Manifesto

While sifting through my documents, I came across an interesting article that I had written in 2020. Upon rereading it today, I felt the urge to publish it. It represents the manifesto of my vision of the orthodontic profession, and although almost three years have passed since I wrote it, it is still relevant and, in its conclusion, even visionary (but not too much, given the latest technological developments).

To all those who wish to engage with it, with the hope of finding it interesting, happy reading!

Notes on Aesthetic Myofunctional Orthodontics “from 3 to 99 years old” (i.e., my point of view on orthodontics in 2020, with a simplified lexicon, addressed to colleagues and professionals, but also to curious and intuitive patients).

Introduction (simplified):

• Dentistry is a medical specialty that deals with the health of teeth and the middle and lower third of the face (the part between the chin and nose).
• Orthodontics is a branch of dentistry that deals with straightening crooked teeth.

From the moment I started practicing dentistry, I knew I would dedicate a lot of passion and resources to orthodontics, while never losing sight of general dentistry, which I enjoy exploring in every aspect.

I try to be a “generic” dentist, never losing sight of the overall view of the stomatognathic system and how it influences the rest of the body. One only needs to think about how improper development of the jaw can cause breathing problems in young or adult patients or the intimate relationship that can exist between Vision, Posture, and Temporomandibular Disorders.

The concept of “contamination” between the various branches of dentistry and between these and general medicine reaches its fullest expression in the discipline that goes by the name of orthodontics, a term that I find somewhat limiting given our current knowledge of the subject, but that I will continue to use for convenience.

For me, malocclusion should never be approached solely from an orthodontic point of view, even if patients, young or old, come to us professionals because they want straight teeth. If I were to approach resolving a malocclusion solely from a traditional orthodontic perspective, I would study the case based on the patient’s dental-skeletal situation, study the models and the cephalometric tracing, and finally determine which, how many fixed and/or mobile devices, how much stripping, how many extractions, and for how long the patient should undergo treatment to achieve the desired result. Unfortunately, this approach refers to protocols that worked well until the late 1990s. Until then, all attention was focused on the teeth, at most the jaws, with little or no consideration of the causes that may have determined the malocclusion. Many colleagues still accept this type of approach, even waiting for young patients to complete their development before doing anything, attributing most orthodontic problems to the patient’s genetic makeup.

Today we know that this statement, which was once almost always considered valid, has now been greatly diminished. Almost all malocclusions have a dysfunctional origin, and we have an obligation to correct the function, at the neuromuscular level, to achieve the best possible result, even before thinking about the teeth. To do this, we must always approach the case in a multidisciplinary way, first of all, looking for the causes, especially those related to dysfunction, that may have determined the malocclusion. To be able to correctly interpret each individual malocclusion and therefore establish the best path for complete rehabilitation, taking note of all the variables that are inherent in each individual patient, a myofunctional bioprogressive orthodontic treatise would be necessary, and certainly this is not what I want to illustrate here in these notes.

Given that the principle that each case is unique remains valid, I will have to simplify a little, dividing patients into at least two main categories: patients in the growth phase and adult patients (at least from a dento-skeletal point of view).”

Growing patients and orthopedic treatment

By growing patients, I mean all children who come to my attention and who still have unrealized growth potential that I can orthopedically condition to solve malocclusion, so hypothetically from 3 to about 12-14 years old.

Except for some exceptions, the age at which I prefer to approach orthodontic treatment in these cases is around 5-6 years in the most severe cases, where there is a significant orthopedic problem of transverse and sagittal hypodevelopment of the upper jaw, and 8 years for all others. Obviously, this is possible if the patient is intercepted on time, otherwise, treatment begins when it can. In fact, the right thing to do would be to start the treatment as soon as the presence of an OMD, or Orofacial Myofunctional Disorder, is intercepted, regardless of the patient’s age. However, for obvious reasons, managing the patient is a bit easier in some age groups than in others.

In growing patients, the main part of the treatment is provided by the new generation of preformed myofunctional orthodontic devices. The protocols for using these devices are primarily aimed at treating respiratory dysfunction and muscles, particularly the tongue. The devices also contain information that is interpreted by tissues during growth, going to stimulate deficient areas, and are symmetrical, tending to correct asymmetries and re-center the chewing.

