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ORTHODONTICS FOR ITS PATIENTS

By Dr. Claude MAUCLAIRE, Orthodontist

14, rue Ravelin


10000 Troyes
FRANCE
cmauclaire.orthodont@free.fr

March 2010
Orthodontics for its patients

Table of Contents

CHAPTER I: INTRODUCTION ............................................................................................................ 5


 Good Dental Health = Well Placed Teeth ................................................................................... 5
 The Position of the Teeth is the Result of the Overall Way the Mouth Functions ...................... 5
 Simple Principles of Hygiene to Keep Teeth Healthy................................................................. 6
 Eating Well Means Good Health................................................................................................. 6
 Establishing a Good, Balanced Diet ............................................................................................ 7
 Giving Up Dietary Excess ........................................................................................................... 7
 Well Placed Teeth Throughout Life ............................................................................................ 8
BASIC PRINCIPLES .............................................................................................................................. 8
- A: Malformed Dentition is Not a Fatality ............................................................................... 8
- B: The Origin of Problems is Essentially Functional.............................................................. 8
- C: The Various Functions of the Mouth ................................................................................. 9
 Chewing and Swallowing Food ...................................................................................... 9
 Swallowing Saliva ........................................................................................................... 9
 Speech ............................................................................................................................. 9
 Breathing ....................................................................................................................... 10
 Facial Expression .......................................................................................................... 10
- D: The Importance of Swallowing ........................................................................................ 10
 Suction Swallowing in Babies and Toothless Elderly People ....................................... 11
 Mature Swallowing in the Older Individual .................................................................. 11
 The Importance of Mature Swallowing for the Teeth ................................................... 12
- E: The Flesh Sculpts the Bone and Positions the Teeth ........................................................ 12
- F: The Key Role of the Tongue in the Way the Mouth Functions ........................................ 13
 The "Orchestra Conductor" of the Mouth ..................................................................... 13
 Its Role in Articulating Words ...................................................................................... 14
 Its Role in Swallowing .................................................................................................. 14
 Its Role in Breathing...................................................................................................... 14
- G: Voluntary and Unconscious Movements ......................................................................... 15
- H: An Attractive Profile: the Decisive Role of the Lower Incisors ...................................... 16

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Orthodontics for its patients

CHAPTER II: PROGNATHISM .......................................................................................................... 18


- A: Prognathism, Alveolar Protrusion and Retrusion ............................................................ 18
 Of the Upper Jaw or "Horse Teeth" .............................................................................. 18
 Of the Lower Jaw or "Protruding Chin" ........................................................................ 22
- B: Labioversion without Prognathism .................................................................................. 25
 Only in the Lower Jaw (Labioversion of the Mandibular Incisors) .............................. 25
 Only in the Upper Jaw (Labioversion of the Maxillary Incisors).................................. 26
 In Both Jaws at Once (Double Protrusion of the Incisors) ............................................ 26
CHAPTER III: WIDTH DEFORMITIES ............................................................................................. 29
- A: Upper Molars Wider Apart Than Lower Molars (Maxillary Expansion) ........................ 29
- B: Upper Molars Not as Wide Apart as Lower Molars (Maxillary Contraction) ................. 30
CHAPTER IV: VERTICAL DEFORMATION OF THE FACE.......................................................... 33
- A: Long Face (Vertical Growth) ........................................................................................... 33
- B: Square Face (Horizontal Growth) .................................................................................... 35
CHAPTER V: GENETIC ABNORMALITIES .................................................................................... 37
- A: Agenesis ........................................................................................................................... 37
- B: Supernumerary Teeth and Odontomas ............................................................................. 38
- C: Microdontia ...................................................................................................................... 38
- D: Crowding.......................................................................................................................... 38
- E: Impacted Teeth and Wisdom Teeth .................................................................................. 40
 Impaction of the Upper Canines .................................................................................... 40
 Wisdom Teeth ............................................................................................................... 42
- F: Cleft Lips .......................................................................................................................... 42
CHAPTER VI: FUNCTIONAL DEFORMITIES ................................................................................ 44
- A: Retained and Ankylosed Teeth ........................................................................................ 44
- B: Open Bite ......................................................................................................................... 45
 The Three Main Types of Open Bite............................................................................. 45
- 1: Unilateral Open Bite.............................................................................................. 45
- 2: Bilateral Open Bite ................................................................................................ 46
- 3: Total Open Bite ..................................................................................................... 47
 Consequences of Open Bites ......................................................................................... 48
- 1: Jaw Joint Dysfunction ........................................................................................... 50
- 2: Tooth Grinding or Bruxism ................................................................................... 50
- C: Supraocclusion ................................................................................................................. 52
- D: Diastema or a Gap Between the Teeth ............................................................................. 55
- E: Neuralgia or Toothache .................................................................................................... 56
- F: Receding Gums or Periodontal Disease ........................................................................... 56
CHAPTER VII: CURING BY FUNCTIONAL RETRAINING .......................................................... 59

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Orthodontics for its patients

- A: Restoring Correct Function .............................................................................................. 59


 Establishing Mature Swallowing................................................................................... 60
 Restoring Correct Articulation of Sounds ..................................................................... 61
 Exercises........................................................................................................................ 61
 Establishing Correct Chewing ....................................................................................... 62
- B: Gaining a Beautiful Smile ................................................................................................ 64
 By Correct Positioning of the Teeth on the Bone.......................................................... 64
 By Correct Intercuspation and Good Alignment of the Teeth ...................................... 64
- C: Stabilizing the Results ................................................................................................... 65
 Through Appropriate Exercises..................................................................................... 65
 By Fitting a Tooth Positioner ........................................................................................ 66
- D: The Use of Corrective Appliances ................................................................................... 67
 The Activator................................................................................................................. 67
 The Crib......................................................................................................................... 69
 The Quad Helix ............................................................................................................. 70
 The Delaire Mask .......................................................................................................... 71
CONCLUSION ..................................................................................................................................... 73
 Theory Proven by the Results ................................................................................................... 73
 The Case of Caroline O. ............................................................................................................ 73
 In Support of Functional Retraining Orthodontics .................................................................... 76
SHORT GLOSSARY ............................................................................................................................ 78
INDEX

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Orthodontics for its patients

CHAPTER I: INTRODUCTION

 Good Dental Health = Well Placed Teeth

Having well placed teeth is not just a matter of aesthetics. Above all it guarantees that your dentition is
strong and, consequently, healthy. Orthodontics, which literally means "the science of straight teeth,”
is not satisfied with simply establishing an attractive smile but takes effective action in cases where
there are oral and dental health problems.
During my many years' experience as an orthodontist I have become convinced that good dental health
depends on certain basic principles that can be explained to anyone, and this is what I propose to do in
this book.
The idea of writing this book came to me recently while I was reading an archeological report on
examination of the skulls of our early ancestors. This report was considering some 600 prehistoric
skulls exhumed from a necropolis in the southwest of France. In the skulls where the jaws were
correctly aligned with the teeth in their right positions (they "interacted correctly"), the teeth were
healthy: there were no caries or loose or missing teeth. In contrast, the jaws that were misshapen in
any way had lost all their teeth.
What conclusion should we draw from that? Quite simply, that there is an undeniable relationship
between the health of our teeth and how they are placed in the bone. What was true for our ancestors
is also true for us.

Marie Hélène G.

 The Position of the Teeth is the Result of the Overall Way the Mouth Functions
Olivier G.

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Orthodontics for its patients

We still need to understand what is meant by the teeth being in their correct position, and what the
causes are, particularly of their not being so.
Is it Nature that places our teeth in a good or bad position right from birth? Many people believe this
to be the case, but they are wrong since congenital abnormalities (abnormalities present from the time
of birth) are not the most frequent cause of correct or incorrect positioning. Might it not instead be the
individual himself who, day after day, shapes his own dentition, so that his teeth become well or badly
placed in their bony support?
This is where we touch on the root of the problem of which most of us are unaware. My clinical
experience has awakened me to the irrefutable fact that, apart from in rare cases, the positioning of the
teeth is not innate and certainly not permanent, but results from the overall way the oral cavity
functions.
Even if we must all make do with what Nature gives us at birth, we shape our own dentition. We need
to be aware that the mouth is not a rigid system: the organs forming it have a certain plasticity or are
even malleable—including the bony parts. We will see later what is meant by this.
The function or role of each part of the mouth—the tongue, lips, cheeks, jaws, teeth—helps shape the
oral cavity as a whole. All the parts work together and should therefore be considered as a unified
entity and not, as many believe, as separate items. The relationships between the parts of the mouth
determine whether the teeth are well or badly positioned and consequently whether oral health is good
or not.
Teeth with caries, receding gums, teeth poorly fixed in their bony base or not fitting together well
(known as poor "intercuspation"), or even abnormal differences in level between the teeth which
create open bite (i.e., space between the upper and lower teeth, which cannot therefore intercuspate),
must not be treated as isolated problems. The functional defects of the other parts of the mouth which
are the source of the problem must be examined and corrected.
The orthodontist will therefore seek to reestablish good overall function for all the elements of the
mouth, in order to correct abnormal positioning and thus any health problems that may have
developed as a consequence.

 Simple Principles of Hygiene to Keep Teeth Healthy

After several decades of practice, I have gradually compiled a number of simple principles which,
once understood and applied, make it possible to maintain healthy dentition throughout life. It is the
simplicity of these principles and their empirical validation (which I will illustrate with dramatic
examples) that made me decide to write this book for parents, particularly those whose children are
going through the prime period of dental development. Good dentition can be achieved by following a
few pieces of advice which can be perfectly understood by anyone.

 Eating Well Means Good Health

The principles of dental hygiene that have come to the fore are based above all on the patient’s
ordinary, everyday behavior. We need to analyze the way we usually do certain things, remembering
that while our habits may be "second nature,” they are often bad and have been inflicted on us more
by society than by Nature, particularly where eating is concerned.
The interests of the food industry are not necessarily compatible with good dental hygiene, nor with
the interests of the human body as a whole, which must be constantly fed for it to develop, survive and
defend itself against the bacterial and viral attacks that constantly assail it.
It is not fate that causes a large number of minor viral infections to affect certain individuals who are
thought to be predisposed to becoming ill. In a great many cases, illness in fact results from a
deficiency in the body's defenses, the efficacy of which depends on the food ingested each day and

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Orthodontics for its patients

with which the organism renews itself. If it relies on an unbalanced diet the body will naturally be
poorly protected and will not be able to defend itself adequately against bacterial or viral attack.

 Establishing a Good, Balanced Diet

Our diet has become very unbalanced relative to what is naturally essential for our organism. We often
eat too much and inappropriately: too much sugar, salt and saturated fats, particularly at the expense of
fruit and vegetables. This leads to excess weight and obesity, a scourge unfortunately becoming more
and more widespread in children, the main target of manufacturers of sweets, sodas, hamburgers and
pizzas.
The disastrous consequences of childhood obesity for the adult are well known. In the United States
the upsurge in cardiovascular diseases and cancers caused by incorrect diet is becoming a real
"epidemic," according to statements by health authorities. Obesity has even begun to reduce life
expectancy for the first time in the history of the country.
In addition, doctors have developed the habit of readily prescribing many medicinal products to
combat repeated colds and sore throats, attacking the consequences and not the causes of the problem.
The frequent recurrence of such illnesses in many patients should nevertheless alert medical
practitioners to the problem, which is actually structural, due above all to bad dietary habits, and not
linked to climate or pollution in cities.
It is essential to teach our fellow citizens to eat correctly again, considering the implications of an
unbalanced diet. Poor habits have repercussions for their dental health, both before and after
encountering problems.

 Giving Up Dietary Excess

A female patient consulting her doctor for digestive disorders or for being overweight is not so much
motivated by health as by aesthetic reasons. Putting on too much weight affects the image she has of
her body in relation to the models of perfect slimness and beauty impressed on our minds by
advertisements, fashion and the media.
It is not just chance that causes many adolescent girls to feel torn between the desire to give in to the
consumerist temptation fostered by the food industry and the wish to conform to the models of
slimness, or even utter skinniness, displayed each day in magazines and on screens. One minute they
stuff themselves with sweets and industrial foods saturated with fats and salt, and the next they think
they can compensate for it by creating nutritional deficiencies through excessive dieting, which is
often harmful to health and completely ineffective. Rather than bulimia and anorexia, it is better to opt
for a varied, balanced diet, combined with regularly practicing a suitable sporting activity.

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Orthodontics for its patients

The Role of Diet in Dental Health


These observations may seem remote from dental problems, but that is not at all the case, for it is to
the diet that we should be looking to discover one of the explanations for the good dental health of our
prehistoric ancestors, mentioned earlier, whose skulls retain their dentition intact. The nature of the
healthy and natural food consumed at that time, and also its physical consistency, must be considered:
our prehistoric ancestors had to chew their food well, as it was often raw and therefore harder than the
food we consume today.
The fact that nowadays we willingly consume foods that have been softened (mainly by successive
cooking, freezing and reheating), as well as food that is often doughy or even liquefied, has had an
impact on our dental health and explains the fact that toothless jaws are more frequent now than in
earlier times, and in younger and younger people.
The basic reason has to do with chewing (mastication), which has become increasingly inadequate, if
not altogether disregarded. The sacrosanct hamburger is a good example of this: the ground meat and
soft bread encourage the eater to swallow without chewing.

 Well Placed Teeth Throughout Life


The observations and recommendations that follow are intended to help anyone keep his or her teeth
intact throughout life, as long as the bones in which they are placed are not deformed and the teeth
themselves are squarely in those bones. This is the raison d'être of orthodontics. We are going to show
you how to achieve this result, in cases where it has not "spontaneously" occurred, by using the forces
exerted naturally by the various constituent parts of the mouth. Our method aims to reestablish correct
functioning of these parts so as to naturally reestablish good positioning of the teeth, without having to
resort to major and intrusive surgery, the effects of which, in the long term, may prove to be worse
than the problems themselves.

