Replies to This Discussion

Permalink Reply by Rohan Wijey on May 25, 2010 at 12:50am

With these photos, Dr Raphael has put it more succinctly than I ever could with words.

Abnormal muscle function can be evaluated by analysing the way a pt swallows and postures his/her lips and tongue at rest. If you want to know more, visit myoresearch.com or lessbraces.com. Alternatively, come to one of our courses; I'm sure there's a lot more we can teach you.

Does fixed mechanotherapy give you more stable results? All serious orthodontists use permanent retention after braces because they know they cannot guarrantee any degree of stability - we don't use permanent retention because we help children correct the cause of their malocclusion and relapse: Muscle dysfunction.

Permalink Reply by Ravi Kumar on May 25, 2010 at 9:18am

gr8 discussion :-)

"Patient selection" is the key factor in this. Here is a good article with all the research quoted which refutes benefits of a two stage treatment.

http://www.oralhealthjournal.com/issues/story.aspx?aid=1000107603

"Unfortunately, today's trends are to treat earlier and often. The resulting array of techniques runs the gamut from the refuted (arch development for mixed dentition) to the patentedly ridiculous (braces for baby teeth). Can in utero treatment be far off? Most disturbing is that this trend is occurring without support in the referred literature."

I am of the same opinion as Dr.Randy Lang in the article (read at the end of the article). So I will always offer my patients a two stage treatment (gr8 practice builder) with the caveat that they may have to got for a Phase II treatment later. Isn't this a win-win situation for both patient and me?

Permalink Reply by Barry Raphael on May 25, 2010 at 12:29pm

Speaking of in utero treatment, when DOES a malocclusion begin to form? And why? Most of us who are "tooth-centric" (I'll explain...) believe that the malocclusion forms when the teeth come in crooked. But I would like to suggest that the seeds of the malocclusion have already been planted BEFORE the teeth come in. For instance, when the apical base is large enough, wide enough, deep enough, etc, then the teeth CAN come in straight - a feat that DOES happen in real life. And when it is not large enough the chance of proper eruption is diminished, obviously. Teeth fit in where they can. (Like four people in the back seat of your car. We could argue about whether the car is too small or the people too wide, but what's the point? If you know you're going to take that many people, bring the van.....)

So why do jaws form inadequatly for the job they have to do? Heredity? Perhaps, but only heredity? Doesn't the principal of the Functional Matrix suggest we look at all the forces that surround the bones as they grow? Forces from eating, breathing, posture, swallowing, etc. And when do those forces begin to affect the growth of the jaws? When the teeth come in? I don't think so. Certainly, the forces that surround the bones begin when the bones begin to grow! If that is in utero, so be it!

I'm not suggesting in utero orthodontics, but I am suggesting we begin to pay attention to the true etiology of malocclusion - the formation of the skeletal bases - and all the factors involved. These include but are not limited to: heredity, in utero nutrition, the birthing experirence, early nursing methods, early chewing patterns, early and transitional swallowing patterns, soft tissue development such as frena, general nutrition, body posture, breathing habits and deficits (asthma, allergies, swollen tonsils, nasal obstruction, etc), and all manner of "Soft Tissue Dysfunctions" stemming from these influences.

When we go from being "dental-centric" to "etiology-centric" or "development-centric" we will, I believe, begin to see a bigger picture and have a much clearer vision of what to do. This shift in paradigm will make the 1-phase/2-phase, the extraction/non-extraction, and the Angle Class arguments moot.

The discussion of the MRC system is just the beginning of our awakening to this broader issue (though many have been trying to wake us up for over a hundred years....), and it asks the question: is it better to prevent a health problem or let it take full bloom before treating it? Ask yourself this question about the pictures I displayed earlier: would you rather have your child entering adolescence with the arch form on the left or the arch form on the right. Your answer will guide your discovery...

Permalink Reply by tarik aouad on May 26, 2010 at 4:33am

hello my colleagues
as myobrace is a new method of orthodontic treatement easier than braces , we should we need to help MRC in it's workand not discourage
remember when the implants have emerged that ended the discussion to eliminate the pretext that they cause cancer
implants are now widely used worldwide
i wish the same thing for the MYOBRACE it remplaces the messy bulky braces
with best regards

Permalink Reply by Ravi Kumar on May 26, 2010 at 4:36am

"Doesn't the principal of the Functional Matrix suggest we look at all the forces that surround the bones as they grow?"