My main concern in this phase towards the patient is to transform the patient from dysfunctional to functional (this is a completely different concept from conventional orthodontics, which pursues different objectives). Early correction of myofunctional habits, in a growing patient, leads to better craniofacial development, resulting in adequate space for erupting teeth and also facilitates correct alignment of teeth in their natural position. Moreover, improvements in the patient’s upper airways are obtained, with great benefit to their overall health.

Achieving these results does not happen simply by asking the patient to wear the device for an hour a day with closed lips and all night, but through a path of exercises, an integral part of therapy, that the patient will have to practice correctly month after month to reprogram that necessary neuromuscular balance to obtain a result that remains as stable as possible over time, minimizing or eliminating the use of retainers. Myofunctional Therapy is so fundamental that it could be enough to correct malocclusion alone (as stated by the father of myofunctional orthodontics, Dr. Alfred Paul Rogers), and preformed devices can be considered as tools to enhance and increase the predictability of the result. A real paradigm shift.

The myofunctional treatment can sometimes be integrated with any other surgical technique, device or fixed appliance that is deemed useful to achieve the best possible result, but always in combination with myofunctional treatment. By surgical technique, we mean, for example, labial or lingual frenectomies (which I like to perform with LASER) if we are dealing with short frenula that prevent proper development of the stomatognathic apparatus (such as the correct posture of the tongue at rest on the palate) or adenoidectomy, which is the responsibility of the otolaryngologist, linked to the presence of inflamed and/or hypertrophic adenoids that prevent proper breathing. The same goes for tonsils. By devices or artifacts, I mean tooth lifts or selective grinding (i.e., raising and/or filing down some elements to eliminate interference in occlusion), or palatal expansion arches. The latter are used when the transverse diameter of the palate is “too narrow” and can be without a palate, such as the BWS (Bent Wire System), to be used in combination with the myofunctional appliance, or in more severe cases, where the transverse diameters of the palate are critical, and because of lack of space, the myofunctional appliance cannot be used, I still resort to the RPE (Rapid Palatal Expander), an orthopedic appliance that acts on the palatal suture to widen the palate and the airways above it, for a period of 6/8 months, before moving on to myofunctional treatment. I must say that I rarely use it anymore.

Apart from these techniques, which are known to any orthodontist, I also use other specific tools to work directly on the patient’s muscles, such as Local Vibration Therapy.

Most of the treatment is not carried out in the dentist’s chair, which for obvious reasons does not put the child at ease, but in dedicated rooms, with tablets or screens on the walls to watch the exercises, large mirrors to repeat them, both alone with the myofunctional educator (who can be a speech therapist, someone from their own staff, or both) and in small groups. Fun and colorful rooms, child-friendly. During the treatment, a series of tools are provided to keep track of timing, measurements, and scores of the progress made and to explain, in a simple way, what is being corrected at that moment and why it is important for the child’s health. Self-motivation to treatment is the key to success, and it is important to involve parents in this process as well.

In a growing child, a period of 2 years (3 years in more complex cases) is necessary to achieve a result that satisfies my expectations if the treatment is carried out with the right collaboration from the patient. This is enough time to put the potential for growth on the right track and correct functions in a stable manner. Afterwards, the patient is left to grow while being observed a couple of times a year, perhaps coinciding with bi-annual dental cleanings. If you are wondering whether in the future, once the patient has grown and completed the dental transposition, simply having undergone a myofunctional orthodontic treatment will eliminate the need for further orthodontic care, the answer is that it cannot be determined in advance until the patient has completed their development. What I can say with reasonable certainty, however, is that if orthodontic intervention is still needed in adulthood, we will certainly be dealing with a much less dramatic situation than if we had decided to do nothing and wait for the patient to finish their development, not only from a dental standpoint, but also skeletal, functional, and therefore overall health. All children can survive with poorly developed jaws, atypical swallowing, or predominantly breathing through their mouth, but we have a moral duty to correct these pathologies before they can cause greater damage, or at least we must inform and sensitize parents about them.

Breathing through the mouth is PATHOLOGICAL and, in more severe cases, can lead to neurocognitive developmental deficits!

