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V International Congress IFUNA 14 -16 August 2011 (Hiraizumi, Japan)



Official Journal of International Functional Association - IFUNA - www.ifuna.info Volume 1, Issue 1 2010


Michael Gorbonos Editor in Chief President of IFUNA

Dr. William J. Clark - Scotland Editor Developed the Twin Block Technique and Trans Force Lingual Appliances Scotland

Prof. Franco Magni -ITALY President of International Editorial Board Adjunct Professor of Orthodontics, University of Parma, Italy Past President of EOS (European Orthodontic Society) and SIDO (Italian Society of Orthodontics).

Prof. Leonid S. Persin - Russia Editor President of Russian Association of Orthodontics. Professor and Chair Department of Orthodontics, State University of Medicine Dentistry, Moscow Russian Republic

Prof. Bakr Rabie - Hong Kong Assistant to Editor in Chief Professor in Orthodontics Faculty of Dentistry The University of Hong Kong Hong Kong

Prof. Brian Preston - USA Editor Professor and Chair of Department of Orthodontics, University of Buffalo, USA

Prof. Jose Duran von Arx - Spain Scientific Editor Professor and Chair Department of Orthodontics, University of Barcelona, Spain

Mark Levine - Canada Editor and Language Adviser Craniosacral Therapist, Private Practice, Toronto, Canada

Prof. Wilma A. Simoes - Brazil Editor Professor and Director of Research Department of Functional Orthopedics at UNICSUL University, Brazil

Prof. Toshio Kubodera - MĂŠxico Editor Professor and Chair Department of Orthodontic University of UAEM, Toluca, Mexico

Dr. Catalina Canalda - Spain Editor Specialist in Orthodontics and Cranio Mandibular Difsunctions Neuro Occlusal Rehabilitation by methodology of Prof. Pedro Planas Private Practice. Barcelona, Spain

Dr. Michel Champagne- Canada Editor Editor of International Journal of Orthodontics, Quebec, Canada

Dr. Mario Pistoni -Argentina Editor President of Argentinian Association of Functional Jaw Orthopedics, Buenos Aires, Argentina

Prof. Ritsuki Ito - Japan Editor Visiting Professor at the University of Mexico, UAEM,Toluca, Mexico. Private Practice, Japan

Dr. Carlos de Salvador Planas Spain Editor Doctor in Medicine and Surgery President od Spanish Association of Pedro Planas (SAPP) Private Practice, Barcelona, Spain

Prof. Pietro Bracco - Italy Editor Professor and Chair Department of Orhtodontics University of Turin, Italy

Angela Caine - England Editor Director Voice and Body Center, England

Roger Price- Australia Editor Consultant Respiratory Physiologist -Australia

Prof. Rebeca Fernandez - Cuba Editor Professor of Orthodontics, University of Havana, Cuba

Prof. Herbert Orrego - Peru Editor Professor of Orthodontics, University of Lima, Peru

Prof. Barbara Bimler - Germany Editor Permanent Visiting Professor, University of Havana Medical School, Cuba Director of Bimler Laboratories Germany

Dr. Marie-Josephe Deshayes France Editor Club Telecrane International, Caen, France

Prof. Florica Glavan - Romania Editor Professor and Chair Department of Pedodontics and Orthodontics, Medical and Farmaceutic University Victor Babesh Timishoara, Romania

Contents Page No.

Editorial Introduction Contemporary Orthodontic Considerations The Potential of Functional Treatment Myth and Reality Education, Preservation, Documentation of Functional Treatments Beyond Occlusion: Craniosacral Therapy and Functional Orthodontics Why Early Functional Treatment of Tooth Rotation? Add the Voice to your Functional Treatment Plan Association between neurobehavioural status and motor disorders in children with malocclusion Book Reviews Advertisers

04 05 07 10 17 19 22 30 39 45 46 47 48 49

Ifuna magazine Ifuna magazine Franco Magni Jose Duran von Arx A .B. Bimler Mark L. Levine

Wilma Alexandre Simöes Angela Caine L.S. Persin Arno Geis Yasunaga Laboratory Myofunctional Research Co. Appliance Therapy Group ASO International, Inc.

All statements of opinion and of supposed fact are published on the authority of the writer under whose name they appear and are not to be regarded as views of the Ifuna. All rights reserved. ISSN: 2173-0172 Request for index Publisher: Ifuna View E-mail: infuor@hotmail.com Visit the Ifuna online at www.ifuna.info As a president of the IFUNA I thank all the sponsors of our Scientific Association for several reasons: They help us in carrying out the research program that is so important for us all, they allow the Ifuna to publish the Electronic journal that is sent to more than 40.000 professional in the field and they are very special sponsors because they work with us as a great team in order to design and fabricate newer and better functional appliances for the total benefit of our patient. Thank you Dear Sponsors and welcome to work with us. The president of IFUNA: Dr. Michael Gorbonos.

Ronda del Caballero de la Mancha, 135 - 28034 - Madrid, España. Tel.: (+0034) 913 721 377. Fax: (+0034) 913 720 391 - ripano@ripano.es - www.ripano.eu - www.ripano.es Director y Editor: Rafael López Gómez. Dirección Adjunta y Diseño: Francisco Soriano López. Departamento Administrativo: Karina Dávila Merizalde


Editorial On behalf of the International Functional Association, IFUNA , it is my great pleasure to welcome you to the first issue of the IFUNA Electronic Journal, published by Medical Editorial Ripano, Spain. The Journal is in English and is distributed electronically, at no charge, to more than 40,000 practitioners world wide, including orthodontic associations, universities, orthodontists, dentists, orthodontic laboratories, medical doctors, chiropractors, therapists and many others. IFUNA has been created in response to the demand and interest of a growing segment of our profession to build an international platform for the documentation, preservation and education of Functional Treatments - starting to treat at early age and treating the whole body. A new earlier orthodontic protocol and standard is warranted. We want to introduce a new concept for earlier orthodontic and orthopedic diagnosis and treatment from birth to age seven. Increasing the size of jaws and airway during early growth and development may reduce human disease. Early jaw treatment is relatively nonexistent for most children under six years of age today because early diagnosis is relatively nonexistent. The current orthodontic speciality protocol that recommends an orthodontic screening by age of 7 by the American Orthodontic Association confirms the early jaw diagnosis gap and the indisputable need for earlier diagnostic training. “These new concepts may very well help orthodontists, paedodontists and dentists to move dental care into a future world of medical dentistry which includes the ability to work with such diverse concerns as airway development, bed wetting, ear disease, heart disease and longevity�. Today IFUNA is engaged in Education, Publication and in International Research Projects to help work towards this goal. IFUNA is a non-profit organization and I personally invite you to become an IFUNA member. The membership for 2010 is free. You can register on www.ifuna.info I would like to thank: Charles Lellouche, Raaya Kisilevich, Editors, Ripano, Sponsors and all the Ifuna friends for helping in producing this issue. The new IFUNA JOURNAL will appear just on the birthday of Bimler Prof hon. Cau. Dr. med H.P., 10 december. This happy coincidence will hopefully bring good luck and sucess to the objetives of the International Association of Functionalism, to educate the public to the values of functional orthodontics to the world. Michael Gorbonos President of IFUNA -4-


Introduction THE FIRST ISSUE OF THE IFUNA ELECTRONIC JOURNAL The IFUNA, International Functional Association, was founded about three years ago in Paris with the following aims: to be a reference network for everybody interested in functional treatment; to organize a public data bank with results of the approaches that involve the whole body; to promote an interchange of ideas, opinions, experiences, with solid information provided by news, books, courses, new products release, scientific research results and international meetings world-wide. The international congresses have already been held: Paris (France) 8-9 November 2007; Barcelona (Spain) 30th October-1 November 2008; Turin (Italy) in 1-4 October 2009 and Barcelona (Spain) 13-16 October 2010, these provided a progressive sequence of successful meetings and now the first issue of the Ifuna Electronic Journal. The Ifuna Electronic Journal is intended to be a world-wide reference platform for Functional Therapy and related subjects, and is therefore open to anyone around the world. You are invited to send to the editor your articles, ideas, experiences, suggestions, new products information, etc., related to the subject. Your material will be carefully evaluated and when interesting, published immediately. In the field of orthodontics functional therapy is concerned with the production of beautiful smiles, in beautifully functioning bodies, in postural equilibrium: something that goes far beyond the simple alignment of the teeth only: an holistic approach. A chance not to be missed during the important phase of growth and development. I am honored to be charged with introducing to you the inaugural issue of Ifuna Electronic journal and to personally thank, on behalf of us all, the dear colleagues who worked so hard to make this dream came true: the chief Editor, the Co-Editors and the all other intercontinental Editors. After all the IFUNA is a non profit, no boundary, super-national scientific association. Franco Magni



