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ENGLISH INFO INFORMATIVO ORTO-ORTOPÉDICO Informative ortho-Orthopedics GRUPO DE ESTUDO E PESQUISA EM ORTO-ORTOPEDIA Study and Research Group In Ortho-Orthopedics Editores: Brasil - Leon Daghlian (CD e TPD) Silvia Monfredini (TPD) Peru - Virgílio Gonzales Vargas (TPD) Itália - Massimo Rosella (TPD) Revisão: Year 2 #. 1 Jan/Feb 2022 ORTHODONTISTS and DENTAL PROTHETICS TECHNICIANS Brasil - Virgínia Magri (CD-Me.) OPEN FUNCTIONAL DYNAMIC DISTALIZERS Prof. Paulo N. Schinestsck 2 THE POSTURAL ROUTINE OF DENTISTS AND RELATED PROFESSIONALS: PAIN AS A WARNING SIGN AND MOVEMENT AS THERAPY Profa.. Dra. Tania Urbanavicius Guerra 10 ACCESSORIES 4 Prof. Leon Daghlian 13 Informativo Orto-Ortopédico #1 #2 #3 #4 (Ortho-Orthopedic newsletter) https://www.facebook.com/gepoo.ortoortopedia/ Português / Español / English Criação e Edição: Leon Daghlian (55-11) 97118 5799 E-mail: [email protected] INFO INFORMATIVO ORTO-ORTOPÉDICO 2 OPEN FUNCTIONAL DYNAMIC DISTALIZERS Distalization movements are very important in clinical practice and one of the main movements responsible for the reduction of extractions in treatments. In the world literature, we find a large arsenal of fixed and removable devices designed to perform dental distalization, with therapeutic maneuvers aimed at avoiding or reducing the need for extractions in orthodontic treatments, whose treatment protocols would lead to the loss of dental elements for their resolution and completion. In many cases and types of bad occlusions due to lack of space and flawed diagnosis, tooth extractions are performed in early stages of development where growth potentials still exist. These radical decisions can complicate the treatment, compromising facial function and aesthetics, which are important objectives of our intervention and, often, the main desire of the patient. For Jurandir Barbosa, one of the first challenges he faces when starting a treatment is to provide sufficient spaces in the dental arches to properly accommodate all teeth. "By inserting the wires, without prior space, undesirable displacements are created with side effects such as protrusion, changes in the angles and inclinations of the teeth, and even open bite." The distalization techniques of Jones Jig, Pendulum de Hilgers, Pendex, Distal Jet, Magnetos, Ertty System and nitinol superelastic springs are the most used fixed techniques and were developed to work primarily on the upper jaw. These techniques require a good anchoring device to avoid or neutralize possible unwanted effects derived from Newton's 3rd Law, action, and reaction: root inclinations, vestibularization of anterior teeth, extrusion and rotation of molars. Figure 1 The distalization and verticalization of the lower molars presents greater difficulty and requires a stronger intraosseous skeletal anchorage system, with mini-implants and/or mini titanium plates. However, this system cannot always be used, and its main disadvantages are the cost of a surgical procedure, risks of infection, discomfort, and requiring greater care and hygiene around the device. Among the removable techniques, the FDRJ distalizing appliances stand out, (Functional Dynamic Rehabilitation of the Jaws), conceived by Dr. Maurício Vaz de Lima from Rio de Janeiro, Brazil. According to Vaz de Lima and Soliva the name Functional Dynamic Rehabilitation of the Jaws, FDRJ, "means to act by reorganizing and recycling the dysfunctions and dental and postural disorganizations of the patient, returning the normal, functional and aesthetic physiology without mutilation". INFO INFORMATIVO ORTO-ORTOPÉDICO 3 Maurício developed the method of distalizing dental segments in blocks using "the principle of the majority against the minority, with the philosophy of taking the wrong to the right place and with common sense and providing morphological and functional reorganization of the stomatognathic system, stimulating and redirecting bone growth through encapsulation with constructive bites." The FDRJ devices do not require extra anchorage and, according to De Luiz3 (1988), can perform distal movements in blocks and body in the order of 1mm per month, with a force of 90g. However, according to Vaz de Lima and Soliva "we cannot distalize two segments of the same arch simultaneously because we inevitably lose anchoring and overload the anterior region. The system of Functional Dynamic Distalizers, DDFAs, were developed in our clinic since 1994 from the concepts, principles, and appliances of the FDRJ, added to others from Orthopedics and Functional Orthopedics of the Jaws (FOJ), attached and applied in its structure and functioning. Figure 2 Main changes made to the FDRJ distalizer device 1. 2. 3. 