES 3-12 YEARS At this phase the focus is on preventive and preservative care. Sometimes, it is necessary
to help the speech and language pathologist with installing several obturators to close OroNasal fistulae to improve speech (Fig. 17).
Figure 17. Obturator of Oro-nasal fistula.
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Figure 18. Malformed teeth and subgingival restoration.
Many children undergo orthodontic and
functional orthodontic treatments. (Figs. 2025).
Figure 19. Palatal Bulb.
Again it is highly important to preserve the teeth at the cleft site. Also since the permanent teeth may be deformed, the restoration may require imagination and improvisation and often using the Electro surgery to allow restoring sub gingival areas (Fig. 18).
Figs. 20-25. Example of a functional orthodontic treatment for a cleft patient:
Figure 20. M.B. aged 3. Female patient affected by
a bilateral cleft lip and palate with an evident vertical excess of the pre-maxilla. This condition is due to an
unusual growth at the vomer cartilagenous- premaxillae junction, worsens with age and causes serious psycho-
logical problems to the child and the family. In the most severe cases bone graft placement is not possible.
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Figure 21. Lateral view of the same patient.
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Figure 22. The functional appliance (Sn6) used
to improve the deep bite. It has a central screw to correct horizontal discrepancy, an anterior bite
Figure 23. Intra-oral view nine months later showing the repositioning of the pre-maxilla.
(equiplan) to correct vertical discrepancy, a buccal
arch and a lower vestibular shield to control sagittal discrepancy
Figure 24. The latero-lateral cephalometric projection showing the intrusion of the pre-maxilla.
Figure 25. Lateral view of the patient at the end of the treatment.
Healthy teeth are imperative for the success of other surgical procedure in the patient,
since dental caries and infection may lead to infection and surgical failure of fistula closure, bone graft or palatal flap surgeries.
In case a tooth at the cleft site should be extracted for the bone graft surgery, it is recom-
mended to extract the tooth 2-4 weeks before the surgery, to allow proper healing of the soft tissue without losing the precious alveolar bone that supports that tooth.
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TREATMENT PHASE 4: ADOLESCENCE (AGES 13-18) This phase too is characterized by intense preventive measures mainly due to the fact the
there are some kind of orthodontic appliances in the mouth for long periods of time that diminishes the ability to maintain proper oral hygiene.
Frequently, the pediatric dentist or the orthodontist work closely with the SLP and the ENT
to adapt special obturators for palatal closure as Palatal Bulb or Palatal Lift (fig. 19).
CONCLUSION In our experience Pre Surgical Orthopedics (PSO) is an excellent way to control maxillary
growth and improve dento-maxillary development by molding the alveolar segments into a better arch form, preventing so the tongue from positioning in the cleft.
The dentist is an integral part of the Cleft and Craniofacial Team. The dentist is the one
who is in close and intensive contact with the newborn’s family from early in life because of
the NAM treatment and after that routinely for the check-ups and maintenance appointments. With the goal of working together with the rest of the team helping the family grow their child as normally as possible and become a healthy and fully functioning person both in mind and esthetic appearance.
REFERENCES 1. Murray JC Gene/environment causes of cleft lip and/or palate. Clin Genet. 2002;61:248-256. 2. De Ladeira PR, Alonso N. Protocols in cleft lip and palate treatment: systematic review. Plast Surg Int. 2012;2012:562892 3. Papadopoulos MA, Koumpridou EN, Vakalis ML et al. Effectiveness of pre-surgical infant orthopedic treatment for cleft lip and palate patients: a systematic review and meta-analysis. Orthod Craniofac Res. 2012 Nov;15(4):207-36. 4. Ball JV, DiBiase DD, Sommerlad BC. Transverse maxillary arch changes with the use of preoperative orthopedics in unilateral cleft palate infants. Cleft Palate Craniofac J. 1995;32:483–488 5. Fish J. Growth of the palatal shelves of post-alveolar cleft palate infants. Br Dent J. 1972;132:492–501 6. Hotz MM, Gnoinski WM. Comprehensive care of cleft lip and palate children at Zurich University: a primary report. Am J Orthod 1976;70:481–504 7. Mishima K, Mori Y, Sugahara T et al. Comparison between the palatal configurations in UCLP infants with and without Hotz plate until four years of age. Cleft Palate Craniofac J. 2000;37:185–190 8. Huddart AG, Huddart AM. An investigation to relate the overall size of the maxillary arch and the area of palatal mucosa in the cleft lip and palate cases at birth to the overall size of the upper dental arch at five years of age. J Craniofac Gen Dev Biol. 1985;suppl 1:89–95 9. Mars M, Asher-McDade C, Brattstro¨m V et al. The RPS. A six-center international study of treatment outcome in patients with clefts of lip and palate: part 3. Dental arch relationships. Cleft Palate Craniofac J. 1992;29: 405–408
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10. Prahl C, Kuijpers-Jagtman AM, van ’t Hof MA et al. A randomised prospective clinical trial into the effect of infant orthopedics on maxillary arch dimensions in unilateral cleft lip and palate (Dutchcleft). Eur J Oral Sci. 2001 Oct;109:297–305
11. Prahl C, Kuijpers-Jagtman AM, van ’t Hof MA et al. A randomized prospective clinical trial into the effect of
infant orthopedics in UCLP. Prevention of collapse of the alveolar segments (Dutchcleft). Cleft Palate Craniofac J. 2003 Jul;40:337–42
12. Pruzansky S, Aduss H. Prevalence of arch collapse and malocclusion in complete unilateral cleft lip and palate. Proc Eur Orthod Soc. 1967:365–382).
13. Warren DW, Hairfield WM. The nasal airway in cleft palate. In: Bardach J,Morris HL, eds. Multidisciplinary Management of Cleft Lip and palate. Philadelphia: WB Saunders; 1990:681–688
14. Ross RB. Treatment variables affecting facial growth in complete unilateral cleft lip and palate. Part I: Treatment affecting growth. Cleft Palate J. 1987; 24:5–23
15. Shaw WC, Dahl E, Asher-McDad C et al. A six-center international study of treatment outcome in patients with cleft lip and palate. Part 5. General discussion and conclusions. Cleft Palate Craniofac J. 1992; 29:413–418.
16. Barry H. Grayson and Pradip R. Shetye Presurgical nasoalveolar molding treatment in cleft lip and palate patients. Indian J Plast Surg. 2009 Oct; 42(Suppl): S56–S61.
17. Da Silveira AC, Oliveira N, Gonzalez S et al. Modified nasal alveolar molding appliance for management of cleft lip defect. J Craniofac Surg. 2003 Sep;14(5):700-3
18. Grayson BH, Cutting CB: Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. Cleft Palate Craniofac J 38: 193–8, 2001.
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Reasons Why Orofacial Myology Has Been Slow Developing as a Profession Dr. Sandra Coulson USA
Early practitioners exploited the field with sensationalism and high fees, and other dental
professionals did not see demonstrable results.
University Orthodontic Programs picked up on this, and taught that OFM did not work. Terminology was poor. Terms like “Reverse Swallow� were nonscientific and non-descrip-
tive since the patient was not regurgitating. This does not promote confidence in it as an etiology of malocclusion.
There were no scientific studies done, and therefore no scientific papers published. If stud-
ies had been done properly, it would have indicated that habitual tongue posture was the
primary reason for malocclusion, and that the tongue should be higher and away from the teeth with the tip resting in the rugae area. This does not seem logical at first, but when it is demonstrated that upper intermolar width can be increased with O M therapy it supports habitual low tongue position as a reason for the development of a narrow upper arch.
The lack of standard record keeping also slowed progress. Photographs should be taken
of the patient’s teeth at various intervals
To demonstrate progress and motivate the patient, but care should be taken to make sure
the angle to the face is identical to show changes in vertical overlap of the teeth. This has been
abused in some cases, and it discredits the author. Standard Cephalometric x-rays would be a big help in demonstrating changes, but there are logistic challenges. The ideal setting for research would be one therapist treating in one office or University, using all of these tools.
As a result of the aforementioned shortcomings, University Orthodontic departments actu-
ally taught students that therapy at that time did not work.
As we look at these issues, it illustrates why the profession has been slow to grow. It also
demonstrates the difficulty encountered when a new therapist starts a new practice. That person must build his/her own data base and educate her/his own referral base.
The need for a supportive professional organization becomes obvious. This has been slow
to develop as well. The organization needs to promote standardized scientific research and share the results. There needs to be agreement in the organization on what background is necessary for a therapist to begin training to be an
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O M, then there needs to be standard training with strict standard certification of that student. This takes years to accomplish. The referral base needs to be taught what to look for. This is not a small task. The Dental curriculum does not teach any of it. The dental specialty programs do not teach any of it. The good news is that significant progress is being made. Early scientific research has been done and more is in progress. More and more people are becoming interested, and the field is expanding because people are realizing additional ramifications of poor habitual tongue position. Airway studies and breathing implications would be an example. This is an exciting field.
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Functional jaw orthopedics in the treatment of TMJ fractures in the growing patient Dr. Patrizia Defabianis Italy
ABSTRACT Facial or dentofacial injuries are of particular interest in the field of dentistry. They need
long-term follow-up because of the risk of possible complications as they may cause craniomandibular disfunction, growth alterations and/or esthetic problems1-3.
Diagnosis and treatment of facial trauma must focus not only on direct damage to osseous
structures, but also on future disturbances in dentofacial development. Normal development of the mandible - as well as some portions of the maxilla and face - is related to proper func-
tion of the masticatory apparatus. When, for any reason, function is altered, for example due to a traumatic event, abnormalities may occur which might have serious consequences for the development of the face.
The inability to adequately assess pain may lead to a delay in diagnosis and treatment
resulting in growth disturbances and facial asymmetries. Conservative management is the
mainstay of treatment in the vast majority of condylar injuries in growing children; they seem to receive great benefit from the use of myofunctional interocclusal appliances. Long-term follow-up of these patients is critical to monitor for any sign of TMJ disfunction and growth abnormalities.
The aim of this paper is to draw attention to the importance of a correct diagnosis and
therapeutic approach of condylar fractures in children. Professionists must be aware of these problems as they play an important role in diagnosis and co-management of these patients as signs and symptoms may be recognizable in the dental practice and any delay in diagnosis and treatment may cause prolonged morbidity.
Key words: Trauma, condylar fractures, children, functional orthopaedics.
INTRODUCTION Condylar fractures in children may result in torn ligaments or capsules, intra-articular bone
fracture, soft tissue lesions with effusion or hemorrage in the joint space, dislocation (luxation) or fracture, separately or in combination. Such trauma inavariably causes a traumatic arthri-
tis characterized by resting pain, pain on movement and limited jaw movement due to the reduced mobility of the TMJ3. Minor injuries such as facial lacerations, abrasions and dental
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lesions can also occur. Some injuries may resolve, either leaving the joint normal or with a predisposition of later deleterious changes.
Any trauma affecting the condyle alters the normal progression of function and harmonic
development of facial structures4,5. For the cranio-facial-oral complex to function properly, jaws,
masticatory muscles and cranial bones must be in harmony with each other: a change in any of them must be proportionally matched by appropriate growth adjustment to sustain and progressively achieve functional and structural balance of the whole6. Disturbances in the harmoni-
ous interplay of masticatory muscles may result in a dysplastic pattern of growth. If not treated, the dysplastic patterns of growth may continue and worsen during the years. This will affect the course of development and even though the deformity may not be progressive, it may not be self-correcting and there may be no way to compensate for the loss or retarded growth7,8. After
consolidation of mandibular dysfunction and facial mal-development, treatment is simply aimed at preventing further worsening during growth, but full recovery is impossible9,10.
Facial bone fractures in general and temporo-mandibular joint (TMJ) fractures in particular
may go unnoticed in children for many reasons. One of these is that the clinical findings asso-
ciated with them are far less evident in children than in adults. Swelling and malocclusion, for instance, are not often seen at all in children; in adults, on the other hand, these findings are
the most important ones indicating a mandibular fracture in general and condylar fractures in particular.
An additional problem with regard to children is the lack of major pain at the time of the
injury: traumatic lesions can apparently occur without sufficient reaction by the child to get any adult’s attention regarding the seriousness of the injury. In general, self-report about char-
acter, location and intensity of pain is often the most useful guide to pain assessment and to correlate symptoms with signs for a final diagnosis. Furthermore, mechanisms of pain perception in infancy are quite complex: first, pain sensitivity differs somewhat from other sen-
sory modalities; pain experience is dependent on a learning process and seems to be strongly
related to the stage of cognitive development of the child11 . Adequate and age-appropriate
pain assessment is essential to provide optimal care; in infants however, self-report is often unavailable, which makes clinical evaluation of these patients challenging12,13. In an older
child, correlating the signs with the symptoms makes often the final diagnosis an easier task. For all the reasons described above, these types of trauma are often overlooked and only
one or two years later, when growth disturbances appear, they are perceived as a problem, but by that time, the dysplastic pattern of growth has stabilize and will continue during the subsequent years.
