We find that the most common reason practitioners come unstuck is that they simply hand the patient an appliance and tell them to wear it, without supplementing it with a support system to reiterate compliance and motivate children. Myofunctional therapy in orthodontics has been around for around 100 years and the reason it hasn’t reached its full potential is partially in the delivery of the system. That is how MRC differs from all the rest, in that we have revolutionised the system delivery and packaged it into a simple and effective system.
MRC recommends that all clinics establish an activities area so that children aren’t in a dental setting when they’re learning their exercises. An activities centre constitute a very important part of creating a child-friendly program which facilitates good compliance and understanding of treatment goals.
To improve compliance, staff must speak with the child on their level, explain to them the importance of why they should wear their appliance and give them tips on different times during the day they can wear it (homework, TV or smart device etc). The importance of their activities must also be discussed. The educator must be sufficiently competent in sustaining motivation and compliance levels in the parent/patient, especially towards the latter
treatment stages.
Another crucial part is to motivate and educate parents on the importance of their role in monitoring the child; giving the child daily reminders and encouragement to help them improve compliance, and emphasizing to parents that the best results are achieved when both patient and parents are on board. There should be no excuses for non-compliance, and this instruction is strictly, a minimum of 1 hour per day of Myobrace® wear and all night when they sleep, every day, for the duration of their treatment. Anything short of this will result in a less than ideal outcome.
- There may be several reasons underpinning this occurrence. The most common reasons, outside of poor compliance, that are an impediment to patient progress are listed below. However, before you read the options below, make certain that you have investigated in detail that the patient and parent are properly complying with the program (often patient’s understanding of compliance is different to your expectations):
- Do they have an airway obstruction or persistent allergies that are an impediment to establishing nasal breathing, and need a referral to a medical practitioner (ENT)?
- Do they need to undertake a Myosa® program before they continue with Myobrace?
- Do you need to use an auxiliary arch expansion appliance for more tongue space?
- How is the patient’s function? Do they need to use any of the specialty appliances (lip trainer or MyoTalea TLJ appliance) to improve function?
- Do they have a tongue tie (anterior or posterior)?
- Are they using their appliance properly? Sometimes children don’t rest their teeth into the Myobrace® enough, so it floats in their mouth.
- Are they aware of the correct myofunctional habits they should adopt when they’re not wearing their appliance?
- Are they as compliant as maximally possible with exercises and appliance wear?
- Are you using the correct appliance for this particular child?
- Is your expectation of results in line with the patient’s age?
Remember you can never make a person grow once they are past a certain age, but you can always train correct muscle habits, nasal breathing and align the teeth.
A clinical understanding of the pathophysiology of maxillofacial growth and development problems is paramount to being able to apply Myofunctional Orthodontic treatment effectively. Unless you understand what is going wrong, you can’t problem-solve throughout treatment to ensure the best outcome for the patient. This is once again why practitioners should attend as much training and read as many resources as possible so that they avoid over-dependence on solely issuing the appliance and hoping for the best.
The stage 2 appliances can only be issued when the patient is able to retain the Stage 1 appliance in their mouth for at least 30 consecutive days. This realistically shouldn’t take longer than 3-6 months with good compliance.
If after 3 months of compliant Myobrace wear and an inability to improve the retention of the appliance overnight, strong consideration of ENT referral should be undertaken.
If the patient is slowly improving, it may just require a longer period of time and attention for the patient to adjust to the stage 1 appliance and efforts should be continued. Consider further use of Myotalea appliances and ensure compliance is adequate.
It is preferable that patients only remain on 2nd stage appliances unless BWS is being used, in which case it is acceptable to revert back to a stage 1 appliance or the T1-BWS. If the patient for any reason reverts to mouth breathing and cannot retain their stage 2 appliance overnight, it is permissible to go back to the stage 1 appliance until nasal breathing is established. Assess whether the patient’s Myobrace treatment plan should be suspended and the patient
should undertake a Myosa treatment plan.
Remember the aims of treatment are to correct FUNCTION. Generally, if you have expanded enough to accommodate the incoming dentition then that is a good indication that the tongue will fit in the top jaw (in the correct tongue resting position). However, the best way to gauge for this is to observe the patient during their Myobrace® Activities and to observe whether the tongue is comfortably fitting in the palate without splaying over the upper molars. The tongue suction hold activity is also a good way to check whether there is adequate room in the arch for the tongue.
Wearing the Myobrace® during the day is what we refer to as ‘active’ Myobrace® wear and at night is ‘passive’ Myobrace® wear.
The day-wear is to train the patient to perform certain Myofunctional habits correctly, whilst they are conscious; namely training lip seal by closing their lips over the appliance and correct tongue posture by placing their
tongue on the tongue tag.
Night-wear predominantly focuses on arch expansion and swallowing retraining. Both are equally important and essential to successful treatment outcomes.