BASIC PRINCIPLES

- A: Malformed Dentition is Not a Fatality

Individuals' dentition and, more generally, their facial appearance, varies so much that it is not always
easy to know how to define "good" dentition or "correct" jaw position.
The wide variety in facial appearance is usually attributed to the random hand of Nature, and thus to
the laws of genetics: each person is said to have his own dentition, just as he is said to have inherited
his precise eye or hair color. A protruding chin or the opposite, prominent upper teeth known as "horse
teeth," are very often considered to be "natural." When correction is envisaged, it is essentially for
aesthetic reasons, as these profiles are considered to be unsightly.
Just as a cosmetics surgeon is called upon to modify some part of the body, the orthodontist is often
asked to provide a solution to problems perceived to be more aesthetic than functional, consisting of
correcting natural malformation, rather than retraining poor mouth function, due to bad habits
acquired.

- B: The Origin of Problems is Essentially Functional

The aim of orthodontics is not just to realign the teeth so that they are straight and consequently
pleasant to see, producing a beautiful Hollywood smile with the teeth in a row like piano keys. Its
purpose, above all, is to reestablish correct functioning of each of the different parts of the mouth to
prevent future health problems, which could prove serious. Aesthetics, here, goes hand in hand with
good health, with "correct function" being the common denominator.

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Orthodontics for its patients

Our dentition was not created exclusively to be seen when we smile but to serve the vital function of
mastication. Our teeth break down the food we consume and grind it like a mill. Solid, well positioned
teeth are needed to perform this function satisfactorily. Yet it is perfectly commonplace to see many of
us with receding gums (that is to say, teeth moving within the bony alveolus or socket), teeth with
caries and, in the worst cases, teeth requiring extraction or spaces where they have already fallen out
—all of which shows that the functions of the mouth are not being fulfilled as they should be.
The orthodontist's role is not therefore limited to fitting braces to mechanically correct the position of
the teeth and "straighten" them; above all he must try to identify the dysfunction that has caused the
teeth to be poorly positioned and the health problems that have developed as a consequence. What is
the point of mechanically straightening the teeth by temporarily fitting a brace if the dysfunction of the
mouth has not been corrected? As soon as the brace is removed, the teeth will just move out of
alignment again, since the problems related to function have not been resolved.
We know, for example, that the effect of a child habitually sucking his or her thumb hollows the
palate, preventing certain teeth from developing normally and sometimes pushing the upper incisors
forwards into the position known as "buckteeth." It is obvious that if the thumb-sucking is not stopped,
any corrective device will only have a short-lived effect and will not serve any useful purpose.
For the teeth to be straight and well positioned, the many forces at work inside the mouth must be
considered as a whole, not individually, the teeth being only one of the components involved, even if
they are the most visible. The orthodontist uses the natural forces in the mouth to restore its correct
functioning and straighten the teeth.

- C: The Various Functions of the Mouth

The situation is clear: problems generally seen as aesthetic are in fact functional, since they are the
result of poor functioning within the oral area. If we want to understand the mechanisms affecting the
teeth, the way they are fixed in their sockets and how they wear, we need to consider the main
functions of the oral cavity.

 Chewing and Swallowing Food


It is here in the oral cavity that food is chewed or masticated (mastication being the action of
shredding and grinding food) and swallowed (the action of the ground food passing through the
esophagus to the stomach). These functions are the most obvious because we are most aware of them.

 Swallowing Saliva
We swallow our saliva on average 2000 times per day without noticing it; this function is virtually
automatic and therefore we are not conscious of it, in the same way that we blink our eyes and
breathe. We become aware of it when in a moment of emotional stress we notice that our mouth has
become dry.
Saliva continually moistens the mouth (just as tears moisten the eyes), even when we are asleep.
Swallowing, when it occurs correctly, leads to pressure between the jaws, involving contact between
the upper and lower teeth. This mechanical action has decisive consequences on whether the teeth
become correctly or poorly positioned in the jaws.

 Speech
The mouth is an important organ of speech.
Spoken language appeared in humans about 100,000 years ago.
We articulate phonemes, the basic sounds from which we form words. We pronounce thousands of
phonemes a day, and each of them involves the tongue being in a specific position and then making

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Orthodontics for its patients

contact with the teeth and palate. Each language produces its particular effects on the oral cavity,
depending on the particular phonemes that it uses.
It is highly probable that the major cause of the so-called "horse-toothed" dentition of
English-speaking people, a physical characteristic greatly exaggerated by cartoonists, is, among other
factors, the intensive use of the phoneme “the,” which is produced by touching the upper incisors with
the tip of the tongue, producing what the French consider a lisp. The incisors are thus pushed forwards
hundreds of times a day, from childhood onwards. The "horse teeth" observed among English
speakers cannot be attributed to excessive love for the animal of the same name.

 Breathing
This most important vital function normally occurs through the nose (nasal passages). We know that
some children do not breathe through their noses because their nostrils are narrow, owing to
infections, allergies or growths which frequently block the nasal passages. As the air is unable to pass
through easily, such children breathe through their mouths, keeping them permanently partly open,
with the tongue low and slightly protruding. This has an effect on the overall functioning of the mouth
and consequently on the way the teeth develop.

 Facial Expression
Facial expression is also one of the functions of the oral cavity, as our mouth allows us to
communicate our emotions and reactions. Depending on our dentition we may have a wide, toothy
smile or a thin-lipped or crooked smile. We can even make our emotions visible by moving our cheek
muscles.
These many functions are related to the complex organization of the oral cavity. The latter has no less
than 34 joints: these are the joints of the 32 teeth in the two jaws and the two temporomandibular
joints, i.e., the joints connecting the mandibles to the rest of the skull in the temporal region. Besides
these 34 joints, the mouth includes a large number of muscles, with the tongue alone having
seventeen. The oral cavity also provides communication with the external environment (via the lips).
The cranial nerves are nearby and can be the cause of all sorts of pain or neuralgia.
For the teeth to be well positioned and able to carry out their functions correctly, all the elements of
the mouth must be taken into account as a single unified functioning unit.
Apart from problems of genetic origin, there are two primary causes of most problems concerning
tooth position, both linked to bad habits:
- Inadequate swallowing
- Poor tongue posture

- D: The Importance of Swallowing

When we swallow, the food bolus (the chewed food) and the saliva pass from the oral cavity into the
esophagus and stomach to be digested. Surprisingly, the way we swallow may be the root of dental
problems.
Swallowing consists of two distinct phases:

- The food/saliva is conveyed onto the tongue—a conscious, voluntary movement.


- The food/saliva is evacuated by the tongue into the esophagus— an unconscious reflex.

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Orthodontics for its patients

While swallowing food is an intermittent process and happens at particular times, evacuating saliva is
a continuous process. The salivary glands constantly produce saliva, so that as a result, swallowing
continues even during sleep.
Individuals swallow in different ways, depending on whether they have teeth or not (babies, for
example, and elderly people who have lost their teeth).
There are two types of swallowing in humans:
- Suction swallowing (infantile swallowing)
- Mature swallowing

 Suction Swallowing in Babies and Toothless Elderly People


This is essentially the way small babies swallow. It is explained by the fact that babies have no teeth
and consume an exclusively liquid diet. Infantile swallowing is important not only for feeding
purposes but also for promoting the development and growth of the lower jaw, which is mobile, the
upper jaw, or maxilla, being fixed. The baby needs a sufficiently long sucking time to make his or her
lower jaw “work,” which is achieved when he or she is breastfed.
In contrast, bottle feeding takes much less time because the milk is sucked out and drunk more easily,
which explains why the baby compensates by sucking his or her thumb or a pacifier given for the
purpose.
An infant swallows by contracting his cheeks, projecting his tongue forwards and sucking with his
lips. Toothless elderly people who can no longer chew return to these baby reflexes to consume food
which, of necessity, comes in liquid form.

 Mature Swallowing in the Older Individual

This is normal adult swallowing and develops as the teeth take their place in the oral cavity. At the
same time, food becomes more and more solid, requiring chewing before being swallowed.
The mastication needed for solid food is an important function for correct dental equilibrium since it is
the only time the teeth exert considerable force, in order to grind and soften the food before it is
swallowed. During this process, as long as the teeth intercuspate correctly and the temporomandibular
joints are properly aligned, the food is crushed by the molars acting like a mill.
While the food is being crushed, a special reflex comes into play called the proprioceptor reflex
(specific to muscles), which prevents the teeth from striking each other, so that it is only when
swallowing itself occurs that the upper and lower teeth come into direct contact with each other,
providing a necessary leverage point for the tongue, to assist swallowing.
While this is occurring the teeth are subjected to a strong vertical force, the consequences of which are
vital for the health and solidity of the teeth. This pressure, correctly exerted, strengthens the
periodontal tissues (those connecting the teeth to the bone), particularly the ligaments that surround
the roots of the teeth and connect them to the bone of the jaw.
In mature swallowing, the lips and cheeks do not participate in the movement in which the food/saliva
from the oral cavity passes into the esophagus. Everything occurs inside the mouth, which is like a
closed box: the teeth are clenched and the tongue sucks up the saliva while pressing against the palate,
occupying the whole area without coming into contact with the teeth (particularly the incisors). The
tongue alone draws the food/saliva into the depression created in its centre, triggering the muscular
swallowing reflex. The movement of the food bolus downwards is evident as it passes the "Adam's
apple," which makes an up-and-down movement during swallowing.

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Orthodontics for its patients

 The Importance of Mature Swallowing for the Teeth


Mature swallowing plays a decisive functional role in dental equilibrium. Indeed, every time we
swallow saliva or eat, the repeated pressure exerted on the teeth produces two positive effects:

- It stabilizes the teeth by strengthening their establishment in the sockets of the bone.
- It stimulates blood circulation in the gums and periodontal tissues.
Natural development in the growth of any individual means that infantile swallowing becomes mature
as the teeth develop and solid food gradually replaces liquid food.
Only mature swallowing ensures a harmonious balance in a mouth containing teeth.
However, there are many people who, at an age when the swallowing process should be mature, for
various reasons, including heredity, but particularly related to bad functional habits, continue to
swallow by suction—they habitually sucked a thumb, finger or pacifier until quite late, consumed
lollipops during adolescence, have a lisp, etc. There can be many consequences of poor swallowing
habits such as caries, teeth that loosen, bleeding gums, etc. Grinding the teeth while sleeping and
wearing them down, known as bruxism, is probably due to poor swallowing of saliva associated with a
badly positioned tooth. Since the upper teeth cannot properly exert pressure on the lower ones during
swallowing, the circulation of blood in the gums and around the roots of the teeth is poor and the
subject compensates, as it were, by making the uncomfortable tooth or teeth work. The blood
circulation is reactivated by grinding the teeth, but they suffer abnormal wear.

- E: The Flesh Sculpts the Bone and Positions the Teeth

To understand everything that happens in the oral cavity, we must first be aware that it is the soft
tissues (the tongue, lips and cheeks) that control the hard tissues (the bones, teeth), and not, as is
generally thought, the other way around. This has actually been known for a long time. Did not
Lao-Tzu say, "The soft overcomes the hard, the weak overcomes the strong"? Did not La Fontaine
compare the solid oak tree to the supple reed? In fact, this phenomenon is very broadly applicable. We
know for example that the orbit without its eye will close up and be reduced to the size of an eye of a
needle, as I was personally able to witness in India in a young blind beggar.
By their slight but constant and continual action, the muscles of the tongue and cheeks and the
position of the lips have an effect on the position of the teeth, just as, day after day, the water traces
the bed and banks of a river, eroding the hardest of soils. The sinuous nature of the flow of water
causes the formation of meanders: the phenomenon, hardly begun, is amplified by erosion (hollowing)
of the concave bank and silting up (refilling) of the convex bank. Water sculpts shorelines and
mountains through its physical and chemical action on rocks. The same is true of all fluids including
the wind, with its effect on vegetation, shaping even the largest trees, or on the hardest of rocks.
Identical natural processes are at work inside the mouth. There is no doubt that the muscles forming
the tongue fundamentally control how the teeth are positioned, so that we can say without
exaggeration that most dental problems occur through poor use of the tongue, from which it follows
that, in the particular case, the tongue is badly positioned. This explains why restoring correct posture
of the tongue in the oral cavity is necessary and will usually be sufficient to permanently correct the
position of the teeth.
The teeth take up their positions according to the muscle forces exerted around them. They find a
"neutral", or, even better, a "neutralized" position, that is to say, a point where opposing muscle forces
acting on them cancel each other out. Each tooth thus assumes a position of equilibrium and occurs at
the point where the forces exerted by the fleshy parts of the mouth have placed it. This is an individual
equilibrium, individual to each tooth, since there are a great many complex forces acting within the
mouth.
The teeth have to be mutually interdependent for the functions they fulfill to be properly performed
and for the entire dentition to be firmly and permanently established. If everything is to function

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Orthodontics for its patients

correctly, there must be overall equilibrium throughout the oral cavity, not just as concerns the
position of one specific tooth.
For the environment of the teeth to remain stable, they must only be subjected to vertical forces,
namely the forces of mastication and swallowing. In these conditions the mandibular and maxillary
bones (the jawbones) and the periodontal tissues (the connective tissue attaching the teeth to the
jawbones) are able to become strong and create suitable conditions for a set of solid, healthy, stable
teeth which are well aligned, vertical, close together, with no open bite, and which, in addition, but
less importantly, are aesthetically pleasing.
To sum up, the shape of the jawbones and the position of the teeth results from the pressure exerted by
the functional forces produced by the various groups of muscles which make up the oral cavity:

- The cheeks, with the zygomatic muscles in particular, which, for example, pull the mouth
backwards and allow us to smile
- The tongue, the real orchestra conductor of the mouth
- The lips
- The chin muscles, known as the mentalis muscles
- The pharynx
- The masseter muscles which raise the mandible, particularly to close the mouth
- The medial pterygoid muscles which move the mandible for mastication
These muscles are the most powerful in the body. It is the tongue, however, which is the real
conductor of the oral cavity's orchestra.