Contemporary Orthodontic Considerations

Prof. Franco Magni Department of Orthodontics, University of Parma, Italy It is rather obvious that any malocclusion represents the best and most stable equilibrium (or compromise) found by nature to warrant the best possible function to preserve periodontal health, temporo-mandibular joint health, soft tissue and postural health in a specific subject presenting dentoalveolar, skeletal and soft tissue anomalies, etc. The etiology is not the malocclusion: on the contrary, the etiological factors are causing the malocclusion. Trying to correct the malocclusion without the elimination of the etiological factors is like trying to train the person who limps, because of a shorter leg, not to limp anymore. Without first lengthening the shorter leg which causes the limping, this will be an impossible task. No wonder that the vast majority of the corrected difficult malocclusions will relapse eventually. The correction of the malocclusion does not lead by itself to a stable result unless at least some important etiological factors are removed. It appears that orthodontists, generally speaking, are well aware of most of the important etiological factors that are producing the malocclusion, like the skeletal discrepancies in the three planes of space, the dentoalveolar discrepancy, the interdental discrepancy, the bad oral habits, the oral or oronasal breathing. They are well aware also of most of the inconsistent etiological factors like the anterior tongue trust, the infantile swallow and speech anomalies. Unfortunately they are not aware of the most important etiological factor: the postural tone of the soft tissues. The postural tone of the muscles of mastication and, on the other side, especially, the postural tone of the soft tissues surrounding the dentoalveolar arches (the tongue inside, the lips and checks outside). These tissues exert a continuous, constant force on the dentoalveolar structures much better than any other orthodontic appliance. They do not need any reactivation anytime, and they are “worn� 24 hour a day without exception... for the whole life!. Soft tissue postural tone is an inherited characteristic as is the red muscle morphology and the number of sarcomeres. The adaptive elements are the ligamentous attachments. Why this very important and almost invariable etiological factor frequently is neglected or forgotten? I imagine because soft tissues are very difficult to study: a) they are continuously changing their shape as they function: it is difficult to evaluate their volume and size; b) the basal postural tone that is so important, shows a very low electrical voltage value which is difficult to measure; c) very few animal studies have been done to surgically lengthen the lip muscles and the buccinator bundle in order to decrease their excessive basal postural tone. -7-

IFUNA JOURNAL Relapse is the common consequence of the surgical mandibular advancement for the correction of skeletal class II malocclusions. Although it is somehow recognized that this is caused by the buccinator bundle exerting a force to bring the mandible back to its original position, maxillo-facial surgeons are not able yet to perform the necessary operation to elongate the buccinator muscle the same time they are advancing the mandible. This must be considered a fundamental procedure to avoid the otherwise almost inevitable subsequent relapse. I personally knew two excellent operators able to successfully perform the marginal myotomy to elongate the buccinator bundle together with inferior vestibuloplasty to unload the lower jaw and lower dentoalveolar structures from the excessive basal postural tone of the lower lip: one was Dr. Robert Ricketts and the other Dr. Samuel Frederick: both have since passed away. I would like to know who else today is able to perform such type of operations on the soft tissues with success. The above introductory part is always necessary, before illustrating the use of any orthodontic or orthopedic appliance in order to correct successfully dentoalveolar skeletal discrepancies or dentoalveolar neuromuscular skeletal discrepancies (the worst to retain after the treatment). No author of a scientific paper should give the idea to the reader that the technique or appliance he illustrates is a panacea for the ideal correction of any case and it may be used without thinking. Every technique or appliance will work well only if the orthodontist has been able to discover the etiological factors that should be taken care of. It is not enough to concentrate only on the correction of the malocclusion as it has been illustrated naively in the recent past. If one does not get to that point then the orthodontist should not be disappointed if few years after the end of treatment the patient will experience a relapse to the original condition, no matter what type of treatment was undertaken: orthodontic, orthopedic, surgical, mixed, etc. In my time orthodontics was much more exciting and challenging. The objective of the treatment was not focused on the aesthetic of the “perfect� standardized smile only. One had to find the best solution not only to get a good smile and occlusion, but also one had to look for the future stability of the dentoalveolar structures in equilibrium with the soft tissues basal postural tone, the future periodontal health of the dentoalveolar structures, the coordination of the occlusal plane with the body posture and last but not least the health of the temporo-mandibular joints. The solution was not a standardized smile but a smile in harmony with the individual face and structure. One needed often much charisma to persuade the patient to wear some obtrusive extraoral appliances like the extraoral traction (headgear), the Delaire appliance, the Orthodontopedic collar, etc., that were necessary to reach the objectives. -8-

IFUNA JOURNAL Presenting treated cases for the ABO examination with a fixed lingual retainer was not acceptable once upon a time: it meant that the orthodontist failed to move the lower anterior teeth into the equilibrium zone or the neutral zone: the zone of stablility. Today, with passive self-ligating brackets and the super elastic preformed ideal arches everything appears so easy. Even the most unskilled chair assistant in the office can handle the case by inserting the preformed arches into the brackets and locking them in. The result often will be the resolution of the crowding by two expanded arches that will have to be retained for ‌ a lifetime by a lingual and often a palatal fixed retaining device. In many of these cases I suppose that, given the time, the soft tissue basal tone would win the game by pushing the over expanded arches back to the original position and this would mean a relapse. Relapse is the best solution nature has to preserve the periodontal health and TMJ health by reallocating the dental arches anteroposteriorly and laterally in their equilibrium zone: the neutral zone. Unfortunately for the patient, in these specific cases the dental arches cannot reallocate because of the fixed lingual and palatal retainers, therefore the dental alveolar structures buccally and anteriorly will have to sustain a light but continuous pressure of the soft tissues‌ for life. It is likely that many of these patients will eventually experience periodontal disease with gum and bone recession in the involved areas. Let us only hope that our dental colleagues will never discover that the causes of those widespread periodontal recessions are two: the previous improper orthodontic treatment plus the improper orthodontic retention. The litigation that would inevitably follow from such a discovery would be disastrous for our profession of orthodontics.



The Potential of Functional Treatment

Prof. Jose Duran von Arx Department of Orthodontics, University of Barcelona, Spain

IFUNA AND FUNCTIONAL TREATMENT First of all, I would like to mention the important role played by the IFUNA (International Functional Association) as the organisation that represents functional treatment in the world, and particularly the figure of Doctor Michael Gorbonos, an untiring fighter who has managed to promote an idea that drives and unites all the professionals of the world of orthodontics who believe in functional treatment. This is why we should admire this tenacious and passionate man who has made his dream come true. IFUNA is the instrument that is needed to promote and project functional treatment in the world of orthodontics, without detracting from other ways of thinking. But IFUNA also represents a philosophical movement that needs a teaching instrument to convey – through education – its ideas to those who wish to learn the essence of biofunctional treatment. Teaching can be delivered through courses, but a standardised and regular educational mechanism is also called for. This is why we have decided to organise a University Master in Functional Treatment Sciences in the City of Barcelona, and invite any relevant teachers or clinicians who wish to make inputs to come to this forum to participate in the teaching of the discipline. Co-managed and supervised by Doctor Michel Gorbonos, the Master in Functional Treatment should be the teaching platform that will encompass all the different families of Functional Treatment, and unite them under the IFUNA umbrella. The ideas of Bimler, Fränkel or Planas should underpin the thinking behind the Master program although neither should the more recent breakthroughs in the field be overlooked.

FUNCTIONAL TREATMENT AND ORAL FUNCTIONS Moreover, when we refer to Functional Treatment, not only should we be addressing the broad variety of functional appliances that have gradually emerged, but also the essence of this concept. When Moss posed the concept of the functional matrix, he opened up, once and for all, the gateway towards the future evolution of Functional Treatment. He led us to see that there was no form without its function and by doing so afforded value to the oral functions. Before that, many other investigators had sought to establish valid criteria that would serve as a guiding light for this clinical ideology model but Moss’s positioning was more precise and revealing. Many studies have subsequently been performed on oral dysfunction and its relationship with malocclusions, i.e., its etiopathogenic involvement in them. Breathing, swallowing and chewing patterns have been addressed by numerous studies. - 10 -

IFUNA JOURNAL The influence of MOUTH BREATHING on the individual’s skeletal and dental development has been studied by many authors. In 1981, McNamara (1) clearly demonstrated that mouth breathing causes posterior rotation of the mandible, determined cephalometrically, due to the change in orientation of Ricketts’ growth facial axis. This author also showed, in cases treated with adenoidectomy, that once the respiratory problem had been solved, the facial axis reverted to anterior rotation. In 1983, Durán (2) published a case in which several teleradiographic records were made (6, 9, 13 and 18 years), and observed that the facial axis of growth underwent posterior rotation while the subject breathed through (his, her) mouth, and that this direction of growth was maintained for some time, although the respiratory problem had been solved, and the jaw subsequently reverted to anterior rotation. The subject had not developed any type of malocclusion. On superimposing the initial (6 years) and final (18 years) cephalometric plots, the two facial axes were seen to be superimposed, which leads us to think that mandibular growth (its degree of rotation) can be modified temporarily – as a response to existing mouth breathing – and the growth pattern can revert to normal once the functional problem has disappeared, provided that there has been no malocclusion that “triggers” and maintains posterior rotation of the mandible. In 1997, Yamada et al. (3) reached the same conclusions in a study performed in Macaca fuscata monkeys. In 1998, Beckman et al. (4) demonstrated the importance of the inclination of the polar axis of the upper incisors as a determining factor in the development of an anterior open bite. On the question of SWALLOWING, Van der Linden (5) considers that, with regard to the action of the tongue as the genesis of malocclusions, we must consider: “atypical swallowing”, which may involve up to four hours of activity a day; “postural position of the tongue” which is active sixteen hours a day; and “lingual interposition”, which is present twenty-two hours a day. Chia-Feng Chieng et al. (6) studied tongue movements during swallowing with ultrasound and compared them to the morphological characteristics of models and teleradiography, ascertaining the existence of a statistically significant correlation between tongue movement during swallowing and dentofacial morphology, and that the magnitude of movement during the beginning of the final phase of swallowing has special importance in tongue movements. Another important aspect to be considered is the degree of lingual mobility and its coding, developed by Durán et al. (7) CHEWING PATTERN tends to be confused with growth pattern, even although the latter is somehow a consequence of the former. But it has been demonstrated that the chewing pattern (of growth) is impacted by respiratory and swallowing patterns. A study performed in rats by Rubert et al. (8) demonstrated that chewing muscle activity entails the presence of growth cells, both and in the medio-palatine suture. On the other hand, bone growth cells disappear when muscle activity is inhibited, by surface section of the masseter muscles. - 11 -

IFUNA JOURNAL With regard to the relationship between GROWTH AND MUSCLE PATTERN, orthopaedic correction should be carried out before or during peak puberty growth. It is well known that this growth takes place two years earlier in girls than in boys. Nanda, RS and Nanda, SK (9) published a study on growth changes between two samples of subjects: one with a brachiocephalic growth pattern and another with a dolichocephalic growth pattern. They reached the conclusion that patients with a skeletal overbite present retarded growth of one and a half years in contradistinction to patients who present with an anterior open bite. According to these findings, girls with an anterior open-bite pattern will grow three and a half years before boys with a dolichocephalic growth pattern with overbite.

