Management of Malocclusion in Children Using Myobrace Appliance: A Systematic Review

Introduction

A habit is a pattern of behavior that is repeated and is generally a normal stage of development. Repetitive behavior is common in childhood and most of these behaviors start, and can stop, spontaneously. The mouth is a general and permanent location for emotional expression and is a source for releasing desire and anxiety in both children and adults. Stimulation can be through the tongue, fingers or nails which can be a palliative action (a state that can provide calm). Habits that occur in the oral cavity (Oral Habits) can be classified into two, namely physiological and non-physiological Oral Habits. Physiological oral habits are normal human habits such as nasal breathing, chewing, talking, and swallowing. Non-physiological oral habits are abnormal human habits that cause pressure and tendencies that persist and are repeated continuously so that they affect craniofacial growth and are usually called Bad Habits^1–4.

Bad habits are normal in children aged less than six years and can stop on their own (spontaneously). If these bad habits continue after the age of six years, it can cause malocclusion in children. Malocclusion is defined as an abnormal dentofacial condition which refers to an abnormal occlusion or impaired craniofacial relationship that can affect appearance (aesthetics), function, facial balance, and psychosocial states. Malocclusion is one of the most common dental problems with, a prevalence ranging from 20%–100% in different studies, and is a common study^5–7. Examples of bad habits that can lead to malocclusion include thumb sucking, pacifier sucking, the tongue placing pressure on teeth, nail biting, mouth breathing, bruxism, and lip biting or sucking. The habit is carried out at least six hours a day, a high enough frequency with sufficient intensity to cause malocclusion. Of these three factors the most influential is the duration of the habit. Bad habits are often distributed as a cause or risk factor for various types of malocclusion. Malocclusion may include the occurrence of an open bite, with the maxillary incisors sloping to the face (protrusive), the mandibular to lingual (retrusive) incisors, and the eruption of some incisors being obstructed leading to increased overjet and reduced overbite^1,8–10.

In the world of pediatric dentistry, one of the treatments for malocclusion is Oral Myofunctional Therapy (OMT). OMT is defined as the treatment of dysfunction of the facial and mouth muscles, with the aim of correcting orofacial functions, such as chewing and swallowing, and improving nasal breathing^11,12. The goal of myofunctional therapy is to strengthen the muscles necessary for normal breathing, chewing, and swallowing, with a focus on increasing the tone and mobility of the oral and cervical structures^13–15. One myofunctional tool that can be used to correct malocclusion, as well as bad habits, in children is the Myobrace Appliance. Myobrace is an intraoral appliance system used in interceptive orthodontics, designed for the treatment of malocclusion in mixed dentition patients (ages 8–12 years). Myobrace can also be used in adult patients but only for non-extractive cases and for mild or moderate malocclusion. This tool works to improve the balance of facial muscles and chewing, and restore tongue posture. Myobrace has the following objectives: 1) to get a myofunctional effect, 2) to restore the position of the mandible, 3) to stimulate the muscles of the face, masseter and tongue, 4) to move the mandible forward, 5) and to stimulate horizontal growth^16,17.

Methods

Result

After eliminating duplicate articles, the titles and abstracts of each article were analyzed across 108 articles. Then a Journal Search on Google Scholar took place using the keywords 'Malocclusion in children and Myobrace Appliance', for articles published between 2016–2020. We then judged the titles and abstracts in correspondence with the topic, resulting in 51 articles. Of these, there were 36 articles not in line with the topic and six articles that could not be freely accessed, so that 42 articles were excluded. The full text articles in the other nine articles were reanalyzed and three articles were excluded with reason and six articles were produced which were then included in the analysis.

Discussion

The results of this systematic review show that the Myobrace appliance can be used as an alternative treatment for malocclusion in children, especially to correct class II malocclusion and class III malocclusion (mandibular prognathy and maxillary retrognathy). In addition, this tool is also capable of correcting overbite, overjet, crowding of upper and lower anterior teeth, sagittal molar relationships, lip seals, and facial asymmetry^18–21. The Myobrace appliance is a prefabricated functional appliance with myofunctional training characteristics, which is used to correct malocclusion in children who are in the development stage²². The form of the Myobrace appliance can be seen in Figure 2.