The clinical examination of the patient must be very accurate, no matter how light or asyn-
tomatic it may be. Often, there is a diagnostic dilemma, especially when the clinical findings
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are not clear: in an infant or young child, reliance often has to be placed on the physical examination alone. The practitioner should look for signs of local swelling, pre-auricolar hollow or depression, ecchymoses, malocclusion and limited mandibular movements. Nonetheless, a thorough negative clinical examination and normal occlusion do not rule out condylar head fracture. Clinical suspicion of condylar displacement should be raised in case of a history of severe trauma to the chin, limitation in jaw mobility, inability to reach a stable and reproducible occlusion, deviation of the chin toward the side of injury during mouth opening, premature occlusion on the side of injury14,15. Pain and swelling in the pre-auricular region are often referred. Dental lesions may also be noted; it is well known that traumatic injuries to the chin may result in fractures of the posterior teeth16-18. According to Holan16, fractured primary molars are detected in 32% of those children who receive traumatic injuries to the chin and multiple fractures are found in 35% of traumatized primary molars.
CASE REPORT A healthy 11-year-old boy was referred to our attention by his pediatrician for clinical and radiologic examination following a facial trauma. The child had fallen while running at home and had cut his chin with apparently no disturbances to her dental or facial structures. He reported mild pain in the area of the right temporomandibular joint, particularly during mandibular movements and a change in occlusion after the trauma. The clinical examination showed a reduction in mouth opening (down to 22 mm) with a shift of the chin towards the right side and limitations in lateral excursions. Gentle palpation of the area of the right condyle elicited crepitation. The postero-anterior cephalometric projection (fig. 1) and TC scan imaging (fig. 2) revealed a unilateral, medially dislocated fracture of the right condyle. The patient was treated with conservative methods: soft diet and antiphlogistic drugs were recommended for a week to mitigate symptoms and to avoid adhesions between the articulating parts and then he was immediately scheduled for functional appliance therapy. Figure 1. The postero-anterior cephalometric radiography shows the fracture and the medial dislocation of the right condyle
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The appliance was to be used as many hours a day as possible, except at meals. After a year of functional orthopaedic appliance therapy, no
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Figure 2. CT scan imaging shows the medial angulation of the right condyle compared to the left one.
Figure 3. CT scan imaging confirms the restoration of the condylar morphology (arrow).
Figure 4. MR scan shows the almost perfect restoration of condylar shape in frontal view (arrow).
Figure 5. MR scan shows the almost perfect restoration of condylar shape in lateral view.
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developing facial asymmetry was present and mouth opening was 40 mm. TC scan imaging
confirmed the restoration of the condylar morphology (fig. 3). Functional appliance therapy
was then interrupted, but the patient was kept under observation to evaluate growth and face development.
Two years after the trauma, results are very encouraging: no facial asymmetry can be no-
ticed, no subjective symptoms and/or objective signs of TMJ disfunction are present and the occlusion is normal and stable. Magnetic resonance imaging (MRI) supports an almost per-
fect restoration of condylar shape; the functional unit of the disk and the condyle is preserved either in static conditions or during mouth opening (fig.4, 5).
DISCUSSION Conservative management is the mainstay of treatment in the vast majority of condylar in-
juries in growing children. Simple greenstick or non-displaced incomplete fractures with mini-
mal clinical findings and a satisfactory occlusion generally require no more than supportive therapy. Observation, analgesia and soft diet is commonly used where there is intracapsular
contusion or no to minimal displacement of the fractured condylar process. This is provided that normal occlusion is maintained after the painful muscle spasm has subsided. The em-
phasis of therapy should be on active jaw movements and return to normal diet as soon as possible.
If a condylar fracture is documented radiographically but it is not displaced and the occlu-
sion remains normal, close observation and exercises to maintain good function are all that is required.
Different consideration must be given to displaced condylar fractures. In these cases, since
surgical repositioning of the condyles appear to worsen rather than improve the tendency
towards growth disturbance and seems to be more resource-intensive without producing better results, closed reduction obtained by the use of functional orthopaedic treatment combined with physiotherapy is the advocated treatment.
In the case report described above, the patient was immediately scheduled for functional
orthopaedic treatment. The rational in functional appliance therapy is that it provides stimulation to the muscles (even if within the painful limits) and helps in washing away the me-
tabolites resulting from the muscle spasm5,8,19-23. This limits disturbances in the interplay of
the masticatory muscles. Proprioception of the TMJ(s), muscles, ligaments and other related structures determine mandibular position relative to the maxilla during excursive movements. Infact, with regards to the growth and adaptative requirements for the mandible, it is not just
the condyle that partecipates, but the whole ramus is directely involved. It is the ramus that
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places the mandibular arch in occlusal relation and position with the maxilla, its dimensions and morphology are directely involved in the attachment of the masticatory muscles and it
must accomodate their growth and size5. Early stimulation and control of muscular activity is an important key-point in treatment: the mobilisation of tissues within and around the joint, frees restraints of fibroses capsular components and the lateral eminence and increases disk
mobility, reducing so load concentration24-31. In this way, restoration of a proper function of the
masticatory system and prevention of mechanical restrictions created by scarring and loss of motion is promoted from the very beginning31.
Indeed, most authors agree with the fact that mandibular immobilization does not seem
a benign procedure as once thought. Detrimental effects on several tissues have been observed following mandibular immobilization; atrophy of the muscles of mastication, degen-
erative changes within the mandibular condyle and decrease in range of passive bite opening are all consistent findings following several weeks of mandibular immobilization.
The emphasis of treatment is on the maintenance of function. In young children, from 0
to 2 years of age, the highly vascularized and high osteogenic condylar environment necessitates the encouragement of active jaw function, which is helped by analgesics as a means
of combating joint ankylosis22,23. Similarly, in children from 3 to 12 years of age, jaw function is encouraged by virtue of the high regenerative and remodelling potential which is also inherent
in this age group. Complete regeneration of the condyle is not uncommon in young patients thanks to a combination of remodelling and repositioning processes, with no residual deficiency in function and growth following fractures30,31.
CONCLUSION Goals treatment of mandibular fractures include restoration of normal occlusion, main-
taining facial symmetry and aesthetic balance of the face. Treatment of fractures implies the recognition of an existing problem.
Long-time results with functional appliance therapy seem to be more effective than those
obtained with traditional physiotherapeutic exercises. Physiotherapeutic exercises are very
useful in case of joint hypomobility, but they are not able to favour the repositioning of the
two parts in displaced condylar fractures. When proper reduction of a displaced fracture is not achieved, physiotherapy is useless, as it cannot stimulate a physiologic movement, but
only improver mobility of joint with an altered shape. This inevitability results in malpositioned fracture consolidation and remodelling of the glenoid fossa. In the end, the biomechanics of
the joint is completely altered, due to chronic post-traumatic hypertonicity of the muscles on the fractured side. Progressively the strength of these muscles decreases, and the symmetry on contraction is lost, ending in asymmetric face development.
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The subsequent deformity of jaw and face will depend not only on the type, intensity extent
and chronology of the noxious agent, but also on the particular time of occurrence and growth activity5,6.Thus the effect will be more decided if the disturbance occurs early in life, during childhood, when growth activity is greater and mandibular shape and size have not been as-
sumed yet. From birth to age 12, the face undergoes continual growth, but the velocity of that growth varies with age. Up to six months of age it is very rapid, whereas from six months to 4
years is relatively slow. Rapid growth returns between age 4 and 7 and then slower growth is seen between ages 9 and 15. The last facial growth phase, between ages 15 and 19, primar-
ily affects the mandible. It is likely that condylar injury before age 3 will result in significant mandibular growth distortion, whereas such injury after age 12 will have little overall effect on growth30,31.
Any delay in diagnosis and treatment of patients may cause prolonged morbidity. Profes-
sionists must be aware of these problems as they play an important role in diagnosis and
co-management of these patients as signs and symptoms may be recognizable in the dental practice. Long-term follow-up of these patients is critical to monitor for any sign of TMJ disfunction and growth abnormalities.
REFERENCES 1. Wilkes CH :”Internal derangement of the temporomandibular joint: pathologic variations” Arch.Otolaryngol. Head Neck Surg. 1989:115:469-77
2. DAHLSTROEM L, KAHNBERG KE; LINDAHL L 15 years follow-up on condylar fractures Int J Oral Maxillofac Surg 1989;18:18-23
3. LEAKE D, DOYKOS J, HABAL MB, MURRAY JE Long-term follow-up of fractures of the mandibular condyle in children. Plast Reconstr Surg 1971;47:127-131.
4.
KATZBERG RW, TALLENTS RH, HAYAKAWA K, MILLER TL, GOSKE MJ,WOOD BP Internal derangement of
the temporomandibular joint: findings in a pediatric age group”. Radiology 1985, 154:125-132.
5. ENLOW DH, HANS MG.
Essentials of facial growth W.B.Saunders Company, Philadelphia, 1996: 57-77.
6. DEMIANCZUK AN, VERCHERE C, PHILLIPS JH The effect on facial growth of pediatric mandibular fractures. J Craniofac Surg 1999;10:323-328
7. NEGIN GHIABI, WHITE GE Intraoral craniofacial manipulation J.Clin.Pediatr. Dent. 1998;23:9-16. 8. SCHELLHAS KP :”Internal derangement of the temporomandibular joint: radiology staging with clinical, surgical and pathologic correlation.”. Magn.Reson.Imaging 1990:495-515.
9. DEFABIANIS P. TMJ fractures in children and adolescents: treatment guidelines. J Clin Pediatr Dent 2003; 27:191-199
10. ROCABADO M, JOHNSTON BE Jr,BLAKNEY MG Physical therapy and dentistry: An overview. J of Craniomandibular Practice, 1982,1:46-49.
11. PIIRA T, TAPLIN JE, GOODENOUGH B, VON BAEYER CL. Cognitive-behavioural predictors of children’s tol-
erance of laboratory-induced pain: implications for clinical assessment and future directions. Behav Res Ther. 2002;40:571-584.
12. ZELTZER LK, BARR RG, MCGRATH PA, SCHECHTER NL. Pediatric pain: interacting behavioral and physical factors. Pediatrics 1992;90:816-21.
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13. MCGRATH PA
Evaluating a child’s pain J Pain Symptom Manag 1989;4:198-214.
14. SCHELLHAS KP Temporomandibular joint injuries. Radiology, 1989:173:211-6 15. LINDHAL L Condylar fractures of the mandible II. Positional changes of the chin Int J Oral Surg 1977;6:153165
16. HOLAN G Traumatic injuries to the chin: a survey in a pediatric dental practice. Int J Pediatr Dent 1998;8:143148
17. SASAKI H, OGAWA T, KAWAGUCHI M, SOBUE S, OOSHIMA T Multiple fractures of primary molars caused by injuries to the chin: report of two cases Endod Dent Traumatol 2000;16(1):43-46
18. MARECHAUX SC Chin trauma as a cause of primary molar fracture: report of case ASDC J Dent Chil 1985;52:452-454
19. LASKIN DM The role of the meniscus in the etiology of post traumatic temporomandibular joint ankylosis. Int J Oral Surg 1978;7:340-345
20. RAZOOK SJ, GOTCHER JE, BAYS AR:”Temporomandibular joint noises in infants: review of the literature and report of cases” Oral Surg.,Oral Med., Oral Pathol 1989;6: 658-663
21. ROWE NL Fractures of the jaws in children. J Oral Surg 1969;27:497-507. 22. THOREN H; HALLIKAINEN D; IIZUKA T; LINDQVIST C Condylar process fractures in children: A follow-up study of fractures with total dislocation of the condyle from the glenoid fossa J Oral Maxillofac Surg 2001 Jul;59(7):768-773.
23. SCHELLHAS KP Temporomandibular joint injuries. Radiology, 1989:173:211-6 24. KILIARIDIS S, BRESIN A, STRID KG. Effect of masticatory muscle function on bone mass in the mandible of the growing rat. Acta Anat 1996; 155:200-205.
25. WALKER RV. Traumatic mandibular condyle fracture dislocations: effect on growth in the Macaca Rhersus monkey. Am J Surg. 1960;100:850-863.
26. SESSLE BJ, WOODSIDE DG, BOURQUE P., GURZA S., POWELL G., VOUDOURIS J., METAXAS A., ALTUNA G.: “Effect of functional appliance on jaw muscle activity” Am.J.Orthod.Dentofacial Orthop. 1990;98:222-230.
