EXPERT VIEW - Rafi Romano's "pearl"

Here is a “Pearl” from one of the Aligner “greats”: Active Retention for “unstable” orthodontic result in open-bite cases.
Rafi Romano, Tel Aviv, Israel

One of the main obstacles in modern dentistry is the ability to predict the orthodontic result. Yet, the most complicated and unpredicted is the teeth movement and their stability during the retention period.
Open bite cases present probably the most challenging malocclusions since it is dominated not only by teeth position but also by the muscles’ activity (or more by their inactivity...) and by the tongue malfunction.

Clear aligners are the most suitable treatment modality to correct open bite cases due to their ability to control and execute very accurately anterior extrusion and posterior intrusion movement, arch expansion and torque control.

The challenge we have is to avoid any future relapse, as many patients had already encountered relapse in previous orthodontic treatment and had not changed their wrong myofunctional behavior such as anterior tongue thrust, mouth breathing, hypotonic muscles of the face and neck and natural tendency for teeth relapse to the malocclusion position.

To ensure stability during the retention phase, we need to eliminate the etiology and create active force during the long retention phase to contradict the relapse tendency.

Our “active” retention protocol in open bite is the following:

  1. Bond rectangular attachments for pure extrusion forces or vertical for extrusion and upright forces on all anterior teeth which were in open-bite before the orthodontic treatment. The attachments can be bonded “free hand” before scan is taken for retention aligners or with template of the clear aligners technique which you are using. (Figs 1-4)
  2. DO not bond fixed retainer on upper anterior teeth. Lower fixed retainer 3-3 is bonded in most cases
  3. Create “active aligners” in which there is extrusion force of 0.5 mm per aligner.
  4. Instruct patients to change aligners if slight gap is visible in the incisal edges and make sure that the next aligner has again extrusion force of 0.5 mm.
  5. Use Chewies on regular basis
  6. Use upper and lower aligners for unlimited night wear. The arch shape will be maintained only if aligners are used constantly
  7. Give patients exercises to strengthen the facial muscles and change the tongue thrust habit. The exercises are done daily at home with weekly support by a myofunctional therapist.
  8. Froggy Mouth is given to the patient. It is effective in the myofunctional correction of the atypical swallowing mechanism, providing the clinician a new therapeutic approach for neuromuscular re-training of atypical deglutition and dysfunctional deglutition in patients. (3)
  9. Patient also received MYOSPOTS, small circular pads, made of biodegradable natural polymers with strong adhesive power which enable them to adhere easily to the surface of the palate. (Fig. 7d). Upon adhering to the palate, they involuntarily induce the tongue to elevate and touch them. The repetitive induced elevation of the tongue to touch and dissolve the adhered pad, provides targeted exercise for tongue muscles to increase the tone.
  10. Take record every 6-12 months including face and teeth photos and intraoral scan. Compare the records from previous appointments and trace every relapse tendency and address it as needed by strengthening the above-described procedures.

 

Fig. 1a - before

Fig. 1b - after

Fig. 1c - with palatal attachments for active retention

Fig. 2a - before

Fig. 2b - after

Fig. 2c - with palatal attachments for active retention

Fig. 3a - before

Fig. 3b - after

Fig. 3c - with palatal attachments for active retention

Fig. 4a - before

Fig. 4b - after

Fig. 4c - with palatal attachments for active retention

Fig. 5a - push spoon with the tongue to strengthen tongue muscles

Fig. 5b - hold spoon with small weight with closed lips to strengthen lips and facial muscles

Fig. 6 - Froggy Mouth (www.froggymouth.com) for 15 minutes per day to strengthen the facial muscles and change tongue posture

Fig. 7 - Myospots (www.myospots.com) to train the tongue to rest on the palate during function and rest
a. Place a MYOSPOT on your dry, clean thumb
b. Force the spot against the anterior part of the palate with gentle force for 10 seconds
c. Remove your thumb and keep pressing the SPOT using your tongue until it dissolves

The author
Rafi Romano, Tel Aviv, Israel

 

Dr. Rafi Romano is a specialist in orthodontics and dentofacial orthopedics (Hebrew University, Hadassah Jerusalem). In his private orthodontic practice in Tel Aviv, he emphasizes adult and esthetic orthodontics.
Dr. Romano is AAO Ambassador representing the Israel Orthodontic Society.

He is the editor of five books:  Lingual Orthodontics, (Decker, 1998), The Art of the Smile (Quintessence, 2005), The Art of Treatment Planning (Quintessence 2009), Lingual & Esthetic Orthodontics, (Quintessence 2011) and The Art of Detailing, (Quintessence, 2013).

Dr. Romano is a member of the Editorial Board of the International Journal of Esthetic Dentistry – IJED, is former Editor-in-chief of "Orthodontics: The Art and Practice of Dentofacial Enhancement," Quintessence Publishing and former Editor of the Journal of the Israeli Orthodontic Society,

He is an Invisalign Diamond Provider, an Advisory Board Member for Align Technologies and lectures worldwide on esthetic orthodontics and adult multidisciplinary orthodontic treatment. He is an Active Member of the EAED, AAO and the WFO.

He is an Invisalign Diamond Provider, an Advisory Board Member for Align Technologies and lectures worldwide on esthetic orthodontics and adult multidisciplinary orthodontic treatment. He is an Active Member of the EAED, AAO and the WFO.

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