This is the most critical aspect of treatment. Carefully observing the patient throughout the appointment is important and this involves the entire team of receptionists, educators and clinicians. It is assumed for the purposes of Myofunctional Orthodontics, nasal breathing is achieved once the patient has retained their stage 1 appliance in their mouth overnight for at least 30 consecutive days. Although this is an indication to move on to the stage 2 appliance, this doesn’t always mean that the patient is habitually nasal breathing for the entire day. At MRC clinics there are games and toys set up so that the patient can be observed when they are distracted with these things.
The use of the Breathing Function Tests also serve as a means of assessing the patient’s breathing. It is also permissible to ask the parent whether they haven noticed an improvement in the patients breathing patterns at home and whether the patient sleeps more with their mouth closed. Remember that if nasal breathing either hasn’t been established or improved by the three-month mark, consider referral to an ENT doctor.
Yes and no. The protocols are the recommended protocol in an ideal situation to achieve reliable results. However, we understand that not every case will be straight forward. In anything health related, there are always exceptions to
the rule. This is why it is more important to understand what your primary aim is in treatment (to establish correct function) and then accordingly consider the relevant recommendations above. Remember that the Myobrace is simply a tool to help you achieve your treatment aims.
Use your knowledge of Myofunctional Orthodontics to make appropriate judgements on a case by case basis but as much as you can, stick to the protocol, as these techniques have been refined over the past three decades.
Although you cannot in the technical sense ‘expand’ the lower jaw, there are times where you need to help advance or upright the lower dentition.
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Once the upper jaw has become expanded and allowed for the lower teeth to upright and advance, compliant Myobrace® wear alone is sufficient in correcting the lower arch. However rarely in some cases where lower adult
teeth are severely crowded or are completely blocked out from an eruption, you may adopt the help of a lower BWS.
It is exactly the same protocol as the upper BWS except used on the corresponding lower teeth. Often the composite stops are not necessary but we recommend assessing case by case. Be sure to only use this appliance if you have a sufficient anterior overjet for the lower dentition to move.
The aim of Myobrace® is for natural development of the arch through retraining of the oral musculature. If the appliance is worn for an extended period of time during the day, the focus shifts from myofunctional training to dental movement. This takes away from the purpose of the appliance and therefore we do not recommend wearing the Myobrace® for more than 2 hours. However, it is imperative to strictly wear the appliance for 1-hour minimum.
Dental alignment in itself is usually a cosmetic undertaking; unless there is an interference with function, or an increased risk of trauma and adverse periodontal outcomes, the practitioner should only undertake dental alignment in consultation with the patient and parent.
The T3 appliance is MRC’s only ‘positioner’ appliance which has individual
tooth slots to align the teeth. The benefits of this appliance is that with good compliance it can finish cases off like braces and continue habit correction. The disadvantage is that it still requires compliance.
If towards the end of treatment, function has been largely resolved but the teeth are mildly irregular, be sure to ask the patient whether THEY want to have their teeth perfect with fixed orthodontics or clear aligners. If this is the case, they will likely need conventional retainers. Be sure to warn them of all the potential side effects of fixed orthodontics including root resorption, enamel damage and relapse.
Certain Myobrace® appliances are very proficient at mild de-rotations of erupting teeth. Already erupted incisors may also be de-rotated using the BWS (engaged onto the most palatally placed aspect while advancing the tooth). In such a case where the patient has a severely rotated tooth, you may need to use fixed appliances to fully de-rotate the tooth.
In addition to rotations, we also advise our patients that small spacing and mild midline discrepancy may remain at the end of Myobrace treatment. Recall that the aim isn’t to achieve artificially aligned teeth, but rather to correct function. Rarely, the patient may request the case to be finished with a course of fixed orthodontics for cosmetic reasons.
In case, you have ruled our poor oral hygiene, the next most common reason is that the patient is ‘sucking’ on the Myobrace, thereby causing negative pressure to build between the gingiva and the appliance. A simple solution is to cut a few small ‘windows’ in the appliance, which will break the seal. In MRC clinics, our practitioners use rubber dam hole punchers to do this.
You should NOT place a new patient on a stage 2 or 3 Myobrace® immediately. These appliances are significantly harder than stage 1. The pressure they exert onto the displaced teeth will be very uncomfortable. Therefore, you are more likely to run into compliance issues and potential adverse effects on the dentition. ALWAYS start with a stage 1 Myobrace® and work your way through the series.
This is a very simple adjustment and is often due to the tightness of the tongue tag against the incisive papilla. Cut ‘slits’ on either side of the tongue tag. This increases the length of the tongue tag relative to the base of the appliance, thereby increasing the flexibility and reducing pressure on the papilla. Re-issue and enquire if this improved the comfort for the patient. You may need to lengthen the cuts if required.