Functional therapy

Functional therapy

Functional therapy has its origins in the ideas of Roux, who put forward the hypothesis of a close relationship between the form and function of organs and the skeleton.

According to Roux, skeletal development disorders originate from postural defects and dysfunctions of support systems.

The primary objective of functional therapy is to eliminate functional disorders that interfere with normal development.

This involves early recognition of dysfunctions, as well as their correction to remove limitations and delays in achieving normal growth.

1. Reminders:

• Dysfunction : Dysfunction is a disorder and a malfunction of the function that can be pathogenic.
• A parafunction : refers to a vicious, voluntary or

unconscious, which is not necessary for life such as: thumb or object sucking, lip sucking, nail biting, bruxism, mimicry, mandibular protrusion, etc.

• A tic: a voluntary movement that is repeated without external motivation, nor any disturbance of motor skills or tone.
  • A postural disorder : which designates an erroneous position of the organ or skeleton at rest, this can concern:

The facial envelope : lips and cheeks.

The tongue : in relation to its shape, its volume, and the insertion of its frenulum.

The craniospinal complex : that is, the way the head is supported by the spine. Some children who have difficulty breathing through their nose instead move their mandible forward, often with their head between their shoulders, tilted forward, and their neck quite short.

2. Goals of functional therapy :

Functional therapy can be used in a preventive, interceptive, curative or restraint framework, with the following common objectives:

• Correction of abnormal neuromuscular behaviors (dyspraxias) in order to acquire new automatisms, and continue to normalize functions.
• Restoration of a physiological functional environment by creating conditions for exercising a physiology that does not generate morphogenetic disorders.
• Removal of pathological interpositions (lips, tongues, cheeks, fingers, objects).

3.  Means of functional therapy
   1. Myotherapy:
      1. Definition :

Myotherapy is a form of gymnastics aimed at increasing power

muscle, and to improve the function of certain deficient muscles.

It requires the voluntary collaboration of the subject, because the exercises are quite repetitive and the results take a long time to obtain, which makes it very random for most people.

It consists of a series of muscle contractions , which must be:

Ample, relatively slow, separated by short poses, repeated ten to thirty times, until a feeling of slight local fatigue occurs, and at a frequency of 3 to 4 times per day.

2. At what times?

It is desirable before orthodontic treatment to prevent the worsening of certain already existing deformations.

It is difficult to undertake before the age of 8 or 9 (child’s cooperation).

Myotherapy remains possible at any age, especially when the oral environment is modified.

3. the disadvantages:

Myotherapy must be continued throughout life . As soon as it is stopped, the muscles resume their initial function, unlike functional rehabilitation, the result of which is definitive once the normal circuit is established.

It only gives results if it becomes a habitual attitude and not an intermittent daily exercise.

4. Techniques:

– Mandible thruster gymnastics:

In the case of retrognathia: Voluntarily and slowly move the mandible forward as much as possible and keep it propelled for 10 seconds.

• Labial muscle gymnastics : This is necessary in the case of:
  • Superior proalveolism.
  • Lip occlusion due to shortness of the upper lip.
  • Mouth breathing.
  • Muscle hypotonia.
• Exercises for both lips:

• Cross-curricular exercises:
  • They consist of bringing the corners of your mouth closer together, while an exerciser or simply two fingers oppose this movement with a slight pull directed outwards.
• Vertical exercises

They consist of grasping between the lips (lips only) a disc or a metal blade 3 to 4 cm long, 2-3 mm

thickness, and hold it horizontally for a minute at the beginning; gradually increase the duration of the exercise and the weight of the disc.

• Buccinator gymnastics:
• All children with atypical swallowing tend to tighten their lips when swallowing, contracting the orbicularis oris and stretching the buccinator.

The exercise consists of contracting the buccinator by stretching the corners of the lips “to smile from ear to ear”, the teeth must be in occlusion without clenching during the exercise.

• The exercise is done 10 times a day except in case of fatigue (very common). The child must check the symmetry of contraction by working at home in front of a mirror.
  • Gymnastics of the labio-mental muscles:
• The patient is asked to inflate this area as if he were inflating his cheeks, the air should smooth out the furrow and make it disappear.
  • Toning of the floor of the mouth:
• Piston exercise
  • The patient controls his mylohyoid and geniohyoid muscles, which are essential for swallowing.
  • The patient’s head is in a natural position relative to the spine. The patient must place the tip of their tongue on the most posterior palatine papillae, pressing very hard (press for 2 to 3 seconds then release) and repeat this exercise ten times in a row.
  • He then places his fingers on the basilar edge of the mandible so that he feels the contraction.
  • Tongue toning:
• Horse step exercise (clacking):
  • You are asked to click your tongue to imitate the sound of a horse’s hooves, 20 times in a row at first, then more as you progress.
  • To increase the difficulty, the patient will be asked to distinctly alternate the two sounds “clack” and “cloc”. In case of difficulty, do not hesitate to explain that the front part of the tongue must stick to the palate and detach from it like a suction cup.

