Maryvonne Fournier versus Froggymouth: agreement or disagreement?

Dr. Patrick Fellus compares Froggymouth and the theories of Maryvonne Fournier on orofacial re-education. Discover how these approaches align to transform orthodontic protocols and promote better oral health in children.

Dr. Patrick FELLUS

- Founder of the French Society of Pediatric Orthodontics
- Inventor of Froggymouth

RE-READING MARYVONNE FOURNIER IN HER ORIGINAL VERSION I WAS COMFORTED BY THE SIMILARITY BETWEEN THE TWO APPROACHES. I WOULD EVEN SAY MORE: FROGGYMOUTH IS THE DEVICE SHE COULD ONLY DREAM OF. AS A STUDENT LIKE ME OF JEAN DELAIRE WE HAVE ALWAYS DEFENDED THE NECESSITY OF INTEGRATING A RE-EDUCATION PHASE IN ALL ORTHODONTIC PROTOCOLS. BUT THE VERY RANDOM AND TIME-CONSUMING RESULTS HAVE DISCOURAGED MORE THAN ONE PRACTITIONER.

  « It is clear that neuro-muscular, labial, and functional lingual re-educations frequently relapse.

But is it really a relapse?

This would suggest that there had been healing. It seems rather that the sought-after goal, namely the automation of the posture of the function, was not achieved. Yet, that is the real healing.

We are not vigilant enough to meticulously check if automation has been achieved.

We often content ourselves with observing the neuro-muscular responses to the given orders. On the contrary, it is about obtaining an automatism, therefore a praxis without consciousness. »  Maryvonne FOURNIER.

DOESN'T SHE DIRECTLY CALL FOR THE USE OF AN ANOETIC* PATH?

*without active participation from the patient

Swallowing re-education necessarily goes through three stages: engrammation, automation and inhibition of the old program.

The first step, engrammation, traditionally involves the patient becoming aware of the movements they are making and then becoming aware of the movement to be made, repetition should allow for automation.

Studied by Eric Kandel, Nobel Prize in Medicine in 2000, the modification of the neuronal circuit occurs at the level of synapses by increasing neurotransmitters, generally glutamate. This stage is time-consuming, tedious, and requires strong motivation.

It is only usable from the moment the child can have sufficient motor control to perform the perfect gesture and does not concern either the disabled child or the young child around the age of four, a time when yet 60% of them will physiologically modify their swallowing programs, without any exercise.

It is often mentioned the necessity of having closed lips to be able to breathe through the nose. But do not confuse closed mouth and closed lips.

SEVERAL TYPES OF DIFFICULTIES CAN BE ENCOUNTERED: THE TONGUE WORKS CORRECTLY, BUT THE LIPS STILL PARTICIPATE IN SWALLOWING. THE PATIENT WILL HAVE TO WORK WITH LIPS PARTLY OPEN... OTHERWISE LINGUAL INTERPOSITION IS INEVITABLE.

IT IS PERFECTLY POSSIBLE TO SWALLOW SALIVA WITHOUT CLENCHING OR JOINING THE LIPS.

We agree again, asking the patient to clench their lips activates the facial nerve and will therefore inhibit the action of the trigeminal nerve whose role is to ensure mouth closure.

As for automation, the Froggymouth usage protocol refers to the work of Robert Björk (UCLA). We have already talked about it in the previous article, but it is a crucial aspect and worth repeating.

He proposes 4 learning protocols:

A.A.A.A. E
A.A.A.T. E
A.A.T.T. E
A.T.T.T. E

A representing for example a classic learning session, T intermediate tests to evaluate the progress made, and E the final evaluation.

He asks participants to choose, in their opinion, the best protocol. The majority will choose program 1 whereas the most effective is program 4.

This strategy 4 will be taken up in game programs managed by artificial intelligence.

« It is generally only at the end of the game that one knows if it is won or lost...

The trick that computer scientists have found consists of learning two things at the same time: acting and self-evaluating.

One half of the system, called the critic, learns to predict the final score. At every moment, this neural network evaluates the state of the game and tries to predict the reward: am I rather winning or losing the game?

Thanks to the critiques it forms over trials, the system has an evaluation of its actions at every moment and not only at the end of the game.

The other half of the network, the actor, can then use this evaluation to correct itself. Over trials, the actor and the critic progress together, one learns to act wisely focusing on the most effective actions while the other learns to evaluate the consequences of its actions ».

These control sessions can be entrusted to parents who must three times a day tell the child if their lips are in the correct posture (the correct circuits will be unconsciously reinforced by the release of dopamine) and three times a day correct them if they notice a contraction of the orbicularis muscles.

Under the orders of the premotor and motor cortexes, the motor sequence will be managed by the circuits of the grey matter of the spinal cord and the tegmentum of the brain stem (alpha motoneurons). It will be controlled at the level of the cerebellum, which detects and corrects the difference between the executed movement and the desired movement, and the basal ganglia which suppress erroneous data and prepare upcoming movements.

A simple test will allow us to judge if our re-education has been effective: ask the child to count to 60, if you see the tongue between the dental arches automation has not yet been achieved, if the tongue stays well inside the dental arches, you can space out your surveillance sessions more and more.

It is indeed impossible to do two things at the same time with the same organ: if the child articulates with their tongue, they will swallow saliva by contracting the lips conversely if it is the lips that modulate the sounds a simple contraction of the elevating muscles of the mandible will allow dental occlusion and the peristaltic movement of the lingual dome.

This allows us to return to Maryvonne Fournier:

« The whole: resting position, swallowing, pronunciation of palatals is never dissociable, either all three functions are abnormal, or they are all three correct ».