STIMULI AS A WORKING INSTRUMENT • STIMULOTHERAPY (10) is a new treatment concept based on the application of stimuli – by means of functional appliances or simple prefabricated elements for night use – which generate automated exercises while the pre-fabricated appliances and/or elements are being used. We wish to bring these criteria into the IFUNA scientific framework, and also into the Master in Functional Treatment Sciences as a method for the standardisation of functions, as well as a new Prevention Programme in Orthodontics. The elements we use are as follows: • NASAL STIMULATORS (11, 12, 13): they are tubes specially designed to correct alar collapse. They come in seven sizes, and permeabilise the passage of air through the nose intubation” effect, mould the nasal cartilages (normalising the shape of the nasal pyramid), thus centring the lower edge of the nasal septum in growing subjects, and as stimulators of the perinasal muscle (improving the nostril-dilating effect).

Figura 1.

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Figura 2.


Figura 3.

Figura 4.

Nasal stimulators are also used in snorers, with a positive effect in 80% of cases. They are placed in the nasal fossa (figure 1), at night, either in pairs or separately (cutting the strap that joins both tubes). • BUCCAL OBTURATORS (14): They are oval-shaped strips placed between the teeth and the lips (figure 2) in order to progressively control the passage of air through the mouth. For this purpose, permeable obturators with large holes are used first for two or three months, after which semipermeable obturators with a small hole are applied, followed finally by impermeable obturators. They should be used jointly with the nasal stimulators in order to promote nighttime nasal breathing. They are supplied in six sizes. • LABIAL STIMULATORS (15): this appliance is similar to the obturator, but without the anterior membrane (figure 3), and with straps that lie at the bottom of the labial vestibule, leading to lip-closing exercises. When the patient goes through the exercise of closing the lips, the position of the tongue moves back. The main purpose of labial stimulators is to reposition the tongue backwards, but these elements also promote correction of labial incompetence and elongation of the upper lip. • LINGUAL BUTTONS: they are used commonly in orthodontics. If they are cemented at the level of the upper lateral incisors as anterior palatine stimuli they favour elevation of the tip of the tongue. On the other hand, if they are cemented at the level of the first upper molars, they will attract the back of the tongue towards the palate. - 13 -


Figura 5.

Figura 6.

• ANTERIOR OPEN-BITE APPLIANCE (16): it is a horseshoe-shaped element with lateral bite planes (figure 4) for the back teeth and with a shield or anterior tab. The appliance – which comes in six different sizes – is placed in the mouth inside the lower arch, around the tongue,

and placing the lateral bite planes on the occlusal sides of molars and premolars, stimulating contraction of the masseter muscles. The rear shield prevents protraction of the tongue. This combined mechanism of combined planes and the rear shield acts as a correction mechanism of anterior open bite. It can also be used in combination with fixed appliances. • MUSCLE RELAXANT: it is a figure-eight element (figure 5) that it comes in six sizes, with

discoid ends that act as lateral shields, like Fränkel shields, and anterior straps that act at upper or lower lip level, like a lip bumper. This action relaxes the perioral muscles and is particularly indicated in cases with perioral muscle contractures.

• ANTIBRUXISM APPLIANCE (17) or overbite corrector: it is the combination of the previous appliance – muscle relaxant – with an anterior bite plane. The two parts assembled (figure 6)

afford the unit a functional appliance-like appearance. The bite plane promotes the extrusion of the back teeth, increasing the vertical posterior dimension of the occlusion, with posterior rotation of the jaw and consequently elongating the masseter muscles, reducing their action potential. They may be used for the simple correction of overbite or in the treatment of bruxism. This appliance is recommended for use in combination with the nasal stimulators. It can be used in combination with fixed appliances. - 14 -


NORMALISATION OF FUNCTIONS AND PREVENTION IN ORTHODONTICS Scheduled stimulotherapy is thus a mechanism that helps to normalise functions and does not depend on the patient’s collaboration. On the other hand, it must be clear that the role of the myofunctional reeducator or speech therapist cannot be replaced with this work protocol, since the scope of their work is much broader and is irreplaceable. Taking into account the fact that oral dysfunctions are, generally speaking, the cause of malocclusions and dysmorphia of the dental arches, and more particularly of deviations from craniofacial growth pattern, we can establish a cause and effect relationship between alterations of oral functions and orthodontic problems. Consequently, if we can balance oral functions at early ages in the population, we can prevent a major percentage of dental arch dysmorphias and deviations from the growth pattern of the subjects thus treated. It is also clear that the mechanical causes of oral dysfunction (hypertrophy of the tonsils and adenoids, rhinitis, nasal septum deviations, tense frenulum of the tongue, etc.) must be diagnosed and treated early. The application of the clinical principles of scheduled stimulotherapy at early ages in the individuals of a population is therefore the cornerstone of the Prevention in Orthodontics Programme that we are proposing. It is based on the “muscular stimulus-reflex” binomial and its automation. It must be protocolled according to the normalisation priorities of the orofacial “functional triumvirate”: breathing, swallowing and chewing pattern, in this order of importance.

REFERENCES 1. Mc Namara, J Jr. Influence of respiratory pattern on craniofacial growth. Angle Orthod. 1981; 51(4): 269-300. 2. Durán, J. Interrelación entre crecimiento maxilofacial y el síndrome de obstrucción respiratoria. A propósito de un caso. Revista Española de Ortodoncia. 1983 13(1); 8

3. Yamada, T. Tanne, K. Miyamoto, K. et al. Influences of nasal respiratory obstruction on craniofacial growth in young Macaca fuscata monkeys. Am J Orthod Dentofacial Orthop. 1997; 111

4. Beckman, SH. Kuitert, RB. Prahl-Andresen, B. et al. Alveolar and skeletal dimensions associated with overbite. Am J Orhod Dentofacialial Orthop. 1998; 113: 443-52.

5. Van der Linden FPGM, Proffit WR. Orofacial functions. Quintessence Publishing, 2004. 6. Cheng, CF. Peng, CL, Chion, HY. et al. Dentofacialial morphology and tongue function during swallowing. Am J Orthod Dentofacial Orthop. 2002; 122(5) 491-9.

7. Durán, J. Técnica MFS: Diagnóstico de la matriz funcional: codificación. Ortodoncia clínica. 2003; 6(3): 138-40. 8. Rubert, A. Manzanares, MC. Ustrell, JM. Inmunohistochemical identification of TGB-beta1 at the maxillaries in growing Sprague-Dawley rats and after muscle section. Arh Oral Biol. 2008; 53(4): 304-9.

9. Nanda, RS. Nanda, SK. Considerations of dentofacialial growth in long-term retention and stability: is active retention needed?

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IFUNA JOURNAL 10. Durán, J. Carrasco, A. Ustrell, JM. La “estimuloterapia programada” como base para el desarrollo de un protocolo de reeducación funcional oral que nos lleva al concepto de “prevención en ortodoncia”. Dentum. 2008;3: 123-9. 11. Durán, J. Merino, M. Echarri, P. Carrasco, A. Una nueva propuesta de tratamiento para el paciente con el síndrome de la respiración oral. Ortodoncia clínica.2009; 12(2): 73-9. 12. Durán, J. Estudio clínico del efecto de los tubos estimuladores nasales. En Padrós, E. Bases diagnósticas, terapéuticas y posturales del funcionalismo craneofacial. Primera edición. Barcelona. Ed. Ripano. 2006; Pag. 1018-22. 13. Carrasco, A. Durán, J. Merino, M. Echarri, P. Dilatadores nasales como estímulo para pacientes roncadores: estudio en 55 pacientes. Ortodoncia clínica. 2009; 12(1): 7-11. 14. Durán, J. Carrasco, A. Echarri, P. et al. El obturador bucal “MFS” como un método clínico de tratamiento de la incompetencia labial en los pacientes respiradores bucales. Dentum. 2008; 3:102-7. 15. Durán, J. Ustrell, JM. Carrasco, A. Et al. Efectos de los estimuladores labiales a nivel del grado de incompetencia labial y la longitud del labio superior. Dentum. 2008; 3: 108-11. 16. Durán, J. Carrasco, A Echarri, P. et al. Cambios clínicos obtenidos con el uso del “aparato para la mordida abierta” MFS en pacientes con mordida abierta anterior. Dentum. 2008; 3: 119-22. 17. Durán, J. Echarri, P. Ustrell, JM. Et al. Un nuevo elemento prefabricado para relajar la musculatura en los pacientes bruxistas. Dentum. 2008; 3: 112-8.

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Myth and Reality Education, Preservation, Documentation of Functional Treatments: Prof. A .B. Bimler Bimler Laboratories, Germany

(The following article highlights some old problems of Functionalism).

1. EDUCATION This is doubtlessly the clue word for the use of any method in any field. The myth says that the selection of a treatment method is guided by the needs of the patient. In reality, it might be politics. In reality, doctors can only apply a method they have learned before. Hence, the selection of the treatment is guided by the preferences of the university professor. But what can the university professor teach? In reality, there is no frivolous selection according to preference, but an official curriculum. This must be so because of the state approbation, without which the exercise of the profession is unlawful. This curriculum is usually the decision of a political body. Of course the politicians know little about dentistry, and rely largely on advisors or lobbyists. Partly they also follow a political idea or ideal. For example, Functional Orthodontics had a first wave of fashion in Central Europe during National Socialism and after the war in East Europe during regular Socialism. Today, to my knowledge, the country where Functionalism is handled best is Cuba. And now do not laugh and say, that is all they can afford, because that would reflect a rather superficial arrogance. Couldn’t these countries afford quite a bit at times? And isn’t their medical reputation rather high? The more some social security pays for straight teeth, the bigger the political component necessarily gets. I recall the 70’s in England where a removable treatment, including the appliances was paid £100 in toto. Which dentist could afford to work for such little money? After a generation, of course, knowledge of functional methods is practically erased. This is even more true for USA where the bracket companies successfully suppressed any economic competition. Functionalism was an endangered species.