2. Functional rehabilitation without equipment:

Functional rehabilitation is that which, based on psychophysiological processes, tends to restore a function disturbed in its coordination and efficiency. It allows to transform a childish praxis into an adult praxis, by modifying the defective motor image which controls it, responsible for the numerous dysmorphoses and malocclusions.

1. Principles:

Stage 1: Make the patient aware of erroneous postures and praxes and show him the correct postures and praxes.

Stage 2 : give him the muscular and joint means to practice praxis and maintain these correct postures.

Stage 3 : the most important: automating these acquisitions , the longest and most difficult stage. If it is not perfectly mastered, it leads to relapses.

2. Age of rehabilitation:

Engramming ends around the age of 10, because all the neural circuits necessary for establishing function are in place.

Rehabilitation should therefore be undertaken before this age. It requires a sufficient IQ. The ideal age is 8-10 years, during the development of the child’s logical thinking.

However, if a ventilatory disorder exists, Mr. Fournier states that rehabilitation must begin at the age of 3-4 years.

3. Relationship between rehabilitation and orthodontic treatment:

Rehabilitation exercises can be prescribed in isolation and constitute

them alone a therapy.

• After mechanical treatment: the advantage is that the morphological conditions are improved, the tongue can spontaneously adapt to these new conditions. As a restraint, functional rehabilitation stabilizes the result obtained by restoring neuromuscular balance.
• Simultaneously :

Generally during late treatment when the child is not sufficiently motivated by isolated rehabilitation.

• Before mechanical treatment:

It is required before any treatment in the following cases:

• Anterior open bite with lingual interposition.
• Tongue on the floor.
• Immature language.

4. Indications for functional rehabilitation:

• Dentoalveolar dysmorphosis of behavioral origin (dysfunction),
• Treatment of resting abnormalities first, and of function secondarily.
• In children with tongue malposition, atypical swallowing, phonation disorder or mouth breathing.
• In adults when the patient who has undergone orthodontic or surgical treatment has an intolerable neuromuscular imbalance, which could be responsible for a relapse.

5. Contraindications to functional rehabilitation:

• Global damage to the neuromuscular system.
• Mental or emotional disturbance (lack of attention or understanding).
• Patient non-cooperation.
• Presence of anatomical obstacle: true macroglossia, short lingual frenulum, adenoids, etc.).
• Severe basal anomalies (significant sagittal and transverse shifts, significant hyper or hypodivergences).

6. Functional rehabilitation techniques without equipment:
7. Posture rehabilitation :

It concerns organs at rest, it is done as a first intention because the posture is maintained 24 hours a day, unlike the function which only lasts a few seconds to a few minutes.

Example: rehabilitation of incorrect tongue posture, by making the patient aware of the importance of repositioning the lingual tip at the level of the retro-incisive papillae, in order to promote the remodeling of the palate and its development, and correct positioning of the mandible.

2. Ventilation rehabilitation:

Functional rehabilitation of ventilation is only possible if the airways are clear (hence the importance of working in collaboration with the ENT doctor)

Make the child aware of the importance of nasal breathing and the benefits of a developed sense of smell.

Different recommended exercises:

Always start by becoming aware of breathing and general attitude in front of a mirror; the child must become aware of what he sees (open mouth, fixed face, asthenic posture from the front and from the side).

Show the child the corrected posture: 2 feet resting on the ground, stomach slightly contracted, shoulders low, head clear of the shoulders.

The child tries to breathe gently through the nose in lip occlusion,

lying on his back, eyes closed. He concentrates on the air, its path (abdominal breathing), his tongue, the different smells.

• Effective work of nasal breathing:

Work on the nasal muscles: (contraction of the upper nostril and lip lifters), dilate the nostrils by opposing them with your index finger and thumb.

Adapted exercises: blow out a candle with the head held straight, the flame on the axis of the nasal breath to extinguish it (by alternately closing the right and left nostrils).

Language work (clearing the upper air junction).