4. Removal of previous encapsulation Placement of Hawley's vestibular arch Introduction of front springs Bilateral distalization and expansion with the same device The devices work according to the need of each clinical case and according to the Laws of Planas and the Fundamental Principles of Functional Orthopedic Techniques described by Wilma Simões: Neural Arousal, Posture Change and Therapeutic Posture Change. They can be used in the upper and lower arches of children and/or adults, with intermittent forces and activations on alternate days. The frontal springs are important accessories for dental alignment and, especially, to stimulate neural receptors located in the periodontium, Terminal button. Terminal ring and Spontaneous discharge. According to Patricia Valério: "considering periodontal receptors, we can understand that the shape of the device touching the teeth and the way it changes the mandibular maxillary relationship lead to the activation of these periodontal receptors, generating a modification in the pattern of motor efferent in the CNS." Figure 3 - Valério P. Functional Jaw Orthopedics, Research and Clinical Excellence, What is OFM's form of action? Ed. Napoleon - Quintessence, São Paulo, 2020 INFO INFORMATIVO ORTO-ORTOPÉDICO 4 However, to capture more efficient response, it is necessary to touch the point where the teeth best react to excitation. According to Planas "This action is performed with a small fold in the terminal part of a front spring, also called "finger or little finger." The neural excitation of a part of the teeth responds to the group.” Figure 4 - Simões, W. Functional Jaw Orthopedics through of Neuro Occlusal Rehabilitation, Ed. Artes Médicas, São Paulo, 2003 Open Functional Dynamic Distalizers can be programmed to perform 2 different types of movements with the same device: expansion and distalization, which can be unilateral or bilateral. According to Planas, the basal bone will accompany the alveolar bone in its movements, whenever the stimulus is provided biologically and through the occlusal faces of the teeth. In this aspect, lies the greater differentiation between the two types of block distalizers, FDRJ and DDFA. Types of Open Functional Dynamic Distalizers and their movements • • • • DDFA S1 and DDFA I1: unilateral distalization DDFA S2 and DDFA I2: bilateral distalization DDFA S3 and DDFA I4: unilateral distalization and expansion DDFA S4 and DDFA I4: bilateral distalization and expansion The most used devices are: • • • • DDFA S2 superior bilateral distalization DDFA I2 inferior bilateral distalization DDFA S3 superior unilateral distalization with expansion DDFA I3 inferior unilateral distalization with expansion Distalization and expansion devices are activated on alternate days and do not require extra anchoring. They provide the professional with greater safety and control over movements and their undesirable side effects, commonly found in distalization mechanics: root inclinations, vestibularization of anterior teeth, extrusion and rotation of molars. It is important to say that open distalizers are part of the OrthoFunctional Treatment System; a treatment methodology that uses concepts and techniques of FDRJ, Fixed Orthodontics, Removable Orthodontics, OFM, Aligners and Be Flash. Klammt's Elastic Open Activator is the most widely used functional orthopedic appliance and, depending on each case, can be used at the beginning, in the middle, jointly or at the end of treatment. INFO INFORMATIVO ORTO-ORTOPÉDICO Examples of clinical cases with the main distalizers used: DDFA S2: clinical case -16 years: superior bilateral distalization Figure 5 5 INFO INFORMATIVO ORTO-ORTOPÉDICO 06 years after treatment Figure 6 DDFA S3: clinical case of a 23-year-old adult - superior unilateral distalization with expansion. DDFA I4: lower bilateral distalization with expansion. Figure 7 6 INFO INFORMATIVO ORTO-ORTOPÉDICO Figure 7 11 years after treatment Figure 8 7 INFO INFORMATIVO ORTO-ORTOPÉDICO 8 DDFA I3: adult clinical case aged 30 years – unilateral inferior distalization with expansion: obs. on medical recommendation, the 48 was not extracted. Figure 9 04 years after treatment Figure 10 INFO INFORMATIVO ORTO-ORTOPÉDICO 9 Conclusion Although we recognize all the existing difficulties and challenges, the clinical application of FDRJ and DDFA distalizers have come to add, aggregate and represent a simplified, safe and low operational cost alternative. According to W. Alexander, creator of the philosophy and orthodontic technique Discipline Vari Simplex, "my concern is with simplicity to encourage cooperation, more comfort and greater patient control. An easier and more convenient treatment for this will eventually reduce the stress of the orthodontist, his team and will decrease the time of its duration. Complicated techniques make life difficult for the patient and decrease their chances of succeeding. References 1- ALEXANDER W.- Ortodontia - Conceitos Contemporâneos e Filosofias, A Disciplina de Alexander, Livraria e Editora Santos, 1997 2- BARBOSA J.