And so I did it!


Eh, something, for me, truly ‘revolutionary’. Something I always say and show at every course, at every seminar, summit, webinar, something that I had already said a few times at university, for example at the lecture to the Insubria postgraduates, but this time it was different, this time there was the officiality, the honour and the burden of sharing the stage with illustrious colleagues such as Professor Vincenzo Quinzi and Dr. Dina Buonocore. There was the invitation from Professor Vincenzo D’Antò and Professor Ambra Michelotti to give a lecture at the 2nd level Master’s Degree Course in ‘New Clinical Approaches in Contemporary Orthodontics’, University of Naples ‘Federico II’, School of Specialisation in Orthodontics.

In short, the preconditions to be a bit excited were all there, because I knew that, in this almost sacred context, I would be questioning more than a century of the School of Orthodontics from the very first slides.

The topic was interceptive orthodontics, and it is always very fascinating how, from 3 speakers, 3 completely different approaches were proposed. Professor Quinzi talked a lot about structure and palatal expansion with the rapid expander and other devices, with a very well-documented approach endorsed by the scientific literature. Dr Buonocore, on the other hand, addressed the topic using a protocol involving the use of clear aligners. I can only offer my sincere compliments to both of them for their academic work and the beauty of the cases they showed.

I was assigned ‘Myofunctional rehabilitation with elastodontic devices’.

To explain to learners how myofunctional therapy (MFT) can be the true driver of orthodontic treatment (which is exactly the principle behind myofunctional orthodontics as it was theorised by its founding father Alfred Paul Rogers more than 100 years ago), we need to start with the role of Epigenetics in craniofacial growth and development, which I have already discussed in this article.

Therefore, having established that in order to promote structural changes one has to go and implement a strategy that addresses the functional and muscular problems that led to the anomalies in the development of the jaws, I was able to state in one of the slides that I showed to the learners that the diagnosis of malocclusion begins with the investigation of OFMI, the “Oro Facial Muscular Imbalances”.

Now, to say that the diagnosis starts from here, and not from the structure analysis, is a paradigm shift. If structure abnormalities are determined by myofunctional imbalances, and are therefore the effect and not the cause of the malocclusion, then what is the point of setting the treatment plan from the cephalometric tracing or waiting for the growth peak?

Yet almost all Italian orthodontists approach their treatments in this way.

Not that I am against structure analysis, not at all. In the meantime, even the structure at some point prevents the function from expressing itself, so Planas-type elevations to reposition the mandible or expansion to the upper jaw are welcome, but even before that I would be concerned with eliminating the underlying causes of an obstruction of the upper airway or lingual or labial frenula that are too short.

But where is the sense in doing a structure survey at point 0 of an interceptive orthodontic treatment in a growing patient without first treating the OMFI?

If it could, it would make sense to do it on his genotype, not his phenotype, but this for obvious reasons is not possible (at least for the time being, but ‘Gattaca’ scenarios are not that far off). If the patient has unexpressed potential for growth and development due to the interactions he has with himself and his environment, isn’t it better to first worry about putting him in the best possible condition to express his true nature? This alone would eliminate most malocclusions (not to mention the positive repercussions on general health).

If that growth potential then denotes a serious structural abnormality that is independent of OMFIs, before surrendering to surgery we can always implement an orthodontic-myofunctional strategy with myofunctional therapy amplified by preformed devices that guides, almost ‘forces’ growth towards the phenotype we want to achieve, because ‘Where there is a struggle between muscles and bones, bones always get the worst’ Thomas M. Graber (1917 -2007).

The earlier you embark on this path with your patient, the more likely you are to succeed (other than waiting for the growth spurt).

And here is the body of the crime, the offending slide 😀

Of course, it would then need to be assessed whether the problem (often more than one) causing the onset of OMFI has a descending and/or ascending origin, i.e. whether it is factors beyond the middle and lower third of the face that have led to the onset of an orofacial imbalance (e.g. a structural abnormality such as a spinal stenosis, or leg heterometry), or whether OMFI is the cause of problems that go beyond the orofacial district such as those related to vision and posture.

Perhaps it is better not to completely uncover Pandora’s Box (however, a little humble advice on tiptoe, try to look beyond the teeth and jaws when diagnosing).

Again, a huge thank you for the invitation I received, and which I hope I was able to honour, to the School of Specialisation in Orthodontics, University of Naples ‘Federico II’, in particular to Professor Ambra Michelotti and Professor Vincenzo D’Antò, to the Master’s students and to the city of Naples.

I would also like to take this opportunity to thank Dr. Marco Gaia, lecturer and tutor at Professor Luca Giannelli’s School of Clinical Neuro-Visio-Postural Studies, with whom, years ago, I had the pleasure of delving into the neurophysiological relationships and the impact of the stomatognathic apparatus on the visual and postural system. A school that gave me so much in terms of training and that I always mention with pride in that slide.

I close with a quote that the osteopaths I work with always like: the jaw is the first cervical vertebra.