- F: The Key Role of the Tongue in the Way the Mouth Functions
 The "Orchestra Conductor" of the Mouth
Some people wrongly think that the position of the teeth determines the position of the tongue in the
mouth but, on the contrary, it is the tongue that plays the most important role in positioning the teeth.
The tongue is very much the "conductor of the oral orchestra." It is so powerful that it can cause dental
or even bone deformities when used incorrectly.
To discover how the tongue is being used in a particular case, it must be examined at rest to see
whether it rests between the upper and lower teeth on one side, or on both sides at once, at the front or
throughout the entire length of the dental arches. Its position (whether low, centered or even high in
the mouth), its volume (whether thick, pointed or flattened) should also be observed, as well as
whether the insertion of the lingual frenulum is towards the front or not. If the lingual frenulum is
inserted too far forwards, movement of the tongue is greatly reduced: it can only move at the bottom
of the mouth, and from back to front, causing the lower jaw to move forwards as a consequence
(prognathism).
The behavior of the tongue must also be observed as it functions in order to assess whether its
mobility is strong or normal, how far it extends over the dental arches (to the side, to the front, and
over the entire arch), and its position when swallowing saliva. Interposition of the tongue at the side
prevents the teeth from developing completely (they do not fully erupt), which leads to the height of
the molars and premolars being inadequate and the incisors being excessively covered
(supraocclusion). At rest, since the teeth do not intercuspates, the space left free between the upper
and lower molars increases, allowing the tongue to occupy it.
Thrusting the tongue forwards between the teeth (sticking one's tongue out) can deform the mandible
due to torsion, and sometimes leads to open bite of the incisors, with cessation of growth of the
alveolar bone (the bone holding the teeth).

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Orthodontics for its patients

 Its Role in Articulating Words


When we speak, the tongue is positioned in a way that is almost identical to its position when we
swallow. Articulating sounds is therefore affected if tongue posture is poor.
To pronounce the dental sounds ([d], [t] and [n]) the tongue must not touch the incisors: just a small
area of the tip of the tongue must be raised and touch the palate behind the incisors. There is a hiss
when the tongue is interposed at the sides.
For the sibilants ([s], [z]), the tongue must not be in the middle between the two arches, but must
remain still, at the bottom in the lower arch.

 Its Role in Swallowing


Let us recall, first, that there are different forms of swallowing depending on whether or not the oral
cavity has teeth. Infants and edentulous elderly people do not swallow in the same way as young
children or adults (see below).
There are several indications that an individual is swallowing in an adult manner. Firstly, the cheeks
must not relaxed when saliva is swallowed; secondly, the lips, regardless of how thick or thin they are,
should come together when at rest and have normal tonicity; and finally, when swallowing, the lips
should be relaxed and touch without effort.
In contrast, swallowing in the older individual is atypical, still resembling that seen in the infantile
stage, when the lips are strongly contracted, as an effect of residual original suction, or quiver slightly.
At the same time, contraction of the chin muscles can be seen, with abnormal swelling of the sublabial
muscles. Indeed, the purpose of contracting the lips is to accumulate saliva behind the incisors in order
to apply suction, using the tongue in the same way as a baby does when sucking at the breast. Tartar
deposited behind the lower incisors is a clear sign of swallowing that has remained infantile. If the lips
were to be separated during this type of swallowing, it would be seen that the teeth are not closed
together as they should normally be and that the tongue is thrust forwards.
Adult swallowing should occur without any movement other than that of the tongue, which moves up
and down, and the masseters, which contract; the molars should remain in contact.

 Its Role in Breathing


Normal breathing takes places through the nose (nasal breathing), but a large number of individuals
breathe through the mouth (mouth breathing). This is the cause of many problems often considered to
be of unknown origin, such as a dry mouth when sleeping, sleep disturbed by frequent waking,
allergic rhinitis, snoring and sleep apnea.
Mouth breathing is caused by hindered nasal breathing, due either to the presence of adenoid growth
resulting from repeated infection or to having a palate that is too deep or too narrow, which decreases
the volume of the nasal fossae. The quantity of air drawn in via the nose is not sufficient for
pulmonary ventilation.
A deep palate may be the consequence of sucking a thumb or finger, but also the consequence of
high tongue posture at rest, and therefore also when functioning. This posture can be corrected by
wearing a device that forces the tongue to occupy a lower position. With the tongue retrained the
palate is remodeled; air passing through the nostrils helps enlarge its own passage and is filtered by
the hairs in the nose, thus improving allergic rhinitis.
The same applies to too narrow a palate, which is easily treated with a Quad Helix (see chapter VII)
or a Tongue Right Positioner, thus improving nasal breathing and correct posture of the tongue.
Once nasal breathing is reestablished, sleep problems disappear, providing relaxation and a sense of
well-being. Colds are less frequent and allergies subside.

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Orthodontics for its patients

- G: Voluntary and Unconscious Movements

Malocclusion becomes apparent when an individual closes his teeth and the two jaws, fitting poorly
together, leave an open bite or exhibit imperfect intercuspation or interlock between the upper and
lower teeth. Many of these cases of malocclusion originate from abnormal neuromuscular functioning
of the mouth. The results of treatment to reestablish good occlusion will only be sustained if corrective
dental devices are fitted associated with retraining sessions to correct the muscle behavior at fault,
which is almost always the source of the problem. The difficulty is that these incorrect behavior
patterns will have been present from birth and have therefore become unconscious.
Nature provides for the neuromuscular activities of the mouth and face to be present from birth so that
the infant can survive by being able to breathe and consume food (sucking and swallowing his or her
mother's milk). Studies have shown that these neuromuscular reflexes appear in the fetus at 11 weeks
for the nose/mouth region and at 16 weeks for breathing movements. At about 29 weeks, stimulation
of the mouth already provokes sucking movements.
When a baby is born, the tactile acuity of the lips and tongue is already highly developed. The tongue
extends beyond the toothless jaws and projects between the lips. The infant will follow a finger that
touches his lips with his mouth; indeed his entire relationship with his environment is via his mouth,
pharynx and larynx. These parts of the body are the site of a very high concentration of nerve
receptors. When stimulated, they pass information to the brain, which regulates respiration, sucking
and the position of the head and neck during breathing and breast-feeding. At this stage, the tongue
and lips are the most sensitive reflex area of the body and many external sensory signals are
concentrated here.
Later, with acquisition of mastication and spoken language, development of the neuromuscular
functions will be determined by the teeth. Mastication becomes mature therefore when the incisors
come into contact and stimulate the muscles that control the position of the jawbones. When the upper
(maxillary) and the lower (mandibular) incisors begin to touch, the jaw musculature gradually adapts
how it functions to the arrival of the teeth. Since the incisors erupt first, the mouth acquires its closure
position from the front towards the back following the direction of suction, before closing laterally
when the premolars appear at the sides of the mouth.
The child thus learns in stages to shut his mouth, or acquire his occlusal functions. There is a cause
and effect link between maturation of the central nervous system and maturation of the musculature of
the face, mouth and jaw. The development of the jaws and dentition is synchronized, with the first
mastication movements being irregular and still poorly coordinated. When the first dentition (the milk
teeth) is complete, mastication stabilizes and becomes increasingly effective as foods offered become
more solid, but it is only when the deciduous molars are present and making contact that true
mastication movements appear and mature (adult) swallowing replaces infantile swallowing.
The young child stops feeding from the breast and begins to learn to talk and express himself. This
transition, which takes several months, is helped by the maturation of the neuromuscular components.
It has usually been completed by the time the child is about two years old. The change which has to
take place is considerable, because the mature swallowing process is virtually the opposite of the
infantile process: the jaws are brought together, the end of the tongue is drawn back and no longer
touches the front teeth or those at the side, and the lips are relaxed because they no longer play the
active role they had in sucking.
When this transition fails to occur or is only partial, the result is "atypical swallowing." In this case the
orthodontist does not simply have to retrain the patient, but has to teach him a movement that he has
not naturally acquired. In particular, the tongue must remain supple and immobile. It normally
"knows" what it has to do to swallow if the environment is correct. The muscles connecting it to its
bony base have to be sufficiently developed to allow it to move so that chewed food is carried towards
the esophagus. This also applies to the muscles that control vertical movement of the lower jaw (the
only mobile jaw) and allow mastication, and, moreover, provide the tongue with support as it
performs its backwards swallowing movement. Closing the teeth together is normally enough for this
movement to occur.

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Orthodontics for its patients

Just as singers, for instance, keep their tongues in a low position to allow sound to pass, actors are
taught to articulate clearly by making them talk with a pencil between their teeth to keep the tongue
relaxed and in a low position. The tongue should only move in the mouth to pronounce the dental
consonants ([t], [d], [n] and [1]).

- H: An Attractive Profile: the Decisive Role of the Lower Incisors

The position of the lower incisors is decisive for the profile and therefore for treatment too, because
the upper jaw fits over the lower jaw, enveloping it. Because the tooth and the bone form an
interdependent unit, the lower incisors must be stable, so that the forces arising during mastication do
not put a strain on them but rather strengthen them. Once the lower incisors are stable, the upper
incisors must fit in front of and slightly overlap them to properly fulfill their role as scissors, cutting
and "incising" food, hence their name.
The profile should be straight, with the upper and lower lips well defined and displaying slight
concavity. The nose and chin are included in the profile.

Long face Square face

A long face should have a flatter profile, with the incisors positioned further inwards, whereas a
Position
square face can of theincisors
take lower incisor
more depending on whether
inclined towards the the face issolong
exterior thatorthe
square
lips are more visible
in profile.
oooooooooooooooooooo

It is clear that the aim of orthodontic treatment is to obtain correct occlusion, with the teeth coming
into contact properly when the jaw is closed, that occlusion stabilizing over time with the teeth firmly
in place. Occlusion is not a purely mechanical phenomenon, but the result of diverse, discontinuous
and dynamic forces acting in particular on the teeth. The growth of bone, the force of muscle
contraction during mastication and the natural tendency of teeth to move are decisive factors. Finally,
functions performed abnormally can influence the shape and direction of growth of the facial skeleton
and skull, and therefore even the physical appearance of the face.
The volume of the soft tissues and the way they function depend on the brainstem of the central
nervous system, which induces unconscious mouth reflexes. The latter are inherited, as has been
shown by the most recent discoveries in the field of embryology. Indeed, the genes which control
these reflexes in particular are present from the third week of embryonic life and are inherited from
the parents. Nevertheless, heredity is not a fatality, because tissues are continually being renewed

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Orthodontics for its patients

during the course of existence. We know, for instance, that the body's entire store of calcium is
completely renewed in less than three months.
It follows from this perpetual activity that while incorrect functioning of the tongue, cheeks and lips
may ideally be corrected during the period of growth, it may also be rectified after the growth period,
since tissue remodeling is a process that occurs throughout life.
Everything is dependent on continual remodeling of the hard tissues (bones and teeth) by the soft
tissues (the tongue, lips and muscles of the mouth and face) with which they are in contact.
Normally, when the muscle forces of the mouth are balanced, the teeth will grow straight and
perpendicular to the bony base. However, lips exerting too much pressure on the teeth (excessive
labial force) will push the incisors inwards, and, conversely, a constantly moving tongue thrusting
forwards will push the incisors and sometimes even the jaws forwards.

As surprising as it may seem to the non-specialist, the functioning of the tongue has considerable
impact on the position of the teeth and the shape of the face. The resulting deformations create
particularly what are known as facial disharmonies: endognathism, retrognathism, prognathism, etc.
Deformations to the front or rear, in width or height, are again functional, and may have serious
consequences for oral health in general unless they are corrected in time. These malformations depend
on the point of application of the harmful forces in question (the precise point of action in the mouth)
and on their intensity and duration.
It is easy to see that the problems posed are not simply aesthetic: the harmony or disharmony of the
jaw is only a visible reflection of the state of dental health, intimately related to the good or poor
functioning of the different components of the mouth.
Aesthetics is the tip of a much larger medical iceberg than it was first perceived to be.

oooooooooooooooooooooo

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Orthodontics for its patients

CHAPTER II: PROGNATHISM

Prognathism is deformation of the basal bone, causing the upper and/or lower jaw to project forwards
abnormally. The jaws are therefore no longer aligned one with the other, one of the two being offset
forwards.
Forward projecting teeth (alveolar protrusion) or the opposite, posteriorly projecting teeth (alveolar
retrusion), may be added to this problem, complicating still further the orthodontist's task of correcting
the position.

- A: Prognathism, Alveolar Protrusion and Retrusion

 Of the Upper Jaw or "Horse Teeth"


This results from excessive pressure of the tongue on the upper jaw. When the tongue also exerts
strong pressure on the upper incisors, the alveolar bone, which holds the teeth in the jaw, projects too
far forwards. Alveolar protrusion, (also known as labioversion) of the upper incisors is added to the
maxillary prognathism, so that not only does the upper bone project forwards, but so do the teeth.
An abnormal space is created between the upper and lower incisors: the upper incisors are long and
protrude from their alveoli because there are no antagonist teeth with which they are able to make
contact. The lower incisors rest against the palate instead of against the upper incisors. Because they
are thus weaker, these teeth loosen in adulthood, and a child will not use his incisors because they are
sensitive, preferring to cut up his food with his side teeth.

Damien P
Interposition of the lower lip exerts pressure on the lower incisors, which are pushed
backwards. While the chin has continued to grow, the mandibular incisors are obstructed and
rest against the palate. The maxilla markedly protrudes and the upper incisors rest on the
lower lip. The space between the teeth equals the thickness of the upper lip.

If, in addition, the lips are very tonic and strong, the upper incisors can be pushed back inwards so that
the canines, the last teeth to emerge in the anterior part of the arch, erupt very high in the gum or may
not even be able to emerge at all (they are "impacted"). The lateral incisors pivot sideways due to lack
of space, and the central incisors more or less completely cover the lower ones, resting against the
lower gum. The upper arch is caught between two powerful muscle forces. In such cases upper
alveolar retrusion complicates the maxillary prognathism: the top bone protrudes while the
corresponding incisors incline inwards.

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Orthodontics for its patients

Xavier P: Before treatment


Example of a smile showing the gums; the upper incisors are inclined inwards, but protrude;
they completely cover the lower incisors, so that the smile line has moved downwards.

