[Retraining in dento-facial orthopedics. An orthodontist's viewpoint]

In dentofacial orthopedics, rehabilitation concerns the performance of the orofacial functions. Orthodontists will therefore speak of rehabilitation of functions, or functional therapy. Orofacial functions seem to obey a hierarchical system in accordance with their physiological importance; the impact of their disorders on both muscular behavior and facial morphogenesis, proportionally to their physiological importance. Therefore, priority will be given at a very early stage to the rehabilitation of respiration: restoring nasal ventilation is indeed an essential condition to obtain balanced oral functions because oral ventilation conditions both muscular posture and the performance of other functions. A little later, affective immaturity symptoms closely linked to various persisting bad suction habits will be looked after. At last, the rehabilitation of phonation and chewing both affected by the previous dysfunctions will participate in acquiring correct lingual position. The age for intervention will before all depend on the dysfunctional etiopathogeny. The morphological context, the importance of the malocclusion, and some orthodontic appliances also play a role in the the dysfunctional requests and the alterations of oral behavior.

Suffer the little children: fixed intraoral habit appliances for treating childhood thumbsucking habits: a critical review of the literature

A critical review of the literature is presented covering the treatment of childhood thumbsucking habits using fixed intraoral habit appliances (hayrake, palatal crib). The habit appliances are classified into type and function. Data is tabulated for key references revealing the fragmented and distorted nature of the literature and its lack of consistency. A chronological approach is presented to confirm the confused and idiosyncratic character of the literature. Information is provided on the early work of Massler and Graber and the paradox of Mack, Korner and Reider. Haryett's seminal studies at the University of Alberta regarding aspects of the treatment used are critically reviewed. Reflections are presented on why Larsson's study, casting doubt on the wisdom of using habit appliances, continues to be ignored. The emergence of the Bluegrass Appliance is discussed in terms of its being a more humane appliance and the seeming reluctance of practitioners to apply it as a kinder form of appliance therapy. Information is reported on the pain and serious injuries inflicted on children by habit appliances. A comparison of the use of appliances in the USA is made with the UK, where fixed habit appliances are not popular. Concludes that fixed intraoral habit appliances are cruel and inflict pain and suffering on children out of all proportion to their necessity. Questions why these appliances continue to be used, implying that it could be a combination of financial inducement, professional insularity and the absence of concerted opposition from behavioural therapists.

Riga-Fede disease: association with microcephaly

A case of microcephaly associated with traumatic ulceration to the ventral surface of the tongue (Riga-Fede disease) in a 12-month-old female is presented. To the best of our knowledge, such association has not been described previously. A conservative treatment regime was used, involving medical management, elimination of the sharp edges of the teeth and use of topical triamcinolone, and the ulceration healed over a period of 4 weeks.

Consequences of oral rehabilitation on dyskinesia in adults with Down's syndrome: a clinical report

The aim of this article is to demonstrate that the presence of orofacial dyskinesia is often owing to underlying facial dysmorphology in persons with Down's syndrome. A series of cases is presented where orofacial dyskinesia was successfully treated by therapy establishing occlusal stability. The diagnosis of dyskinesia owing to dysmorphology should be precluded before any link with the degree of intellectual disability or neurological deficit is presumed. A multidisciplinary approach may be necessary to diagnose and treat these patients.

Temporary tongue thrust: failure during orthodontic treatment

This report presents the case of a 25-year-old male patient who sought orthodontic treatment. Oral examination revealed an Angle Class I relation, with a bimaxillary dento-alveolar protrusion, evidence of anterior crowding, and a large overbite and overjet. Radiographic examination revealed a skeletal Class I occlusion. During the distal movement of the canines, occlusal interferences between the canines occurred and the commencement of a tongue thrust was observed. After correction of the applied forces, the canine movement was completed and the habit was no longer detectable. The incident indicates that an unusual oral habit suspiciously occurring during treatment should lead to an immediate reconsideration of the orthodontic treatment strategy.