27. HOTZ RP Functional jaw orthopedics in the treatment of condylar fractures Am J Orthod 1978;73:365-377 28. KAHL-NIEKE B, FISCBACH R: “Condylar restoration after early TMJ fratures and function: appliance therapy. Part II: Muscle evaluation” J.Orofac.Orthop. 60(1):24-38, 1999.
29. LINDHAL L Condylar fracture of the mandible.IV. Function of the masticatory system Int J Oral Surg 1977;6:195.
30. PROFFITT WR, VIG KWL, TURVEY TA
Early fracture of the mandibular condyles: frequently an unsuspected
cause of growth disturbances. Am J Orthod 1980;78:1-24.
31. INGERVALL B, HELKIMO E: “Masticatory muscle force and facial morphology in man” Arch.Oral Biol. 1978,23:203-206.
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How to upgrade from suction deglutition to swallowing deglutition trough cortical or subcortical networks Dr. Patrick Fellus France
The deformities that orthodontists have to cure are mostly caused by a lack of balance between the opposing forces produced by the cheek muscles and the forces generated by the tongue. Whether orthopedic treatment in the deciduous dentition, orthodontic treatment in the mixed or permanent dentition, it is necessary to reach at the end of any treatment a functional balance that will ensure the stability of the results. The transition from sucking deglutition to the physiological deglutition takes place spontaneously for 60% of the children between the age of three and a half and four by a subcortical activation of the a pre-existing neurological wiring which have just matured. Suction deglutition was a physiological function during the first years. It has a paleocortical origin, and the facial nerve controls it. But it becomes archaic when the full set of teeth is in place, and when the mastication appears. •
If suction-swallowing habit continues, the forces exerted by the labio-jugal muscles will disturb the physiological growth and will lead to various skeletal disorders in the three dimensions of space.
If it does not happen by itself, then, like in a computer, a new program will have to be downloaded, controlled by the trigeminal nerve It is what the practitioner or the speech therapist is going to do through a series of exercises to code a new praxis. But even with an accurate cooperation of the child, it is a long and complicated process because it need a participation of the cortical brain. According to Eric Kandel, Nobel Price of Medicine in 2000, when this action comes from the cortical area we have a stimulation of neurotransmitters in our synapses, but when it comes from the subcortical area we have a creation of new synapses. The swallowing rehabilitation must not be based on the control of voluntary movements but on the stimulation of automatic movements: •
Froggymouth is a new appliance which helps young children at the age of 3 - 4 years to use the best swallowing method for a toothed patient through the subcortical way and not anymore the suction deglutition method.
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• This Appliance is based on the idea of deconnection between the upper lip and the lower one. Froggymouth is not placed inside the mouth but beetwen the lips (fig.1). It will prevent the upper one from touching the lower one. So, it is impossible to create the negative pressure which is necessary during suction deglutition thanks to a water-tight joint around the lips. Indeed, it will force the child to find by himself a new way for the deglutition, in the lower part of his brain, by raising the upper back part of the tongue to the palatal bone when the teeth are in occlusion. Figure 1.
The activity of the seventeen muscles of the tongue against the internal side of the teeth allows an optimal stimulation of the transversal and antero-posterior growth of the dental arch. This appliance has to be worn 15 minutes per day and should not be worn during the night like a trainer as the quality of the sleep is so important for young children. Froggymouth must be worn in front of a TV screen to have a good orientation of the head and to catch the attention of the patient. It will stimulate his neuron circuits, which are related to the subconscious functions. At rest the lips are not in contact, the teeth are in occlusion and the trigeminal nerve control this program.
Figure 2. Position of the lips during suction dĂŠglutition and during swallowing deglutition.
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At the opposite, when the lips are closed, the teeth will not be in contact, and the facial nerve will be the leader, the child will use the old swallowing pattern. This Appliance is only an auxiliary that you will be able to use during your treatments for a few weeks whatever the techniques you apply (functional or mechanical).
Figure 3. Case treated by G.Altounian.
It is obvious that results will be achieved much faster if the muscles and the appliance are both working in the same direction rather than if they are fighting against each other. Froggy mouth is perfectly adapted to young children and it can even be used alone if the deformity is slight: •
The simple fact to rebalance the functions will allow a spontaneous correction of slight deformity when the child still has deciduous teeth.
Figure 4. This little girl of three years old had been wearing Froggy Mouth for only two weeks. She is perfectly at ease with it. She is not dribbling saliva, her face and muscles are relaxed, and the deformity is less significant than it was at the beginning.
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CONCLUSION Froggymouth will not only reduce the length of your treatments but much more important; it will ensure its durability when the treatment will be over and then reduce the risk of relapse.
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To breath or not to breath by the nose: Why? Dr. Franco Magni and Dr. Peter Bimler Italy
1. Soft tissue problems, by Franco Magni and 2. Hard tissue problems by Peter Bimler Compiled by Barbara Bimler, Genova (Christmas 2015).
INTRODUCTION Why does the same treatment succeed in one case and fail in a similar one? The disappointing follow-up of many orthodontic treatments led to the search for help in neighboring fields. One is the effort to re-educate muscles and nerves for an upkeep of the new tooth position. This raises the question of the necessity and effect of the respective intervention which could embrace posture, breathing, swallowing and related muscular activities, not to mention habits. No doubt that there is a connection between tooth position and its stability and the soft tissue functions. When MOSS published his research on functional matrix, he made the functional school of orthodontics very happy as he, for the first time, put a relatively recognized scientific base into orthodontics. However, a big question is the one of cause and effect. In the following text, Franco MAGNI tells us about the difference of functional adaptation and dysfunction.
SOFT TISSUE RELATED PROBLEMS – FRANCO MAGNI At the beginning of my profession it happened that I had a historic book in my hands. It was written by an English guardian of a prison in British Guyana. Guyana was originally colonized by the Netherlands. Later, it became a British colony, and remained so for over 150 years until it achieved independence from the United Kingdom on 26 May 1966. In his prison, the use of the ball and chain was compulsory (Fig. 1). The ball and chain was a physical restraint device historically applied to prisoners on one leg, primarily in the British Empire and its former colonies, from the 17th century until as late as the mid 20th century.
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Figure 1. Ball and chain.
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In fact he was the officer responsible for the checking-in of the prisoners and of their check-
ing-out, once they had terminated their term of imprisonment. The prisoners were sentenced
to forced hard labor therefore he was responsible not only to ensure the proper application of leg cuffs, shackles, foot cuffs or leg irons around the smaller part of the leg just over the ankle, but also of its removal years after, some cases up to 30 years, when the same prisoner was dismissed. He was not a doctor, his education optimistically reached the high school level, nevertheless after having observed what happened to the dysfunctional asymmetrical walk of the pris-
oners after so many years he stated in his book: “I learnt the difference between a dysfunction and a very common functional adaptation”. This happened more than one hundred years ago.
What did he discover so interesting? He had noticed that these prisoners, as soon as they
had to walk with a ball and chain attached to one of their legs, naturally developed immedi-
ately a strange walking dysfunction ... the free foot was advancing normally while the other,
connected to the chain and ball, was dragged along strenuously. The individual prisoner had
developed a new way of walking in a second. But surprising to him was the fact that when the prisoner was freed of his restraining devices after 5, 10, 20, or 30 years, only the first step was
dysfunctional, thereafter he was walking perfectly. Up to thirty years of dysfunctional walking did nothing to compromise or even only modifying his normal walking behavior. The guardian realized that it would have been wrong to call the strange walking with the iron ball a “dys-
function”. The proper definition of the strange behavior had to be a “physiological functional adaptation to an altered environment” (the ball and chain). The ball and chain were the etio-
logical factor producing the “physiological functional adaptation”, not a “pathological walking dysfunction”. Once the etiological factor had been removed, the “dysfunction” disappeared. This type of “dysfunction” was a simple physiological functional adaptation to an altered environment. I would agree totally with him.
Let us look into similar situations of the stomatognatic system to realize that much too of-
ten we erroneously call such a simple physiological functional adaptation a “dysfunction” as the real factor causing it can be hard to find.
For a doctor or an orthopedist, having noticed that the patient who limps has one leg
shorter that the other, it would be idiotic to prescribe a walking training program to begin with. He will definitely firstly prescribe surgery to make the two legs of the same length (or a pros-
thesis on the shorter leg, when indicated) because it is easy to realize that the real etiological factor of the limping is the different length of the legs. Only after having removed all the “easy
to get” possible etiological factors, he will think of a walking rehabilitation treatment in case the patient still limps.
Unfortunately, in our stomatognatic system, things are not so simple and easy and the dif-
ference between a physiological functional adaptation and a real dysfunction may be hard to discover.
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One function of the oral soft tissue is the shaping of the dentoalveolar arches. About 250
years ago, Pierre Fauchard (1728) noticed that after applying a constant directional force
for about two weeks to a tooth, it began to move in the desired direction and continued to
move as long as the force continued to act. Later it was discovered that the force transmitted to the dentoalveolar bone via the periodontal tissues was producing a differentiation of the histiocytes of the alveolar bone into osteoclasts on the pressure side and osteoblasts on the tension side. The tooth was moving by bone transformation. Later, other orthodontists func-
tionalists like FRAENKEL (1908 – 2001), etc. demonstrated that the use of shields keeping
away the muscles from the alveolar bone on one side, of the buccinator strap as an example,
produced an expansion of the alveolar bone and of the dental arches also, without applying any classic orthodontic force. Apparently the alveolar bone was functionally different from the basal bone.
The alveolar bone is characterized by a strong plasticity in order to adapt its form not only
via pressures of the roots of the teeth inside but also when forces were exerted on his sur-
faces. In our example, the expansive force was the tongue. The shaping of the dento-alveolar
arches would be dictated by the continuous postural tone of the soft tissues: tongue on one side and buccinator strap and lips on the other.
As a consequence of observations like those, the theory developed that an atypical, infan-
tile momentary dysfunctional deglutition would also influence the alveolar bone.
There is a lot of confusion about the atypical deglutition and its importance in the produc-
tion and maintenance of an anterior open bite. Let us illustrate the sequence of a physiological deglutition in patients with a normal occlusion. This was shown by RICKETTS (1920 – 2003) in
1980. At that time he was able to take fluoroscopic tele-radiographic movies with the contrast
medium Barium on the tongue on 50 patients: 25 with normal occlusion and 25 with different types of malocclusion. Each movie lasted between 10 to 12 seconds: today this would be totally forbidden.
The first interesting thing was that in the total of the normal occlusion cases, the rest posi-
tion of the tongue was with the tip against the lower incisors and cuspids at the gingival mar-
gin. This explains how the tongue inside, together with the lips outside, determine the shape
of the dento-alveolar structure and the position and inclination of the lower incisors and lower cuspids. In this rest position the tongue divides the mouth in a lower lingual space between the lower surface of the tongue and the floor of the mouth, and the upper lingual space between the upper surface of the tongue and the palate.
The deglutition did not start with the peristaltic wave emptying the upper lingual space
toward the throat, but with the earlier contraction of the Mylohyoid and Geniohyoid muscles,
in order to empty the lower lingual space of saliva. Only thereafter, the peristaltic wave would
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start beginning from the tip of the tongue against the lower incisors and cuspids to complete
the deglutition sequence. This is the physiologic normal deglutition that requires the smallest quantity of energy to be performed.
The body may utilize more energy in order to perform the deglutition in case of some
morphological anomalies. For example in an open bite, the tip of the tongue has to seal the
anterior open space, therefore the deglutition has to start with a higher position of the tongue and a greater lower lingual space. This requires at the beginning a greater contraction of the Mylohyoid and Geniohyoid muscles plus of the base of the tongue in order to empty the bigger lower lingual space before initiating the peristaltic wave.
The conclusion is that the atypical, infantile and dysfunctional deglutitions usually are
physiological functional adaptations to an altered morphology (the lack of an anterior dental seal) and therefore no educational training is required.
Once the etiological factors have been completely eliminated, if the patient still presents
a dysfunctional deglutition, than is the time for educational training. This in my office is done
by putting the tip of the tongue against the lower incisors, the physiological way, and usually it works rapidly.