2. PRESERVATION BECAME CONSEQUENTIALLY CRUCIAL FOR ITS SURVIVAL This is a job which IFUNA has already excelled in three years of existence. The library in Turin and the developing plans for a re-introduction into the university systems are promising signs for the future. - 17 -

IFUNA JOURNAL A big help could be the co-operation with the technicians. They are often, (though some dentists hate to hear this), much better than dentists / orthodontists at the inevitable wire bending and activation of removable appliances. It was the technicians and the general practitioners who kept up the knowledge of functional appliances during the years of fixed treatment. But how could Functionalism be so easily pushed away? Because so often, the representatives and authors really promised too much, including improving the body, the mind and the soul. Notwithstanding a good personality, intention and success, this smells of quackery. The average dentist could not reliably repeat the results. Many efforts were made to look for scientific validation confirmation for functional treatment, to separate “myth” from reality. The results, alas, are mostly irrelevant and boring. Why? Because in the end, the angulations of some cephalometric landmarks do not mean much to anybody. What counts ideally, besides good looks, is: • healthy periodontium • healthy enamel • a good working occlusion • healthy joints, And all this about 20 or 40 years after the end of the treatment. (And I do not mean life long fixed retention which might backfire in some places.) Of course this ideal will not be possible in all patients, but a good number could still have at 60 and 70 years of age all their own teeth and still chew a steak. But how can anyone convince the skeptics (as there is no need to convince the believers) what the ardent functional fan is convinced of: that treatment in long-term concordance with the face and the body (and then why not also the mind) exists? This question leads to the following point:

3. DOCUMENTATION The documentation of the long term results could be a way of proving the worth of a treatment, like the survival years of a cancer patient. In Germany, any medical record must be kept for ten years, so a recall is possible. But hardly anybody has time, money or interest. Of course it is crucial to be honest with the results. At courses and congresses, I often have the feeling that we are shown only the success cases, and the failures are pushed under the carpet. Without honesty, there can be no progress in knowledge, and Functionalism will smell of wishful thinking and quackery. - 18 -


Beyond Occlusion: Craniosacral Therapy and Functional Orthodontics

Mark L. Levine Craniosacral Therapist, Private Practice, Toronto, Canada

A ʻconsumer / survivorʼ is one who self-describes experiencing disempowerment and iatrogenic sequelae from previous psychiatric services. As a loosely defined movement, the moniker suggests that patients themselves have elaborated a more comprehensive model of mental health than is currently practiced among mental health professionals. Analogously, there exists an as-yet unnamed population of orthodontic ʻconsumer / survivorsʼ. Cumulative anecdotal evidence suggests that in many cases a pattern of somatic, cognitive and emotional dysfunction arises precisely at the onset of orthodontic treatment. All too frequently, the periodicity of visits to the orthodontist marks a tempo not only of temporary stomatognathic discomfort, but of diverse, significant, and sometimes lasting, sequelae to treatment. The acute discomfort typical of wire tightening that arises within minutes of the procedure often is resolved by a progression towards chronic whole body and cognitive and behavioral adaptive changes after several weeks. My own experience of braces is a case in point. My orthodontist, Dr. Y., (the best in the city I was assured), was a professor at the university and taught many orthodontists currently in practice. This was the mid 1970ʼs, and I was subjected to the standard extraction of 4 premolar teeth - a significant trauma in itself - banding, heavy wires tensioned across the maxillary suture and a rapid series of tightenings. I clearly remember, around age 12 or 13, the first evenings after my appointments with Dr. Y., holding my head and drooling in pain over my bathroom sink with a headache, acute maxillary discomfort, sinus congestion, cervical hypertonicity, a sensation of heaviness, fatigue, mental confusion, and the cognitive dissonance of knowing rationally that, while I was told this treatment was necessary, I wondered how my parents could let me suffer so much. Several days following my appointment, the acute orofacial pain would usually subside, yet I would feel that the left side of my face was increasingly ʻlockedʼ; a unilaterally and persistently blocked sinus, a dull ear ache, TMJ crepitus, and an occasional ʻfireballʼ of pain from the left side of my neck when I rotated too far. The heaviness, fatigue, mental confusion and cognitive dissonance would all slowly diminish over the weeks, only to return full force again following the next appointment along with another round of - 19 -

IFUNA JOURNAL acute orofacial discomfort. I developed a marked craniofacial asymmetry as evidenced through family photos during those years. Perhaps it was a property of adolescence and the complexities of family life in modern times, but I still associate an enduringly, oppressively claustrophobic sense of trauma around those years of braces. And I suspect that my adolescent behavior and academic performance would have been better had I not experienced that persistent sense of being so bound. I can remember the sense of freedom, vitality and cognitive clarity surging through me as soon as the maxillary wire was removed at each appointment, and I relished the few minutes of this novel sensation before the next, likely thicker wire was twisted into place. I was overjoyed when Dr. Y. announced that we were finished treatment, and I resented having to wear a retainer that felt similarly binding, so I lost or broke 3 of them before my parents and Dr. Y. agreed not to make a 4th. I have a wide gap between my front teeth today as a result. As a practitioner of craniosacral and osteopathic manual therapy for the last 20 years, I now know that my unilateral symptoms and the development of my craniofacial asymmetry had its origins in a congenital anterior fascial restriction - I was born with a mild club foot for which I wore an external rotation brace fixated to my legs at night as a baby. I also had a high maxillary arch, forward head carriage, pectus excavatum, a left sided torticollis and positional plagiocephaly, a mild scoliosis, and was a mouth breather. I also was poorly co-ordinated and I sucked my thumb until I was 7 years old. This history was not asked about on Dr. Y始s intake forms, nor did my parents convey it to him. I suspect it was not of interest to him because, like most orthodontists even today, he was interested in my smile. Though groundbreaking discoveries such as Richard Buckminster Fuller始s tensegrity model of physical structures (synergetic balance among discontinuous compression elements bound by continuous tension) had already been introduced and was influential in engineering, physics, chemistry and bodywork circles by that time, it clearly was not reflected in Dr. Y始s paradigm of orthodontic treatment. Dr. Y.始s strictly occlusal approach to orthodontics made life worse for me. I strongly believe that the more sophisticated tensional integrity models of functional orthodontics, had he been aware of them at the time, would have instead ameliorated my pre-existing fascial imbalances and facilitated high level wellness. Many young clients I work with today are the beneficiaries of a gradually developing consensus among pioneering leading edge orthodontists who, by chance or inclination, have discovered the clinically significant relationship between the alignment of teeth and a more comprehensive model of somatic, cognitive and emotional healthcare. - 20 -

IFUNA JOURNAL Today I work closely with orthodontists knowledgeable about functional approaches to design individualized programs of craniosacral balancing prior to orthodontic treatment, sessions timed between orthodontic appointments to ameliorate acute tensions, followed by a series of sessions after orthodontic treatment to rebalance the whole system. The positive health outcomes of such a multidisciplinary approach transcend a simple reduction of the discomforts of orthodontic treatment; many pre-existing functional conditions, such I experienced in my own case, can be resolved via appropriate orthodontic appliances and manual therapy techniques; and conversely, a spacious and fully functional craniosacral system facilitates the project of occlusal alignment. I have learned much from the dentists and orthodontists who have referred to me over the years, and I know of several who have themselves gone on to take courses in craniosacral, osteopathic and manual therapies. In teaching craniosacral therapy, we often have physicians, chiropractors, physiotherapists, massage therapists, dentists, orthodontists and psychologists all sharing a class. Such a diverse group with a nuanced understanding of anatomy and physiology tends to generate a unique synergy, excitement and high degree of specificity in practice. This is only possible amongst professionals from multiple disciplines who can check their turf-kicking boots at the door and meet with open minds and the intention to cross fertilize paradigms. Such is the stuff of scientific revolutions. I would argue that for more patients to have better outcomes, entry-to-practice dental training programs ought to include at least a rudimentary introduction to the concepts and techniques of cranial bone movement, autonomic reflexes, and dural and whole body fascial effects of the sustained mechanical tensions characteristic of dental procedures and orthodontic treatment. Introducing this model into the curriculum at the beginning, when students are least ideologically conditioned, would have the eventual effect of moving functional approaches out of the small and as yet politically insignificant fringe of practitioners into the mainstream. Then, perhaps, more orthodontic patients would experience high level wellness along with a nice smile. Mark Levine is clinical director of Mark L. Levine, B.A.(hons), R.M.T., Pediatric + Family Craniosacral Therapy, providing craniosacral and osteopathic manual therapy services to infants, children and adults for a wide variety of physical, emotional, neurological and trauma related concerns.

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Why Early Functional Treatment of Tooth Rotation?