The functional matrix concept, as a generalized picture, is established and valid. But it describes what happens during growth, not how the growth control mechanism actually functions. The term functional can be misleading since the forces of (1) function and (2) growth itself are equally basic, and both must be taken fully into account; either without the other is incomplete. The latest theories of craniofacial growth points towards a multifactorial effect rather than a single theory for facial growth and development. The functional matrix theory therefore suggest only one of several mechanisms that may have an effect on facial growth and development. It is a fact that all cases of nasal obstruction / "adenoid" etc does not lead to malocclusion. To base our treatment (MRC system) on just one aspect of facial growth and development will not be correct till we have a more definitive theory on the issue.

I found this interesting article which points towards the importance of brain growth effecting the facial skeleton. This study also point towards brain growth leading to increase in the functional spaces and is dismissive of tongue muscle force in developing malocclusion.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2703201/

"Although each of the models has added to our attempt at understanding CFG, none of the CFG models seem to directly neither address nor provide a model for the differing patterns of maxillomandibular rotation in hypo- and hyperdivergent individuals as described by Bjork"

I had also come across an article about the development of a novel transgenic mouse model of fetal encephalization and craniofacial development, where increased brain size lead to changes in the facial skeleton.

So until we have a more definitive concept of CFG, we can offer the insistent patient some kind of myofunctional appliance therapy with the caveat that they may have to go for fixed appliance therapy at a later stage.

Permalink Reply by Barry Raphael on May 26, 2010 at 9:22am

I agree with Ravi that CFG is multifactorial and there is much we don't know. I admit that the model MRC proposes seems oversimplified, as if the tongue rules all. But our traditional approach to ortho has been oversimplified in the other direction, at least by the practicing orthodontist - blaming heredity for all and looking for the simplest mechanical remedy.

Biology is never black and white across a population, and the practitioner has an even harder time placeing an individual along even an "evidence-based" continuum. Yet we spend the decades arguing about the same old dilemmas (See 2010 New-Conn seminar this year : "Extraction vs Arch development" where proponents from each side extract in exactly the same percentage of cases and ALL complain about long term stability) . I am proposing that MRC and their progenitors have a point that should not be overlooked: the teeth come in the way they do for a reason. And to the extent we can determine the reason, intercept its influence, and lessen its effect, we have a OBLIGATION as health practitioners to do so.

I believe its time to open our eyes to a new way of thinking.

Permalink Reply by Rohan Wijey on May 26, 2010 at 7:09pm

Very interesting debate!

Answering the question of the etiology of malocclusion is the holy grail for the orthodontic community. To state a truism, revelation of the causes will lead to the revelation of the best treatment modality.

Genetic vs Environmental?

If malocclusion is genetically inherited, Mendelian laws would suggest that it has gone from being rare to common. John Mew in his Biobloc book cites the example of sickle-cell anaemia, which provides near immunity to malaria and is thus prevalent in certain populations where this is an asset for survival.

When one observes the distribution of malocclusion, every type is seen in every geographical area with no sign of progressive spread; if inherited, this pattern defies Darwinian and Mendelian theories. Furthermore, what advantage has malocclusion provided for survival?

We know from studies of Begg in the 1950s and many others that a massive increase in malocclusion has coincided with the introduction of softer diets. It has literally occurred in one generation. Mew suggests that a major evolutionary change such as this would normally require thousands, maybe millions, of years, not one generation.

Permalink Reply by tarik aouad on January 17, 2011 at 7:01am

HELLO again

I have used myobrace for more than 6 patients but i think it doesn't give significative results

 

Permalink Reply by Barry Raphael on January 17, 2011 at 12:51pm

Tell me more, Tarik.  Did you have cooperation issues?  Did you pay attention to the muscular issues of each case?  Let's talk some details.

tarik aouad said:

HELLO again

I have used myobrace for more than 6 patients but i think it doesn't give significative results

 

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