Also the anterior tongue thrust and the oral seal are of high interest. In 1960, as a MD student visiting our major lunatic asylum of Quarto in Genoa, hosting
mentally retarded and dementia patients, I noticed that a considerable number of them were suffering of a very unaesthetic problem: the saliva leak from a corner of the mouth, commonly known as drooling. After a while I asked a neuropsychiatrist the cause of such a problem. To his knowledge it was due to impaired neuromuscular control of the oral cavity with the addi-
tion of impaired swallowing. Responsible of the impairment were cerebral palsy, consumption
of tranquilizers and anticonvulsants, or poor oral muscular co-ordination frequent in elderly individuals, producing the loss of the physiological functional adaptation of the tongue to generate a sufficient anterior tongue thrust to seal the anterior space. The neuropsychiatrist explained how normally the anterior tongue thrust is a physiological functional adaptation to
produce an anterior oral seal to avoid these problem. This, unfortunately could not happen in most of his sick patients.
At that time I could not understand what he really meant, but in 1964, at the Orthodontic
course in London under Professor Clifton Ballard (1910 – 1997), a great expert in soft tissues of the stomatognatic system, I got the message: I understood the difference between the very common physiological functional adaptations of the tongue and the very rare dysfunctions.
We will interrupt here the considerations of the soft tissue and return to the main question
of all orthodontists: Why does the same treatment succeed in one case and fail in a similar
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one? In 1948, Peter BIMLER ( 1916 – 2003) published about this newly developed BIMLERAppliance. Happily he had observed the fast improvements and good results, but why not in all the patients with a good compliance? The same setback in roughly a third of the patients with disappointing results, he had observed many years before working as an assistant doctor in a ENT practice. BIMLER writes: The aspect of the affected patients is highly characteristic and well known to all experienced practitioners. I consider it to be the more important as this syndrome (Microrhinic Dysplasia) is not restricted to a few dysplastic cases of mostly scientific interest, but is relatively common. In about 30% of my clinical cases it can be found in a more or less pronounced degree. The symptoms accessible at external examination are the followings (Fig. 2): 1. A small nose with an upward directed base with the nostrils visible at a natural head position. 2. A straight profile, in some cases even a “dished-in” mid face. 3. Often an open mouth with seemingly or really short upper lip. According to the fashion of the time, adenoidectomy was performed on a routine base. The adenoid face is usually connected to the leptoprosopic body type with a respective long narrow face. The enlarged adenoids impede the normal nose breathing. An adenoidectomy should lead to nose breathing by removing the obstacle. However, even this so obvious operation does not show the desired success in about one third of the cases, thought one important soft tissue obstacle have been removed. The introduction of x-rays in orthodontics from 1933 allowed a further look inside the morphology beyond the models and externally accessible tissue. As the momentum for the adenoidectomy often was breathing-related, the interest would focus on the airways clearly visible on a head plate. The related hard tissue would be the Nasal Floor, not affected by an adenoidectomy. The adenoid problem children share often the similar features like the narrow face, the open-bite tendency, a small nose, and an open mouth. All these can be syndromes of a single cause, an underdeveloped maxillary bone.
Figure 2. External view.
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Figure 3. Fetus, the yellow dots mark the position of the anterior and posterior head organisors.
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Figure 4. Probably from: F. R. Nager, J. P. de Reynier: Das Gehoerorgan bei den angeborenen Kopfmissbildungen. In: Practica oto-rhino-laryngologica (Basel), Bd. 10 (suppl. 2), 1948, S: 1-128.
The maxillary bone development has a crucial phase in the 8th week of pregnancy when
the fetus is just a conglomeration of cells (Fig. 3). At this time the frontal and the posterior head organizers develop which are the origin of the oral capsula and the otic capsula. A ma-
jor disturbance to the dividing cells will lead to orofacial deformities which can cause up to a spontaneous abortion and to a stillborn child (Fig. 4). Milder forms are usually seen in some diseases, or as a consequence of alcohol abuse during pregnancy (fetal alcohol syndrome), or a simple flue of the mother leading to a lack of oxygen to the embryo. A slight underdevelop-
ment of the maxillary bone can be found in about one third of the patient load. This correlates
to the problem cases in the ENT and in the Orthodontic office. Interesting for the orthodontist
and the breathing research is the inclination of the Nasal Plan ANS-PNS in relation to the Frankfort Horizontal. BIMLER continues:
The cephalometric symptoms of the Microrhinic Dysplasia can be listed as follows: 1. A forward-upward tilted nasal plane. 2. A forward-upward over-rotated mandible. 3. An increased inclination of the anterior part of the cranial base as presented by the N-S line.
4. As additional cephalometric finding, we see sometimes a diminished or missing pneumatisation of some sinuses.
Here it seems useful to add some general remarks about the recurrent question, if the FH
or the NS line are preferable as a reference system. It is undisputed that reference points like
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N or S on lateral head plates can be identified and reproduced with greater precision, however this does not mean that the NS line is therefore especially appropriate as a base for a system with which we want to study, with benefit and profit, the deviations of the structure of the visceral skeleton. We do not believe so. The informational value of a tracing based on the FH line is by far superior, as also the studies for this research have been showing. (...) While the dentition can well be considered a functional unit but not an anatomical one, it is no surprise that its skeletal units act independently. Therefore it proved necessary and useful to check the behavior of maxilla, mandible, the anterior cranial base, and the joint region independently from each other. Under these aspects we want to consider now some sample cases. Our first case shows the already familiar 8-year old girl from the first picture. I selected
her because she shows, in an extreme way, the main feature of this complex, the small and upward directed nose which gave the name to the syndrome (Fig. 5). The factor 4 of Bimler analysis (= Nasal floor ANS-PNS) representing the disturbed mid face shows a high negative value of minus 6 degrees. Additionally, the pre-maxillary bone is distinctly tilted upwards and distinct of the maxillary part of the nasal plane. It is easy to understand that also the upper incisors will be protruded together with their tilted base, and the problem of the Class II at the posterior teeth level appears in a new light now. (...) Like in most cases, the frontal cranial base is involved and the value for the factor 7 of the Bimler analysis (NS-line) of 9° is slightly higher than the average value which in harmonious faces is 7°. In this patient we find in all three factors 4, 7, and 8 (tangent to maxillary ramus) a change in the same direction which we describe as a rotation towards the Frankfurt Horizontal.
Figure 5. Tracing of the head plate oft the girl from Fig. 2.
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Our next case (Fig. B-5) is a progenism in a 11 year old boy, who displays again the typical facial features of the slanted eyes, the protruding ears, small nose and open mouth. Looking at him, the progenic dentition is not even very obvious. In the x-ray evaluation (BIMLER Cephalometric Analysis), we find again our 3 components: an upward titled nasal floor = negative factor 4, a steep NS-line = high factor 7 of 12°, and a forward tilted ramus = negative factor 8. The last one shows that also here,
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the mandible is over-rotated to compensate the anterior height deficit in the midface, like in edentulous patients. When the patient does not close his teeth but leaves the mandible in the
Figure 6. Chondro-Dystrophy.
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physiological rest position, the posterior margin of the mandible is situated more or less in a vertical plane to FH. It might be interesting to know that just such progenic cases were the first to draw our attention to the different degree of flexion of the mandible, as they show a particularly high difference between the physiologic rest position and the occlusion. The stereotype occurrence of similar symptoms in the structure of the visceral skull now leads to the question if we could not find a similar origin for these similar changes. Especially the exterior appearance with the small saddle nose suggests to look for some growth inhibition. Accordingly we controlled a number of deformities where the origin is already more or less established. First example is a Chondro-Dystrophy, the well-known disorder where the growth of the long bones is considerably reduced by a disturbance of the condylar growth
(Fig. 6). For the visceral skull, Chondro-dysplastic dwarfs are characterized by tower skulls (Oxycephaly) and saddle noses. With our analysis we see the usual picture with the negative factors 4 and 8, while here we do not find the characteristic flattening of the cranial base, while we see a reduction of the T-TM (Tuber-vertical to TMJ) distance to 25 mm. (…) The clinical picture at which the dentist is looking can be caused by a variety of structural components which can either – in a favourable case – compensate each other or vice versa lead to extreme deviations. Now I want to lead you away from pathological extreme cases to the every day case of the
daily practice, and may present to you a 16 year old boy (Fig. 7). He shows, beside the now
well-known external feature of a small saddle nose only the factor 4, the nasal plane, rotated upwards in the usual manner, while the other factors behave in an almost normal way. The skeletal deviation manifests itself clinically in a very treatment-resistant open bite. Of course, at a local observation, immediately a tongue interposition was visible and originally taken as the cause for the open bite. Meanwhile we got doubts to overvalue functional causes at the presence of distinct cephalometric skeletal findings. With this presentation I want, above all, underline that any sagittal malocclusion may not be understood unilaterally as an abnormal position of the mandible, and that the skeletal conditions leading to a Class II molar relation can indeed be manifold. Summarizing we should say that we tried with this presentation of the Microrhinic Dysplasia to define a stereotype reaction within the visceral skull by a triad of symptoms, and to underline the connection of the clearly visible external features with the skeletal ones. Thus the clinical practitioner should be enabled, once faced with the external symptoms, to check for the respective skeletal deviations and keep them in mind with his treatment plan and prognosis.
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Figure 7. Common patient.
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Of course the underdevelopment is a three-dimensional phenomenon of the bone, so
transversally it shows the posterior cross bite, vertically the anterior open bite, and the sagittal problem (more often the anterior cross-bite tendency). Such cases have a poor prognosis and
a relapse tendency. Though it is possible to detect them radiographically, by comparing the Frankfurt Plane to the Nasal Plane, one should definitely start treatment soon, as the adapt-
ability of the alveolar bone is often enough to achieve a satisfying long lasting result. Possibly an even earlier intervention could get an even better result.
Of course the question of oral or oronasal breathing is crucial for the stability of the result.
If the oral breathing is due to skeletal deviations, it might be hard to cure. In many cases there seems to be no easy solution, as Franco MAGNI continues:
Too many times I heard of the oral breather that after having had surgery to remove tonsils
and adenoid was diagnosed by a colleague as a dysfunctional breather because he was still an
oronasal breather. As a consequence he was sent to the specialist for a breathing rehabilitation training. How the colleague can be so naive to ignore the the upper airway obstruction can
be posterior = adenoid), and/or middle = turbinates and/or anterior = narrowing of the nostril entrance?
Only after having solved professionally the three obstructions problems (posterior, middle
and anterior) if the oronasal breathing does not disappear at this point only one should be in-
volved with the treatment of the dysfunctional breathing with the proper rehabilitation training. I do not mean that there is never need of proper breathing rehabilitation in the oral and
oronasal breathers, but if you behave in the indicated way you will discover that over 99% of
the oral or oronasal breathers will automatically revert to nasal breathers once the three pos-
sible obstruction areas (posterior, middle and anterior) have been adequately corrected (do not forget allergies, etc).
CONCLUSIONS I do not mean that real dysfunctions requiring reeducation program do not exist: they
do exist, but to my personal clinical experience they are very rare indeed. I started treating orthodontic patients since 1965 this means since 50 years ago. I have been treating about ten thousands patients, since that time, with all sort of “dysfunctional habits�. My approach
has been always the one of the differential etiology: finding all the etiological factors first and remove them all, from the scene, firstly!
The results: only in 7 cases I needed the help of an external specialist for a reeducation
training program (speech, deglutition, breathing, etc.).
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When you see a dysfunctional habit in your patient think in term of differential etiology first. Ask to yourself the question: “Is it really a rare dysfunction that requires a reeducation program or … is it a very common, simple and normal physiological functional adaptation to compensate for the presence of an altered morphological environment (the etiology)”? Eliminate all the etiological morphology factors firstly. Only in case that the dysfunctional habit persists after the elimination of all possible altered morphological factors seek for a specific reeducation training program: before it is not necessary nor indicated.” And as Peter Bimler shows: a disappointing treatment result in mouth breathing patients can also be due to an underlying skeletal growth change!
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122 Hippos a life well lived Dr. Bridgette Preston USA
Eighteen months have passed since dad’s incredibly hard fought battle against Central
Nervous System Lymphoma ended, and we are coming to a reluctant acceptance of our great
loss. The for-sale sign went up outside the South African house, we said good-bye to the
rocky, tree covered outcrop that filled our kitchen window view, and closed the blinds against the evening sun. For the final time we drove past the small wild creatures frolicking in the park, and, in the rear view mirror, I saw the last glimpse of the blue-grey guinea fowl chicks scratch-
ing in the dirt. For weeks I wondered how to package up this house so filled with a lifetime of collectibles – some having only sentimental value as I turned them over and over in my
hands – each touch evoking a thought of dad, sometimes so real it is a like a splinter of glass in flesh. So too, this journal entry is a virtual walk through of what seems to me to be a man-
sion of a life. Should I arrange the boxes in it by degrees, certificates, testimonials, awards or perhaps by pallets of books, journals and articles? Or what about all the carefully written
letters and cards signifying decades of collegial relationships and of deep friendships – some
spanning 50 years. Then there are albums of photographs flowing together in a kaleidoscopic contemporary rendition of dad’s life – many taken by dad across the world, reflecting his keen appreciation for the interesting, the beautiful and the poignant. As I shuffle these into order, I am reminded of his evolving ever present study of form and function.