The roots of these incisors become prominent and deform the bone of the maxilla at the base of the
nose, pushing it forwards (the gums become clearly visible when smiling).

Françoise G

Françoise G: Before treatment After treatment

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Orthodontics for its patients

Françoise G: Before treatment After treatment

In the case of Françoise G. (above), it was not possible to put the canine back into place because of
fears of serious damage, surgery proving to be impossible. The canine remains within the palate.
The root of the lateral incisor was being worn away by the development of the canine, but the
treatment undertaken should allow it to be repositioned.
If the lower lip is interposed between the upper and lower incisors, mandibular alveolar retrusion is
added to the maxillary prognathism: the maxillary bone projects, while the lower incisors are
abnormally directed towards the interior of the mouth.

Isabelle S.

The face is long, the upper lip short and the chin long. The maxilla protrudes a long way: the distance
between the upper and lower incisors is 12 mm, which is the same as the thickness of the lip interposed
between the teeth. The premolars must be extracted in order to pull the upper incisors back and put
them in the correct position.

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Orthodontics for its patients

The lower incisors rest against the palate. Maxillary labioversion and supraclusion can be observed
in cases where the mandible is small. The growth of the mandible is slowed by the lower incisors
which rest against the palate. To make contact possible between the two jaws, the mandible is
subjected to torsion. It must be freed so that its growth can catch up with that of the maxilla. This is
possible here, as growth has not been completed.

In the case below, of Damien P., the distance between the upper and lower incisors was 1.4 cm.
Treatment consisted of slowing the growth of the upper jaw while freeing the growth of the lower jaw
and decreasing the height of the incisors by retracting them into the bone.
It was also necessary to retrain Damien's swallowing function; he sucked in his lip each time he
swallowed, abnormal behavior that was responsible for the difference in bone growth between the
two jaws. A banding appliance was fitted for 18 months to exert forces in opposite directions. Less
than 4 mm of mandibular growth was obtained, with equivalent shortening of the maxilla, which thus
became correctly superimposed over the mandible, with the teeth correctly positioned. The profile
obtained was good, as the after-treatment photos show.

Damien P: Before treatment After treatment

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Orthodontics for its patients

Damien P: Before treatment After treatment

 Of the Lower Jaw or "Protruding Chin"

This results from excessive pressure of the tongue on the mandible.


If the upper molars are posterior to their normal position, compared with the lower teeth, the upper
incisors will also be behind those of the lower jaw. This is mandibular prognathism: the chin is
prominent, forming a "protruding chin.”
The growth in length of the maxilla (and sometimes even its width) is impeded by the mandible,
which, because of its mobility, is able to encircle it.

Stéphanie L.

The growth of the upper dental arch is completely hampered by the mandible, both
transversely and in the anterior-posterior direction.

The upper teeth overlap through lack of space (dental crowding), while the lower teeth develop
normally and line up correctly without hindrance.

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Orthodontics for its patients

As in maxillary prognathism, mandibular labioversion can occur with mandibular prognathism: both
the jaw and the lower incisors protrude.

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Orthodontics for its patients

Before treatment After treatment

Before treatment After treatment

Before treatment After treatment

A protruding lower jaw is not only unattractive but also functionally deficient. The tongue moves at
the bottom of the oral cavity and to the front of it and the teeth are positioned beyond it. Growth of
the maxilla must be encouraged to reestablish normal function.

Alveolar retrusion does not occur with mandibular prognathism because the lower lip does not exert
the same force as the upper lip. It is incapable of pushing the lower incisors inwards into the oral
cavity.

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Orthodontics for its patients

- B: Labioversion without Prognathism

In this case, the malformation only involves the teeth and the alveolar bone, not the basal bone (as is
the case in prognathism). The teeth may protrude abnormally in the upper jaw (labioversion of the
maxillary incisors), in the lower jaw (labioversion of the mandibular incisors), or in both jaws at once
(double protrusion of the incisors).
 Only in the Lower Jaw (Labioversion of the Mandibular Incisors)

Before treatment

Before treatment

After treatment

The upper incisors project forwards by 18 mm, the thickness of the lip. Their growth is not curbed by
the lower lip. Treatment reduces this difference and repositions the incisors correctly, the upper
incisors resting against the lower ones, without completely covering them.

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Orthodontics for its patients

 Only in the Upper Jaw (Labioversion of the Maxillary Incisors)


This problem is entirely functional in origin, i.e., lingual, meaning that the tongue exerts too much
pressure on the lower incisors.

 In Both Jaws at Once (Double Protrusion of the Incisors)

There is no bone deformity but rather a lack of bone at the base of the nose, which makes it appear
flattened. The problem only involves the alveoli and the teeth they contain, which project forwards.
This is the "Asian" profile. Appropriate treatment, pulling the incisors back to the correct angle,
refines the nose, as the photos below show.

Bernadette N: Before treatment

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Orthodontics for its patients

Sometimes the four premolars need to be extracted before the actual

Bernadette N: After treatment

Sometimes the four premolars need to be extracted before the actual orthodontic treatment
can be undertaken to obtain substantial straightening of the incisors and the resulting
modification of the profile.

Van N: Before treatment

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Orthodontics for its patients

Van N: After treatment


In the case of young Van N., banding treatment and retraining produced excellent results after the four
premolars had been extracted. The wisdom teeth, once they emerge, will be retained and will hold the
entire dentition of the two arches in place, stabilizing the straightened incisors.

Before treatment

Before treatment

After treatment

Advancement of the maxilla affects both the basal and the alveolar bone. If treatment is
initiated early enough, it is possible to take advantage of growth, stimulating it in the mandible
and curbing it in the maxilla.

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Orthodontics for its patients

CHAPTER III: WIDTH DEFORMITIES

These deformities affect the upper jaw, originating in the bone rather than the teeth. Since the teeth,
however, are attached to the bone, they follow the deformation it sustains. Such deformities are also
linked to incorrect tongue or lingual function.

- A: Upper Molars Wider Apart Than Lower Molars (Maxillary Expansion)

Maxillary expansion occurs when the palate is wide as a result of having been shaped by a large
tongue exerting pressure all around the upper jaw. The maxilla develops too greatly in width so that
the first upper molars "articulate" (are sited) lateral to their normal position.

Palate

As the above diagram shows, the upper teeth are to the outside of the lower teeth, the upper jaw being
wider than the lower. The consequences on how the mouth functions are generally significant. Not
only are the upper incisors pushed forwards excessively, but the upper molars, being wider apart than
the lower ones, are no longer in occlusion with them, i.e., they do not intercuspate to fulfill their
grinding function. Chewing and crushing food is not possible, which may lead to significant digestive
problems.

Huu Hoa

The upper arch is wider than the lower arch: it is impossible to chew because the molars do not
make correct contact.

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Orthodontics for its patients

Huu Hoa
- B: Upper Molars Not as Wide Apart as Lower Molars (Maxillary Contraction)

In contrast, when the tongue does not fill the entire volume of the palate during swallowing, it does
not exert sufficient lateral pressure on the walls of the upper jaw. Maxillary contraction ensues,
with the result that the palate narrows and the upper molars are positioned to the inside of the
lower molars, whereas normally the upper dental arch circumscribes the lower.

Palate

Contraction may be unilateral, involving only one side of the jaw, or bilateral, involving both
sides.

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Orthodontics for its patients

Séverine F: Before treatment After treatment

The palate is narrow; only one side is affected and articulates to the inside of the
lower molars. The midline between the incisors is off center and misaligned,
producing repercussions on the temporomandibular joints

Thierry P: Before treatment After treatment

Before treatment After treatment

The tongue functions low in the mouth and does not shape the palate, which remains
small and narrow. The upper molars and premolars articulate to the inside of the
lower molars. The narrow palate is circumscribed by the mandible at the sides, and
the detrimental transverse pressure exerted on the molars causes them to loosen.

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Orthodontics for its patients

Since the palate remains narrow and deep, breathing difficulties may develop.

Florence F, 11½ years old: Before treatment

Florence F, 11½ years old: After treatment

The palate of this 11½-year-old girl, Florence F., resembled that of a 3-year-old child. The lateral
incisors were hardly visible, the canines had not had enough space to erupt and the premolars had not
developed. The milk teeth were still present and the tongue was spread out between the upper and
lower jaw. The gums were swollen by the presence of tooth buds that had not erupted because of lack
of space.
Treatment consisted of extracting the extremely damaged first molars, then fitting a Quad Helix (see
chapter VII) to enlarge the palate. Subsequently, a banding appliance was fitted. Surgery to the
canines allowed them to erupt. Retraining, with fitting of a directional appliance, completed the
treatment.
In expansion, as in contraction, chewing cannot occur normally, that is, vertically, because the teeth
do not make correct contact (they are misaligned). The individual compensates for this problem by
chewing horizontally, as ruminants do. The forces then exerted on the molars are transverse and cause
shocks that weaken the teeth concerned. In the adult, the molars are damaged and the very joints of the
jaw may be altered. Untimely clicking sounds and pain develops, which, in the most serious cases, can
prevent the person from opening his or her mouth.

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Orthodontics for its patients

CHAPTER IV: VERTICAL DEFORMATION OF THE FACE

Examination of the face and the position of the teeth in the bone must take into account the type of
facial growth, which may be vertical (long face), horizontal (square face), or normal.
In the absence of treatment, the shape of the face is not modified during growth because it remains
subject to the same forces: growth occurs by bone deposition and resorption, so that the shape is
maintained the same throughout growth, rather than being inflated like a balloon.

Forces exerted during growth

- A: Long Face (Vertical Growth)

When the length of the face is considerable, or excessive, the lower jaw grows downwards and
posteriorly, while the upper jaw grows forwards. There is a constant discrepancy between the two
during growth and, as a consequence, the angle between them is abnormally open.

When the face is long and in addition, the incisors are slightly prominent, the facial profile also
becomes pronounced, almost horse-like.

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Orthodontics for its patients

Before treatment

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Orthodontics for its patients

This type of deformation can nevertheless be treated by moving the lower incisors backwards so that
the chewing forces are exerted vertically on the bone base.

After treatment

The angle of the lower jaw is very open. A long face requires incisors which are retracted, to avoid
having a face like Fernandel's, the French comedy star.

An excessively long face may be inherited but may also be due to tongue dysfunction and finger
sucking, which exert a vertical force and consequently cause torsion of the lower jaw. In this case,
while the upper jaw grows forwards, the lower jaw grows downwards, producing a discrepancy
between the two and deforming the profile: the upper jaw projects while the lower jaw is retracted.

- B: Square Face (Horizontal Growth)

When facial growth is horizontal, the lower jaw grows forwards to an excessive extent, becoming
square. It is strong, as is the chin, which protrudes, and the masseter muscles (which open and close
the mouth).

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Orthodontics for its patients

This type of deformation can also be the consequence of the tongue being interpositioned over the
sides, which slows the growth of the teeth. Incomplete eruption of the teeth causes the jaw to close
more tightly, giving the impression of a flattened face. The teeth become worn and tooth grinding
(bruxism) sometimes occurs during sleep.
Treatment consists of avoiding interposition of the tongue by functional retraining, and also of
positioning the lower incisors to protrude slightly (with slight labioversion), to allow the teeth to
withstand the forces involved in chewing.

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Orthodontics for its patients

CHAPTER V: GENETIC ABNORMALITIES

- A: Agenesis

Agenesis (in orthodontics) is the total absence of a tooth bud for a permanent tooth and the
persistence of the corresponding deciduous tooth (the "milk tooth"). Instances of agenesis are
generally hereditary and may involve several teeth (up to 12 or more, counting the buds of the
wisdom teeth). In the majority of cases this problem concerns the lateral incisors and the wisdom
teeth.
Normally, the roots of the relevant deciduous teeth are resorbed over a longer or shorter period of
time, leading inevitably to the milk teeth falling out. If tooth buds are missing, the milk teeth are not
replaced by permanent teeth. It is best to anticipate the situation by closing the space that will result
by orthodontic treatment. The other solution is to fit implants.

Audrey P: Before treatment: agenesis of the lateral incisors

Audrey P: After treatment

In the case of Audrey P., the buds of the two upper lateral incisors and a lower molar were absent and
the two central incisors were very widely spaced. The treatment was designed to compensate for the
lack of these teeth by closing the spaces through fitting a banding appliance. The empty spaces for
the missing lateral incisors were filled by the canines, which were ground into the shape of incisors.
Owing to the banding treatment the premolars and molars could also be moved towards the front.
The emergence of the wisdom teeth in due course will help establish an overall equilibrium, and the
end result of the treatment will be aesthetically pleasing.

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Orthodontics for its patients

- B: Supernumerary Teeth and Odontomas

The difference between supernumerary teeth and odontomas is that the former arise from normal tooth
buds and are tooth-shaped, while the latter arise from abnormal buds and are not tooth-shaped. The
origin of these extra teeth is often hereditary and the abnormality concerns particularly the incisors
(upper and lower) and the wisdom teeth. Supernumerary teeth may interfere with the development of
adjacent teeth, and several such tooth buds can be found in a single mouth (Crouzon's disease),
although this is quite rare.

- C: Microdontia

Microdontia refers to the condition in which the teeth are too small to occupy all the space available
on the jaws. When this condition affects the upper lateral incisors, they become pointed and round and
detract from the attractiveness of the smile.

- D: Crowding

Crowding, or disharmony between tooth and jaw size, is basically due to the size of the teeth being too
great for the bones that support them (i.e., the two jaws).

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Orthodontics for its patients

This problem is of hereditary origin, a child possibly inheriting tooth size from one parent and jaw size
from the other. The jaw may thus lack sufficient space for all the teeth to erupt and assume their
correct positions. The teeth overlap and/or erupt too high (or, for the lower jaw, too low) in the gum.

Claudette G: Before treatment After treatment


The case above shows that the canines have emerged high in the gum because there was not
enough room, and that the lower incisors impinge on each other, and have also erupted low in
their gum.