Prof. Wilma Alexandre Simรถes Department of Functional Orthopedics,University of Cruzeiro do Sul -UNICSUL St.Paul, Brazil When roots reach approximately two-thirds of their final length, the periodontal ligament, alveolar bone and cementum have not been completely formed. At this stage of root development, functional occlusion is established through the contact of antagonist teeth. It may take from one year and three months to three years and five months for the teeth to have a complete occlusal function and development1. Before teeth have a functional role on the occlusal plane, tooth rotation treatment should be carried out, including the appropriate type of contention, which should be, at a minimum, triple the time needed for correction, thus reducing the risk of relapse2. Longitudinal studies have confirmed3 that the teeth most affected by relapse in the treatment of tooth rotation are the upper canines, more than the lower ones; they are followed by the upper lateral ones and finally by the second lower premolars. These studies reported relapse cases 10 years after contention, independently of age, gender, extractions and growth of maxilla and mandible, suggesting that they happened due to inherent mechanisms of tooth rotation. The priority of treatment that precedes tooth rotation may be posture change movement with predominant mandible rotation, mainly in cases of severe hyperdivergency that needs it in the anterior direction2. Functional occlusion established through the contact of antagonist teeth will appear later. The time needed to correct tooth rotation will be longer, with an increased risk of unsatisfactory and unstable results. Rotation of the first molar should be corrected at the start of mixed dentition. The older the patient, the more complicated is correction then the less stable is the result, which depends of on rotation intensity2. Rotation intensity is one of the difficulties that should be evaluated. The risk of relapse increases gradually when initial rotation surpasses about 40 degrees. The treatment of posterior teeth is more difficult. Limited results are expected, even when initial rotation is less than 40 degrees2. The difficulty increases at around 30 and 25 degrees, considering premolars and molars respectively; the crown morphology of the former may complicate the rotation correction. Satisfactory results can be found in cases of rotation of incisors up to about 70 degrees, with an increased risk of relapse as the rotation nears 90 degrees. Incisors have a lower degree of difficulty and the probability of relapse - 22 -

IFUNA JOURNAL is virtually nonexistent if they do not have contact in the position of maximal intercuspation4, except during development, when they participate at the support zone during mixed and early permanent dentition. On the young adult period they start to have no contact. The Relapse is precluded if the incisors additionally maintain contact with antagonists following the patterns of a balanced kinetics of lateralprotrusion5 and physiological free protrusion6. A larger number of roots may be another unfavorable element to correct tooth rotation. As the first permanent molars have multiple roots, they should be treated as soon as possible; preferably up to one year after they reach the antagonists2. The sinuous form of the roots, or with a curved apical third, may negatively influence the length and result of tooth rotation treatment. Canine roots are usually longer and thicker in the vestibular-lingual direction and are firmly anchored on the alveolar bone7. Upper canines have longer and more sinuous eruption curves2. All of these may be elements that make it more difficult to correct canines, as opposed to incisors. The complete formation of the root, the form of the crown and a poor eruption caused by any impairment must be considered during tooth rotation treatment. Teeth that have uncommon forms or sizes must be touched cautiously because they may react differently from what is expected, and this doesn’t apply only to tooth rotation. Eruption speed and motion are variables that depend on the type of tooth, i.e., if the tooth is an incisor, canine, premolar or molar; and on genetic, systemic, nutritional and environmental conditions2. Upper canines with an obstructed eruption curve2, which depend on surgery or traction to reach the occlusal plane, may maintain a mild rotation, a position that many times is considered acceptable8,9. Still, harmony is maintained if rotation does not interfere with occlusal balance2. However, depending on the conditions of forced eruption, there is no other alternative but to accept an unfavorable solution. Even then, it is worth to make the tooth part of the occlusal plane. Morphological rehabilitation and a better relationship between neighbors and antagonists may be obtained through the ability, for example, of the general practitioner or dental prosthesis specialist. When it is not possible to correct tooth rotation, the objective becomes the adjustment of the tooth as a participant of mandibular kinetics2. It has been proven3,10,11,12,13 that relapse occurs 10 to 14 years after fixed orthodontic treatment with correction beyond the desired rotation, or with the removal of transseptal fibers, which pass over the alveolar crest, with no bone insertion, penetrating the cementum of each tooth; due to this continuity, they are called interdental ligament. Studies2,10 have demonstrated that fibrotomy was more effective in teeth with rotation only, and less effective when labiolingual inclination was also present. The results are the same should an orthopedic treatment be used. Up to now, available orthodontic, orthopedic and surgical techniques have not been able to generate better results under identical biological conditions, - 23 -

IFUNA JOURNAL unless treatment is early, correcting and containing rotation before functional occlusion is completely established. Finally, understanding the force’s anterior component14,15,16, still only partially known, increases the complexity of relapse prevention. Interdental ligaments1 help control tooth rotation and keep teeth together17,18 by contributing to the elastic flow of mechanical energy through the collagen of transseptal fibers. All energy applied on teeth is distributed inside them through adequate entry paths for transmission, absorption and egress. When the tooth is crossed, the energy is partially dissipated on surrounding tissues, partially on remote structures, in addition to the amount spent to destruct the bolus by masticatory impact. Dental intercommunication is expressed by entries and strategic circuits, defined trajectories through which energy passes and is dispersed for the best functional response and preservation of the structures2. Relapse continues to be a challenge19 due to the combination of causes that lead to still inscrutable codes. It does not matter whether or not the treatment included a previous surgery3,10,11,12, two months before placing the appliance13. Causes can range from genetic to ethological, and the mechanisms are unknown. For this reason, it is not possible to avoid a relapse after a certain period of time. Additionally, there are multiple and unforeseen influences following treatment, such as illness, bone loss, dental loss, unfavorable growth, periodontal and articular problems, among others. Correction may be favored, or not, by the density of the bone that involves the rotated tooth. It varies according to with the region of the dental arch20; with Haversian or connecting canals21,22,23; and with the greater thickness of the trabeculae, as in the mandible, or lesser, as in the maxilla24. The denser it is the more difficult is the result of treatment. Eruption is a physiological inflammatory process. When a tooth is erupting, no part of the functional orthopedic appliance should touch the region of the inflamed gum. If the erupting tooth is rotated, the same criterion should be followed. Dental anatomy shows the so-called interproximal crown bulge, through which is established contact between neighboring teeth in a relationship named interproximal. All contacts occur on the occlusal or incisal third, except between the second premolar and the first upper molar, whose contact area is located on the middle third7,25. Premolars are difficult to correct and relapse is easy, especially in second premolars2. After the start of eruption, the physiological inflammation around it varies depending on the individual, but in general, in the case of incisors and canines, it occurs when the crown has the mesial and distal interproximal crown bulges completely exposed, or advancing towards the oral cavity one or two - 24 -

IFUNA JOURNAL millimeters beyond their profiles. Under these conditions, we can start to act on the lingual side, without any action on the buccal side, where the eruption force naturally favors correction. Considering the first premolars, we should allow eruption to reach a minimum of three millimeters beyond complete exposure of the interproximal crown bulges in the oral cavity. The occlusal third and the middle third must be apparent in the oral cavity. However, depending on crown morphology, in the case of a premolar with a very low lingual cusp, two millimeters below the vestibular cusp, we should wait for a greater exposure than that of the middle third. S-springs working properly on the lingual side may have a favorable effect without the need of a support on the buccal face, and vice-versa, as the natural force of eruption acts as a stimulus agent if the rotated tooth has approximately one third of its crown erupted. It is important never to touch the mesial and distal faces, Therapy should be limited to the lingual or buccal faces. After a more complete eruption movement, the same criterion must be maintained, adding, however, the application of supports on the buccal side, with accessories and/or buccal arches, especially of the undulated type. S-springs must be free of acrylics in order to be able to vibrate, especially if the objective is to correct tooth rotation. The elbows should be pointed towards the side with greater rotation, where there is a need for a

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greater correction movement. S-springs should not touch neighboring or antagonist teeth2. Figs 1 A to E. Frontal half-springs2 counteracting buccal arches can control the position of lower incisors, correcting their rotation. Frontal half-springs and buccal arches must be in the same direction and above the area of contact of the rotated tooth. The activation of the frontal half-spring should not be done if

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the incisor does not have at least half of the root already formed. The same concern exists with regards to the frontal spring, especially for the upper lateral incisor. Figs 2 A to H; Figs 3 A to E. The relationship between the interproximal contact areas and the functional orthopedic appliance is of utmost importance to obtain better and more permanent results2.

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The results and stability of tooth rotation treatment depend on the type, shape and size of the tooth; crown morphology; root development stage; the length of time that the tooth has been a part of functional occlusion; the number of roots; root morphology; eruption stage, velocity and movement; age; growth direction; impaired eruption; surgical processes; on pathologic reactions; on rotation intensity; on bone density and growth. Furthermore, we do not know the inherent mechanisms of tooth rotation.

BIBLOGRAPHY 1. Moss-Salentijn L, Klyvert M. Dental and oral tissues. Philadelphia: Lea & Febiger, 1980.p. 191, 286. 2. Simões WA. Ortopedia Funcional de los Maxilares. A través de la Rehabilitación Neuro-Oclusal. 3ª ed. São Paulo: Artes Médicas; 2004. pp. 257-280, 331-348, 646-648, 715, 716, 719-722, 763. 3. Swanson WD, Riedel RA, D’Anna JA. Postretention study: incidence and stability of rotated teeth in human. Angle Orthodontist 1975; 45: 198-203.. 4. Arnold, NR, Frumker, SC Occlusal treatment. Philadelphia: Lea & Ferbiger; 1976. pp 95, 99, 103-105 5. Planas P. Comment éviter la récidive? L’Orthod Franç 1986; 57: 629-642. 6. Simões WA. An Orthodontic challenge. Juvenile Rheumatoid Arthritis: Examination Protocol. World J of Orthod 2001; 2:56-68.