Who would expect to find an Orthodontist in the Amazon jungle, walking along the Great
Wall of China, drinking tea with a Persian Carpet dealer in Damascus, riding a bicycle in Mon-
treal or collecting soapstone hippos in an African market. How wonderful for my mother and
I to have walked some of those steps with my father and how much I would give to be able to do it again.
Dad’s thirst for knowledge and experience didn’t stop at books – he was an avid cyclist
and tennis player, taking up flying during his stay in London, followed by water skiing, downhill skiing, and scuba diving. Other pursuits ranged from energetic household Do-it-yourself projects, motor sport and wild plant collection to studying Persian carpets and learning languag-
es. Naturally, coming from a musical family, dad passed university exams in piano and loved several genres of music. There was always music playing in our house, the car and his office and today at home his iPod continues to fill each room of the Buffalo house with memories.
Some of my earliest recollections however revolve around dad in his professional role - as
a family we would spend hours at the university in Johannesburg sorting slides into carousels
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for lectures, enjoying social gatherings with post graduate students and visiting with his col-
leagues, many of whom became close friends. We took for granted that our home telephone would ring at all hours. As I reflect on this today, I appreciate how much dad cared about the
well- being of those who crossed his path and how seriously he took his role of mentor and
sponsor. I took for granted his wise counsel on management topics, and miss our sometimes heated philosophical discussions on responsibility, goals and life in general.
From 1997 to 2014, dad spoke at graduation ceremonies for Orthodontic students receiv-
ing their degrees from the State University of New York at Buffalo. Each student would receive
a carved hippo from dad and each audience would hear the same story of the origins of the hippo – a very vain but beautiful animal with beautiful flowing hair. It spent most of every day
staring at itself in the reflecting pools by the river. The other animals became annoyed at the hippo’s constant boasting and came up with a plot to bring it down a peg or two. The rabbit
made a bed of straw for the hippo and persuaded the self-important creature to take some beauty rest. As the hippo sank into a deep sleep, the other animals set the bed of straw alight.
The hippo lost its magnificent mane of hair, and was so consumed by embarrassment that it fled into the depths of the river, when it remains today, coming out only at night to graze, in the moonlight.
The few minutes spent on this fable did not reflect the time spent on selecting each hippo
for each recipient, nor the time spent speaking to the artist who carved the animal. Sometimes it was difficult to find these local carvers as they had to travel from outside South Africa’s bor-
ders, and at times could not undertake the journey. We drove great distances at these times to ensure that there would be the right hippo for graduation day.
Dad’s message to the graduates and their families was to celebrate the great achieve-
ment of becoming an Orthodontist, but to never forget the personal sacrifices made by both student and others who supported them through their studies. He encouraged them to re-
member where they came from, the support that carried them to a successful career, and, to always give back to their profession.
He lived this message every day and to me his humility came through in his customary
farewell - we’ll try again tomorrow.
My favorite document among those recently discovered is my dad’s high school letter of
recommendation at age 18, and which could easily have been written at age 78 – the principal writing about his student’s mature poise, a curious intellect, kindness, a strong sense of duty,
a keen sporting ability, and, noting a quick, clever sense of humor – as if 60 years had already
passed. How wonderful that those qualities remained with dad throughout an incredible life.
There’s a hippo on my mantel - and 112 like it on desks all around the world - keeping us grounded, grateful and gracious.
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The Form - Function Spiral (FFS) Dr. Roger L. Price USA
SUMMARY - ABSTRACT How Functional Compromises of whatever etiology, be they genetic, epigenetic, birth or
acquired, are responsible for many and varied Form Compensations, which in turn perpetuate the Form-Function Spiral. These compromises can arise as early as pre- conception, be
created during gestation, be as a consequence of incomplete apoptosis, arise during the birth process and be further exacerbated by inappropriate nursing and feeding. Add to the mix
dysfunctional chew-swallow patterns and a soft ‘Western style” diet, and one has the ‘perfect storm’ for malocclusion, food intolerance, poor posture, dysfunctional breathing, sleep disorders and behavioural and concentration issues.
KEYWORDS tongue-tie, frenectomy, tongue thrust, reverse swallow, GERD, malocclusion, asthma,
mouth breathing, ‘allergies’, adenotonsillar hyperplasia, nocturnal enuresis, disrupted sleep patterns, snoring, “sleep disordered breathing”, OSA, nasal congestion, ADHD, myofunctional therapy, Central Sleep Apnea.
INTRODUCTION One of the first publicised books outlining the negative effects of mouth breathing was
written by George Catlin (1796 - 1872) and published in 1860. Catlin was an artist who specialised in painting North American Indians, and lived amongst them for many years. He
noticed how particular they were in ensuring that their babies and children functioned with closed mouths. This was again reinforced by Weston A Price (1870 - 1948), an American den-
tist who spent many years traveling the world and researching the diet, nutrition and breathing habits of a variety of ‘primitive cultures’ which had not yet fallen prey to the soft Western diet. His conclusion was that a combination of soft foods, minimal chewing and mouth breathing was responsible for the development of malocclusion in Western populations.
This debate has raged for many decades with two distinct ‘camps’ forming. One com-
prised of those orthodontists whose focus is purely on ‘straight teeth’, with little consideration
that the techniques they apply to achieve this goal could cause possible issues later in life.
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Their group chorus is that no published evidence exists to confirm or deny the link between orthodontic intervention, airway disorders and craniofacial pain. The second group, which is a mixture of enlightened orthodontists as well as general dentists practicing orthodontics, claims that crooked teeth are caused by soft-tissue dysfunction and that the teeth are not the problem - just the consequence of imbalances elsewhere in the body. This debate has heated up significantly over the past three decades and becomes quite heated and intense at times.1,2,3 More recently, with the major increase in sleep apnea and other breathing disorders, dentists and orthodontists started to become more involved, as it became increasingly obvious that doctors were treating the end-stage diseases associated with airway dysfunction, and not addressing the origin of the problem. Medical doctors have been reluctant to relax their grip on this worldwide issue, which has reached epidemic proportions, with some 50 million Americans suspected of suffering obstructive sleep apnea, and only 2000 sleep specialists available to treat them4. This is a perfect example of the Form-Function Spiral and it is now inevitable that other professions and modalities will have to become involved in order to address the issue.
TOP-DOWN VS BOTTOM-UP APPROACH “Best Practice” and “Gold Standard” does not necessarily mean that either of these approaches are the most appropriate or effective. All it means is that they have become the de facto norms through aggressive marketing, massive advertising and high-dollar promotion. Add to this the “sheeple factor” coupled with the fear of litigation, and professionals of all kinds seek safety in convention and conformity. This prompted the well known British economist - John Maynard Keynes - to make the following observation, which is so true. “It is better for the reputation to fail conventionally than it is to succeed unconventionally” The problem with the top-down model is that it regards everyone as being ‘severe’ and in need of seeing a “Sleep Specialist” right from the start. The reality is that many cases of ‘Sleep Disorders’ are in fact not ‘Sleep Disorders’ at all. They are “Breathing Disorders” which become worse at night, as a result of lying down, reduction in muscle tone, and biochemical changes taking place during the various stages of sleep. If this is not an obstructive issue neither CPAP nor OAT will work and the patient will be doomed to failure.
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There are no other alternatives to the two “Gold Standards”. By addressing the ‘Sleep Disorder” from the bottom up it will be possible to eliminate all those daytime dysfunctional behaviour patterns which are largely responsible for the night time issues. In addition to this, posture and breathing retraining can address the inflammation/congestion problem - and - if further intervention is required, the patient can then be evaluated for a dental appliance. Once this has been tried - and failed - the final step is full-time intervention with PAP therapy. This bottomup process will provide a more economical and wider spread solution.
ASSESSMENT APPROACH AND RATIONALE Because of the multi-factorial etiology of the Form-Function Spiral it is not possible for one modality, discipline or profession to fully address the plethora of issues involved, and this requires a true multi- disciplinary approach. To use the analogy of the iceberg, where 10% is visible, with the bulk remaining submerged below the surface, the ratio of symptomatology to etiology is around the same. Billions of dollars are being spent on invasive treatment and intervention, in the name of ‘symptom management’, most of which is short-term and has the potential to cause serious side-effects if used as on long-term basis.
Examples of this are:
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•
Unacceptably high incidence of orthodontic relapse after moving teeth from their
•
Position to an unstable (straight) position.5
stable (crooked)
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•
Development of Central Sleep Apnea as a consequence of long term use of CPAP.6
•
Creation of occlusal imbalance as a consequence of regular night-time protrusion of
•
Creation of drug dependency/tolerance by ignoring the etiology of stress issues
mandible with OAT.7
and prescribing medication.8
ASSESSMENT METHODOLOGY Unless a comprehensive assessment and history is done it is not possible to identify all the underlying factors which cause and perpetuate the problem. This is where Function influences Form and Form perpetuates Function. The assessment and history require full details across a range of topics, and also need to include baseline data, consisting of photographs, objective reproducible graphic metrics and measurements of the areas of dysfunction, so there is a basis for comparison as well as reporting.
ASSESSMENT AIDS In addition to the traditional Sleep Studies, Sleep Reports, Pan, Cephs. and Plaster Models, which have been the Gold Standard for decades, there are now many additional tools which can be used to obtain a far better idea of the factors, both internal as well as external, that are involved with the condition at hand. The more we can see and measure what is happening in the body the easier it is to evaluate whether the treatment being used is appropriate. •
CBCT - gives us a far better view and understanding of the spatial positioning than we have ever been able to get from 2D cephalograms.
•
HRPO - high resolution pulse oximetry allows us to see the tiny shifts in oxygen saturation which do not show up on a normal oximeter. This is due to a much faster cycling time.
•
CPC - Cardio-Pulmonary Coupling gives a simple, quick, low cost and non-invasive indication of sleep efficiency by measuring the low to high frequency peaks, indicating the ratio of stable to non- stable sleep.
•
Capnometry - the ability to measure carbon dioxide in the body without having to draw
arterial blood and send it to a laboratory for processing. Capnometry is also invaluable
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as a breathing retraining aid as well as being able to indicate breathing mechanics, dynamics and rate. •
SnoreLab - a sophisticated smartphone App that ‘listens’ to sleep noise and snoring and produces a range of extremely helpful data in the morning. It is very low cost, non invasive and accurate.
•
Posture-Screen - a smartphone App that provides multiple images and measurements of whole body posture, weight distribution, as well as gait analysis, and this all ties in with the compromised Form as a result of poor Function.
ADDITIONAL ASSESSMENT TECHNIQUES Furthermore, by incorporating the skills of Myofunctional, Craniosacral and Orthopostural therapists it is possible to get an accurate picture of other issues that are either the cause of, or the consequence of the Form-Functional Spiral. •
Evaluation of tongue and other oral tissue tethers. This is of significant value when considering that a low postured tongue has a far greater tendency to migrate into the airway, as it is a hydrostatic organ that will simply expand in whichever direction it is able to, and if tethered to the floor of the mouth will not be able to position itself in the palate, as it is designed to do. Release of these tethers has an almost immediate beneficial effect.
•
Identification of stressors and incorporating strategies to manage these diverse, but seriously complicating factors, is a critical part of management of the Form-Function Spiral. There is only one factor that causes breathing to become dysfunctional - and that is stress.
•
There are numerous stressors encountered in daily living but they are all of three basic origins.
- Functional Stress - What you are doing. (sitting, talking, sleeping, occlusal issues).
- Ingestional Stress - What you are ‘eating’ (includes environmental factors).
- Emotional Stress - What’s eating you (work, family, finances, commuting etc).
•
An accurate evaluation of breathing mechanics and dynamics is a valuable indicator of breathing efficiency - and the subsequent biochemical balance in the body - which is the prime driver of breathing rate and depth.
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•
Evaluation of airflow rate and mode has a direct correlation with naso- and oropharyn-
•
If the air in not nasally inspired, it lacks filtration and sterilization and causes inflamma-
•
Failure to breathe nasally inhibits the release of nitric oxide - a potent antimi-
geal mucosal tissue integrity.
tion, infection and congestion.
crobial and vasodilator - which is largely responsible for keeping the nasopharynx free from congestion, inflammation and infection.
•
Overbreathing inflames mucosal tissue resulting in congestion - one of the contribu-
tors to UARS (Upper Airway Resistance Syndrome) which is not usually recognised by sleep physicians.