Abdominal breathing work: lying on your back, knees bent, inhale through the nose while contracting the stomach without arching the back and exhale through the nose while tightening the stomach. The aim is to synchronize the diaphragmatic dynamic with the nasal dynamic.

3. Swallowing rehabilitation:

BARETT programs lip and tongue muscle building; only once mobility and perception have improved can it be possible to begin learning the adult swallowing sequences.

According to BOUVET, it is appropriate to explain the disorder and have it observed using a mirror. The patient must then be made to understand the movement that he must perform by slowing it down and breaking it down into its different times:

The child must first learn to place the tip and edges of his tongue on the palatine mucosa in the appropriate place, which the rehabilitation therapist sensitizes using a finger.

He must then occlude the jaws in the usual position, then join the lips without exaggerated contraction.

He then swallows his saliva without opening his dental arches, without moving the edges and tip of his tongue and without contracting his labiojugal muscle strap.

4. Speech rehabilitation:

It mainly concerns: the tongue, the soft palate, the lips but also the clinical observation of the pronunciation of certain words.

CHATEAU had developed a simple method that could be applied to any person of average intelligence. It consists of:

1st step: to have all the consonants pronounced successively, to recognize those which are defective then we teach the subject to pronounce the consonant in its pure state, by showing him the correct supports when pronouncing the phonemes.

Step 2: When the patient reaches this point, they must end the prolonged sound with a vowel. The patient is then asked to repeat these phonemes while being very aware of the stresses.

Step 3: Once the previous step is completed, we gradually shorten the consonant. Then, we will gradually move on to reading aloud words, then entire sentences, always paying attention to the effector organ.

5. Chewing rehabilitation:

In the case of unilateral preferential pathological chewing (on the right or left side), PLANAS recommends the correction of occlusal interferences and prematurities by selective grinding. This neuro-occlusal rehabilitation will lead to freedom of mandibular movements, and therefore the symmetrization of the masticatory function which will become unilateral alternating.

For preventive purposes, a suitable diet is recommended (a diet rich in fiber, with a hard consistency that would force the child to perform correct chewing movements and therefore energize their masticatory system) and the removal of any painful carious foci responsible for a deviation or disruption of the masticatory function.

6. Rehabilitation of parafunctions:

There is no substitute for a gentle psychological approach to the child, drawing his attention to the bad influence of his harmful habits.

When a thumb sucker, for example, presents himself, the practitioner tries to support his words by showing him the casts of a child for whom the damage caused is more significant than his own, who in a few months without a device (cast before and after) made his gap disappear by stopping

simply sucking his thumb. The operator can even give him the means to stop his tic (which has become automatic), such as using adhesive bandages around the thumb, which allows the child to realize it in case of forgetfulness.

3. Functional rehabilitation with equipment:

This involves training neuromuscular behavior through the use of a device that aims to correct dyspraxia. Several devices are available to us to address these behavioral disorders:

1. The nocturnal lingual envelope (NLE):

Also called the “slide” or “night tongue tunnel,” the tongue becomes the natural functional apparatus of the oral cavity.

The placement of the ELN performs a pre-correction of the lingual functioning space, acting directly on the functions.

Description : it is made up of the following elements:

Anterior selective opening: creating a tactile target for the tongue , anterior palatine, median sagittal, retro-incisive papillary.

Anterior slide: which blocks the anterior lingual motor route by depriving the tongue of contact with the lips. Anterior oral locking is no longer ensured by the tongue but by the lips, promoting lip elongation and nasal breathing (reeducation of swallowing and breathing).

The lateral walls of the tunnel: which block the lateral lingual motor route by depriving the jugal tactile environment.

Mode of action:

The ELN, through its function as a barrier against inappropriate motor behavior, allows the deforming forces to cease and consequently, secondary morphogenetic normalization.

Indications:

Indicated in all dysmorphoses of lingual origin , because it acts as a functional re-educator and dento-alveolo-skeletal corrector by suppressing malformative forces.

ELN constitutes the early treatment of certain prognathic syndromes and the ideal functional contention of DELAIRE’s “after-mask”.

Wearing time:

The ELN should be worn for a minimum of 14 hours a day . It is recommended to wear it at night, as a paradoxical increase in swallowing frequency has been noted during sleep.

2. The pearl of TUCAT

It is a pearl placed in the region of the incisive papilla of a palatal plate or a palatal loop welded to 2 rings. This can rotate freely around its fixed axis, allowing the tongue to play with it, and to adopt a new posture in function and at rest. It allows or attempts to correct disorders such as low tongue posture, dysfunctional swallowing by repositioning the tongue posteriorly.