Richard R: Before treatment

This is more or less the same as the previous case. The canines are prominent and have not developed
in the axis of the milk teeth canines because of lack of space.
Crowding can be easily corrected by extraction: the teeth chosen by the practitioner are removed to
make room and reconstruct a harmonious dental arch, which inevitably will contain fewer teeth. The
teeth removed are often the premolars and the remaining teeth are positioned correctly using various
techniques, such as fitting corrective devices and functional retraining. The aim is to achieve good
intercuspation (the posterior teeth fitting together well), with the incisors properly positioned on their
bone base, the midline of the two jaws in alignment, facial symmetry, etc., and an attractive smile.

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Orthodontics for its patients

- E: Impacted Teeth and Wisdom Teeth

 Impaction of the Upper Canines

The upper canines are the last teeth of the smile to appear. If the tooth buds (embryo teeth) do not
grow in the normal position, they may cause more or less serious problems such as the root of the
adjacent tooth being displaced, with the lateral incisor then slanting forwards or backwards.

Cécile E.

One of the lateral incisors has been pushed out of place by the canine tooth bud. Surgery will
be necessary to straighten the canine bud and extract the canine milk tooth.

If there is enough space for the canine, the tooth bud can be correctly repositioned by surgery.
Banding treatment will then align the dental arch properly.
On the other hand, if there is insufficient space for the impacted canine to emerge, two premolars must
be extracted, one on the right and the other on the left, to produce symmetry. As it grows, the canine
will take up the space left by the premolar.
In other cases, the canine can destroy the root of the lateral incisor and cause its loss or at least cause
its crown to be worn down.
The problem can be even more complicated when there is considerable lack of space and the canine
tooth bud is crooked. In this case, the premolar must first be removed, then the canine tooth bud
straightened. An orthodontic bracket must be attached to the space cleared on the crown of the
impacted canine, and traction applied, using a fixed device, to position it in its normal place.

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Orthodontics for its patients

Marie-Agnès M: Before treatment

Marie-Agnès M: After treatment

Impacted canines: The two canine tooth buds are developing behind the roots of the incisors. Surgery
will be necessary at the same time as the two premolars are extracted.

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Orthodontics for its patients

 Wisdom Teeth

The third molar is known as the "wisdom tooth." Its late appearance, though not abnormal in itself,
can cause problems when space is lacking for its development. It must then be extracted. However, if
the wisdom tooth is healthy, the first or second premolar may be extracted instead, if it is damaged,
highly reconstructed or devitalized, to free space for it.
Another solution is to remove the second premolar if, by doing so, sufficient space can be reclaimed to
allow the wisdom tooth to grow properly.
Sometimes there is sufficient space for the wisdom tooth, but its tooth bud is crooked. Rather than
extracting it, it can be straightened to allow the tooth to grow in the right place.

- F: Cleft Lips

Harelips or cleft lips and palates are due to damage to the fetus during development. Clefts may be in
the palate or lip, or both.
In cleft palate, the palate is not completely closed at birth, and the mouth and nose communicate. In
dental terms, a tooth bud is lacking in the cleft and the tooth buds round about appear randomly
placed.
It is essential to first perform surgery on the bone. Carried out very soon after birth, it closes the
communication between the palate and the nose. To avoid the palate retracting as it heals, a small
palatal obturator should be inserted, which will be modified as growth progresses.
Later, the actual dental treatment will cause the teeth to fill the gap and take up their normal positions.

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Orthodontics for its patients

Sébastien F: Before treatment

Sébastien F: After treatment

As can be seen in the case of little Sébastien F., the teeth are badly positioned. They are rotated 90°
relative to their normal position. In addition, this malpositioning of the teeth is maintained by poor
tongue position and the manner of occlusion (closure of the mouth). Development of the tooth buds
either side of the cleft is totally disordered, and a lateral incisor is missing at the site of the cleft.
After treatment, the lip has been repaired, the cleft is no longer visible in the dental arch, and the
canine has taken the place of the missing incisor and been reshaped to resemble such a tooth, to
establish a harmonious smile.

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Orthodontics for its patients

CHAPTER VI: FUNCTIONAL DEFORMITIES

As their name indicates, these deformations are the result of one or more parts of the mouth
malfunctioning, with the tongue once again playing a decisive role.

- A: Retained and Ankylosed Teeth

In the case of retained teeth, the cause is functional: abnormal spread of the tongue in the mouth
prevents the teeth from erupting.
In the case of ankylosed teeth, the cause is accidental: the teeth are welded to the bone following a
blow or reimplantation and cannot be moved.
Retained teeth develop but do not appear in the mouth. The tongue, which is always obstructing the
place where they should be growing, prevents them from erupting. Consequently, the roots of retained
teeth develop by penetrating into the bone of the jaws, and in extreme cases, such roots of upper teeth
may reach the sinuses or those of lower teeth, the lower side of the mandible.
There are many disagreeable effects, including in particular, sinusitis following a dental infection and
the risk of fracture of the mandible.

Fabien T: Before treatment: retained tooth

Fabien T: After treatment

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Orthodontics for its patients

Appropriate treatment allowed Fabien T's retained teeth to develop normally. The results obtained
were stabilized by functional retraining to correct the position of the tongue in the mouth, which
consequently corrected the occlusion.

- B: Open Bite

When the tongue is interposed between the two dental arches, whether at rest or when functioning, it
causes open bite, or space, between the upper and lower teeth, which is visible when the jaws are
clenched. The tongue may be interposed at the sides, between the premolars and molars, or be spread
over the entire surface of the arches. Deformities can result, which vary depending on the areas of
the mouth affected and the degree of pressure exerted by the tongue on various parts of the dental
arches.
 The Three Main Types of Open Bite
- 1: Unilateral Open Bite

The tongue is only interposed on one side of the mouth, producing asymmetry of the face.

In the case of Stéphane R., thumb sucking, not the tongue, is responsible for the open bite. Because
of this, the canine lacks space and the incisors are deformed.

Christelle L
Here, the tongue interposed on one side of the mouth is preventing the lower teeth from developing
on the mandible, which is the reason for the space observed. The face has become asymmetrical,
with the chin deviating to the left. To compensate for this, the patient moves her jaw to the side to
increase her area of mastication, which is decidedly inadequate. The repercussions on the joint are
significant (see below).

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Orthodontics for its patients

- 2: Bilateral Open Bite

The tongue, interposed on both sides between the teeth, creates gaps on either side of the axis of the
mouth.
In this case, occlusion occurs on the last molars and the incisors, that is to say, only the last molars
and the incisors of the upper and lower teeth make contact. The premolars, occasionally the first
molars, and from time to time the canines are infraoccluded: these teeth, having been unable to
complete their vertical growth, have not completely erupted and their crowns remain short in height.

Patricia G: Before treatment

Patricia G: Before treatment

When the teeth are clenched, the upper incisors cover the lower ones to too great an extent and only the
molars make contact. Interposition of the tongue is retarding the development of the premolars.

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Orthodontics for its patients

Patricia G: After treatment

- 3: Total Open Bite

The tongue is spread completely between the dental arches, with only the last two molars making
contact. In this case, the child swallows without chewing and is unable to articulate words.

Karine F: Before treatment After treatment


In little Karine F., the teeth are not making contact with each other at all, and are thus finding it
difficult to develop. The interposition of her tongue between her teeth each time she swallows is
slowing the development of her permanent teeth.

Marie Hélène G: Before treatment After treatment

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Orthodontics for its patients

Here we have an adult. When the teeth are clenched, only the last molars are in contact. The
upper canines are prominent. Since chewing is impossible, the patient simply swallows. This
open bite is due to complete interposition of the tongue

 Consequences of Open Bites

In all cases of open bite, interposition of the tongue interrupts growth of the alveolar bone (which
directly surrounds the teeth in the alveoli). As a result, not only does this bone fail to grow, but growth
of the teeth is likewise impeded.

Before treatment

After treatment

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Orthodontics for its patients

The thumb and the tongue have been interposed between the two jaws, preventing bone, alveolar and
dental growth. A device providing a barrier against the tongue allowed growth to resume normally
and correct occlusion to be achieved.

In unilateral open bite, the face becomes asymmetrical because the individual is obliged to move his
lower jaw out of line to make maximum contact with the teeth of the upper jaw and facilitate
chewing, in which he uses essentially horizontal movements resembling those of ruminants. On
studying the face it can be seen that the chin is no longer aligned with the nose, while both dental
arches have shifted laterally to an equivalent extent. On one side, the upper molars are to the inside of
the lower molars (maxillary dental arch contraction) while on the other side, the upper molars are
to the outside of the lower molars (maxillary dental arch expansion). As a result, the individual has
a crooked mouth without being aware of it.

Before treatment

The roots of the canines are developing towards the lower edge of the mandible

After treatment

The tongue works asymmetrically either for inherited reasons or because of prolonged sucking on a
finger at the side of the mouth. Treatment consists of preventing the tongue from spreading to one
side and restoring the ability of its muscles to work symmetrically, to avoid temporomandibular joint
problems.

However, this is not only a problem of aesthetics. It often leads to two others, particularly in
adulthood, namely dysfunctioning of the jaw joints (the temporomandibular joints) and grinding the
teeth while asleep, also known as bruxism.

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Orthodontics for its patients

- 1: Jaw Joint Dysfunction

Poor functioning of the mouth can lead to wear of the temporomandibular joints (TMJ) resulting in
clicking sounds, pain and, in extreme cases, the jaw becoming locked, making it impossible to eat. In
cases of unilateral open bite, the upper jaw does in fact shift to fill the gap when chewing is required.
The individual involuntarily compensates for the gap by moving the lower jaw sideways to increase
the surface available for chewing. The joint on the open bite side is depressed inwards, and conversely
the opposite joint is stretched. After several years, joint pain, clicking, locking and neuralgia occur.
These problems can be treated by reducing the open bite by preventing the tongue from being
interposed between the teeth on the side affected. An appliance known as an activator is used to do
this. It is generally worn at night and keeps the teeth closed and correctly aligned one above the other.
On the open bite side, since the teeth are no longer being hampered by the presence of the tongue,
they gradually grow as they should and erupt completely. With regular readjustment of the appliance
as these teeth grow, the open bite gap responsible for all the problems will be filled. A painful surgical
procedure can thus be avoided, and the relief provided by this appliance is almost immediate.
The corrective effect of the activator must be reinforced by retraining for a period of six months to a
year. This will consist of daily exercises, for a quarter hour with the appliance and a quarter hour
without it, to strengthen the muscles of the tongue symmetrically and thus reestablish normal function
during swallowing and chewing, without the tongue being interposed between the teeth.
A check is also needed to see that the tongue is not interposed between the teeth when articulating
words. This requires performing exercises in articulating sounds with the lips, only moving the tongue
to pronounce dental sounds.
If it is necessary to align the teeth, the activator treatment + retraining can be supplemented by fitting
bands and other appliances, depending on the size of the open bite to be reduced.
Treatment ends when the upper and lower teeth come naturally into contact, having been recentered
and symmetrically aligned on each side of the axis formed by the two midlines of the jaws. The teeth
on the open bite side must also have fully emerged to come into contact with their antagonists. The
open bite will have disappeared, the jaws will be recentered, and the patient will be using his tongue
correctly to swallow saliva and food, and to speak. His pain and locking of the jaw will be no more
than bad memories. The results should nevertheless be made to last by fitting a retention appliance
(see the lexicon).

- 2: Tooth Grinding or Bruxism

Bruxism is grinding the teeth during sleep. It leads to premature wear on the teeth, with the enamel
becoming progressively thinner.
It seems that insufficient stimulation of the soft tissues (periodontal tissues) during the day causes
accumulation and congestion of blood. The resulting discomfort leads to the individual grinding his or
her teeth while sleeping, to compensate for insufficient daytime stimulation.
The orthodontist will check that no obstacle is present (no tooth or extra point on a molar, called a
cusp) that would prevent lateral movement or cause the teeth to shift combined with wear to the joints
of the jaw. A slight open bite with midlines out of alignment may also provoke a shift and grinding
of the teeth. Treatment consists of reestablishing normal occlusion, followed by exercises in which
the teeth are clenched, to encourage normal blood circulation during the day.
With a bilateral open bite, two main problems arise simultaneously:

- The first occurs in the open bite itself: the teeth are not able to grow completely on the sides of the
jaw affected, resulting in lateral (meaning, on the side) infraocclusion.

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Orthodontics for its patients

- The second concerns the upper or lower incisors: when the teeth are clenched, the only contact
between the molars is of those at the back, forcing the upper incisors to overlap those of the lower
jaw. This is known as supraocclusion and in this case is anterior because it affects the front teeth.

Before treatment

Result obtained at the end of treatment

The tongue had to be prevented from entering the spaces so that the teeth (canines and
premolars) could develop. Banding proved effective.

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Orthodontics for its patients

As the above examples show, the treatment, which is essentially functional, consists of preventing the
tongue from impeding normal growth of the bones and teeth. Functional retraining of the tongue is
essential for optimizing the corrections achieved by fitting banding appliances or carrying out other
orthodontic treatment.

- C: Supraocclusion

As we have just seen, the upper incisors may excessively cover the lower ones, producing what is
known as supraocclusion. They are visibly projected forwards until they meet the lower lip, which
hinders their growth.

Marie Ange F: Before treatment

The growth of the upper incisors has been obstructed by the lower lip, resulting in incisor
supraocclusion. The incisors are visible even with the mouth closed.

Marie Ange F: After treatment

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Orthodontics for its patients

Treatment consisted of moving the upper and lower incisors backwards by freeing the space needed
via 4 extractions, reducing advancement of the maxilla, and causing the incisors to retract into their
alveoli so that the relationship established between the jaws and the teeth would be correct.

Since the lower incisors are covered by the upper ones, they touch against the palate, which slows
alveolar growth. The lower jaw finds it difficult to develop, while development of the upper jaw is
exaggerated.

Before treatment

After treatment

The upper incisors protrude, growing until they meet the lower lip. The lower incisors are
obstructed by both the palate and the lower lip.

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Orthodontics for its patients

Supraocclusion may also be caused by the teeth at the side lacking height. When the teeth are
clenched, the upper incisors cover the lower ones to too great an extent.