•
The restoration of functional breathing and the concomitant reduction in local inflammation and congestion allows for lower PAP settings and less protrusion of the mandible - in order to create a patent airway.
PROGNOSIS AND TREATMENT PLAN The prognosis is excellent once a measure of functionality and balance is restored to the
body. The body has amazing powers of regeneration and healing once the underlying obstacles have been removed, and this is not a case of “creating health”, it is rather one of removing the impediments to a natural healthy state.
The Treatment Plan differs in each of the cases, as no two people present with the same
symptoms or underlying issues. The plan is based around three key processes. 1. Identify and address the factors causing stress to the body.
2. Restore functional balance patterns to posture, breathing, swallowing and chewing. 3. Retrain the brainstem response to maintain the correct inhalation/exhalation ratios in order to address cortisol dominance and to extend parasympathetic rest and recovery.
TREATMENT PROTOCOLS CENTRAL SLEEP APNEA IS MISUNDERSTOOD AND POORLY MANAGED Despite published clinical trials in leading medical journals which prove that Central Sleep
Apnea is a defense mechanism against hyperventilation, the old fashioned notion of CSA being “a failure of the brain’s message to breathe to reach the muscles of breathing”9 still
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persists, as does the ‘Best Practice’ treatment for a biochemical disorder being a machine designed for an obstructive condition. It makes no sense - yet it still persists.
The claims that ASV (Adaptive Servo Ventilation) is the final stand in the treatment of CSA
says it all10. Any benefit derived from using this invasive and very expensive machine is in fact by default, as the presence of the mask and positive pressure stems the loss of CO2 from overbreathing and the apnea does not occur.
This is again one of the clearest examples of the FFS in daily life: •
Stress causes hyperventilation Hyperventilation causes hypocapnia Hypocapnia
•
The brain responds to the hypoxia and temporarily halts breathing so that the CO2
•
Once normocapnia is reached and oxygen flow restored (Bohr Effect), breathing re-
causes hypoxia
pressure can rise.
sumes.
In the several studies which you will find in the references,11-15 CSA was ‘cured’ by the ad-
dition of supplemental CO2 via a mask. If that is the case, preventing it from being lost in the first place would obviate the need for adding it back. This is precisely what Breathing Retraining achieves.
ASTHMA - THE MOST MISDIAGNOSED RESPIRATORY CONDITION OF ALL16 The symptoms and manifestations of ‘asthma’ are almost identical to those of hyperventi-
lation induced bronchoconstriction and the two are regularly confused - due in no small mea-
sure to the fact that the “Gold Standard” and “Best Practice” diagnosis of asthma involves
the forced exhalation of air from the lungs, whether through Spirometry or Peak Flow. There is a detailed paper attached titled “Asthma - The end of the Beginning”17 in which this issue is fully covered.
OTHER BREATHING RELATED SLEEP DISORDERS Although the basic protocol is the same for the majority of breathing-related functional is-
sues there are often different starting points, based on the outcome of the investigation and assessment.
One would obviously treat a patient with a breathing rate of 28 breaths per minute dif-
ferently from one breathing at half that rate and this is not the forum in which to discuss the treatment in any detail. What can be described however is the general process by which dysfunctional breathing can be rectified.
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1. Obtain an accurate baseline evaluation of three key markers, 1. Breathing rate per minute. 2. Breathing mechanics and dynamics - nose-mouth, chest-diaphragm. 3. Biochemical balances as evidenced by the ET CO2 (end tidal CO2 pressure in the alveoli). 2. E valuation of posture - relative to tongue, head (forward/back), neck, shoulders, back and feet. 3. Evaluation of stress triggers - as detected from assessment process. 4. Commence by training the patient to breathe nasally-diaphragmatically. 1. Sleep with lips together. 2. Reposition tongue to roof of the mouth.
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3. Activate diaphragm and train away from upper thoracic breathing. 5. Institute a regimen of daytime breathing retraining to address the ANS imbalance. 6. Monitor on a regular basis to track progress and encourage compliance. HYPERVENTILATION SYNDROME - A DIAGNOSIS BEGGING FOR RECOGNITION18 More than 65% of Emergency Room admissions in the USA list Hyperventilation (HVS) as
a symptom. This is accepted and acknowledged but no treatment, advice or management is offered apart from stabilization on admission.
The Form-Function Spiral is also directly related to the following symptoms and those
marked with an asterisk* are almost always present in people suffering from Hyperventilation Syndrome HVS.
REPRODUCIBLE OBJECTIVE DATA One of the major issues in the realm of breathing and sleep disorders is the nebulous na-
ture of much of the data. Much is subjective and anecdotal - such as the reporting of snor-
ing, and the most popular method of Breathing Retraining - The Buteyko Method - suffers from such a disadvantage, as it a subjective measurement of the person’s ability to hold their
breath until they feel they would ‘like to breathe’. The same situation also applies to some of the HRV (Heart Rate Variability) programs available, where ANS activity is not always clear.
The instrumentation referred to in Assessment Aids above has proved to be of in-
estimable value in identifying the dysfunctions and allowing people to actually see what it is that they are doing.
CONCLUSION By examining and understanding the Form-Function Spiral it is possible to identify and ad-
dress many issues which are currently being missed in the Top-down medical model of man-
aging “Sleep Disorders”. The inordinate focus on a mythical concept called “Sleep Disordered Breathing” is responsible for driving the direction of looking for a solution during “Sleep”, and that is not where the root of the problem lies.
“Sleep” is not the problem. In the same way that crooked teeth are an indication that there
are imbalances elsewhere in the body - disturbed sleep is an indication that dysfunctional daytime patterns are largely responsible for the load on the body at night - and during the process of sleep.
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The reality is that this is a problem created primarily during the two thirds of time that we
are awake and ‘functioning’, and everyone is hell-bent on finding the solution during the one third of the time that we are trying to sleep.
REFERENCES AND CITATIONS 1. Mouth Breathing in Allergic Children: It’s Relationship to Dentofacial Development Bresolin, Shapiro E.T. Al. American Journal of Orthodontics 1983.
2. “All experimental animals gradually acquired a facial appearance and dental occlusion different from those of
the control animals”. Egil P. Harvold, DDS Ph.D.,L.L.D.Brittta S. Tamer, DDS, Kevin Varervik, DDS., and George Chierici, DDS - American Journal of Orthodontics Vol 79. No. 4 April, 1981.
3. The amount of maxillary and mandibular growth and the direction of maxillary growth were studied in 38
children during the 5 years after adenoidectomy for correction of severe nasopharyngeal obstruction. Donald G. Woodside, Sten Linder-Aronson, Anders Lundstrom, John William. American Journal of Orthodontics July 1991.
4. What is the Future of Sleep Medicine in the US? AJRCCM Articles in Press. Published on 26-August-2015 as 10.1164/rccm.201508-1544ED. Barbara Phillips, MD, MSPH, FCCP, Division of Pulmonary, Critical Care and Sleep Medicine University of Kentucky College of Medicine. David Gozal, MD Herbert T. Abelson Professor of
Pediatrics University of Chicago Medicine and Biological Sciences, Atul Malhotra, Kenneth M. Moser Professor of Medicine UC San Diego Pulmonary, Critical Care and Sleep Medicine Division La Jolla CA
5. Expansion and Relapse in Long Follow up Studies. Orthodontic Dept. of the University Dental Hospital in
Cologne - A Study of 500 patients from 1964. Schwarze C. Very soon it became clear, that Orthodontically induced transverse sizes of dental arches are very unstable.
6. Central Sleep Apnea on Commencement of Continuous Positive Airway Pressure in Patients with a Primary
Diagnosis of Obstructive Sleep Apnea-Hypopnea J Clin Sleep Med. 2007 Aug 15; 3(5): 462–466. PMCID: PMC1978327. Sanaz Lehman, M.B. B.S.,1 Nick A. Antic, M.B. B.S.,1,2 Courtney Thompson, B.Sc.Eng.,1 Peter G. Catcheside, B.Sc., Ph.D.,1 Jeremy Mercer, B.A., Ph.D.,1 and R. Doug McEvoy, M.D.1,2
7. Side Effects of Mandibular Advancement Devices for Sleep Apnea Treatment. Karsten M. Fritsch, Angelo Iseli,
Erich W. Russi, and Konrad E. Bloch, American Journal of Respiratory and Critical Care Medicine, Vol. 164, No. 5 (2001), pp. 813-818. doi: 10.1164/ajrccm.164.5.2003078
8. Addiction: Part I. Benzodiazepines—Side Effects, Abuse Risk and Alternatives Lance P. Longo, M.D., Uni-
versity of Wisconsin Medical School, Milwaukee, Wisconsin M.D. Brian Johnson, Harvard Medical School, Boston, Massachusetts, Am Fam Physician. 2000 Apr 1;61(7): 2121-2128. This is Part I of a two-part article on addiction.
9. Sleep Disorders - Another Perspective. Roger L Price Respiratory Physiologist and Integrative Health Educator, Journal of Lung, Pulmonary and Respiratory Research, Volume 2, Issue 4 - 2015 Published: April 15, 2015
10. The Treatment of Central Sleep Apnea Syndromes in Adults: Practice Parameters with an Evidence-Based
Literature Review and Meta-Analyses. Aurora RN, Bista SR, Casey KR, Chowdhuri S, Kristo DA, Mallea JM, Ramar K, Rowley JA, Zak RS, Heald JL. Updated adaptive servo- ventilation recommendations for the 2012 AASM guideline:. J Clin Sleep Med
11. Effects of inhaled CO2 and added dead space on idiopathic central sleep apnea. Xie A1, Rankin F, Rutherford R, Bradley TD. J Appl Physiol (1985). 1997 Mar;82(3):918-26.
12. Treatment of refractory sleep apnea with supplemental carbon dioxide. Badr MS1, Grossman JE, Weber SA. Am J Respir Crit Care Med. 1994 Aug;150(2):561-4.
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13. Low-concentration carbon dioxide is an effective adjunct to positive airway pressure in the treatment of refrac-
tory mixed central and obstructive sleep-disordered breathing. Thomas RJ1, Daly RW, Weiss JW. Sleep. 2005 Jan;28(1):69-77.
14. Effect of CO2 inhalation on central sleep apnea and arousals from sleep. Szollosi I1, Jones M, Morrell MJ, Helfet K, Coats AJ, Simonds AK. Respiration. 2004 Sep-Oct;71(5):493-8.
15. Normalizing CO2 in chronic hyperventilation by means of a novel breathing mask: Authors Troels Johansen,
Sandy Jack, Ronald Dahl First published: 20 March 2013 Clinical Respiratory Journal John Wiley and Sons Ltd.
16. Asthma statistics - Lung disease in the UK - British Lung Foundation https://statistics.blf.org.uk/asthma 17. Asthma - The End of the Beginning. Roger L Price Respiratory Physiologist and Integrative Health Educator. Journal of Lung, Pulmonary and Respiratory Research, Volume 3, Issue 2 - 2016
18. “A Diagnosis begging for recognition� Magarian G J, Middaugh DA, Linz DH: Hyperventilation syndrome: A
diagnosis begging for recognition. West J Med 1983 May; 138:733-736. From Ambulatory Care and Medical Services, Veterans Administration Medical Center, and the Division of General Medicine, Department of Medi-
cine, Oregon Health Sciences University, Portland. Supported in part by HEW grant No. 1-028-PE10051-02. Reprint requests to Gregory J. Magarian, MD, Ambulatory Care Service (llC), Veterans Administration Medical Center, Portland, OR 97207.
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Removable Orthodontic Appliances with High Retention. A new concept in the approach and treatment using removable orthodontic appliances Dr. José Roberto Ramos Brazil
ABSTRACT Globally, orthodontists are increasingly reducing the use of preventive and interceptive treatments with removable orthodontic appliances in children each day. The mixed dentition, in most cases, does not provide good retention for the removable appliances into the children’s mouth as the short teeth allow the removable appliance to disengage from the dental arch, resulting into a negative impact on cooperation and causing the failure of preventive or interceptive treatment. Aiming to develop a way of solving this major issue, a bright idea to enhance removable appliances retention was conceived. Based on clinical evidence, the Ramos OrtoSystem retention brackets are bringing back the use of removable Orthodontics worldwide. Keywords: Retention clasps – Preventive Orthodontics – Removable orthodontic appliances – Pediatric Dentistry – Ramos OrthoSystem – Retention brackets. How to cite this article: Ramos R. J. Aparelhos Ortodônticos Removíveis com Alta Reten-
ção. Revista Ortotécnica / 2016; 1 (1): 38-46.
INTRODUCTION In most cases, the use of removable orthodontic appliances involve children, whose pri-
mary or mixed dentition featuring short crowns present low retention.