Adult patient

For adult patients (approximately from 13-15 years old and up, depending on gender), the term refers to a patient whose growth potential can no longer be significantly influenced and whose bone structure is therefore already defined. It is possible to change the position of the maxilla in space, to some extent also the shape of the maxilla, and certainly the position of the various teeth, compatibly with the presence of bone. As with growing patients, although in a more simplified way, I have decided to systematically integrate myofunctional treatment with orthodontic treatment in adult patients, to try to re-educate the neuromuscular function and balance of the mouth, even though I am aware that at the end of treatment we will hardly be able to avoid a retainer, which will be more effective in a mouth where we have also acted to improve the neuromuscular balance. This is also to prevent or improve, if already present, problems with the temporomandibular joints. As with children, my first concern with adults is to transform them from dysfunctional to functional, or at least try to. Regarding cases related to adult patients, I will not describe those purely orthodontic treatments where the problem is only aesthetic, related to derotations or small dental misalignments to be corrected, nor the more severe cases, so-called “surgical” cases, which are fortunately few, and must necessarily be treated by a maxillofacial surgeon.

I want to talk about those adult patients who have had improper development of the maxilla, with skeletal and dysfunctional problems, more or less serious, within the competence of the orthodontist-orthognathodontist. Patients with uncorrected orofacial myofunctional imbalances during growth, which have led to improper development of the maxilla, and therefore incorrect positioning of the teeth.

At the first appointment, while getting to know the patient, I try to understand what developmental and/or dysfunctional problem may have caused improper development of the maxilla, and whether there is a genetic or familial component to consider. At this stage, I mainly observe and ask some targeted questions, but I already have enough information to talk about therapy. To propose a complete and as precise treatment plan as possible, it is necessary to complete the visit with the so-called “Case Study”, i.e., the collection of data such as photos, impressions (from which study models will be derived), and radiographs (optical and tele).

• Photo: They represent a document that shows the initial state of the patient’s mouth, both for the shape of the jaws and for that of the teeth. Orthodontics moves teeth but does not change their shapes. If there are elements that, once repositioned, will show the patient defects, perhaps signs of wear related to an incorrect occlusion that were less noticeable when they were “crooked,” it is better to be clear from the start and have something that documents the “before.” The photos are to be repeated throughout the duration of the treatment at every appointment or almost, also to have a historical record of progress.
• Study models: They establish the current status before starting treatment. By observing the shape of the arches, it is evaluated how they will need to change during treatment. Vertical, horizontal, and transverse problems are analyzed. It is evaluated whether, by eliminating functional blocks, there can be a repositioning of the jaws and to what extent. The best strategy is established to restore the correct vertical dimension, already trying to understand in this phase if it makes sense to do everything orthodontically alone (it will depend on how much the teeth have to travel), or if it is worth using artifacts such as definitive esthetic composite lifts (such as occlusal facets) to correct vertical problems first and better (with less risk of relapse). It is tried to understand with which devices to restore the correct transverse dimension and arch form, whether NiTi (nickel-titanium) arches will suffice, or whether we will need to use slightly more energetic systems with SS (steel) arches in combination with myofunctional or mixed systems.
• X-rays: Panoramic and cephalometric. The former makes sense; it serves to exclude surprises and is a general evaluation element that must always be carefully observed. The latter is needed because the cephalometric tracing must be performed, important from a medico-legal point of view (but does not add anything clinically, it is an old and outdated examination, in all its declinations). A more interesting examination in this regard could be low-dose CBCT, useful but not essential unless previous examinations reveal critical issues that merit a more in-depth investigation in the three dimensions of space.
• Myofunctional evaluation: A questionnaire about sleep disorders, a check on how the patient breathes, tongue posture, swallowing, and lip competency. Simple tests are performed, and the results are recorded.

Once the strategy is established and the therapeutic plan described to the patient, the first thing we will do is try to release the occlusion and eliminate all functional blocks, starting with those related to occlusion. The repositioning of the jaws, linked to the use of the preformed device, will determine the new occlusal plane of reference for the patient, thanks to the myofunctional therapy that we will integrate into the treatment. Meanwhile, arches and brackets will work together to modify the arch forms and, of course, correctly reposition the dental elements.

The aesthetics of the treatment

Many years ago, certainly more than 10, I abandoned any type of “visible” orthodontics, i.e. treatments with “braces” that are visible on the teeth, in favor of lingual orthodontics, which uses brackets behind the teeth and is the only true invisible orthodontics. This is true for 100% of my cases, from children to adults of any age. In an era marked by the explosion of transparent aligners, curiosity prompted me to try these techniques as well. But the problems I encountered with aligners due to the high use of laboratories that inevitably inflate the cost of treatment and constantly bind us to a third party, the difficulty of instantly changing something during treatment, the poor efficiency of the system that moves the teeth spasmodically, the high level of patient cooperation necessary for the success of the case, and the concept of aesthetic treatment that is not really aesthetic (between attachments and aligners that get dirty as soon as you drink coffee), have always made me return to the main path, that of lingual orthodontics.