[A study on improving tongue functions of open-bite children at the mixed dentition period--modifications of a removable habit-breaker appliance and their sonographic analysis]

In open-bite cases at developing dental stages, oral morphologies have been thought to have a close relationship to tongue movement. The aim of this study was to design a new type of removable habit-breaker, and to examine its effects on tongue movement compared with the conventional habit-breaker. The examinees in the mixed dentition period, who had anterior open bite with tongue thrust, consisted of two groups: 10 children who had been treated with conventional habit-breakers with tongue cribs (the upper group), and 10 children treated with the modified habit-breakers (the lower group). And 10 children with normal occlusion of the same age were added, as a control group. The tongue movements during swallowing, with and without the appliances, were analyzed twice: at the start of, and 6 months after, application of the appliances, by sonography. The results were as follows. 1. The design of a habit-breaker was decided according to the results of a preliminary experiment. The appliance had not only a resin-fence but also a tongue-lifting guide. 2. The upper group showed significant changes in the movement only at the lateral margin of the tongue after 6 months, with and without the appliance. 3. The lower group, however, showed significant changes in the movement at the wider area of the tongue, including the central groove formation, just after applying the appliance, and after 6 months, with and without the appliance. 4. The present results indicated that the modified appliance was more effective in improving tongue function than the conventional habit-breaker.

Case presentation: resolution of an oral lesion as a result of orofacial myofunctional therapy

This case presentation examines the etiology, evaluation and treatment of a 57 year-old-female presenting with an area of irritation/chronic lesion on the anterior lingual surface. Orthodontic history and lingual and labial postures are discussed.

The evaluation and treatment of pediatric oral habits

Oral habits continue to be a common problem in pediatric dentistry. This article briefly describes the most common oral habits and presents treatment options for resulting problems.

Electropalatographic and cephalometric assessment of myofunctional therapy in open-bite subjects

Myofunctional therapy (MFT) is often prescribed to correct tongue-thrust swallowing, with the expectation that anterior open bite (AOB) will reduce spontaneously if a more posterior tongue posture is learned. However, MFT has not been subjected to systematic evaluation. Electropalatography (EPG), which is used in speech pathology to measure dynamic tongue function for diagnostic, therapeutic and research purposes, is a suitable technique for the evaluation of MFT. This prospective clinical study assessed the effect of tongue re-education therapy on tongue function and dento-facial form in AOB patients. Electropalatography recordings of speech and swallowing, and lateral head cephalometric radiographs were obtained from eight 10-year-old boys with tongue-thrust swallowing behavior and AOB before and after a course of tongue re-education therapy. Although differences in cephalometric measurements before and after therapy were small, there was some evidence of a trend for upper and lower incisor eruption, with concomitant reduction of the AOB. Analysis of the EPG speech data was inconclusive, but the swallowing data showed trends for more consistent and more anterior patterns of EPG contact after therapy. Comparison of pre- and post-therapy EPG data with data from a parallel study using a group of age-matched controls indicated that some "normalisation" of swallowing behaviour had occurred. The results of this research imply that the therapy was partially successful in improving tongue function during swallowing and in reducing AOB. Further research on a larger sample over a longer observation period is required for more accurate assessment of soft and hard tissue changes.

Nonsurgical and nonextraction treatment of skeletal Class III open bite: its long-term stability

Two female patients, aged 14 years 5 months and 17 years 3 months with skeletal Class III open bite and temporomandibular dysfunction are presented. They had previously been classified as orthognathic surgical cases, involving first premolar removal. The primary treatment objective was to eliminate those skeletal and neuromuscular factors that were dominant in establishing their malocclusions. These included abnormal behavior of the tongue with short labial and lingual frenula, bilateral imbalance of chewing muscles, a partially blocked nasopharyngeal airway causing extrusion of the molars, with rotation of the mandible and narrowing of the maxillary arch. Resultant occlusal interference caused the mandible to shift to one side, which in turn produced the abnormal occlusal plane and curve of Spee. As a result, the form and function of the joints were adversely affected by the structural and functional asymmetry. These cases were treated by expanding the maxillary arch, which brought the maxilla downward and forward. The mandible moved downward and backward, with a slight increase in anterior facial height. Intruding and uprighting the posterior teeth, combined with a maxillary protraction, reconstructed the occlusal plane. A favorable perioral environment was created with widened tongue space in order to produce an adequate airway. Myofunctional therapy after lingual and labial frenectomy was assisted by vigorous gum chewing during and after treatment, together with a tooth positioner. Normal nasal breathing was achieved.

Adapted or atypical thrusting?