Routinely, parents bring their children back to the dental practice to have the removable ap-
pliance adjusted only days after it has been tightened on a treatment visit. The main complaint
is that the appliance is loose again or that it hurts, and, thus, the child is unwilling to cooperate and wear it. The appliance is readjusted and after a couple of days, the issue is back on.
Controlling the instability of removable orthodontic appliances, either active or passive,
may be achieved with the use of the Ramos OrthoSystem retention brackets.
Using the Ramos OrthoSystem brackets as retention support, may, in a certain way, make
the removable appliance almost semi-fixed, which means, in several cases, the retention is so precise that only the parents are able to take the appliance of the child’s mouth.
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Figure 1. Kit case of brackets for the retention of removable appliances.
The unity is shaped as a plate inclined to cervical, and beneath it is the C clasp or spring coupling slot if incisors are being treated. There are 4 kinds of brackets and they used in: •
Primary / permanent molars.
•
Primary / permanent canines.
•
Premolars.
•
Primary / permanent incisors.
Retention brackets should be directly bonded to the teeth following standard protocol, but as close as possible to the cervical margin. After treatment with the removable appliance, they are removed the same way conventional brackets are removed. All edges are rounded, ensuring patient’s comfort. Another highlight is the design of the retentive baseplate, created in a way that assures a very high stability of the insertion and removal impact on the mouth, not disengaging from the teeth because of these actions.
RAMOS ORTHOSYSTEM BRACKETS GRAPHIC LAYOUT Primary and permanent molar
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IFUNA JOURNAL Primary and permanent canine/ premolars
With this retention system, the appliance fits the mouth with that “click� sound when the clasp or spring slides on the inclined platform and couples with the respective slot. See the interaction of the C clasps sliding over the inclined platform on the following pic-
tures:
A: Clasps moving and sliding over the inclined edge of the brackets. B: Clasps coupled with the retentive slot of the brackets. Primary /permanent incisors
A spring, when activated, usually slides over the palatal or lingual surface of the tooth. The brackets on incisors lock the springs, concentrating the forces released as close as possible
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to the tooth’s center of resistance. Thus, a bodily movement will take place, eliminating the possibility to tilt the incisor. Using this bracket on incisors allows the spring to also be used as an active retentive element, which means, the spring becomes a retention clasp. The activated spring is coupled to the slot by the patient’s index finger. Type C Clasps or Retainers Along with the brackets, preformed type C clasps matching the exact anatomy of the brackets circumference have also been developed. The caliper of the preformed clasps is 0.9 mm for molars, canines and premolars. Preformed clasps for molars
Preformed clasps for canines and premolars
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The molding of patient’s mouth must be carried out with alginate or silicone. After obtaining the impression, the preformed clasps should be coupled with the cervical slot of the bracket, and subsequently, adjusted to the retention cable in the region where the acrylic will be applied. Similarly, the clasps are coupled to the canines or premolars.
The springs should be made with 0.7 round TMA wire. Before, finger springs were usually made of steel wire, but with the use of retention brackets, the TMA wire comes as an innovation, is more efficient because it is less stressed, ensuring a less aggressive biological action and being less risky for moving primary or permanent teeth with the dental apex still not closed, in eruption.
USING THE RAMOS ORTHOSYSTEM RETENTION BRACKETS Application Method 01- Bonding the Ramos OrthoSystem Brackets Facially Upper Removable Orthodontic Retention with Begg’s Straight Archwire Contention, as the name says, is supposed to contain, but this does not always happen
when this appliance is used. As a matter of fact, many orthodontists activate the contention loops in order to control their retention into the patient’s mouth.
If the loops are activated, this appliance shall not work as merely retentive anymore. On the
contrary, this appliance will turn into an active orthodontic appliance, loading forces on the teeth and stimulating dental movements.
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If the contention appliance cannot be activated, a question is raised: what is the purpose of the loops? Why do not use a straight archwire without loops, then? The loops work as bumpers that eliminate the tension on the arch on the incisors when the appliance is inserted into and removed from the mouth. If these loops were not there, the archwire would apply intermittent forces on the incisors when the patient inserted and removed the appliance from the mouth. Hence, the alveolar processes around the teeth would never be repaired as the contention treatment proposes, because the teeth would be submitted to intermittent orthodontic forces daily. As we know, this alleged loop activation is a resource used to enhance the control of the appliance’s retention into the mouth, so we propose a different kind of stability control for this appliance, indicating the use of retention brackets on the last permanent molars. Therefore, the juxtaposition of the contention would be take place on the upper jaw without loading forces on the incisors. The brackets indicated for this control are brackets for permanent molars.
Figure 27. Patient removes contention from the mouth placing the index finger on the retention bracket area, pulling the arch.
Figure 28. Full view of the continuous stabilized archwire without the need of loop activation.
Removable Upper Space Maintainer with Esthetic Teeth The early loss of primary teeth almost always involves the use of a space maintainer. When
the incisors are involved, the child’s esthetic is the main concern of the parents, who fear their children might be discriminated at school and by society.
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As this device may be used in the long term, it should ideally be removable, thus allowing the patient to take it off for daily cleaning. The use of retention brackets in the primary canines and permanent molars will allow the appliance to have a great retentive performance, in which the patient will feel as if the appliance were part of their own body, being able to eat while wearing it and also wear it during leisure time. The orthodontist may take into account that this kind of appliance must be made with a an expansion screw that can be activated a Âź turn per month, therefore compensating for the transversal growth of the upper jaw that could have been locked by the appliance had it been made without the screw.
Figure 29. Retention brackets
Figure 30. Occlusal view of the
Figure 31. Buccal view showing
nines.
lized by retention brackets.
cal slots of the retention brackets.
bonded on first molars and ca-
appliance after installed and stabi-
the clasps coupled with the cervi-
Negative Effects of Using the Fixed Esthetic Maintainer
Figure 31b. Fixed esthetic spaced maintainer.
When this kind of appliance is created to be fixed, there are several downsides that should be taken into account: the appliance frequently breaks because it is attached to a palatal arch welded to the permanent molar bands. The masticatory force on the artificial teeth is unloaded on the banded molars, that always end up tipping due to the excessive load, and thus, fracturing.
Ischemia of the mucosa supporting the artificial teeth is likely to happen, possibly causing pain and sensitivity in the region. Hence, the patient avoids cutting food with the incisors. And this forced stimulus principle leads the patient to overload one side of the dental arch cutting and chewing food, becoming a unilateral chewer. Dental hygiene is compromised once the fixed appliance is hard to be cleaned, and the children are not always able to clean it all by themselves and end up depending on the parents to help.
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Moreover, this patient should come back to the dental practice for dental prophylaxis monthly. After knowing the alternative to enhance the space maintainer retention through retention brackets, fixed space maintainers are truly more indicated when using removable appliances in some patients may not possible due to developmental disabilities such as Down Syndrome. Hybrid System Without Retention Clasps The hybrid system is highly esthetic because the retention is achieved through the encapsulation of the posterior teeth. The appliance’s baseplate is made of vacuum formed 2 mm hard plates. The plastic base couples with the brackets practically and functionally.
Figure 32. View of the hybrid plate insertion over the teeth with the retention brackets.
Figure 33. View of the hybrid plate stabilized by the retention brackets.
See below some examples of hybrid retention application: Buccal Contraction Arch with Upper Memory on a Hybrid Baseplate This appliance is indicated to patients with incisive dental protrusion. With a well-anchored base, the arch may work moving the incisors to palatal with a constant light force.
Figure 34. View of the retention
Figure 35. Occlusal view of the in-
Figure 36. Side view of the installed
manent molars, second primary
retention brackets.
applying the pressure of retraction arch
brackets adapted to the firs permolars and canines.
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stalled appliance, stabilized by the
appliance, stabilized in the upper jaw with memory springs on the incisors.
IFUNA JOURNAL Laboratory Step Vacuum formed 2.0 mm hard plates are used. Mechanic retention is created in the plates with a stone drill to make them rough. Consecutively, the acrylic is applied to the plate, and the expansion screw is positioned. The 0.9 mm telescopic tubes are placed, in parallel, in the middle of the buccal surface of the canine crowns. Acrylic is applied over the tubes. And finally, a buccal arch is made with 0.7 mm wire and NiTi springs are adapted, and calipered with 120 g using a dynamometer. The tip of the wire is bent with bar bending pliers.
Figure 37. Hard crystal 2 mm base plate.
Figure 38. An expansion key is used to guide the telescopic tube positioning.
Lower Hybrid Expander Plate With Protrusive TMA Springs and Lip-Bumper The hybrid lower retention system is really functional as the vacuum formed hard plate couples well to the retention brackets. Therefore, the springs, when activated will not promote negative tippling effects. Note that the incisors also received brackets to lock the springs and make their own forces work as close as possible to the center of resistance, while the lipbumper eliminates the negative influence of the lower lip on the incisors.
Figure 39. Occlusal view of the in-
stalled appliance stabilized by the retention brackets.
Figure 40. View of the springs stabilized by the retention brackets.
Figure 41. Lip-bumper and its activation loop.
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Figure 42. The incisors are protected with rubber gum so that the thermoforming of the posterior baseplate/blocks (2 mm)
can be performed. Therefore, when the plate is removed to be cut, the incisors do not break away. It is essential to create mechanical retention on the lingual surface of the rigid crystal
baseplate with a maxi cut drill to promote good resin adherence.
Figure 43. A relief with two sheets of wax-7 is performed in the incisive region for creating the lip-bumper structure.
Figure 44. The lip-bumper structure is created with 1.2mm wire.
Figure 45. The mandibular expander and the 0.8 mm TMA springs are adjusted.
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Figure 46. Lingual acrylization is carried out.
Figure 47. Subsequently, the lip-bumper is acrylized. After wearing the resin, the polishing/shine shall be carried out by the photopolymerizable method.
Application Method 2- Lingual or Palatal Ramos OrthoSystem Bracket Bonding The molar brackets may also be bonded to the lingual surface in order to make certain removable orthodontic appliances more comfortable.
Figure 48a. The acrylic body in the lingual region becomes quite uncomfortable in cases of lower arch expansion. Brackets may be bonded on the lingual surface then and the appliance may be created with the acrylic body in the buccal surface.
Lower Buccal Frankel Expander Modified Plate In 1960, Dr Rolf Frankel, published his first experience with a lower buccal plate. In cases of mandibular or lower jaw micrognathism in children, lack of space for the canines is almost always seen as a characteristic, lower atresia is also seen as a feature.
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Figure 49. Lower buccal Frankel plate.
Figure 50. Lower buccal Frankel plate modified by Ra-
Figure 51. This device is a modification of the facial
Figure 52. Occlusal view showing the lack of space for
mos.
Frankel expander plate and was developed to obtain space for the lower canines and increase the transversal
the canines.
perimeter of the lower jaw.
The role of the facial sagittal screws is to promote the retraction of the posterior blocks and the proclination of the incisors through the TMA helicoidal springs connected to the lip-bumper.
Figure 53. View of the TMA helicoidal springs connected to the lip-bumper.
The lip-bumper eliminates the negative muscular influence of the lower lip on the lower jar while acting as transversal ex-
pander agent since it is given a bilateral expander screw on its body.
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This expansion screw incorporated into the lip-bumper can either work to obtain space in cases of light atresia or to ensure that the natural growth of the lower jaw is not transversally locked. And what will ensure this actions is the activation protocol to achieve the expansion or simply compensate the natural transversal growth of the lower jaw. Aiming expansion, a ¼ turn activation a week, aiming the compensation of natural growth, a ¼ turn activation a month. Using anchorage brackets is needed to promote the appliance’s stability and achieve immediate results.
LABORATORY STEP
Figure 54. Relief is performed with two sheets of wax-7 right ahead of the incisors. The facial plate is planned to be 3mm
above the cervical margin and spreads out 1cm below the
cervical margin. The retention of the clasps is headed to the middle of the buccal acrylic body.
Figure 55. Facial view of the wax relief .
Figure 56. Positioning of the expansion screws. Sagittal expanders shall be positioned in the area that needs to gain space and height in the center of root resistance (in the height of facial alveolar walls)
But the lip-bumper shall be positioned relatively to the middle of the acrylic body of this accessory.
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Figure 57. View of all the elements in position, including the 0.8 mm TMA helicoidal spring. It is worth highlighting that the retention of the helicoidal spring shall go through the distal sur-
face of the lateral incisors, positioned on their facial surface, then being integrated to the lip-bumper.
Figure 58. Acrylization may be carried out either by the powder liquid technique or by the manipulation technique.
Figure 59. View of the acrylized appliance removed from the cast model.