I am proud to have had great mentors like my father, who learned lingual techniques inspired by Professor Aldo Macchi, and Professor Franco Bruno, who taught me bio-progressive orthodontic techniques (Zero Base philosophy) and introduced me to the first pre-formed devices used with fixed appliances. Indirectly, I owe my Myofunctional clinical approach to Professor Chris Farrell. I have always used self-ligating brackets such as 2D Lingual with pre-formed NiTi arches or NiTi coils with or without offsets (the so-called mushroom arch, which I use actively when closing spaces), or even with ultra-low friction straight wire technique, using brackets up to the canines and using PET tubes, previously sterilized and bonded with composite, on the occlusal surfaces of premolars and molars, which are excellent when we also need to increase the vertical dimension. Each case is approached in combination with one or more pre-formed devices to be worn for 1 hour per day with closed lips and during the night, and which make the patient perform specific exercises to breathe through the nose, place the tongue on the palate, and recover lip competence. In lingual fixed mechanics, if more force is needed, I can alternate NiTi arches of various diameters with Stainless Steel (SS) arches, or use a mixed technique, namely lingual brackets with NiTi arches in combination with bands on molars into which the Bent Wire System is inserted. Bonding (the term used to describe the process of attaching brackets to teeth) is always done with direct bonding technique, therefore no laboratory cost, and fixed lingual orthodontic technique always works in combination with myofunctional therapy, which, ideally, should be accepted by the patient throughout the entire treatment, regardless of their age. In a well-planned case, the patient is seen at intervals ranging from 4 to 8 weeks, but this varies greatly from case to case. I have also tried so-called “bracketless” techniques, using only the arch bonded with composite, which work well for small realignments, but not for more complex cases and require the intervention of the professional many more times. Instead, for me, cases must “travel alone”. Going even further into the technical aspects, since 2D brackets do not control root torque, once the orthodontic movement of the tooth begins, the use of myofunctional therapy with pre-formed silicone devices in combination with orthodontics itself corrects part of the torque. If it is not sufficient, a NiTi septional can be applied under the main arch to create a moment (couple of forces) on the group of elements that we want to perfect “radically”. In my experience, I have been able to do without 3D brackets, which I used for a period (Incognito/Win period), avoiding the need to manage square-section arches and slots, which can generate unwanted root movements, and using self-ligating brackets, which are simple, thin, inexpensive, standardized, and comfortable for the patient.

Let me introduce myself.

I am Dr. Vincenzo Giorgino, as I have already written, I like to consider myself a “all-around” dentist. I cannot deny that there are areas of my work that I am more passionate about than others, such as orthodontics, which I see as linked to craniofacial development, patient function, and, above all, invisibility, or at least highly aesthetic.

I dream of a future for our profession where artificial intelligence, combining medical history, personal data, photos and videos of a patient, and three-dimensional instrumental exams, can provide a highly predictable myofunctional orthodontic treatment plan, accompanying the patient during every phase of treatment, thanks to the tools that technology offers us today or in the future. The treatment will be readjusted based on the results and the level of compliance achieved, leaving the specialist to supervise and intervene only in selected cases.

For example, a situation where the specialist collects all the data in the first visit, diagnoses the correct clinical picture and inserts all the records onto a portal. The patient follows the treatment through an application (which of course refers to those data) for a mobile phone or tablet, which can measure progress from time to time, control the correct performance of exercises, analyze photos and videos that the patient takes whenever the artificial intelligence requires it, and propose the transition from one preformatted device to another depending on which orofacial myofunctional imbalances have been corrected and which have not, to achieve the best possible result in terms of orthodontics, orthopedics, and correction of functions and muscles that were at the basis of the malocclusion, so that the achieved result can be stable over time.

It is the specialist’s and their team’s task to monitor and control that the patient correctly performs the treatment, through the portal, which will send alerts when necessary to draw the attention of the patient, parents, and the specialist and to carry out routine checks.

Considering the technological advances that have been made in the field of medicine in recent years and, in particular, the ability of artificial intelligence to analyze and interpret data, this does not seem like such a utopian scenario.

Dr. Vincenzo Giorgino

Varese, 28/05/2020