Before treatment

Results obtained after treatment

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Orthodontics for its patients

- D: Diastema or a Gap Between the Teeth

Poor tongue posture inside the mouth is often responsible for the formation of a space between the
teeth called a diastema. During swallowing, the tongue is placed between the teeth, preventing them
from closing up together.
In the case of Carine G., below, there was also a problem of thumb-sucking, which explained the size
of the gap between the incisors.
With banding and the essential retraining of the tongue, the teeth have been correctly repositioned,
producing a much more harmonious profile.

Before treatment

After treatment

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Orthodontics for its patients

- E: Neuralgia or Toothache

Neuralgia is pain, sometimes intolerable, which occurs in healthy teeth despite the dentist being
unable to find any evidence of caries. The pain persists even when the teeth in question have been
devitalized or removed.
At present, there is no clear explanation for this phenomenon. Perhaps the pain is caused by a lack of
stimulation of the teeth. Perhaps the cervical spinal cord is responsible, since all nerves pass through
this area on their way to the brain.
The role of the orthodontist will be to correct any malpositioned teeth and provide exercises to
stimulate the periodontal tissues and blood circulation around the teeth. Four months of such exercises
and fitting an activator are generally enough to make the pain disappear once the teeth start to
articulate normally.

- F: Receding Gums or Periodontal Disease

Older adults are not the only ones to have this problem. Young adults, from 25-30 years old, are also
affected. The first signs are gum retraction and bleeding and the accumulation of tartar around the base
of the teeth. This is due to the habit of infantile swallowing still persisting. The saliva collects behind
the lower incisors and the mineral salts and food debris contained in it are deposited there. As a result
of the insidious interplay of forces exerted by the tongue and lips in this type of swallowing, the
alveolar bone of the incisors (into which the teeth are directly fixed) is dissolved away. As it gradually
does so, the pocket formed fills with the tartar deposit carried there by the saliva, which itself
stagnates behind the incisors before being sucked up by the tongue and lips.
Sheltered from the saliva, which is antibacterial, it is not difficult for the bacterial flora to develop in
the deposits of tartar that have accumulated in the pockets around the teeth. The gums gradually
retreat, a sign of resorption of the underlying bone. This explains why gum grafts applied to teeth
without using bone fail to last for more than six months.
Just as a nail knocked crookedly into wood is continually subject to transverse forces, the teeth, with
demands made on them from right and left and from front and back, enlarge the holes (the alveoli) in
which they are fixed. As its alveolus enlarges, the tooth loses its seating in the bone, which is resorbed
around the root of the tooth. The saliva, with its load of food debris and microorganisms, penetrates
the pockets around the root, causing suppuration. The teeth are finally expelled (fall out), and the bone
and gum is completely resorbed.

Example of periodontal disease

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Orthodontics for its patients

On the other hand, when a nail is driven straight into a plank with perpendicular blows, each blow
secures the nail further in the plank. In the case of a tooth, it must be stable in the bone and receive
vertical forces to be consolidated. Orthodontic treatment will therefore be essential, once the infection
has been successfully treated and the dental hygiene problems are being correctly managed by the
patient (interdental brush, gum stimulator tips, dental floss, etc.). Loosening is essentially due to the
teeth not being sufficiently stable on the bone base supporting them: they tilt either forwards or
backwards on one or both jaws at once. As they are inclined, rather than straight, they are fragile,
which explains the mechanism of their loosening.
What then is the role of the orthodontist? He will set the teeth vertically on the bone using appropriate
treatment. The destroyed alveolar bone will be able to reconstruct itself through the action of the
consolidation forces exerted on the now correctly repositioned teeth, which will stimulate this
periodontal reconstitution.

Reconstitution of periodontal tissues by orthodontic treatment alone

On the first X-ray it can be seen that, at the beginning of treatment (March 1999), the tooth was not
surrounded by bone; one month later, the bone (gray part around the root of the tooth) had already
reached the root; by January 2000, the bone had completely surrounded the tooth, which would
serve as a pillar for a bridge to replace the missing teeth.

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Orthodontics for its patients

Once again, functional retraining will play a decisive role. Frequent exercises, consisting in particular
of clenching the molar teeth tightly, followed by swallowing, will stimulate regrowth of the bone and
gum. The dental arches must be in complete contact over their entire length, while the teeth must be
straight, with the incisors becoming naturally stronger. A pad is created around the gum and the bone
and gum gradually progress up the tooth.
It is important to maintain impeccable dental hygiene in parallel with treatment to avoid residual
infection. The deposition of tartar will be found to decrease as correct swallowing is reestablished.
When this is achieved saliva will no longer collect behind the incisors but will be drawn up by the
tongue, so that it will no longer be able to stagnate. The pockets around the teeth will be resorbed.
Once gum recession has been successfully resolved, it is recommended to wear a night appliance (an
activator) for about a year to reinforce the functional retraining, and to perform teeth clenching
exercises at least ten times per day, contracting the masseters three times before swallowing. Chewing
gum correctly can help strengthen the teeth.

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Orthodontics for its patients

CHAPTER VII: CURING BY FUNCTIONAL RETRAINING

The treatments mentioned in the previous chapters focus on children, individuals still in the growth
stage, but this does not mean that treatment is not possible after growth has been completed. Even if
growth per se no longer occurs in the adult, bone is constantly being renewed and hence there is the
possibility of remodeling and correcting it. Orthodontic techniques associated with retraining avoid
resorting to often major surgery, which may even be less effective than orthodontics if the causes of
the problems are not treated in depth.
Orthodontic treatment is based on the idea of equilibrium within the mouth. The teeth are positioned
where the various muscle forces exerted on them cancel one another out. This "point of equilibrium"
determines the position of the tooth, and may be correct, or not.
The fact that the tongue is the "orchestra conductor" of the mouth means that special attention must be
paid to its position at rest and to the movements it makes when the various functions of the mouth are
performed, such as swallowing saliva, drinking, eating, talking, etc. We must ensure that the tongue
"moves" properly and that people develop a "mature" type of swallowing, as practiced naturally in
most adults and the only type worth performing if preserving the teeth is a priority.
We have seen earlier that the orthodontist can literally rebuild the dental arch so that the teeth are
properly aligned without spaces between them. He will bear in mind the space available on the jaws,
the number of teeth and tooth buds present, the presence of devitalized or endangered teeth,
supernumerary buds, missing teeth, etc. Based on these aspects and many others, he will choose the
teeth to keep, those to extract and those to be corrected, and will always consider the quality of the
intercuspation of the upper and lower teeth, the shape of the face and, of course, the age of the
individual regarding whether growth is complete. He will always pursue his strategy with an eye to the
future, and his treatment will take into account any future changes in his patient's dentition. Each case
will be individually assessed to identify the best possible solutions.
The fact remains, however, that irrespective of specific individual aspects, the orthodontist's treatment
will be based on three principles mentioned earlier in this book, namely:
• 1: Functioning (correct or incorrect) of the components of the mouth, which determines its
shape and, consequently, most of the situations of disharmony treated by orthodontics
• 2: The soft tissues, which exert muscle forces that control the position and possible
remodeling of the bones and teeth— not the reverse.
• 3: Mature swallowing, a prerequisite for any correction. Correct functioning of the mouth
implies that it will have been acquired.
To assist treatment there are corrective devices, which will be described later, and also a series of
exercises aimed at retraining the functioning that has given rise to the malformations seen. Retraining
also aims to stabilize and maintain the corrections achieved with the appliances, since there is no point
to straightening the teeth (orthodontics) if the bad habits that are the source of the problems are not
corrected. The problems will inevitably resurface, otherwise, and will be more difficult to resolve.
It should be remembered that adults as well as children may undergo orthodontic treatment.

- A: Restoring Correct Function

Any retraining can be accomplished without using an appliance if patients are sufficiently motivated.
Fitting a device is not essential for achieving results; it is simply an aid to retraining.
It is difficult, however, to eliminate undesirable reflexes imprinted in our brains and replace them with
new ones that are more consistent with correct functioning of the parts of the mouth. In addition, at
night the subconscious takes over, especially when the phenomenon is hereditary, which is frequently
the case. Yet cases of mandibular prognathism (protruding chin) have been treated without any relapse
solely by retraining.

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Orthodontics for its patients

Good tongue posture can be achieved by swallowing exercises and also by exercises focused on
articulating sounds and chewing, which allow patients to construct new reflexes that this time are
correct. Whether talking, singing, swallowing, chewing or sometimes even breathing, tongue
dysfunction equally involves both the tongue and the position of the teeth. Retraining the act of
swallowing is therefore beneficial not only for swallowing per se but also for articulating speech.

 Establishing Mature Swallowing

The normal swallowing process can be described as follows:

- 1: At first, the tongue is supple and fills the entire lower dental arch, without covering the
teeth, while the lips are soft and parted.
- 2: Then the subject brings his teeth together (the molars in particular need to be in contact),
while the tongue is flattened against the rim of the palate and the saliva drawn into the space
formed in the middle.

With this in mind it is possible to create a few simple swallowing exercises:

- 1: The first is clicking the tongue in the middle of the palate, producing a clear sound (as if
imitating a trotting horse) for one to two hours on the first day and half an hour on subsequent
days. This exercise helps develop certain muscles of the mouth that were not working
adequately before.
- 2: Another exercise consists of strongly clenching the molar teeth, keeping the lips relaxed;
this exercises the muscles that are the point of support that initiates swallowing.
- 3: The next exercise combines the first two. For half an hour each day, the recommended
procedure is to click the tongue ten times in succession, then clench the molars and swallow
the saliva once. If swallowing does not occur, an alternative is to click the tongue ten times,
then clench and release the molars on each side, and finally swallow, with the lips always soft,
relaxed and parted; the cheeks should never be contracted.

For these exercises aimed at developing mature swallowing to be effective, it is important for the
individual to be relaxed so that the tongue can relax as well. It should perform particular movements at
particular times, but apart from these times should be at rest and relaxed.
The purpose of these exercises is to reduce the volume of the tongue and ensure that the movements it
makes are more precise and more limited, since the types of dysfunction seen are often the result of
accidental spreading and uncontrolled use of the tongue.
With this retraining, the tongue becomes a flexible membrane able to draw up the saliva which is
produced continuously and accumulates in the mouth. These exercises also help develop the muscles
in the neck that connect the tongue to the skeleton, as well as those that close the mouth.
Finally, to help young children abandon the suction swallowing characteristic of infants, when the
child begins to eat from a spoon at approximately six months of age we can push the spoon well into
the mouth to prevent the child from sucking up the food, and force the tongue to work towards the
back of the mouth rather than towards the front, as would be the case when sucking.

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 Restoring Correct Articulation of Sounds

Simultaneous correct use of the tongue, jaw and larynx is essential for voice production.
 Because the tongue is the most important moving organ, good control of its anterior part
allows the dental sounds [t] [d] [n] to be articulated correctly, the tip of the tongue being
applied to the palate.
On the other hand, the tongue remains still and low during the articulation of voiceless consonants,
[p], [k], [f], [s], which are produced by the lips with the soft palate (the rear, mobile, flexible part of
the palate) raised.
 The voiced consonants [b], [g], [v], [z] are produced by the larynx, with the soft palate raised;
the tongue does not move.
 The nasal consonants [m] [n] are produced by the nose, with the soft palate lowered.
 For oral vowels, the lower jaw is dropped and the tongue remains low and still, whereas for
the nasal vowels, the lips are slightly parted and the sound passes through the nose.

 Exercises

These are different depending on whether they focus on the articulation of dental sounds ([t], [d], [n])
sibilants ([s], [z]) or fricatives ([sh]).

 For the dental sounds, the tongue remains low, flat and relaxed behind the incisors; the tip of
the tongue is applied against the mucosa of the palate behind the incisors. The exercise
consists of pronouncing syllables containing a dental consonant, completing the sounds with
the various vowels [a], [e] [i] [o] [u], [ou], while keeping the teeth closed together (to force the
tongue to work inside the mouth).

Lists of words from the dictionary made up of these phonemes can also be read aloud.
The subject needs to be aware of the position of his or her tongue, which must be behind the incisors
and just touching them (with the tip pressed against the palate), not interposed between the teeth. The
teeth must be closed firmly together while pronouncing the syllables [ta], [te], [ti], [to], [tu], [da] [de],
[di], [do] [du] and [na], [ne], [ni] [no], [nu].
The subject should stand in front of a mirror to check that the tongue does not extend beyond the teeth.
Movement of the tongue must be gentle and limited. If difficulties occur, [l] can be used as a reference
(because it is naturally pronounced by raising the tongue).

 For the sibilants, the tongue must be flat, supple, relaxed and still.

The subject should smile broadly and let the air pass, whistling over the tongue, which should not be
raised or interposed between the teeth.

 For the fricatives (e.g., the [sh] in "shirt") the tongue should not come between the teeth at the
sides: the lips are pushed forward, the teeth closed together and the tongue low, with the
sounds being articulated by the lips.

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Orthodontics for its patients

 Establishing Correct Chewing

Chewing food is a voluntary action initiated by closing the teeth together particularly tightly. (As we
have already said, the masseter muscles are the most powerful muscles in the body.) During chewing,
food is crushed between the molars. When it has been ground up sufficiently, the molars need to be
strongly clenched to allow swallowing. The lips should stay relaxed during the swallowing process;
they are not required for sucking.
Essential advice: make sure that you chew on both sides!
The enormous force exerted when swallowing, which can be as high as 80 kg/cm2, stimulates the
alveolar bone and, more broadly, the periodontal tissues (the tissues surrounding the tooth and holding
it in the bone). This helps reduce periodontal disease, improving blood circulation problems around
the tooth and strengthening the ligaments that attach it to the bone.
At the end of basic treatment, which will not exceed one year, an X-ray assessment is made to evaluate
the effect on the growth, or the position of the lower incisors, or the reduction in the difference
between the bones of the two jaws.
As the following diagram shows, the results can be seen by superimposing the profiles from before
and after treatment.

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Orthodontics for its patients

Superimposed profiles, beginning (in black) and end of treatment (in red).