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IFUNA JOURNAL 7. Kraus BS, Jordan RE, Abrams L. Anatomia Dental y Oclusion. México: Interamericana; 1972. pp. 33, 226-239, 245262, 294. 8. Becker A, Chaushu S. Success rate and duration of orthodontic treatment for adult patients with palatally impacted canines. Am J Orthod Dentofacial Orthop 2003; 124:509-514. 9. Zucati G, Ghobadhu J, Nieri M, Clauser C. Factors associated with the duration of forced eruption of impacted maxillary canines: a retrospective study. Am J Orthod Dentofacial Orthop 2006; 130(3):349-356. 10. Edwards JG. A long term prospective evaluation of the circumferential supracrestal fibrotomy in alleviating orthodontic relapse. Am J Orthod and Dentofacial Orthop 1988; 93: 380-387. 11. Reitan K. Clinical and histologic observations on tooth movement during and after orthodontic treatment. Am J Orthod 1967; 53: 721. 12. Reitan K.; Rygh P. Biomechanical principles and reactions. In: T.M. Graber; R.L. Vanarsdall JR. Orthodontics. Current principles and techniques. 2ª Ed., St.Louis: Mosby; 1985. pp. 96-192. 13. Vanarsdall RL. Adjunctive orthodontics for the generalist. J Tenn Dent Assoc 1979; 59: 15-18. 14. Southard TE, Beherents RG, Tolley EA. The anterior component of occlusal force. Am J of Orthod and Dentofac Orthop 1989; 96 (6): 493-500. 15. Moraes JCTB, Graziani, AL, Matioli, E, Simões, WA, Catach, C, Rossi,LN. Teoria da Intercomunicação 2002 Dental XVIII CBEB. Univ Vale do Paraíba p 330. 16. Moraes JCTB, Simões, WA, Catach, C Dental Intercommunication Measuring. 2003. 25th Annual Int Conf IEEE EMBC Mexico pp 3294-3297 17. Bath-Balogh M, Fehrenbach MJ. Illustrated Dental Embryology, Histology, and Anatomy. Philadelphia: WB Saunders Co.; 1997. pp. 140,188-209, 214, 215, 222-232, 254, 256, 278. 18. Berkovitz BKB, Holland GR, Moxham BJ. Oral anatomy, histology and embryology. 2ª Ed., London: Wolfe Pub.; 1992. pp. 164-198, 211, 212. 19. Eissendeck MM, Gugny G, Liskenne. Contribution a l’ étude des recidives. L’ Orthod Franç 1948;71: 449. 20. Ulm C, Tepper G. Structure of atrophic Alveolar Bone. In: Watzec G. Implants Qualitatively compromised bone. Germany: Quintessence; 2004. pp. 29-41. 21. Sicher H. Anatomia Oral. 2ª ed, Rio de Janeiro: Liv. Atheneu; 1955. pp. 71 97. 22. Couly G. Développement céphalique. Paris: CdP, 1991; pp. 99-101. 23. Schumacher GH. Factors influencing CFG. In: AD Dixon, BG Sarnat. Normal and abnormal bone growth. New York: Alan R. Liss Inc.; 1985. pp. 3-22. 24. Roberts WE, Arbuckle GR, Katona, Th R. Bone physiology of orthodontics: Metabolic and Mechanical control mechanisms. In: Witt E, Tammoschert U-G. Symposion der deutschen Gesellschaft für kieferorhopädie. München: Urban & Vogel, 1989. pp. 33-55. 25. Vieira GF, Agra CM, Arakaki Y, Steagall Junior W, Ferreira ATM, Liberti EA. Anatomia de dentes permanentes. São Paulo: Liv Santos; 2006

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Add the Voice to your Functional Treatment Plan Angela Caine Voice and Body Center, England

The efficiency of the human musculoskeletal system lies in its economy. The minimum number of levers and pulleys supply the maximum number of different demands. Thus many of the ligaments and muscles responsible for the forces involved in singing, swallowing, breathing, or lifting heavy objects are also responsible for the forces which move the jaw, position the tongue, provide the rhythmic pump action to expel fluid from the Eustachian tubes, balance the head on the spine, or the spine and pelvis over the feet. The clinical disciplines working to correct dysfunction in any one area can include dentists and orthodontists, cranial osteopaths, cranial chiropractors and exercise therapists. Because none of these disciplines can hope to become expert in the total diversity of even one area, multidisciplinary teams are gradually forming to work together to support not only the patient, but each other. Shared input is also shared responsibility. Clinical disciplines all study functional anatomy as part of their training and that can be the starting point for a working relationship. The mandible is suspended from the temporal bones of the cranium, which need to be functioning symmetrically to facilitate successful maxillary expansion or occlusal correction. A cranial osteopath or cranial chiropractor can realign temporal bones and as both disciplines are now accepted as treatments within the European medical framework, there is no danger of unprofessional conduct to an orthodontist who refers a patient there. I first researched the links between dentists and other structural clinicians through searching for ways to solve my own voice problems. Armed with this information I discovered that a large number of the people who consulted me with voice problems also had structural problems. These included clicking jaws, inadequate vertical dimension, or they may have had major extractions, which reduced skeletal support and caused physical misalignment and cranial torsion. I received no training in functional anatomy fifty years ago for my career in singing; even though in 1956 Sonninen (1) discovered that the extrinsic frame of the larynx regulated the vocal folds, thus affecting the voice. According to my findings this situation has not changed. Many of the structurally misaligned performing musicians and singers had been diagnosed with ‘Performance Stress’ and were attempting to deal with it via a psychological or emotional route. Their personal confidence was poor. In order to provide help for them the first multidisciplinary team was put together that included a dentist, a cranial chiropractor and a voice teacher (2). It soon became clear that the result in the ‘team’ treatment of patients who also did voice work was a much faster response to treatment, particularly with appliances. Not only can measurements and pho-

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IFUNA JOURNAL tographs be compared to prove the treatment is progressing well, the patient can hear and feel the changes in the daily use of the voice. There is also the possibility of the patient taking some responsibility for part of the treatment, as opposed to paying for someone to totally provide it. Anyone treated by any means has to at some stage take over the responsibility for linking the

Figure 1. Revisiting the early cross-patterning reflex in adults using balance and stretch (4)

recovery into their own lives. VoiceGym voice and body exercises (Figure 1) can provide the means of this involvement. For instance the patient can personally improve the function of face muscles and tongue through exercise and understand why they are doing it (3,4). This also promotes dialogue between patient and clinician.

People enjoy singing. It is a natural human characteristic that energises and makes you feel good. That ‘feel good’ factor also encourages the patient to express attitudes and feelings about the treatment. A treatment plan which accesses positive factors like these is likely to also access natural selfrighting mechanisms.

MECHANICAL LINKS BETWEEN STRUCTURE AND VOICE The Hyoid The hyoid is part of, and crucial to, the mechanical interface between cranium and mandible. Bibby and Preston (5), discovering the upper airway stability provided by the hyoid triangle stated that “with-

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IFUNA JOURNAL out it (the hyoid) our facility for maintaining an airway, swallowing, preventing regurgitation, and maintaining the upright position of the head could not be as well controlled”. They admit that the hyoid tends to be overlooked and although their paper is the first to review all the relevant literature there is no mention in that literature of the effect of the voice on the hyoid, even though the source of the sound that we make is the larynx, which must retain independent flexibility to speak, and that is suspended from the hyoid. The hyoid is connected to the mandible via the Mylohyoid muscle and to the cranium via the stylohyoid ligament. This ligament also has a connection to the mandibular angle (see Figure 2). Dysfunctional speech and singing often cause an unnaturally high larynx, which, raises the hyoid. Figure 2. Mandibular connection to the stylohyoid ligament Through this connection the mandible is also (6). driven up and retruded into the joint space at the TMJ. The hyoid is the main skeletal connection for the tongue. The excursion of the larynx down the pharynx for the ‘in breath’ requires the position of the hyoid to be flexible, made possible by the supra and infra-hyoid muscles. Balance between these muscles is maintained by the efficient action of swallowing, breathing, speech, singing and natural upright posture. If hyoid flexibility is seriously imbalanced, this can alter the range of flexibility of the hyoid and cause a wave of muscular distress to the TMJ and throughout the neuromuscular system. Tongue thrust is not just a dental problem Andianopoulos and Hanson (7) found that one of the main factors suspected of contributing to the tendency of teeth to return to their pre-treatment position is tongue-thrust. Their study is one in extensive literature devoted to the importance of tongue resting position in the achievement of a satisfactory treatment result with no long-term regression. It also states that a forward tongue causes dysfunctional breathing (through the mouth), deviate swallowing and forward head neck posture through displacement of the hyoid bone. Tongue position and the possible means of changing it are a very serious consideration in the planning of all musculo-skeletal correction. Its connection to the hyoid and from there

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IFUNA JOURNAL into the scapula via the omohyoid muscle links the tongue into a chain of muscles involving muscles of the trunk responsible for physical stability, rotation and strength. Therefore the position of the tongue can stabilize or destabilize whole body posture and function. Numerous dental appliances are fitted with ‘spinners’ and other devices to interfere with the tongue tip and encourage it to move the whole tongue back and up. However, the tongue is made up of both voluntary and involuntary muscles, the latter only responding to the imagination. Singing and the reciting of imaginative poetry accesses both rhythm and the imagination, exercising both voluntary and involuntary muscles of the tongue. However this is only possible if speech and singing are themselves functioning efficiently. Speech, the Mandible and the Tongue Modern man differs from all other creatures in three significant ways: 1. Upright posture 2. The enlargement of the cerebral cortex of the brain 3. The low larynx These developed interdependently over the last 100,000 years and the latter caused the shift of the tongue at between two and six years old from a position totally in the mouth, as in both the infant and adult chimp, to having two thirds of the tongue in the mouth and one third in the pharynx, forming its anterior wall (8). Chimps, with the tongue entirely in the mouth, can be taught vowels by shaping the mouth itself but only the right angled tongue position of the upright hominid can articulate consonants and facilitate sophisticated speech. Crelin (8) stated that “Ultimately, articulate speech led to a complicated spoken and written language, abstract thought, the fifth Symphony and the theory of relativity.” Human speech uses three different articulation systems: 1. The making of pitched sound – by the vocal folds within the larynx 2. Vowels – by the shaping of all three constrictors of the pharynx and its anterior wall, the main body of the tongue. 3. Consonants – by the action of the free third of the tongue in the mouth. There is some muscular overlap in the articulation of vowels and consonants. We function rhythmically as the result of the antagonism between movement and gravity. The pumping of the cranial fluid, the excursion of the larynx down the pharynx and the cross patterned action of walking are some of the - 33 -

