Case Report

Early-Age Orthodontic Treatment: An Approach with “Prefabricated Aligners” Combined with Myofunctional Therapy - Two Case Reports

by Andrea Freudenberg1, Daniel Fuchs1, Maximilian Bleilöb2, Christina Erbe2, Julia Camilla Bulski2*

1Private practice, Fachzentrum für Kieferorthopädie Dr. Andrea Freudenberg & Kollegen, Weinheim, Germany

2Department of Orthodontics, University Medical Center of the Johannes Gutenberg, University of Mainz, Augustusplatz 2, 55131 Mainz, Germany.

*Corresponding author: Contributed equally; Julia Camilla Bulski, Department of Orthodontics, University Medical Center of the Johannes Gutenberg, University of Mainz, Augustusplatz 2, 55131 Mainz, Germany.

Received Date: 24 March 2024

Accepted Date: 28 March 2024

Published Date: 01 April 2024

Citation: Freudenberg A, Fuchs D, Bleilöb M, Erbe C, Bulski JC (2024) Early-Age Orthodontic Treatment: An Approach with “Prefabricated Aligners” Combined with Myofunctional Therapy - Two Case Reports. Ann Case Report 9: 1727. https://doi.org/10.29011/2574-7754.101727

Abstract

Early-childhood orthodontic treatment should be preventive, sustainable, and cost-efficient. Two cases treated with mykie®, an early-age orthodontic approach in combination with myofunctional therapy, will be presented. The use of eruption guidance appliances (EGAs) as “prefabricated aligners” is integrated in this interdisciplinary concept. Advantages and limitations of this approach will be discussed and the possibility of combining EGAs with other appliances, e.g. aligners, will be discussed.

Keywords: Aligner; Early-Age Orthodontic Treatment; Economic Evaluation; Eruption Guidance Appliances; Growing Patients; Myofunctional Therapy

Introduction

Early-childhood orthodontic treatment is very controversially discussed in literature. Opponents criticize frequently observed instability, often failing to avoid a second orthodontic treatment and thus resulting in extended treatment durations as well as a total cost increase [1]. Therefore, many practitioners favor a later start, when patients reach adolescence, to correct the dental and skeletal malposition and primarily base their therapy on functional and/or fixed orthodontic appliances or clear aligners. The results, likewise, are often not stable [2], but longer lasting due to better intercuspation of the permanent teeth as well as life-long retainers regularly applied at the end of the treatment.

But why is orthodontic treatment often not stable? What are the reasons for relapse? What are the causes for malocclusion? According to Schopf [3], only 25% of all malocclusions seen in day-to-day practice derive from genetic predispositions, implying that the majority of roughly 75% arise from functional imbalances of the orofacial system [4]. These include, among others, a low resting position of the tongue and mouth breathing [5-7].

Form follows function (and vice versa) in the growth of the maxillofacial complex [8]. The jaw bones - and consequently the teeth - develop in the direction they are guided towards by the pressure and traction of the muscles and surrounding tissues. Therefore, the teeth (or the malocclusion) reflect the prevalent orofacial function or dysfunction.

Thus, successful treatment of malpositions and prevention of relapses requires a combination of the orthodontic treatment with myofunctional therapy, especially in early-age orthodontics.

Correcting orofacial dysfunction early, allows the jaws and teeth to grow into their physiological position, instead of having to compensate the malposition when they have already been manifested. This topic is controversially debated in recent literature and online: Some studies and trials support the effectiveness of an early approach interceptive orthodontic treatment. This treatment approach is not a novelty since functional appliances such as the Bionator by Balters and the Frankel Functional Regulator by Fränkel have been used successfully for decades in countries all over the world [9, 10]. The comprehensive concept of all these functional appliances is the guidance of the teeth into their optimal position by manipulation or training of the orofacial soft tissues. By retaining the tongue, lips and/or cheek muscles, the appliances allow the teeth to develop into the intended direction.

There exist multiple other approaches on how to treat 6- to 10-year-old patients. The concept of orthotropics, created by Mew in the 1970’s, for instance, focusses not primarily on correcting every single malpositioned tooth, but rather on promoting facial growth [11].

During the last decades, many companies worldwide have developed prefabricated appliances made of silicone (eruption guidance appliances = EGA). The mutual aim of all these appliances is to positively influence the orofacial tissues, establish nose breathing and high tongue posture and to guide erupting teeth into the desired direction. To support the effectiveness of their appliances, companies like Myofunctional Research Co. (MRC, Helensvale, Australia), LM-dentalTM (LM-Instruments Oy, Parainen, Finland) and Orthoplus® (Igny, France) have invented treatment approaches which combine these appliances with a standardized training schedule to exercise the orofacial tissues in the sense of a rudimentary myofunctional therapy.