- Ortodontia com Excelência, na busca da perfeição clínica, Ed. Napoleão, 2013 3- De LUIZ LÚCIA – Distalação em Bloco: Um recurso Terapêutico na falta de espaço no arco superior, Monografia, Universidade Camilo Castelo Branco 4- PLANAS,P. Rehabilitacion Neuro-Oclusal( RNO) Ed. Masson Salvat, Barcelona 5- SIMÕES, W. Ortopedia Funcional dos Maxilares através da Reabilitação Neuro Oclusal, Ed. Artes Médicas, São Paulo, 2003 6- SOLIVA, H. Distalização em Bloco. Jornal Brasileiro de Ortodontia&Ortopedia Facial 7- VALÉRIO P. Ortopedia Funcional dos Maxilares, Pesquisa e Excelência Clínica, Qual é a forma de ação da OFM? Ed. Napoleão - Quintessence, São Paulo, 2020 8- VAZ DE LIMA, M, Soliva, H. Atlas de Reabilitação Dinâmica Funcional dos Maxilares Sem extração, Rio de Janeiro, Quintessence Publishing Co.1992 Paulo Antonio N. Schinestsck Specialist in OFM by CFO Specialist in Orthodontics and Facial Orthopedics at the Universidad Maimonides, Buenos, Aires, Argentina Member of ABOFM Member of SOBRACOM Member of the GEM, with the title of Excellence in Technique [email protected] +55 53 999825620 Whatsapp Instragran: @Pauloschinestsck INFO INFORMATIVO ORTO-ORTOPÉDICO 10 THE POSTURAL ROUTINE OF DENTISTS AND RELATED PROFESSIONALS: PAIN AS A WARNING SIGN AND MOVEMENT AS THERAPY. Over 40 years of working with people who report discomfort in the musculoskeletal system, it is common to observe the symptoms of pain in the daily lives of dentists and related professionals. The frequency of painful complaints in the work place is quite common and leads the professional to partial or even definitive removal from their functions. We also observed the chronicity and effective installation of orthopedic problems from the “naturalization” of bad postures. These bad postures are the result of negative and everyday postural habits that accumulate throughout the professional's life, without the same being aware of what is happening. The beginning The beginning of problems is sabotaging: muscle discomfort is the main complaint and after some time edema and inflammation appear. It doesn't take many years of the profession for problems to appear. In dentistry, it is common for static positions in disagreement with functional and/or antigravity biomechanics to be frequent. Added to these are inadequate furniture, difficulties in accessing the patient's mouth, equipment that does not allow individual ergonomic adjustments, time required for each treatment, the daily workday and others. THERE! The damage has started.... The middle The appearance of low back and cervical pain is common in the lives of dental professionals. This is also the case with carpal tunnel syndrome, tendonitis, circulatory disorders, changes in the upper limbs and shoulders which, due to their repetition, can be characterized as WRMD (Work-Related Musculoskeletal Disorders), which, if left untreated, is progressive and disabling . We also consider the individual variations of each professional in other demands: cognitive background (difficulties of each patient/situation), financial and pressures generated, managers, productivity, etc. Added to all these factors, it is estimated that today around 30% of professionals in the dental field prematurely abandon their function for medical reasons and difficulties in supporting the postural pain that comes with the job. INFO INFORMATIVO ORTO-ORTOPÉDICO 11 The Diagnosis There are several treatment options for the discomfort arising from postural adaptation problems in different professional areas. This discomfort is commonly translated by the word PAIN. Considering the professionals involved in dentistry, it is necessary to observe the topics already mentioned above, which will serve as indicators for the evaluation and choice for the best therapy. The most common are: - Age of the professional It is known that the age factor is directly related to the levels of postural discomfort, as muscle tone decreases with age, making the maintenance of the working posture more tiring and, consequently, more difficult. - Time spent in the profession The effects of bad postural is cumulative on the musculoskeletal system and worsen when they become habitual. The non-perception and/or need to keep the body in disarray ends up becoming natural in certain circumstances and is characterized as necessary (which is not always true). - Functional anatomical features of the specialty Specialties imply repetitions of motor patterns that are not always correct or desirable - Individual anatomical characteristics of the professional The subject/professional's biotypology can be a problem in certain circumstances. Work materials are often not the most suitable for a particular person and when it is, it is not always easy to access. The cost of ergonomic adaptations, when possible, is usually quite high. - General state of health Motor patterns change depending on the subject's health status. Here, issues common to aging are considered, such as changes in metabolic curves, blood pressure, cardiac changes in general, orthopedic and muscle changes, cognitive, mnemonic and other changes. - Daily workday It is important to highlight the importance of the length of the working day, whether in the sum of days or hours in the weekly period. Tiredness will be the result of this hourly adjustment added to the previous factors. - Interval between patients/activities No less important is to note the break from work. Intervals between daily tasks are essential for maintaining the professional's state of balance, whether homeostatic or emotionally. It is indicated that, at least every 45 minutes, postures and routines are disrupted. INFO INFORMATIVO ORTO-ORTOPÉDICO 12 - Emotional charge of the activity It is also worth noting the relationship between professional and patient. It is often in this context that the greatest difficulties are found. Low tolerance for discomfort (whether from