Distinguishing between the terms "adapted thrusting" and "atypical thrusting" is not the critical factor in planning treatment for patients demonstrating tongue thrust behavior. Evaluation of factors including age of the patient, breathing pattern, cranio-facial characteristics, head and body posture are important in determining when, and how to provide treatment.

Open bite, dental alveolar protrusion, class I malocclusion: A successful treatment result

This case report describes the treatment of a dentoalveolar protrusion, Class I malocclusion with an anterior open bite. The 21-year-old woman presented with a significant anteroposterior and vertical skeletal discrepancy. Her face was convex with procumbent lips. Intraorally, she had an anterior open bite of 4 mm, mild crowding, and an overjet of 4.5 mm. First premolar extractions in conjunction with tongue therapy and high pull headgear were used to reduce protrusion and close anterior open bite. Modification of a tongue thrust habit allowed conventional orthodontic treatment to correct this significant malocclusion and provide stability over the last 4 years.

Short-term and long-term results after early treatment with the Castillo Morales stimulating plate. A longitudinal study

The present study is divided into 2 parts: The first explains the concept of stimulating plate therapy at the Muenster Clinic and the second presents a longitudinal study of mouth and tongue posture in trisomy 21 children treated with this concept. 47 children underwent a pre-treatment examination (Rec1), and 38 attended a first follow-up examination (Rec2) after an average of 4 months of stimulating plate treatment. The second follow-up examination (Rec3) was on average 53 months after the end of treatment and covered 18 patients. Data acquisition was based on standardized parent questionnaires and standardized clinical examination records. Rec2 showed in part a highly significant improvement in orofacial appearance. These results were confirmed by the parent interview, according to which the mouth and tongue posture improved in 76.3% of the children during the time they were wearing the plate. Even when the plate was not in place, the result remained stable in 65.8% of the patients. Up to Rec3, further improvement was recorded in some results. The symptoms: "mouth mostly wide open" and "tongue mostly protruding way over lips" were reduced. The number of children whose tongue was "mostly in the oral cavity" increased correspondingly. At Rec3, the parents also rated the mouth posture in 88.9% and the tongue posture in 77.7% of the children as stable or further improved.

[Pre-orthognathic surgery in orthodontics: towards justification]

This work presents long term results of rhinopharyngeal desobstructions on nine years old patients. By using several techniques such as: tonsillectomies, adenoïdectomy, adenoïdotonsillectomies, luxation of inferior turbinates, partial turbinectomies or bilateral turbinectomies under endoscopic guidance, and then, following carefully the oral and nasal peak flows for a period as long as one or two years, it becomes obvious that the most efficient desobstruction procedure is accomplished through a combination of E.N.T. rhinopharyngeal procedures, i.e. adenoïdotonsillectomies and inferior turbinectomies under endoscopic guidance. This global E.N.T. procedure is known as "Chimney Sweep". The author demonstrates that tongue behavior is severely affected by rhinopharyngeal obstruction and by the consecutive dysfunction of the upper airway ventilation pattern. Large tongues and normal tongues pushed forward due to enlarged tonsils or adenoïds are also affected by their necessary participation to oral ventilation (mouth breathers). Addition of a selective lingual glossoplasty or a partial glossectomy is sometimes necessary to put the morphogenic function in a proper order during growth and development. All of the above is part of a new pre-orthognathic concept, that helps control growth and development and helps manage orthodontic or orthognathic treatments.

When children put their fingers in their mouths. Should parents and dentists care?

We have heard mothers tell their children not to stick their fingers in their mouths because they will get sick. Medical and dental professionals know this is true. Oral habits like thumb sucking and nail biting can damage the structure of the mouth and can lead to the spread of infectious diseases.

[Early functional surgery as a component of interceptive treatment of developing dysmorphosis in adolescents]

A discordance in the shape and relation between dental arches may be corrected by functional orthopaedics. Discovered in the adolescence, the dysgnathia has yet run its course and it remains just a bit of growth power, this situation justifies to recourse to interceptive surgery, meant for facilitation of oral reeducation and thus harmonisation of residual facial growth. This "functional surgery" is composed of tongue myoplasty, functional genioplasty and the early corrective orthopaedic surgery which is defined by its association with immediate reeducation. It is characterized by its benignity and stability of its results if occlusal and functional surroundings are equilibrated. Moreover, its profits by residual growth power which became well guided, and assures improvement of immediate postoperative results, if needed.