3. The anti-thumb/anti-tongue grid:

In the form of a grid, this device hinders speech and does not always prevent the passage of the tongue, but acts as a reminder device.

This type of device directly combats the effect of dysfunction (tongue) or parafunction (thumb sucking).

Fixed devices (GAP, GAL) should be preferred to removable devices, which are more unpredictable to wear.

Indications: functional open bite, thumb sucking, with insufficient lingual and/or psychological maturation.

4. Plate with vestibular screen:

Consisting of a strip of resin or rubber, placed between the vestibular dental surfaces and the inner surface of the lips and cheeks to prevent lip biting and sucking, thumb sucking and tongue interposition.

Vertically it occupies the vestibule over its entire height, with a notch at the level of the labial frenulum, extending to the first premolars. Its external surface is in contact with the lips and cheeks.

The device can also be used for habitual mouth breathing with defective lip occlusion. The individual vestibular plate will thus have progressively obstructed orifices.

5. The PLANAS (RNO) slopes:

It was Pedro Planas who invented devices that allowed for unilateral alternating chewing in mouths that were initially completely unbalanced.

The treatment, which he called “Neuro-Occlusal Rehabilitation” (NOR), generally consists of wearing two resin plates in the mouth to which two small ridges called “tracks” have been added.

When the patient closes his mouth, the tracks come into contact, the teeth

Slightly raised, they no longer prevent the jaw from moving sideways. The movements of the mandible and the dental friction thus restored allow the balance and growth of the maxillae.

4. Functional orthopedics:

It is a therapy intended to modify or activate a function to change the shape of a structure. It is based on the use of muscle functions in the correction of skeletal shape.

Mandibular propulsion is a living example of this. Whether it is done with an appliance or any device, the aim is to reposition the mandible through the action of the muscles surrounding it (propulsors).

1. Principles:

The key principle is to intervene early enough during the growth phase,

FRANKEL suggests starting treatment in mixed dentition when the alveolar processes are more active.

However, the orthodontist must always take as a rule: functional orthopedic treatment started in mixed dentition will continue until the eruption of permanent teeth.

2. The activators

Growth activators are functional orthopedic appliances that induce an unusual, reproducible, therapeutic mandibular bite position guided by occlusal, mucosal, or mechanical positioning.

Nighttime wear of the device is strongly recommended, due to the increased secretion of growth hormone during sleep.

The duration of wearing is 12 hours/day. The correction of the discrepancy is obtained after 6 to 12 months.

Different types:

1. Rigid monoblock activators:

They are derived from those of ROBIN and d’ANDRESEN, consisting of a rigid bimaxillary resin block placed between the occluded arches; and a vestibular band.

Depending on the objectives, many auxiliaries can be added such as: FEO, vestibular screens, retention hooks, means

of attaching elastic bands…

• ANDRESEN Class II Activator:

A resin monobloc, to which a vestibular band and possibly a transverse expansion cylinder have been added. Descends around the tongue, covering the occlusal surfaces of the lower and upper arches. Generally used in hyperpropulsion.

• ANDRESEN Class III Activator:

It is a resin monobloc used for the treatment of functional classes III, II with lingual antepulsion. It is constructed in forced retropulsion, to which an ESCHLER arch has been added, its action consists of slowing down mandibular growth, stimulation of sagittal maxillary growth, tendency to lingual and distoversion of the mandibular arch, and vestibulo and mesioversion of the maxillary arch.

• Bionator by BALTERS

It is a rigid monobloc, providing bi-maxillary blocking and comprising: A resin body reduced to a minimum. A palatal loop in the contact zone between the tongue and the palate allowing lingual stimulation. A vestibular arch to which protective screens can be added, which extend laterally by buccinator loops, ensuring the distance of the musculature.

2. Elastic or composite activators

Allow mandibular movements in all directions, while guiding the mandible (elasticity and flexibility of the propulsion device).

Indicated for progressive propulsion.

• FRANKEL device

Functional removable device called: “function regulator”. This device has:

A transpalatal arch. A lingual shield with resin and loops on the lingual surfaces of the incisors. Lateral vestibular shields. Labial pads. A vestibular band.

Operate a passive expansion of the periosteal functional matrix thanks to the labial pads and the cheek screens placed at a distance (2 to 3 mm) from the alveolar processes which push back the musculature, favoring the effect of the tongue.