Since, for the author team, none of the above-mentioned treatment options seemed satisfying enough in synergizing contemporary, viable orthodontics with holistic myofunctional training, Dr. Freudenberg and her team developed their own treatment concept mykie® (= myofunktionelle Kieferorthopädie, German for myofunctional orthodontics). The objectives were the following:

  1. to develop an efficient interdisciplinary early age treatment with reduced relapse tendency
  2. to select appliances from available sources solely based on their performance and remain independent from specific suppliers/companies
  3. to create a treatment approach that is feasible for children in contemporary society
  4. to be focused on the total cost of a child’s treatment as sometimes a second phase of treatment is necessary that also needs to be financed.

Materials and Methods

Additional information to the case-presentation and the treatment concept mykie®

The concept mykie® has been invented to reach the four objectives mentioned above. Ideally, prevention should start directly after birth of a child in form of parental education. In our experience, active treatment with sufficient compliance can start as soon as the child reaches primary school age – sometimes earlier, depending on the child’s maturity and ability to learn and comply. Our treatment plan is spread over 1.5 years, including monthly visits to the orthodontic office. Every appointment comprises two steps: the adjustment of the appliances as well as an assessment of progress by the orthodontist, followed by myofunctional training performed by a specialized myofunctional therapist. Patients are instructed to wear trainers (EGAs) one hour per day and all night. In most cases, transversal and sagittal expansion of the upper jaw is necessary. Those patients have to wear an additional removable appliance 24 hours a day, only taken out for oral hygiene, for about 6 months (Figure 1). All patients are further instructed to perform selected myofunctional exercises for 10 minutes daily.

 

Figure 1: Bioplate appliance modified from Bioblock (orthotropics).

Good compliance and motivation are indispensable, making education and motivation, first of the parents and then the patient, a major part of the mykie®-therapy concept. After every treatment phase of 6 months, the patient and the parents receive verbal feedback and are shown photographs of the patient’s teeth and facial development status to provide both, the patient and the parents, with information of their joint achievements.

After active treatment of 1.5 years, we offer an one-year sustainability phase comprising 5 appointments, again with both, the orthodontist and the myofunctional therapist, present during the appointments. Afterwards, the patient is instructed to wear the EGA only at night and is scheduled at least biannually to monitor the further dentition development as well as the new muscle balance’s stability.

EGAs / Myotrainers

Eruption guidance appliances (“EGAs” or more commonly referred to as “Trainer” or “Myotrainer”, Figure 2) are not very popular among orthodontists who often criticize the lack of patients’ compliance as well as the fact that they are not made-to-measure for the individual patient. Furthermore, many practitioners might be discouraged by the wide variety of prefabricated appliances available as there are multiple different companies offering a large number of different appliances in varying sizes and for different malpositions.

 

Figure 2: a. LM-ActivatorTM 2, b. orthoplus® EFT slim

Despite the downsides arising from the use of EGAs, many benefits can be discovered: The first to be named is the undeniable cost benefit, in comparison to individually produced appliances, which plays an important role because early treatment is often fully or partially self-paid by parents in Germany. While the function as a guard against the pressure of the cheek and the tongue is undeniable, trainers prevent mouth breathing and direct the breathing current automatically to the nose (all other functional appliances do not provide a big labial shield).

Additionally, their function as an orthodontic appliance is surprisingly beneficial and has been shown by Keski-Nisula [12]. In 5-year-old children statistically significant improvements in terms of molar relationship, overjet, overbite, incisor alignment and mandibular growth enhancement can be achieved after three years of treatment compared to a control group, even without any additional myofunctional training and exclusive nighttime ware [13]. Furthermore, these results proved to be stable 11 years posttreatment [13]. In growing patients, teeth (and jaws) are guided by very mild pressure into the space provided by the EGA which act like a set-up or the final aligner in a treatment plan. Thus, the choice of the correct EGA for the respective malocclusion is crucial to allow an effective treatment. Figure 3 shows the alignment that can be achieved with one EGA after 6 months only.

In compliance with the recommended wearing time, the information provided by the EGA is being translated into the position of the teeth. The bony structures are still malleable and respond very well to gentle pressure which is exerted for one hour a day and at night. Therefore, pre-treatment, it is important to know which amount of overjet and overbite is prescribed by the EGA used (Figure 4). The same applies to the transversal width. All these factors vary between manufacturers.

To use the suitable set-up for every single patient and reduce the number of EGAs stored in our office we did a survey, in which we evaluated the prescribed information of more than 100 individual EGAs from different companies by pouring plaster in the EGAs followed by relevant measurements. Out of more than 100 EGAs from different companies, we created our concept that includes about 10 EGAs, particularly from the companies Orthoplus® and LM-Activator®. This survey has been published [14-16].