Orthodontic treatment of an open bite patient with oral-facial-digital syndrome

A case of oral-facial-digital syndrome was treated orthodontically. Characteristics of this case were mandibular protrusion with open bite. Occlusal stability after correction of this malocclusion was achieved with the uprighting of the posterior teeth, surgical reduction of the enlarged tonsils and highly attached tongue frenum, and oral functional training.

Sensory/motor therapy for the treatment of oral dyskinesia. A new approach to the treatment of oromyofunctional disorders with the use of tactile cuing handheld exercisers

Persons with oral myofunctional disorders suffer from multiple risk factors for impairments. A craniofacial malformation may be responsible for both behavioral as well as structural modifications. This includes the effect of appearance on self concept and behavior (Case, 1988). Structural modifications as well as negative oral habits include: an open mouth resting posture; mouth breathing; low forward tongue carriage; forward articulatory tongue placement (linguadental/lingua alveolar); abnormal lip, tongue and facial muscle movements during swallowing; reduced upper lip length and mobility; overcontraction of the mentalis muscle; negative habits such as nailbiting, thumb or finger-sucking, lip biting, and lip licking (Hale and Kellum, 1988). Clinical observations also include hypotonicity of the posterior oral musculature during swallowing activity. The purpose of this article is to explore the etiology of oral myofunctional disorders and present a new approach to treatment using functional prosthetic therapy.

Effects of oral myofunctional therapy on swallowing and sibilant production

This study investigated the effectiveness of oral myofunctional therapy in eliminating a 16 year-old girl's tongue thrust swallowing pattern and mild sibilant distortion. An ABC design was used where Phase A had eight baseline sessions (no treatment), Phase B had 14 oral myofunctional therapy sessions, and Phase C had four articulation treatment sessions. Dependent measures of swallowing and sibilant production were obtained in each session. A third dependent variable, labial diadochokinetic rate, was also measured each session and served as a control for maturation. Oral myofunctional therapy was shown to be effective in eliminating the tongue thrust swallowing pattern of this subject, but not her sibilant distortion. However, her sibilant distortion reduced after one articulation treatment session and was maintained at negligible levels over the next three treatment sessions. As expected, labial diadochokinetic rate remained stable across the three phases. At the conclusion of Phase C, two bi-weekly home visits revealed that the subject had maintained and generalized her new swallowing pattern. Measures obtained six months after completion of Phase C indicated that the subject had maintained her new swallowing and speech production behaviors. The subject's maximal tongue strength and endurance were below expected normal values at the initiation of the study and increased during the study. Her tongue endurance appeared more sensitive to the effects of oral myofunctional training than tongue strength and, unlike tongue strength, tongue endurance decreased in the six month period following completion of the study.

Electromagnetic articulography as a method for detecting the influence of spikes on tongue movement

In orthodontics dysfunctions of the tongue are discussed as a factor in the development of malocclusion. A new objective method for examining tongue movement is the electromagnetic articulography (EMA). This enables movements of the tongue to be followed using the principle of inductive distance measurements. A helmet made of acrylic material serves as a carrier for three transmitter coils. These are located in front of the forehead, in front of the chin, and at the back of the neck. Receiver coils are fixed to the tip of the tongue and at two points on the dorsum of the tongue. The distance between the receiver and the transmitter coils is calculated by means of a personal computer. The movement trajectories are displayed on a computer screen in x-y-coordinates. Tongue movements of one patient with an anterior open bite are shown during characteristic test sounds and during swallowing. The first examination took place without any orthodontic appliance. In a second series in the same session, tongue movement was recorded under the influence of an orthodontic appliance with spikes. While the patient shows vertical combined with sagittal components in the movement pattern of the tongue without an orthodontic appliance, the same patient, under the influence of an orthodontic appliance with spikes, shows a change of the rest and work position of the tongue and in the pattern of tongue movement with a more posterior position of the tongue, and with an increase in the vertical and a decrease in the sagittal components of the movement pattern.

Habits affecting dental and maxillofacial growth and development

In concluding this discussion, it is apparent that altered oral function or rest position may have a significant influence on the developing orofacial region. In the case of non-nutritive sucking habits, the child's commitment and desire to stop the habit is important to the successful elimination of the habit. At times, a hands-off approach is our best approach. Other habits are managed by addressing their cause. We, as dentists, have the ability to influence this process through the proper identification and management of these problems.