Mandibular advancement is ensured by the lingual screen which rests on the retro-incisive mandibular lingual mucosa.

3. Soft activators

These are functional harmonization aligners, derived from “tooth-positioner” type finishing appliances. These bimaxillary aligners made of shape-memory elastomers (or rubber) allow for simultaneous modification of maxillomandibular growth, the shape of the arches and dental alignment.

4. Thrust activator with stop:

These are devices that propel the mandible by mechanical guidance of maxillary and mandibular elements, forcing it to move forward during the closing movement.

• HERBST device

Consists of a bilateral telescopic hinge, attached to the distal part of the maxilla and the mesial part of the mandible. It is the length of the telescopic tube that prevents the mandible from returning to its original position. This appliance allows movement in all other directions

• The JASPER JUMPER

Recently introduced into the world of orthodontics, it is a modification of the HERBST appliance. The rigid telescopic parts are replaced by elastic parts made of spiral-shaped springs covered with rubber. This elasticity allows the patient to perform chewing movements, particularly in the transverse direction.

3. The bumper or Lip Bumper:

Removable auxiliary device intended to increase the perimeter of the fatty arch by pressure exerted by the lower lip.

Description :

Vestibular arch to 10/ ^10ths of a millimeter adjusted on 2 rings at the level of 36 and 46 (or 75 and 85) and comprising at the incisor-canine level a band of soft resin located 3 or 4 mm from the vestibular surfaces of the incisors. It is prefabricated or shaped. It can be made on a removable appliance.

• Dental effects:

Vestibulo-version of the incisors, the pressure of the lower lip no longer being exerted; only lingual pressure exists.

Blocking or slight distalization of the first molars, by transmission of labial pressure to the molar level.

Indications:

• Preservation of mesial drift space.
• Correction of a linguo-version of the sector, of functional origin (strong tone when sucking the lower lip).

4. Limits of functional therapy
   1. Age-related considerations :

Therapeutic treatments must be carried out during the growth period, hence the use of additional examinations to situate the subject on the growth curve (X-ray of the hand, wrist). Class II activators are more effective at the peak of puberty.

Very early use for classes III (between 3 and 4 years old).

Functional rehabilitation takes place around 8 to 10 years of age during the period of

development of the child’s logical thinking, before the end of brain engramming. This is so that the child understands what is expected of him.

Emotional maturity to stop thumb sucking.

2. Human considerations :

Requires significant cooperation from the patient (regular wearing of the device) and from the family (discipline, long treatment).

The practitioner must know how to motivate them.

Functional therapy is contraindicated in cases of psychological or respiratory problems (asthma).

Functional therapy is indicated in cases of financial problems (less expensive), problems of distance from the office (appointments less frequent).

3. Considerations related to facial type:

Functional orthopedics such as the use of activators is contraindicated if the height of the lower floor is increased.

4. Considerations related to the type of dysmorphosis:

Functional therapy cannot be applied in the presence of anatomical obstacles hindering the functional rehabilitation procedure such as: macroglossia, short lingual frenulum, nasal obstructions, etc.

5. Dental System Considerations:

Functional therapy cannot be undertaken in cases of: Poor hygiene.

Linguoversion of the upper incisors. Vestibuloversion of the lower incisors. Severe overbite.

Important DDM: which requires functional treatment to be carried out in a second step.

6. Stability of results:

The results appear to be long-lasting when a functional deficit is responsible for the dysmorphosis. However, when the functional abnormality becomes anatomical, it will be difficult or even impossible to achieve success with this rehabilitation.

functional only after mechanical intervention (orthodontics, orthopedic or surgical). Functional therapy can only serve as a means of contention in these cases, to prevent recurrence and maintain the results.

Conclusion :

The importance of functional abnormalities in the onset of facial dysmorphosis is no longer in doubt. Therefore, functional therapy, if properly conducted and indicated, ensures, on the one hand, the correction of the dysmorphosis and, on the other hand, the stability of the results, thus preventing any kind of recurrence ; hence the importance of a careful neuromuscular assessment.

Functional therapy

  Wisdom teeth can cause pain if they erupt crooked.
Ceramic crowns offer a natural appearance and great strength.
Bleeding gums when brushing may indicate gingivitis.
Short orthodontic treatments quickly correct minor misalignments.
Composite dental fillings are discreet and long-lasting.
Interdental brushes are essential for cleaning narrow spaces.
A vitamin-rich diet strengthens teeth and gums.

Functional therapy