Functional education: a prevention tool for intercepting dentomaxillofacial malpositions in children and for improving functional problems in adults.
Some dysmorphoses can be detected in the young child. Provide they are treated early, maxillofacial growth can occur in better conditions that will contribute to facial harmony.
On the contrary, should these dysmorphoses be allowed to evolve, while waiting for the permanent dentition, they will worsen. Growth will occur around these dysmorphoses, which will make later treatment more difficult and longer, with compromise results (alveolodental compensations).
In 2004, the ANAES (Agence Nationale d’Accréditation et d’Evaluation en Santé) recommended early treatment for anomalies that can:
– endanger the growth of the face or of the dental arches,
– compromise oral functions,
– expose teeth to traumatisms.
Tiziano Bacetti (Florence University) carried out a randomized study about the necessity to intercept or not and about the difference in treatment results according to treatment starting date (early or late). He also compared different devices as the Herbst appliance and the Twin Block.
He stated that in 75% of Class II cases, the mandible is retrusive.
He identified three treatment-start options:
– before the pubertal spurt: mandibular growth is not higher than in the untreated control
– at the pubertal spurt: mandibular growth is higher than in the untreated control
– after the pubertal spurt: mandibular growth is not higher than in the untreated control
Results for interceptions (two phases) are always better for the patient.
Then, should we intercept at the pubertal spurt?
– No, as the line of reasoning only takes into consideration the anterior-posterior dimension
– No, as functional corrections that prevent a normal growth are not taken into consideration.
In our opinion:
With functional education before the pubertal spurt (age 4 to 11), we try to favor a normal growth by eliminating constraints. Thus, the deformation will not worsen and breathing, masticatory and muscular functions will improve. The child will grow without any impairment of his/her growth.
Preventive treatments (deciduous dentition – age 4 to 8) will prevent the emergence of a malocclusion in the permanent dentition.
Then come interceptive treatments (mixed dentition: 8 to 11) for attempting to guide the teeth toward their normal eruptive positions.
In our patients from 11 to 15, i.e. at the pubertal spurt, the appliances will stimulate the growth like rigid jumpers or protraction rods, but will improve other functions: breathing, mastication, posture and muscle tone…
They will work in the three directions of space and be more comfortable than traditional rigid jumpers.
These corrective treatments in the growth period (12 to 15: pubertal spurt in early permanent dentition) allow an orthopedic correction while growth in still in process.
Functional education after the pubertal spurt will eliminate functional constraints in order to facilitate tooth movements and post-pubertal growth. We work on functions and, thus, enhance the patient’s well-being.
Late rehabilitation treatments in the adult dentition will restore an optimal condition in the absence of any growth.
Therefore, in functional education in young children, our goal is to prevent the deformation from worsening, to practice early orthopedics and to put the child in conditions that will allow his/her growth to express itself without any constraint, thus improving his/her breathing, chewing and sleeping well-being.
Now, we can assert that any patient with an orofacial dysmorphosis also has related functional problems. Carl Gugino developed the concept of global dentofacial orthopedics, i.e. an orthodontist must treat the face and not « treat teeth » only.
When a young child comes to our office, we can prevent his/her case from worsening by correcting the dysfunctions.
Should the patient come later, at the pubertal spurt, we can stimulate his/her growth with orthopedics on both jaws, while eliminating any dysfunctions-related constraint.
In teenagers or adults, the orthodontist will have to correct existing dysfunctions in order to make orthodontic movements easier and to achieve better stability.
In the Bioprogressive concept, we call this the form-function unlocking: the patient’s behavior is modified and, thus, functions are modified to allow a change in the form.
Functional education works on:
- The breathing-swallowing couple
- Muscular education
- Postural education
- Behavioral education
Functional education takes into consideration all perturbed functions. The goal is to change the patient’s neuromuscular behavior in order to better neutralize these dysfunctions. This approach allows to successively modify function and form by working in the three dimensions of space and by considering a fourth dimension; time. « Give time some time ».
What are the basic rules of functional education?
- The earlier the correction, the easier the child’s adaptation to our education.
- The older the child, the more our education will have to adapt itself to the facial and functional type of the patient. The ideal would be to treat as early as possible (age 5 to 6), the early limit being the child’s maturity that allows an understanding and assimilation of an exercise.
- Functional education must be understood by the patient who must be an actor in his/her education.
- Communication is essential: similar cases, videos, morphing, and imaging are the most used tools.
- Psychology is paramount.
- Exercises will be included to allow the child to engram a new neuromuscular pattern. They will have to be simple and easy to set up.
- The practitioner and the orthodontic team will have to change their traditional orthodontic habits.
- The appliances are only technical mnemonic aids. They do not exert forces on the teeth, but help the repositioning of the tongue and cheeks, and favor nasal breathing.
- These appliances work in the three dimensions of space. This education needs time: the fourth dimension.
The orthodontist and his/her team are in charge of treating these dysmorphoses. It is the medical aspect of dentofacial orthopedics that must express itself, not the technical and mechanical one.
This unlocking of the dentition will take place in the three directions of space:
The unlocking of the dentition allows a normal growth potential and a proper function of TMJs. It also allows an easier tooth movement, avoiding constraints while inducing a change in form.
According to Slavicek, the goal is to work in a physiological centric relation.
Features of functional appliances.
This functional unlocking is performed through functional education appliances and tooth eruption guides. There are several types.
These different appliances are standard issues and do not need any impression taking. They are soft, made from silicon or soft PVC. They do not induce any pain and act as screens for neutralizing centripetal and centrifugal muscular forces on the dental arches. Upper and lower arch forms mimic the parabolic shape of the natural arch. They were drawn by different authors and are defined according to two criteria:
– the patient’s age,
– the deformation to be corrected
Functional education will consist in learning muscle, breathing and postural exercises that will train proprioception.
These appliances – even being standard made – have very precise features that will work on well defined areas of the dysfunctions:
- « Accuform-type » arch form that will keep the perioral musculature at bay.
- Soft and comfortable material, no irritation and a progressive easy adaptation for the patient
- Progressive posterior « air foil » thickness that will allow the condyles to come down and the mandible to progressively protrude (thus, no rigid hyper-protrusion)
- Systematic tongue guide that will help the tongue to come back up in the palate, and – along with the arch form – allow a light and continuous action in the transversal direction
- « Lip bumper-type » wings at the labiomental fold level that will keep the lower lip muscles at bay from the teeth, and thus allow a release of the mandibular growth and an easier alignment of lower incisors.
- The standard monobloc appliance will allow nasal breathing, and a stretching of the perioral and masticatory muscles through a lengthening of the muscle fibers
These treatments – with a wear of 4 hours daytime and all night long – must be short (about 6 months), then the child will wear the appliance only at night, then every other night, except if a tooth in the lateral segments makes its eruption, then the child will guide it to its proper position through additional wear time. The orthodontist will monitor the child and see him/her every 6 months, except if a problem should occur. He/she will become some sort of a pediatrist who will monitor his/her patients’ facial and dental evolution.
This functional education is essential for a proper development of the child’s facial pattern. It lessens the severity of the case and prevents extractions, should the child be seen early enough. Not performing it, or delaying it, would be a real loss of opportunity for our patient.
This education is also very important for preventing traumatisms and periodontic problems.
In 20 % of cases, it will not be sufficient, because our patients will not wear their appliance. Therefore, the success rate is 80%. From these 80%, 30% of patients will not need any fixed multibanded appliance. As for the remaining 50%, we will implement a two-phase treatment with fixed multibanded appliances, in order to upright long axes, but in a much shorter period (1 to 1.5 years). So, the child is always the winner.