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Orthodontics for its patients

B: Gaining a Beautiful Smile

 By Correct Positioning of the Teeth on the Bone

Let us briefly recall that a tooth correctly placed on its bony base is a basic component of a beautiful
smile. It must be positioned straight and perpendicular to the bone. Indeed, the term orthodontics
means "the science of straight teeth."
However, aesthetics is not the only consideration. As we have seen in previous chapters, having
perfectly straight teeth or having them corrected by orthodontic treatment is a sign of good dental
health and good health in general, since the vital functions performed by the mouth and teeth have a
significant impact on the overall metabolism of the whole body. Teeth correctly placed on their bony
base correctly carry out their functions.

 By Correct Intercuspation and Good Alignment of the Teeth

Satisfactory intercuspation of the molars results in good occlusion, i.e., the teeth fit together properly.
If, after basic treatment, intercuspation is satisfactory, there is no need for banding treatment (also
known as treatment with a multiple attachment device). On the other hand, if adequate improvement
has not been achieved after several months of treatment (usually 6 months), there must be a change of
method for functioning to continue to be retrained.
Correct functioning is essential if the results of treatment are to last. If the permanent teeth are all
present in the arch, banding treatment can be started. Otherwise it must wait until they have
developed. In principle, the aim of banding is to improve tooth alignment and intercuspation
mechanically, providing first that the reflexes are correct. If the reflexes have remained infantile, this
banding approach, which, as has been said, is purely mechanical, has drawbacks, such as the length of
time it is needed, possible pain and lack of stability.
The solution of just stabilizing the teeth by fitting a palatal (top) and lingual (bottom) wire for
several years is not satisfactory. When the adhesive gives way after a few years, the teeth will resume
their former incorrect position because functioning has not been corrected and the proper muscle
reflexes are lacking. The teeth will move back into the neutral zone where the forces exerted on them
cancel each other out. This is why it is extremely important to correct functioning so that the area
where the forces cancel each other out coincides with the correct position of the teeth. Recurrence of
the problem will then be avoided.
In fact, banding needs to be used to align the teeth and bring about intercuspation while at the same
time retraining functioning through exercises, if this has not been done before, and the use of alert
devices; intercuspation will then occur almost spontaneously.
Once functioning has returned to normal, i.e., when the tongue or lips are no longer interposed, all the
problems are solved:
 The teeth are simply waiting to return to their correct position.
 The spaces left by extracted teeth close up easily (because the tongue is not in the way), while
the teeth straighten on the bone.
 Chewing becomes efficient.
 All periodontal tissue is consolidated: alveolar bone grows back around the teeth as do the
gums, without the need for grafting.
 Pockets of pus fill in after disinfection.
 Pain disappears.

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Orthodontics for its patients

With proper functioning, it becomes easy to eat and swallow meat because chewing is effective again.
I have often found that children or adults "who do not like meat," in fact have poor oral function. After
nibbling at the meat, they try to suck the juice out. As a result all that is left in the mouth is a ball of
fibers resembling straw, which is impossible to swallow. When meat is chewed, torn up by the canines
and crushed by the molars, a bolus is obtained which is easy to swallow.
Banding treatment involves attaching bands or brackets onto the teeth, with arches (shape memory
metal wires with the desired correction curvature), of an appropriate diameter and shape to produce the
desired effect, threaded into the bands. The shape of the arch produces repositioning of the teeth, and
their roots, within the bone. Elastic or metal ligatures firmly fix the arch to the band.
Fitting bands and brackets onto the teeth is meticulous and accurate work, but is widely known.
The efficacy of alert devices no longer needs to be demonstrated, even in adults and especially at night
when old reflexes reappear, and fitting them in place presents no major difficulties. When making a
tooth change its position is difficult because of an obstacle, such as the tongue, lips or cheeks, and
exercises are not sufficient to alter the situation, we insert spikes which are painful when a movement
is faulty, but painless when functioning is normal. Fear of being hurt or pricked modifies behavior. At
the same time, the spikes make the individual aware that functioning, without which correction is
impossible, is not occurring correctly.

- C: Stabilizing the Results

 Through Appropriate Exercises

Results will be obtained even faster if exercises are done regularly and functioning has returned to
normal. It is therefore essential to perform the exercises during banding treatment so as to imprint the
reflexes effectively in the brain. Reflexes are indeed acquired by repetition, which makes it possible to
create new reflexes to combat heredity or many years of incorrect functioning of parts of the mouth. It
is true that this is neither easy nor evident, but with perseverance, determination, awareness of
incorrect movements of the tongue and also the use of alert devices indicating lack of compliance with
correct behavior, correct reflexes can be instilled.
When functioning has returned to normal, the treatment is not painful and the teeth are no longer
sensitive. They move easily into place, as they no longer encounter obstacles to their movement. On
the contrary, they are helped into position by the pressure exerted by the various muscle forces and
take their place naturally in the neutral area where the opposing forces cancel each other out.
Treatment is quick, painless and stable, and this stability is ensured as long as functioning is properly
maintained and the muscle reflexes coincide with the position of the dental arches.
On the other hand, if there is difficulty in establishing correct functioning, alerts, such as spikes or
barriers, need to be used to prevent certain abnormal movements of the tongue, lips or cheeks. These
alerts are placed on the bands to make undesirable movements painful. Banding, in addition to its
contribution to correctly positioning the teeth, is thus an effective aid to neuromuscular and functional
retraining.

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Orthodontics for its patients

 By Fitting a Tooth Positioner

If banding has yielded results easily within a year, the appliance can be removed and a tooth positioner
fitted. This is a removable transparent device which takes on a whitish hue when worn (so that the
orthodontist can verify whether it is being used). The purpose of this device is to stabilize the teeth and
reflexes and perfect the alignment of the teeth by correcting any small defects remaining. It should be
worn for a year while doing daily exercises. During the first few days, the device must be worn night
and day, exercising as much as possible. After checking that nothing has changed, it should be worn
for five hours a day as well as at night. The number of hours per day is then reduced by half an hour
each month.
If, on the other hand, results have been difficult to obtain because of the hereditary nature of
significant dysfunctioning, retention can be applied using an activator to maintain correct occlusion
and reinforce a good chewing reflex. This appliance should be worn for a year or more with daily
exercises. When retention ends, the reflexes must be maintained by performing correct swallowing
each morning (e.g., when brushing the teeth).
As these devices are not always easy or comfortable to wear during the day, the teeth can be fitted with
small, invisible appliances or transparent guards; these are practical and easy to wear but are not
effective in stabilizing reflexes. The tooth positioner must therefore continue to be worn in the evening
and at night and appropriate exercises performed.
Midway through retention, an X-ray examination should be performed to check not only the stability
of the effects obtained and the ability of the wisdom teeth to grow normally, but also whether the
procedures have been carried out correctly and are not causing a problem.
During this examination, the following aspects are checked for improvement:

 The position of the upper and lower incisors


 The amount of displacement of the bony bases achieved
 The changes in direction of growth of the teeth that have been induced

All of these improvements can be seen if the profiles from before, during and after treatment are
superimposed on one another.
Banding treatment is complete when occlusion has become normal, i.e., when it meets the following
criteria:

 The molars and canines intercuspate normally.


 The incisors are correctly positioned on their bony bases: the upper incisors should be slightly
in front of the lower incisors (they work like a pair of scissors).
 There should no longer be gaps (diastema) between the teeth as far as the premolars and, if
there is still any gap between the molars, it should be filled by the growth of the second molars
and later, the wisdom teeth (except where the shape is abnormal).

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Orthodontics for its patients

- D: The Use of Corrective Appliances

The mouth must be prepared no later than eight days before the start of treatment. Germectomy
(extraction of tooth buds) of the premolars is performed at between 8 and 10 years of age, and of the
wisdom teeth at 14 years old and older.
To counter bone deformities during the period of growth, appliances will be fitted such as the
Activator, the Crib, the Quad Helix or the Delaire Mask. These devices, which will be described
below, act on growth by either slowing or stimulating it.

 The Activator

Activator

In cases of maxillary prognathism (the maxilla and upper teeth projecting in front of the lower jaw), an
activator is used during the growth period to slow the growth of the maxilla and increase that of the
mandible (lower jaw).
The activator is a simple device that consists of a palatal plate with an arch, which passes over the
upper incisors, and a mandibular plate joined to the maxillary plate in hyperpropulsion (i.e., propelled
forwards), bringing the incisors edge to edge. The device works using muscle force alone, which tends
to pull the maxilla backwards. It is a removable appliance and can be worn at night and for at least
three hours during the day, for a period of 6 to 12 months. It not only affects the growth centers but
also stretches the ligaments in the joints. This effect is offset and neutralized by daily exercises
maintaining the elasticity of the ligaments. The growth obtained in the mandible reduces the space
between the maxillary and mandibular bases, thus providing more room for development of all the
teeth, including the wisdom teeth.
The activator also channels tongue movements for both swallowing and articulating words. Exercises
are necessary on altering reflexes in order to learn how to swallow correctly. Initially the patient
drools and sucks noisily, thus demonstrating his or her impairment. Very soon the behavior changes
and the individual will know how to swallow and articulate sounds, applying the tongue correctly.

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Orthodontics for its patients

Words are articulated by keeping the tongue low, relaxed and still; only the lips move and articulate the
sounds, except in the case of the dental consonants ([t] [d] [n], and [l]).
The entire upper arch retracts and the upper molars are able to intercuspate well with the lower molars,
an effect which is remarkable because it is otherwise difficult to obtain. Wearing a device that protrudes
from the mouth is avoided. It is easier with the activator than with other means to retrain swallowing and
speech, and the appliance also ensures that the teeth are aligned. Wearing it regularly, combined with the
exercises prescribed (see elsewhere), yields tangible results in two to three months.
The activator can also correct double protrusion of the incisors (where both the upper and lower incisors
protrude and tilt forward excessively on the basal bone because they are pushed forward by the tongue).
The activator combined with exercises helps make the lower incisors perpendicular again by promoting
growth of the mandible. Extraction of the premolars is thus avoided. Moreover, the lower incisors, now
squarely placed on the bony base, act as a reference for the profile.
The role of retraining is very important, optimizing the purpose of the appliance and stabilizing the
results obtained.

Sketch of mandibular growth

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Orthodontics for its patients

Activator

The activator is fitted by adjusting the upper part to the palate, then moving the lower jaw forward
until the lower incisors fit into the impressions of the teeth on the lower part of the appliance.
The swallowing exercises associated with wearing the activator consist of placing the incisors in the
spaces reserved for them on the activator, swallowing while firmly closing the jaws and ensuring that
the jaw muscles, particularly the masseters, contract strongly, leaving the lips relaxed, soft and slightly
apart. This movement must be repeated several times until swallowing is triggered naturally, which
can be observed by movement of the Adam's apple. If it is performed incorrectly, the patient drools
and/or sucks in his or her saliva noisily. This exercise should be repeated for 5 minutes at least 3 times
until it becomes easy, and begins to be imprinted on the brain. Furthermore, it prevents the joint
ligaments from stretching, while maintaining their elasticity.
The patient should also practice articulating words properly. With his or her teeth clenching the
appliance, he or she should practice speaking while keeping the tongue still; the tongue must be supple
and relaxed and only move when pronouncing dental sounds ([d], [t], [n] ), which are the most
difficult sounds to produce (the tip of the tongue must be raised against the palate). If there is any
difficulty, the sounds can be practiced by pronouncing them with the consonant [l].
Other sounds are produced with the lips, without significantly moving the tongue. Articulation should
be achieved by moving the lips, not the tongue, which should remain relaxed, still and low in the oral
cavity.
These exercises are extremely important for preventing the patient from drooling, sucking noisily or
speaking by opening his mouth to an exaggerated degree.

 The Crib

The crib is used for open bite, i.e., when there is a vertical gap between the upper and lower teeth (the
upper and lower teeth do not make contact everywhere).
Because the most frequent cause of open bite is interposition of the tongue, the aim of the appliance is
to prevent the tongue from leaving its normal position by virtually enclosing it within the mouth, i.e.,
containing it within the dental arches. It is therefore a sort of temporary "cage" for the tongue so that it
loses its poor functioning habits and remains within the dental arches.
The open bite may be anterior, unilateral, bilateral, or total.
The crib allows growth of the alveolar bone, which accompanies eruption of the tooth.

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Orthodontics for its patients

Crib

The crib, which is made by a dental technician, is a palatal arch (fitted against the palate) welded onto
two bands attached to the first two opposite molars in the upper jaw (see photo). It can go from canine
to canine or molar to molar depending on the size of the open bite and the result desired.
The crib cannot be removed during treatment, which lasts for about three months, since complete
eruption of the teeth occurs relatively quickly. For one or two days it causes discomfort that can be
reduced by teaching the child to clench his or her teeth several times to swallow the saliva, the molars
being kept tightly closed together. He or she must also learn to speak behind the crib and not beneath
it, as this would cause it to sink into the palate, causing injury.

 The Quad Helix

The Quad Helix is used to correct a palate which is too narrow, where the upper molars articulate
within the span of the lower molars (maxillary contraction) and not just to the outside of it, as should
normally be the case.

The Quad Helix

The Quad Helix is composed of four springs attached to two bands around the first upper molars and
two lateral branches which act on the premolars. It helps widen the palate until half the surface of the
upper molars is articulating to the outside of the lower molars. It also encourages wearers to move
their tongue less due to the discomfort caused.
The appliance is adjusted each month to increase the width of the palate and set the lateral branches
along the premolars so that they do not interfere with the tongue. The spring must follow the shape of
the palate and be close enough to it to prevent the tongue from being inserted between the spring and
the palate, otherwise the appliance could be detached on one side, resulting in the child being
prevented from closing his or her mouth.

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Orthodontics for its patients

The Quad Helix is an improvement on the jackscrews which were previously used and which had to
be adjusted each week by a quarter turn and worn for 1 to 2 years. With the Quad Helix, the result is
obtained in three months, but it is better to consolidate it by continuing to wear the appliance for three
additional months.
Exercises to be undertaken consist of clenching the molars ten times a day in order to straighten the
roots.