Figure 1. Flowchart of the systematic review.

Figure 2. Myobrace tool used during treatment.

Source: Primary Data.

Malocclusion is a form of maxillary and mandibular connection which deviates from the standard form which is accepted as the normal form. Malocclusion can be caused by the absence of dentofacial balance. It is a fairly large dental and oral health problem in Indonesia and its prevalence is still very high, around 80% of the population, and is in third place after dental caries and periodontal disease^23–25. One of the causes of malocclusion is bad oral habits. Bad habits that are done repeatedly and continuously during the development of the jaw will result in malocclusion. Bad habits such as finger/nipple sucking, nail biting, lip biting, mouth breath, and tongue sticking have an impact on the prevalence of malocclusion, especially in children^26–28. Examples of bad habits such as finger sucking are likely to interfere with the position of the teeth, this habit can lead to malocclusion, namely an anterior open bite due to disruption of the growth pattern of the cranofacial bones. There is a significant relationship between the development and prevalence of malocclusion and the prevalence of bad habits^29–32. The results of the study on children aged seven to 15 years³³ who have bad oral habits show that around 80% of children suffer from malocclusion, such as class II and class III malocclusion. According to Singh³⁴, children who have bad mouth habits, especially finger sucking, tend to experience class II malocclusion. This indicates that bad oral habits lead to malocclusion. Previous studies involving children aged eight to 10 years revealed that children with malocclusion were more likely to have a negative impact on their quality of life than individuals who were malocclusion free⁴¹. Some types of malocclusion also have a higher impact on quality of life^42,43.

The Myobrace appliance was introduced by Myofunctional Research Company, Australia, followed by other appliances of The Trainer System™ in 2004. It also contains various tools for different age groups and is available in various sizes. The Myobrace appliance is available for four stages of treatment, including habit correction, arch extension, tooth alignment and retention. The Myobrace appliance has a structural element similar to that of a trainer system, consisting of a tough nylon element, called the Inner-Core or Dynamicore. The manufacturer states that dynamicore helps withstand the forces developed on the teeth by the buccinator and orbicularis muscles allowing correction of misaligned teeth by providing better arch shape. The presence of additional channels in the area of the anterior teeth on the Myobrace appliances is claimed to increase its ability to align teeth because it can exert direct force on the teeth. They are available in a variety of sizes for primary, mixed and permanent teeth and for different treatment purposes^44–46.

The goals of treatment using the Myobrace appliance are: 1) Restoring nasal breathing from mouth breathing, 2) correcting correct tongue posture, 3) correcting correct swallowing, 4) Correcting alignment of teeth and jaw to the correct position, 5) There can be retention or no retention, 6) minimal or no use of braces, 7) achieve optimal health, 8) unhindered craniofacial development^47–49. Use of Myobrace at least two hours every day and a maximum of overnight, aims to provide adequate expansion and arch strength of the jaws to align the anterior teeth^50–52.

The parts of the Myobrace appliance consist of⁵³:

Things that need to be considered when using Myobrace appliance are: 1) the patient must wear the appliance for one to two hours every day and overnight while sleeping, and 2) it is necessary to use the appliance every day (if it is not used every day, then the treatment will not be successful), 3) at least one myofunctional function exercise must be completed every day, 4) the patient must learn how to swallow correctly and position the tongue in the correct place in the mouth, 5) the patient must guard their mouth closed when not talking or eating³⁶. Based on the age group, Myobrace appliance is classified into four types, namely:

Conclusion

Myobrace appliance can be used as an alternative treatment for malocclusion in children, especially to correct class II malocclusion and class III malocclusion (mandibular prognathy and maxillary retrognathy). In addition, this tool is also capable of correcting overbite, overjet, crowding of upper and lower anterior teeth, sagittal molar relationships, lip seals, and facial asymmetry.

Data availability