IFUNA JOURNAL many body systems that function rhythmically. The rhythmic down-spring of the larynx in breathing, speech and singing springs a further third of the tongue backwards into the pharynx causing the third of the tongue remaining in the mouth to implode consonants, rather than explode them. This regular implosion of consonants within the syllables of speech uses the styloglossus muscle to pull the tongue back and up to implode against the palate, alveolar ridge and palatine arch, rather than forward and down to explode against the teeth and the lips. It ensures exercise of styloglossus every time we speak. Styloglossus is the muscle that ‘suckles’ the nipple in breast-feeding and if the early development of speech maintains the strength of styloglossus in the articulation of consonants and vowels, natural rest position of the tongue against the palate and away from the teeth to breathe through the nose, is also maintained. The distance the tongue has to cover between its attachment to the styloid process of the skull, the lower rim of the mandible and a hyoid attached to a low larynx demands intricate and muscular movements to articulate the sophisticated speech patterns of Homo Sapiens. Efficient speech builds the strength of styloglossus and imploded consonants encourage vowel resonance throughout the physical structures of the trunk. An efficiently functional tongue thrusts sideways against the maxillary arch posterior of the premolar teeth, thus providing natural arch expansion for life. This simultaneously widens and lengthens the pharynx facilitating both the movement of air from the nasal sinuses and the shaping of vowels. Unfortunately many singing teachers insist that the tongue should lie flat in the floor of the mouth to sing, using the lips and teeth to spring the tongue in consonants and ‘project’ the voice. There is currently no globally consensus on voice training as the disciplines of speech and singing are generally considered to use the voice mechanism differently. The establishment of Interdisciplinary treatment protocol including voice would change that, as it did for me. I am hoping that IFUNA with its International Education programme will be that instrument for change. The Function of the Face The full development of the maxilla in children brings about the downward and forward development of the face. A large percentage of orthodontics is concerned with correcting maxillary underdevelopment (9). Although establishing a natural tongue position is a critical factor in arch expansion, much can be done to help the process by toning the face muscles. What is the first effect of inserting a dental appliance? The face muscles behave in the same way as they do when you get a raspberry pip in your teeth. You play with the offending intrusion with every muscle you can co-opt. Face muscles intended to widen the maxillary sinuses and dilate the nostrils for nose breathing are pulled inwards and downwards towards the teeth exerting the opposite pressure to that required for forward expansion. In the ’team’ protocol for expansion that includes voice I often begin the treatment by giving exercises to drop the hyoid, begin the tongue shift and open up the face with exercises that improve the vocal ef-

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IFUNA JOURNAL ficiency described above. This develops a lateral and uplifting ‘drag’ on the face. In a patient with a narrow maxilla this may be the first time these muscles have been made to work in this way, so silly games and poems that access manic cat faces abound - for adults as well! This is hard work for the patient, until an appliance is introduced which speeds the process. The result is that the patient feels involved, works hard at the exercises, doubles the effect of the appliance and reduces treatment time. The Efficiency of Tensegrity Structures Tensegrity was coined from the phrase ‘tension integrity’ by the designer Buckmaster Fuller, working from original structures developed by the artist Kenneth Snelson (10). Although every structure is ultimately held together by a balance between tension and compression, tensegrity structures maintain their integrity due primarily to a balance of continuous tensile forces through the structure as opposed to relying on continuous compressive forces. Our commonly held impression is that the skeleton is like a brick wall: that the weight of the head rests on the 7th cervical, the head and thorax rest on the 5th lumbar, which must bear the weight of the whole body. This weight is transmitted down to the feet and from there in to the earth. This is a continuous compression structure. The stability of a tensegrity structure is less stiff but more resilient than the continuous compression structure (Figure 3). Load one part of it and it will give a little to accommodate. Load it too much and the structure will ultimately break but not necessarily where the load was placed, as the structure distributes strain through the lines of tension. The different individual treatment of all clinicians must overlap throughout the human tensegrity structure if correction is to return the patient to maximum function. To achieve this there has to be regular discussion between the clinicians involved.

Figure 3a. A compression structure (10).

Figure 3b. A flexible tensegrity structure constructed of rods and wires (10).

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IFUNA JOURNAL The Importance of Voice in the Early Years The newborn infant has six more years of development before the position of the adult larynx and tongue will be stable and the palate of the size ready to begin to accommodate the adult teeth. It is during these years that the development of speech, singing, upright posture and rhythmic movement can have the greatest effect on the development of the maxilla, mandible and dentition. But there are now fewer places for children to run and jump, chatter and climb and all these are necessary activities to develop posture and the dental arches (Figure 4). Many children are now visually over-stimulated, which also reduces physical activity. Introducing Figure 4. Up, up and away! (3). Early VoiceGym (11), which is based on early reflex patterns, in these early developmental years will ensure that the relevant systems are stimulated, exercised and coordinated (Figures 5 and 6). A paediatric cranial osteopath or chiropractor who monitors the child from birth can maintain the balance between genetic predisposition and the development encouraged by voice and body exercise and informed parents. This prepares the way for the orthodontist to assess whether any help is needed, before the maturation of the central nervous system at ages 7 to 8 makes change more difficult. There have so far been no studies, no recorded experiments, on the improvements that could be made to treatment protocol by including voice and body exercise. As far as I can ascertain only a few dentists have taken this step, all from the UK. Where it has been employed, it has been successful. The emails I receive from people all over the world who are seeking ‘voice aware’ dentists indicate that a properly controlled and conducted study is now overdue. At the first IFUNA meeting in Paris in 2007 I noted the desire of everyone there to connect Figure 5. Singing with co-ordinated movement highlights any with a level of discovery that could only be posweakness in early reflex patterns, which can then be revisited sible through working with each other across (11)

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IFUNA JOURNAL the globe. Last week I visited The Eden Project (12), where a disused and organically dead clay pit in Cornwall UK was transformed by Tim Smit and his team into “a global garden exploring our place in nature”. In his introduction to Eden the founder, Tim Smit, says “Eden is about optimism and the possibility of change. It is about the fragility of certainty and the feet of clay we all suffer from. Our work with communities across the globe shows how quickly change can be made to happen when people work together and understand that ’sharing’ makes us more than the sum of our parts (12).”

Figure 6. Revisiting the early cross-patterning reflex in children with Early VoiceGym (11).

In its adult evolution is not Homo Sapiens - the wise hominid - a complete organic environment in itself? If this is acceptable any corrective treatment can only be deemed to be truly successful when there is improvement of function of the whole human being. Treatment should not merely ‘correct’ symptomatically but also reactivate those skills we lost through having the problem, thus increasing personal happiness, spiritual well being and through it giving us something more to do with our lives.

REFERENCES Sonninen AA. The role of the external laryngeal muscles in length adjustment of the vocal cords in singing. Acta Oto-Laryngologica 1956; suppl 130: 1-102. Caine A. Voice loss in performers: a pilot treatment to test the effect on the voice of correcting structural misalignment. Logopedics, Phoniatrics and Vocology 1998; 23 (suppl 1): 32-37. Caine A. VoiceGym Book: get to know your voice. Southampton: VoiceGym; 2006. Available from: <http://www.voicegym. co.uk> Caine A. VoiceGym: voice and body exercises. Southampton: VoiceGym; 2007. Available from: <http://www.voicegym. co.uk>. Bibby RE and Preston CB. The Hyoid Triangle. American Journal of Orthodontics 1981; 80(1): 92-97.

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IFUNA JOURNAL Platzer, W. Color Atlas And Textbook Of Human Anatomy, Volume 1, Locomotor System. 4th ed. Stuttgart: Verlag; 1992. Andrianopoulos MV and Hanson M L. Tongue thrust and the stability overjet correction. The Angle Orthodontist 1987; April. Crelin E S (1987) The Human Vocal Tract: Anatomy, Function, Development, Evolution. New York: Vantage; 1987. Mew J. Tongue Posture. British Journal of Orthodontics 2001; 8: 203-211. Myers T. Anatomy Trains. London: Churchill Livingstone; 2001. Caine A. Early VoiceGym: a voice and body exercise programme for children. Southampton: VoiceGym; 2006. Available from: <http://www.voicegym.co.uk> Eden Project. The Guide 2009/10. St Austell: Eden Project Books; 2009.