 The Delaire Mask

The Delaire mask is used when there is mandibular prognathism (the lower jaw protrudes in front of
the upper jaw).

Delaire Mask

The object of this appliance is to encourage the upper jaw to grow forward while slowing the growth
of the mandible.
It is an external appliance which is supported on the chin and forehead, connected by elastic bands to a
welded vestibular bar attached by bands to the last upper molars. It is usually worn at night or for part
of the day in extreme cases, until the incisors of both jaws are correctly positioned relative to each
other.
This result can also be achieved with a Para-Andresen appliance, which presses on the lower incisors
and causes the upper jaw to develop (see photo below).

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Orthodontics for its patients

Para-Andresen appliance

Tangible results can be obtained in 6 months to 1 year as long as certain exercises are performed:

 The patient must exercise every day by swallowing without thrusting his/her tongue onto the
mandible; he/she should draw back his/her tongue slightly to swallow, with the molars
firmly together;
 He or she must practice speaking every day, keeping the tongue low, except when raising the
tip to the palate for the dental sounds, [d], [t], [n], and as relaxed as possible for other
consonants.

If the mandibular prognathism is not too pronounced, using a para-activator can slow the growth of the
lower jaw and activate growth of the upper jaw, while retraining the tongue.

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Orthodontics for its patients

CONCLUSION

 Theory Proven by the Results

The analyses in this work would be pure speculation and imagination, at best considered appealing or
original, if they were not the fruit of long observation of both young and older patients, and
particularly if they had not been tested in practice. Patients expect orthodontists to provide concrete
results, not extravagant theories.
The simple principles that have been identified to help us understand the proper functioning of the
mouth, a very complex cavity, should assist in establishing accurate diagnoses and, consequently, help
in deciding how to acquire or restore its normal functioning.
The fundamental property of the theories that can be construed in this regard is that the proof is visible
and indisputable, whether positive or negative: the changes obtained by the treatments prescribed can
be objectively recorded by taking photographs and X-rays before and after treatment. There is no
question here of subjective impressions. To validate the effectiveness of treatment, patients are not
asked "if they feel better" or "if they think they have been cured." The condition of the oral cavity at
two different points in time is compared visually.
As we have seen, the mouth is a tool used for several purposes. Like any tool, it needs to be used in a
particular way if the owner wishes to avoid damaging it prematurely. It is, however, a tool that does
not come fully assembled at birth: the owner must steadily construct it over time from his or her
parents' genes.
Two main scenarios may arise:

1. Nature (i.e., heredity) may fail to transmit to the individual all the elements required for the
formation of healthy teeth. This is the case, for example, where tooth buds are abnormally
absent (see the section on Agenesis).
2. The components provided by nature—and which appear progressively—are correct in
number, but the individual has caused them to be poorly positioned in relation to each other
through bad habits in childhood that have tended to persist into adulthood.

The work of the orthodontist is to restore the tool to its proper condition and above all to teach his
patients to use it correctly, giving them appropriate instructions for its use, to ensure that it remains in
good condition. The orthodontist must therefore correct nature when it is at fault (e.g., agenesis, cleft
palate or diastema) or correctly reassemble the various parts of the tool when its deformation (e.g., all
cases of open bite) and consequently early destruction (tooth loss or wear) has been caused by
incorrect use. In every case, he must teach the individual to use this tool properly, hence the extreme
importance of retraining.

 The Case of Caroline O.

Before concluding, I would just like to convince you of the efficacy of orthodontic techniques when
they are combined with conscientious functional retraining of the oral cavity as we have outlined
above, by presenting in greater detail the particularly spectacular case of young Caroline O.
At her birth, the pediatrician warned Caroline O.'s mother that her daughter had significant mandibular
prognathism and advised her to seek advice as soon as possible. She attended many consultations
during which she was advised to wait until her daughter was 15 years old and then have surgery to
readjust the jaws by operating directly on the mandible.

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Orthodontics for its patients

She was told that any earlier treatment would be useless because of the high risk of recurrence during
puberty. There was indeed considerable prognathism, with the lower incisors 5 mm farther forward
than the upper incisors. The palate was narrow, the lower jaw markedly advanced and the upper jaw
underdeveloped (see below).

Caroline aged 6 years 10 months

Treatment at 6 years and 10 months consisted of increasing the width and depth of the palate and
slowing the development of the lower jaw (with a retractor followed by a Delaire mask), combined
with functional retraining (particularly with regard to correct positioning of the tongue). At 7 years and
10 months, the results were already significant.
Banding treatment, which only began when the permanent teeth had erupted, consisted of fitting bands
and brackets and extracting the four premolars. Treatment lasted 18 months and was completed when
Caroline was 13 years old, i.e., well before the age at which a major surgical operation had been
envisaged.
Orthodontic treatment helped to raise the angle of the two jaws relative to the base of the nose from -3
degrees at 6 years old to 1 degree at 12 years of age. Advancement of the upper jaw relative to the
mandible can be clearly seen, while the height between the base of the nose and the chin remains
unchanged.
The X-ray images below show the progress of correction and its stability. By stimulating growth in the
upper jaw and slowing growth in the mandible the difference between the bones was corrected.

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Orthodontics for its patients

7 years 10 months

7 years 4 months

7 years 4 months 7 years 10 months 12 years 10 months

In October 2001, when Caroline was 19 years old, a final procedure was performed, minor surgery to
allow one of the wisdom teeth (lower right) to grow properly by straightening its axis, which was
twisted.
Surgery on the jaw was avoided by early treatment, despite significant bone malformation. Growth has
not caused recurrence of the prognathism, contrary to what had been predicted to her mother. At 23
years old her face is harmonious and she has a lovely smile.
The photos below of Caroline at 23 years of age show the great stability of the treatment.

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Orthodontics for its patients

 In Support of Functional Retraining Orthodontics

From the practical perspective, five important points, based on my long experience in this area,
emerge from the analyses presented in this work:

 The first is that there is considerable plasticity in natural processes so that, where
correcting nature is concerned, orthodontic treatment is not only almost always possible
but is even preferable to major surgical procedures.
 The second is that in the case of major bony malformation, treatment must begin early to
be able to influence both growth—either slowing it or, conversely, stimulating it—and
reflexes, which are difficult to change. It is really important to remember that the earlier
treatment begins, the better and more rapid will be the results.
 The third point is that stabilization is only achieved when the teeth that have been
repositioned correctly by orthodontic treatment or surgery are in an area where the forces
exerted on them are in equilibrium or neutralized. This is necessary for them to be
maintained in their new position. In other words, the system of forces that previously
existed within the oral cavity and was the source of the malpositioning also needs to be
modified. There is no point to repositioning teeth if the initial causes of their incorrect
positioning are not treated as well.

 Point four is that in any comprehensive orthodontic treatment involving the fitting of
appliances to correctly reposition the teeth, it is essential to include functional retraining.

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Orthodontics for its patients

Some practitioners try to maintain straightened teeth artificially in the "correct" position
without trying to rectify the negative forces that caused the deformation and result from
bad habits developed over the years by the patient. If these forces continue to act
adversely, they cause even more severe relapses.
 Finally, functional retraining is based on two fundamental principles: the first is that the
soft tissues of the mouth and jaw (in particular the muscles and the tongue) sculpt the hard
tissues (the bone and teeth), modeling them by continuously acting on them, and the
second, that the older individual should master mature swallowing, quickly abandoning
the type required in an infant. He should no longer swallow by sucking, but should use the
tongue muscles and those necessary for chewing.

Obviously the orthodontist often needs to work in close conjunction with the dentist in treating a
patient. For example, when the teeth lack space in the jaw, the dentist should extract the premolars,
so that the space made in the middle of the arch can benefit both the incisors and the wisdom teeth.
The wisdom teeth are solid molars which are used when chewing. If necessary, a prosthesis such
as a bridge can be fitted to them, whereas the premolars are fragile teeth which develop caries and
break easily. It is thus preferable to sacrifice the premolars rather than the wisdom teeth, but
unfortunately this is practiced by very few.

oooooooooooooooooooooooooooooooooo ooooooooooooooooooooo oooooooooooooooooooooooooooooooooo

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Orthodontics for its patients

SHORT GLOSSARY

 Activator: An appliance for correcting maxillary prognathism.


 Agenesis: Absence of the tooth buds of certain permanent teeth which do not appear after the
milk teeth have fallen out.
 Alveolar bone: The bone which fixes the teeth to the jaw.
 Alveolar protrusion: The condition in which the teeth are inclined towards the exterior.
 Alveolar retrusion: The condition in which the teeth incline inwards.
 Alveolus: The bone directly surrounding the tooth, appearing and disappearing with it.
 Ankylosed (tooth): Said of a tooth accidentally welded to the bone that cannot therefore erupt.
 Antagonists: Said of identical teeth situated on opposite jaws.

 Banding (treatment): A type of treatment


 Basal bone: The hard bone of the jaw
 Bruxism: Synonym for grinding the teeth, especially while sleeping.

 Canines: The sharp teeth used to shred food.


 Cleft lip and palate: Sometimes called "harelip." Denotes a malformation in which the palate is
incompletely closed, so that the nose and mouth communicate with each other.
 Contraction (of the dental arch): The deformation characterized by the upper molars being
offset from their normal position and occurring to the inside of the lower molars.
 Crib: An appliance for correcting open bite conditions.

 Deglutition: The act of swallowing.


 Delaire mask: An appliance used to correct mandibular prognathism.
 Dental arch: The entire set of teeth on the jaw.
 Dental consonants: The category of consonants to which [t], [d] and [n] belong.
 Dental crowding: Insufficient space on the jaw for the teeth.
 Diastema: Abnormal space between the teeth (widely spaced teeth).
 Disharmony: The size of the teeth relative to the jaw is disproportionate.
 Double protrusion of the incisors: A deformation of the upper and lower incisors, which
project excessively.

 Eruption: A tooth emerging from the gum.


 Expansion (of the dental arch): A deformation characterized by the upper molars being offset
from their normal position and occurring to the outside of the lower molars.
 Extraction: The operation to remove a tooth.
 Fricative: A type of consonant such as the sound [sh].

 Germectomy: The extraction of tooth buds.

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Orthodontics for its patients

 Impacted (canine): A canine poorly positioned in the gum which cannot erupt and develop
normally.
 Incisors: The front teeth, whose function is to cut or incise food (hence the name), cutting like
scissors.
 Infraocclusion: Said of a tooth which is unable to grow fully.
 Intercuspation: The term indicating interlocking of molars.

 Labial: Relating to the lips.


 Labioversion: Synonym for alveolar protrusion.
 Lingual: Concerning the tongue.

 Malposition: Abnormal placement (generally of a tooth).


 Mandible: Synonym for the lower jaw.
 Masseters: The muscles of the jaw joint allowing the mouth to open and close. They are the
most powerful muscles in the body.
 Maxilla: Synonym for the upper jaw.
 Maxillary contraction: When the palate is narrow, the upper molars are located to the inside of
the lower molars, whereas normally they should circumscribe them so that together they
correctly perform their role of grinding while chewing.
 Maxillary expansion: When the palate is wide, the span of the upper molars is much wider
than that of the lower, making it impossible to use the molars for chewing.
 Microdontia: A malformation characterized by teeth which are too small and do not occupy all
the space available in the dental arch.
 Molars: The side teeth which are used to grind food, like millstones.
 Multi-attachment device (treatment): Synonym for banding

 Nasal: Related to the nose.


 Nasal consonants: The category of consonants to which [m] (bilabial nasal) and [n] (dental
nasal) belong.
 Neuralgia: In this context, dental and cervicobrachial pain.
 Occlusal: Relating to occlusion.
 Occlusion: The term indicating the jaws being closed.
 Odontoma: A supernumerary abnormal dental bud (which is not shaped like a real tooth).
 Open bite: An abnormal gap between the two jaws on one side of the mouth (unilateral or
lateral open bite), on both sides (bilateral open bite) or over the entire circumference of the
teeth (total open bite).
 Oral: Concerning the mouth.
 Orthodontics: A term of Greek origin meaning literally "the science of straight teeth," this is
the branch of dentistry responsible for correcting dental deformities.

 Palate: The vault of the upper jaw.


 Para-Andresen appliance: An appliance for correcting mandibular prognathism.
© Dr.Claude Mauclaire 2010. All rights reserved 79
Orthodontics for its patients

 Peg-shaped teeth: Term occasionally used to describe small, rounded, pointed upper lateral
incisors that impair the appearance of the smile.
 Periodontal disease: Synonymous with "receding gums." A process weakening the
implantation of the root of a tooth, which is no longer held firmly in the bone. It is due to
resorption of alveolar bone and gum tissue.
 Periodontal tissues: All the tissues enveloping the roots of the teeth.
 Premolars: The intermediate teeth between the canines and the molars.
 Prognathism: The deformation of one of the two jaws which has advanced too far forward
relative to the other. Prognathism can be maxillary (the upper jaw is too far forward,
producing "horse teeth") or mandibular (the lower jaw is too far forward, producing a
protruding chin).

 Quad Helix: An appliance for correcting a palate which is too narrow.

 Receding gums: A synonym for periodontal disease.


 Retained tooth: A tooth which cannot erupt from the gum because the tongue is interposed.
 Retract: To cause a tooth that protrudes to be gently moved back towards the interior of the
mouth.
 Sibilants (consonants): The sub-category of consonants to which [s] and [z] belong.
 Soft palate: The soft, movable part of the back of the palate.
 Supernumerary teeth: Too many tooth buds. A congenital malformation.
 Supraocclusion: Excessive overlapping of the upper incisors over the lower ones, sometimes
completely covering them.
 Temporomandibular: Relating to the articulation of the jaw.
 Voiced consonants: The sub-category of consonants to which [b], [g] [v] and [z] belong.
 Voiceless consonants: The sub-category of consonants to which [p], [k], [f], [s] and [sh]
belong.
 Wisdom teeth: The molars at the back of the jaw, the last teeth to appear on the dental arch.
Also called the third molars.

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© Dr.Claude Mauclaire 2010. All rights reserved 80