Figure 60. View of the polished appliance.
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CONCLUSION The Ramos OrthoSystem brackets have demonstrated to be a necessary resource for the orthodontic treatment with removable appliances allowing the a wide range of uses in several appliances. Clinical evidence has shown they are a highly valuable accessory in contemporary days, redeeming the interest of the whole orthodontic society in using removable appliances for preventive and interceptive orthodontics. They are not only highly effective in retention, but also are esthetic and easy to bond and do not hurt the patient’s mucosa. Another advantage is they are cheap making them cost-effective and viable in any treatment.
REFERENCES 1. Ramos 2014; Aparatologia Ortopédica Mecânica Bio-Propulsora - Técnica Ramos OrthoSystem. Editora Ortholabor.
2. Ramos 2010; Ortodontia e Seus Dispositivos – Atlas operacional. Editora Ortholabor 3. Diseño de aparatos de Ortodoncia. Editora – Pinos Nuevos. Autor: Lázaro Miguel Domingues Fleites. 4. L’ortodonzia e i suoi dispositivi (Appaecchi mobili e fissi rimovibili nella pratica clinica). Editora – Elsevier Masson. Autores: Fabrizio Montagna, Nicola Lambini, Vincenzo Piras e Gloria Denotti.
5. Aparatos Removibles de Ortodoncia. Editora – Mundi. Autor: C. Philip Adams. 6. Ortodoncia Preventiva. Editora – Universidad Javeriana, Bogotá. Autor – Zagarra, M. J.: 7. Practical Guide Orthodontc Appliances (Great Lakes Orthodontics). Brian D. Willisom e Stephen P. Warunek. 8. The principles and Practice of dentofacial Orthopaedics. Editora – Quintessense Books. Autor: Hugo Stokfisch.
9. Removable Orthodontic Appliance Autor: T.M. Graber. 10. Atlas of Orthodontic Principles Autor: Thurow R.H.
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From neural excitation to mechanotransduction
Dr. Patricia Valerio,PhD; Dr. Filipi Perfeito; Dr. Banu Yesilbek, PhD; Dr. Filiz Yamaner; Dr. Sule Simsek Brazil
On the phylogenetic scale, the bone appears to protect soft structures. The developing
creatures achieved a high level of complexity, generating a demand for protection that could not be given by the cartilage capsule. So, the nature found a solution. Mineralize the tissue to enhance rigidity (1). However, the evolution went on and this rigid tissue (bone) started to work also as a supporting and anchor tissue. Bone starts to work together with the muscles and ligaments as a complex mechanical system. This system became extremely dependent of loading. The rigid structures modeling process started to be directly related to functional stimulations. The form and function binomial law stated by Julius Wolff is the maximum expres-
sion of this inter-relation. From that point one we could understand that, there is no correct shape if we don’t have correct functional stimulation (2). But, if the bone growth and shape
are so dependent of function execution and load generation, how this stimulus happens? We can state that muscular tonus, on rest or on movement, is the man generator of loading. It
has as coadjutant the pressures and tensions generated by other growing structures (ex: Size enhancement of brain, Paranasal sinus inflation, etc) (3,4).
We need to understand that, when we are making functional orthopedics stimulation, we
are, among other mechanisms, using neural stimulating pathways that will lead to tonus alter-
ation. This will generate the necessary mechanical stimulus to guide the desired bone growth and development (5).
To understand the relevance and the importance of Jaw Functional Orthopedics, and also
understand its effectivity, it is necessary to start with the question:
WHAT DOES IT MEAN ORTHOPEDICS? The Greek etymology of the word connects ORTHOS (correct, straight, aligned) and PAE-
DOS (child). This neologism was created by Nicolas Andry, in 1741. He was a French physi-
cian that published a book called: “L’orthopedie ou l’art de prévent et de corriger dans les enfants les deformités du corps”. It is impressive how this man was a visionary, and how he
worked hard teaching to his students that early interventions in musculoskeletal system could lead to more effective and stable corrections (1). Later,in 1892, Julius Wolff, created a great
polemic discussion when he published his work: “The law of bone transformation”(2). The
evolution of these concepts, brought to discussion on 1997, the emblematic publication of
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Melvin Moss, an American orthodontist that dedicated 37 years of his life validating scientifically the clinical observations that he made all over his life and that lead him to publish in 1960 his functional matrix theory. He always stated that functional stimulation generates the shape, as previously stated by Andry and Wolff (3,4,5,6). During the last decades great developments on researching tools brought and are bringing clear view of this relation: Mechanical stimulus/ bone remodeling. We now call it Bone mechanotransduction. The discovering that mechanical sign sensed by one bone cell can be transmitted to neighboring cells, potentiating the effect of this sign, clarified the comprehension Of why a small mechanical sign can lead to a great remodeling answering (7,8). A mechanical stimulus sensed by one single cell can be transmitted to the cells interconnected with this one, through 2 different mechanisms: Passing the generating calcium waves by gap junctions or a mechanism similar to synapses, where the depolarization of the bone cells membrane lead to neurotransmitter liberation on the end of elongations. This neurotransmitter connect to receptor on the other elongation, depolarizing this membrane and amplifying the sign (7,8). Figura 1 A, B.
NOW, UNDER SCIENCE LIGHT WE CAN ASK: WHAT IS FUNCTIONAL JAW ORTHOPEDICS? A therapeutic approach that intends to remove the undesirable interferences and promotes desirable stimuli, during growth and development period, aiming the function perfectness.
Figure 1A. Connection Cellular Network. The elongation of osteoblasts connected to each other (picture from main author archives).
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Figure 1B. Gap junctions and mechanism similar to synapse. Schematic draw showing 2 mechanisms of mechanical sign propagation.
Also work after growth period reestablishing proper function. FJO acts directly on neuromuscular system, since it commands the bone modeling.
OF WHICH STIMULI ARE WE TALKING ABOUT? It is the first fundamental principle described by Dr Wilm Alexandre SimĂľes: Neural excitation. It means activation of all sensitive inputs (aferences) necessary to allow central nerve system CNS to interpret and generate outputs (eferences) to motor effectors (9). We are talking about stimulation of proprioceptors from periodontal ligament, TMJ capsule (10,11,12), tongue and mouth mucosa (13) and muscle spindles (14). The stimulation of them will lead to motor eferences generation by CNS. The tonus generation is the main bone shaping stimulus (15). Due to that, to reestablish the correct tonus is a fundamental principle to generate correct growth. Figure 2 shows schematically these pathways.
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Figure 2. Aferences, eferences.
Figure 3. All kind of functional orthopedics stimulation generates afer-ences processed by CNS, leading to changes on eferences to ef-fector organs.
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HOW FCO ACTS ON THESE PROPRIOCEPTORS? First of all it is important to understand that Functional Jaw Orthopedics is not synonym
of removable appliances. Appliances belong to the therapeutic arsenal used to make correct stimulations. The main action of FJO is posture changing. You can chenge posture using ap-
pliances or not. Everytime we change posture on transversal, vertical or sagittal direction we generate different stimulation for bone remodeling.
WHO ARE THE EFFECTOR ORGANS? Everytime we have proprioceptive aferences, they are decodified at CNS and generates
eferences to the effector organs: Muscle, tendon, fascia and ligament). It generates mechani-
cal stimuli to bone tissue. This stimulation will be sensed by bone cells and transformed on growth inhibitor or enhancer, depending of the therapeutic approach (16,17).
So, the functional orthopedics interventions modulate growth and remodeling, leading to
desired shape. We must always remember that the focus of a FJO intervention is the basal bone where these effectors organs are inserted. Changing the amount of stimuli, we can
change the bone shape because its DNA does not have the memory of form. We can give as
an example, the neck of some Thailand women from tribes that use metal rings to enlarge the neck; the elongated skull from some African men submitted to pressure during early
stages of growth, the shortened feet of some Chinese woman, etc. Wolff’s law is known by
intuition. So, use this concept in our benefit, to correct wrong growth and development, is an obligation of health professionals. Understand the FJO and its scientific bases and action mechanisms is opening a new frame that offers to population an efficient and stable intervention, to prevent, make early intervention or even correct craniofacial growth and developing alterations (18).
THERAPEUTIC INTERVENTIONS Temporary dentition occlusal adjustment Since, the main aim of FJO interventions is the generation of adequate functional stimuli,
recovering the correct relation between mandible and maxillae, recover the symmetry of this relation on the three planes is our purpose. The simplest intervention is grinding and compos-
ite adding on temporary dentition. It is easy and very effective and must follow specific rules
to give to the facial structures the opportunity to grow properly. Temporary dentition must be grinded naturally. If it does not happen, we must mimic the nature and do it with burs. Also, adding composite on specific regions, we can guide the movements to allow correct stimulation.
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Sice the main objective of FJO intervention is the generation of an adequate functional stimulus, the recovering of the correct maxillae-mandible relation is fundamental to allow the symmetric growth, avoiding shape alterations. So, selective grinding and composite adding (direct tracks) in accord to Planas laws are simple approaches that lead to relevant effects. On figure 4 we can see a child with unilateral crossbite, that leads to condyle shift (see on tomographic section). After selective grinding and direct tracks placement, the condyle is centralized and the system has the possibility of growing without asymmetries. If we don’t act early, this positional crossbite has great chance to become a skeletal crossbite.
Figure 4A. Unilateral crossbite. On tomographic study we can see the wrong position of right condyle (DIREITO) compared to left (ESQUERDO).
Figure 4B. After direct tracks and grinding. Sequential tomographic cuts showing centralization of both condyles.
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IFUNA JOURNAL Functional appliances The functional therapeutic arsenal is huge. So, here we will not discuss specific appliances.
It is important to clarify what is a functional orthopedic appliance. It is a removable appliance that has as main characteristic the changing of posture. It can occur in three planes: trans-
versal, vertical and sagittal and the combination of them lead to many different possibilities of posture changing. A FOA does not attach to teeth and the confection must be perfect, in
accord to the previous determined posture changing. Sometimes, we can start with selective grinding and tracks and later use FOA.
On figure 5, we can see an example of this approach, where the patient used posterior
tracks, anterior tracks and later he was able to start with an appliance. On figure 6, a retrog-
natic patient treated with FOA without tracks. On figure 7 a prognatic patient treated with FOA and on figure 8 an adult patient treated with FOA.
Figure 5A-D.
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Figure 6A-D.
Figure 7A-B.
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Figure 7C-E.
Figure 8A-B.
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Figure 8C.
Concluding, we can state that FJO has a therapeutic arsenal based on stomatognathic
system physiology, allowing alteration on bone shape due to changing on neural excitation on posture proprioceptors.
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3. Moss ML. The functional matrix hypothesis revisited. 3. The genomic thesis. Am J Orthod Dentofacial Orthop. 1997 Sep;112(3):338-42. Review. PubMed PMID: 9294365.
4. Moss ML. The functional matrix hypothesis revisited. 4. The epigenetic antithesis and the resolving synthesis. Am J Orthod Dentofacial Orthop. 1997 Oct;112(4):410-7. Review. PubMed PMID: 9345153.
5. Moss ML. The functional matrix hypothesis revisited. 2. The role of an osseous connected cellular network. Am J Orthod Dentofacial Orthop. 1997 Aug;112(2):221-6. Review. PubMed PMID: 9267235.
6. Moss ML. The functional matrix hypothesis revisited. 1. The role of mechanotransduction. Am J Orthod Dentofacial Orthop. 1997 Jul;112(1):8-11. Review. PubMed PMID: 9228835.
7. Mason DJ. Glutamate signalling and its potential application to tissue engineering of bone. Eur Cell Mater. 2004 Apr 7;7:12-25; discussion 25-6. Review. PubMed PMID: 15073696.
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8. Valerio P, Pereira MM, Goes AM, Leite MF. Effects of extracellular calcium concentration on the glutamate release by bioactive glass (BG60S) preincubated osteoblasts. Biomed Mater. 2009 Aug;4(4):045011.
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16. Isaacson J, Brotto M. Physiology of Mechanotransduction: How Do Muscle and Bone “Talk” to One Anoth-
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18. Carvalho, Andréa Alves de Aspectos clínicos e imaginológicos da microssomia hemifacial: série de casos / SIBI/UFBA/Faculdade de Educação – Biblioteca Anísio Teixeira – 2013.
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21. Woźniak K, Piątkowska D, Szyszka-Sommerfeld L, Buczkowska-Radlińska J. Impact of functional appliances on muscle activity: a surface electromyography study in children. Med Sci Monit. 2015 Jan 20;21:246-53. doi: 10.12659/MSM.893111. PubMed PMID: 25600247; PubMed Central PMCID: PMC4309728.
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