the professional or from the patient), mechanical limitations (from the patient's anatomy or from the devices to be used and which produce fatigue for the patient and/or professional), the duration of treatment, financial issues, etc. ., can generate harmful stressful effects that are not noticeable to the dental professional. The treatment For the dental professional , pain relapse in conventional drug treatments is quite frequently observed. It is then suggested that more elements be added to conventional orthopedic treatments for greater effectiveness in reducing pain. We've listed some of these suggestions below: 1. Maintenance of locomotor functions: regardless of the dental professional's age, 40-minute walks three to four times a week are essential for the basicl functioning of the subject's circulatory and respiratory systems. In addition to the above, there is a reduction in the negative effects of static positions, as walking increases the basic resistance of the musculoskeletal system, reducing the pain resulting from fatigue generated by muscle weakness. Outdoor walks will always be the most indicated, as they provide, in addition to improvements in physiological parameters and relevant cognitive adaptations that occur beyond the monotony of closed and protected environments. 2. Stretches are always indicated. Increased bone mobility and muscle elasticity are extremely valuable in mitigating the harmful effects of dysfunctional orthopedic positions arising from postural statics. 3. Special relevance should be given to STRENGTH exercises. Not necessarily maximal strength exercises (above 85% of the individual's strength capacity) but mainly strength endurance exercises. Loads ranging from 70 to 80% with a greater number of repetitions provide the practitioner with adaptations of great physiological value and, depending on the difficulty of the exercise, the increase in neuroplasticity, a very important condition after 40 years of age. In conclusion Many of the issues involving the determination of pain are directly related to hypokinetic states and postural mistakes, especially in the professional environment. Orthodox therapies for pain management can be enhanced from the diversity and sum of various modalities and therapies. Regular and guided physical activity stands out as one of the most relevant. We emphasize, however, that the development of individual programs is always more effective if produced by a professional experienced in work ergonomics and specialized in issues related to postural disorders. INFO INFORMATIVO ORTO-ORTOPÉDICO 13 And to finish, a suggestion: "Movement is a property of the human being. So, make it your medicine for continuous use!". Profa.. Dra. Tania Urbanavicius Guerra Physical education teacher Active in several areas, mainly in higher education and, especially, in the reduction of pain resulting from the dysfunction posture with its own methodology for over 40 years. Mobile: (55-11) 994384421 E-mail: [email protected] ACCESSORIES 4 Front Springs In principle, the front springs are those that are positioned on the incisors. There are springs used in orthopedic appliances that have their own names, such as Bimler front springs (Ff and ff) (Figure 1), Klammt AEA guides (Figure 2), etc. There are also those used in removable orthodontic appliances, which are often similar to those mentioned, or adapted to the patient's needs, such as single and double finger springs, single and double helical springs, mixed springs and their variations (Figure 3). Figure 1 - Bimler front springs Figure 2 - Klammt AEA guides INFO INFORMATIVO ORTO-ORTOPÉDICO Simple Digital Simple Helical Double Digital 14 Mixed Spring Double Helical Figure 3 The purpose of the springs depends on the intention to be reached in each case. They can be spaced apart to prevent and/or guide the position of the tongue, or spaced apart to allow the lingualization of anterior teeth (Figure 4), they can also be juxtaposed to the teeth to buccalize or rotate a tooth, or even prevent this tooth from being lingualized by the action of a bow or lips (Figure 5). Therefore, we see how important it is to diagnose and plan a device, whether orthodontic or functional orthopedic. The mechanical/functional action of the springs in different types of braces is common, the important thing is to know the existing varieties in order to plan the action of the accessories, their shapes (drawings), the materials used, and what actions we want them to have. Figure 4 Figure 5 The thin wire (0.6 and 0.7 mm) helps with tooth movement, while the thicker ones guide and impedes the musculature, in addition to acting as the previous ones. There is no specific rule, experience and practice are whats needed for a good result. In figures 6 to 8 we have some examples of front springs. INFO INFORMATIVO ORTO-ORTOPÉDICO 15 Figure 6 - Sweep Spring. Figure 7 - Compact triple-arm spring By: Carlos Barberi (Colômbia) Figure 8 - Simple digital spring and buccal digital spring for tooth gyroversion. Leon Daghlian Functional Jaw Orthopedics Specialist (CFO 2003) Implantology Specialist (FACSETE 2017) Dental Surgeon (UMESP 2001) Dental Prosthesis Technician (SENAC 1985) [email protected] Instagram: @dentearte