The Castillo-Morales approach to orofacial pathology in Down syndrome

Infants with Down syndrome often present with a familiar orofacial disorder which exists at birth or becomes more pronounced by the end of the first year. The primary pathology includes hypotonicity of the perioral muscles, lips, and masticatory muscles and a protruding tongue, later followed by active tongue protrusion. This results in problems with sucking, swallowing, drooling and dentition. Early intervention methods employing the combination of Castillo-Morales Manual Orofacial Therapy and his specially designed palatal plate, can improve orofacial function, facial appearance and prevent secondary conditions like pseudoprognathism, dental diseases, malocclusions, open mouth habit and pseudomacroglossia. This retrospective study examines the outcome of therapy, as prescribed by Castillo-Morales, in 39 children with Down syndrome. Normally, the average age to begin oral therapy is between six to eight months. The children were treated with the Castillo-Morales Manual Orofacial Therapy and his palatal plate for an average of 17.9 months. In this study, clinical evaluations at the beginning and the end of therapy focused only on open mouth posture and tongue protrusion. In addition, the direct stimulating effect of the palatal plate on tongue protrusion was evaluated. Significant positive results were observed in all three areas.

Treatment of a dental phobic with pronounced aversion to rubber gloves

This case illustrates where excessive dental stress on the swallowing reflex caused retching then nausea and eventually dental phobia. Swallowing relaxation enabled normal variable function to be quickly restored, which allowed the phobia to be brought under control.

Cephalometric evaluation of crib therapy for cases of mixed dentition (open bite)

The effect of crib therapy for the treatment of cases of open bite was investigated. Extrusion of the lower and upper incisors and intrusion of the lower first molars were the most significant effects of the appliance. Intrusion of the lower molars resulted in decreased lower facial height. These findings were considered to result from the posterior tongue posture. Thus, the clockwise pattern of the mandibular complex was changed to a counter-clockwise pattern.

Treatment of tongue thrust with hypnosis: two case histories

Tongue thrust is a relatively infrequent habit which can result in disruptive, permanent oral malocclusion, bone changes, and facial disharmony. The use of hypnotic phenomena can augment myofunctional therapy. Temperature control, glove anesthesia, relaxation, and imagery enhance demonstration of the proper way to swallow. The cornerstone of having the patient actually feel the contraction at the insertion of the masseter muscles provides an inner biofeedback which provides a very positive signal that the improper habit is being corrected. Hypnosis can then be used in the manner described to achieve a good clinical result.

Castillo-Morales' orofacial therapy: treatment of 67 children with Down syndrome

Infants with Down syndrome often present with a typical orofacial disorder, the features of which include hypotonicity of the perioral muscles, lips and chewing muscles, and a protruding tongue, later followed by active tongue protrusion, as well as problems with sucking, drooling, etc. This study presents the effects of Castillo-Morales' therapy with 67 Down syndrome children (average age at start of therapy 13.9 months), who wore the palatal plate intermittently for an average of 12.1 months. Significant positive results were obtained in spontaneous tongue position, upper and lower lip tonicity and position, mouth closure, drooling and sucking.

[Good results using maxillary tongue guard for Class III patients with comparatively shallow overbite]

A maxillary tongue guard was used in conjunction with a chin-cap for the treatment of shallow overbite. Correction of the overbite proved to be very rapid. Follow-up treatment also proceeded very smoothly. The tongue guard has been designed to cure the habit of tongue-thrusting, to prevent tongue retraction and lifting of the tongue posture, and to relieve the tongue pressure against the lower anterior teeth, so that the tongue pressure is communicated to the upper dentition and maxilla. The following results were observed. 1. Lower lip pressure caused lingual movement of the mandibular anterior teeth, while elimination of tongue pressure lengthened to mandibular anteriors. 2. Retraction of the tongue posture and hyoid bone resulted in the retraction of the mandible. 3. Communication of tongue pressure resulted in mesial movement of the maxillary dentition and stimulated the growth of the maxilla.

[Restoration of a caries damaged deciduous dentition using ready-made steel crowns and a child's tongue habit apparatus]

This report is on the care of a temporary denture with gaps in the front area of the upper jaw with fixed and removable artificial dentures (children's prosthesis), covering aspects of gnathoorthopaedic necessity (support zone, tongue habit), aesthetic and speech functions.