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Association between neurobehavioural status and motor disorders in children with malocclusion

I.A. Rubleva, A.B. Slabkovskaya, L.S. Persin, N.N. Zavadenko Department of Orthodontics, Moscow State University of Medicine and Dentistry, Russia Child Neurology Department, Russian State Medical University, Moscow, Russia SUMMARY: Many authors point out the association between psycho-neurological disorders and different types of malocclusion in children with sucking habits AIM: Assessment of psycho-neurological status and motor disorders in children with malocclusion. METHODS: 20 children, aged 8-12 years, with malocclusion and a sucking habits were examined. They were assessed by special questionnaire (N.N. Zavadenko, 2005) designed to reveal the symptoms of neuro-behavioural dysfunctions. All patients were examined for soft neurological signs (M.B.Denckla, 1984) and performed stabilometry tests with the BioPostural System. RESULTS: The questionnaire revealed psychosomatic problems in 31% of cases, anxiety symptoms in 37%, hyperactivity in 31%, attention deficit in 31.25% and speech problems in 37.5%. Study of motor function and movement coordination has shown an increased number of mistakes in all patients (by 3-4 times) and an increased performance time (by 1.5-2 times) in tests for 20 repetitive or successive movements. Performing test of upright stance on BioPostural System with Eyes Open in the 1st group revealed Ellipses surface increasing 2 times and during examination with Eyes Closed in 2.7 times comparing with control group. CONCLUSIONS: The patients with malocclusion and a sucking habit need detailed neurobehavioral examination and should be studied in collaboration with other specialists, such as child neurologists and posturologist material. INTRODUCTION: Non-nutritive sucking behaviors such as finger- and thumb-, tongue- sucking, tongue thrust, lips- or cheek-sucking, nail-, lip- or tongue biting and other pressure habits represent causative factors for malocclusion. Many authors noted association between sucking habits and different types of malocclusion. Katz C.R. et al. (1) assessed the relationship between non-nutritive sucking habits, facial morphology, and malocclusion in 4-year olds. They demonstrated that a large percentage (67.9%) of children exhibited non-nutritive sucking habits at some point in their lives. In 49.7 % of those children different types of malocclusion were found. Salkovskaya E.A. (2) revealed different types of malocclusion in 71.8% of children with sucking habits. Warren J.J. et al. (3) discovered malocclusions in 55% of children with sucking habits (including anterior open bite, posterior crossbite, bilateral Class II molar relationship or overjet >4 mm) . While

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IFUNA JOURNAL Okushko V.P. (4) found distal occlusion in 47% of children with sucking habits. The rate of anterior open bite is 17.7% in children with mixed-dentition (5). Analyzing reasons for relapse after orthodontic treatment E.A. Salkovskaya concluded that in 54% of cases relapses are related with non-cured sucking behaviors in children. Many authors point out the association between psycho-neurological disorders and different types of malocclusion in children with sucking habits (6, 7, 8, 9, 10, 11). During neurological examination many children with sucking habits are diagnosed as a having Minimal Cerebral Dysfunction or Attention Deficit Hyperactivity Disorder (ADHD). In addition to cognitive problems, disturbances of motor control and coordination are very typical in children with ADHD (Figures 1, 2, 3, 4).

Figures 1, 2, 3, 4. Child with symptoms of Attention Deficit Hyperactivity Disorder (ADHD).

Dysfunction of muscular and central nervous systems lead to the postural balance disturbance. The method of stabilometric analysis (12) is the modern approach to evaluate motor system functioning. The aim of our study was to assess the psycho-neurological status and motor disorders in children with malocclusion and sucking habits.

MATERIAL AND METHODS Two groups of children, aged 8-12 years, were examined. The 1st group included 28 children (14 girls and 14 boys) with malocclusion and sucking habits. The 2nd (control) group of 10 children (5 girls and 5 boys) did not have signs of malocclusion and sucking habits. The following methods were used to examine the children: Parent’s Questionnaire (N.N. Zavadenko, 2005) for detecting the symptoms of neuro-behavioural disorders. Physical and Neurological Exam for Subtle Signs (PANESS) (Denckla, 1985) (Figure 5) is very informative for the assessment of gross and fine motor functions in children. Poor motor coordination

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Figures 5, 6. Child’s Physical and Neurological Exam for Subtle Signs.

and so-called “soft” or subtle neurological signs are typical for children with ADHD. Most of them demonstrate poor performance in both types of these battery tasks, including: 1. Walking line tasks and sustention postures/stations tasks or 2. Tasks for hands and feet repetitive or successive movements (fine motor proficiency). Motor condition assessment by stabilometric tests with the BioPostural System (Figure 7).

Figure 7. Stabilometric tests.

RESULTS AND DISCUSSION In the 1st group of children the following types of malocclusions were revealed - distal occlusion in 50% (26,9% -boys, 23,1% girls), overjet in 15%, anterior open bite in 7.7%, deep bite in 7.7%, mesial occlusion in 7.7% (Figure 8). - 41 -


Figure 8. The rate of malocclusions in children with sucking habits.

According to Parents’ reports, 31% of children in the 1st group had psychosomatic problems, 41% had fatigue, 25% showed hyperactivity, 31% suffered attention deficit, 37% revealed anxiety symptoms and 38.4% had behavioral problems. In the control group only 20% of subjects had psychosomatic problems, 20% had fatigue, 10% showed hyperactivity, 10% suffered attention deficit, 30% revealed anxiety symptoms and 10% had behavioral problems (Figure 9).

Figure 9. Scores for Parents Questionnaire in two groups of patients

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IFUNA JOURNAL In total 15.3% of children with sucking habits had a history of previously diagnosed ADHD. Speech problems were revealed in 76.4% of the 1st group of children as difficulties of articulation or sounds pronunciation. Speech problems were more common in children with anterior open bite and mesial occlusion. Assessment of motor control and coordination with PANESS has shown significantly worse performance in the 1st group compared to age-matched controls in both types of the battery tasks, including: (1) walking line tasks and sustaining postures/stations tasks and (2) tasks for hands and feet repetitive or successive movements (fine motor proficiency). Performance speed in the tests for repetitive and successive movements and number of mistakes increased 1.5-2 times and was especially poor in children with distal occlusion. Stabilometric assessment confirmed motor disorders in children with sucking habits (Figures 10,11). Performing test of upright stance with Eyes Open in the 1st group revealed ellipses surface increasing 2 times and during examination with Eyes Closed in 2.7 times comparing with control group. Surface of stabilometric ellipses in the 1st group increased in 56% of children from 30.4mm2 (Eyes Open) up to 72.58mm2 (Eyes Closed) at the average, which corresponds to a normal range.

Figure 10. Stabilometric parameters in children with malocclusion and sucking habits.

Most prominent changes were revealed in children with distal occlusion. Sway area and surface of stabilometric ellipses in children with distal occlusion (Eyes Open) increased in 2.3 times and during examination with Eyes Closed increased 2.7 times comparing with control group. - 43 -


Figure 11. Stabilometric parameters in children with normal occlusion (control group).

CONCLUSIONS Many children with sucking habits and malocclusion have comorbid psychoneurological and postural disturbances. The patients with malocclusion and a sucking habit need detailed neurobehavioral examination and should be studied in collaboration with other specialists, such as child neurologists and motor therapist (posturologist).

REFERENCES Katz C.R., Rosenblatt A., Gondim P.P. Nonnutritive sucking habits in Brazilian children: effects on deciduous dentition and relationship with facial morphology// Am J Orthod Dentofacial Orthop.- 2004.- Jul.-126(1).-P.53-57. Salkovskaya E.A. The breaches in lip closure and swallowing pattern, methods of their diagnostics with the aim of prevention of malocclusion abnormality relapse. – Moscow, 1981.-228p. Warren J.J. et all. Effects of nonnutritive sucking habits on occlusal characteristics in the mixed dentition. Pediatr Dent. 2005 Nov-Dec;27(6):445-50. Okushko V. P. Malocclusions connected with sucking habits and their treatment. – Moscow: Medicina. - 1975.- 158p. Paola Cozzaa et all. Sucking habits and facial hyperdivergency as risk factors for anterior open bite in the mixed dentition. Am J Orthod Dentofacial Orthop. 2005 Oct;128(4):517-9). Brenner J.E. Thumbsucking. Dental and psychological aspects. N Y State Dent J. - 1974.- Feb.-40(2).- 78-80. Lester, G., Bierbrauer, Selfridge, B., Gomeringer, D. (1976). Distractibility, intensity of reaction and non-nutritive sucking. - Psychological Reports. - 39.-1976.-C. 1212-1214. Sheldon G.H. Psychological factors in the etiology of malocclusion. N Y State Dent J. 1969 May;35(5):277-84. Jacobson A. Thumbsucking: a psychological and dental understanding of the problem. - Int J Orthod.- 1963.- Oct.- 1(4). C. 8-16. Geis A., Piarulle H. Psychological Aspects of Prolonged Thumbsucking Habits// JCO. - 1988.- Aug. - . 492-495. Green S. That little thumb can do an awful amount of damage. // International Journal of Orofacial Myology. – 2003.- Apr.- . 67-80. N.N.Zavadenko, A.S.Petroukhin. Diagnosis and Treatment of Cognitive and Behavioural Disorders in Children. Inergy Limited, London, 2007, 120 p.

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Book Review: The Bimler Cephalometric Analysis Atlas by Dr. Arno Geis, Germany Seven years after the death of Prof h.c.Dr med Hans Peter Bimler , a new, full colour deluxe edition of the Bimler Cephalometric Analysis has appeared in Japan, published by the Yasunaga Press. The atlas reviews 40 years of clinical application of the tele-radiographic Analysis, which first appeared in 1956 in London at the occasion of the EOS Congress. The fundamental feature of the Bimler Cephalometric Analysis is the harmonious balance of the section of measurements and angles of the subject of examination, instead of the comparison of his or her readings to a norm or average value of a more or less extended group of individuals. This allows for the understanding of structural skeletal or dental mismatches, with a prognosis of their further development by growth, and respectively, the orthodontic/orthopaedic effects. To our German chagrin, the book is written in English and Japanese language; however the graphics are self-explanatory for everybody acquainted with the subject. In the second part, the tools and aids are illustrated and discussed: the Bimler Correlometer, the prepared tracing foil with the symbols, the Bimler Two-dimensional Calliper for measuring on the models or directly in the mouth, and the Bimler Treatment Sheet with the millimetre grid for the individual patient reaction curve; and several original case histories with explanations and analytical support may be found. All those colleagues for whom function is not an empty word but the motor of morphology will cherish the book as a mine of information and as a synopsis of the lifework of one of the “Masters of Functional Orthodontics� (Levrini & Favero). The book has 94 pages and can be purchased at Yasunaga Publisher yasunaga@yasunaga.co.jp ISBN 978-4-904501-00-9. It costs 9000 Yen, about 90 USD.

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