Month: October 2016

“Close your mouth, Michael, we are not a codfish”, Marry Poppins 1964
There is an old wives tale in most cultures that run something like this; “Shut your mouth or the wind will change and it will set like that”. Like many old wives’ tails, there is a strong suggestion that within it is an element of truth. Discussing facial attractiveness is an emotive subject for anyone and one in which many parents refuse to follow a logical pattern since they may thus be forced to reflect negatively on their most precious procession and achievement in the world, their darling and beautiful child. Suggesting that facial form is not a God given genetic endowment is often considered sacrilegious, however this is not scientific.
The next timeyou travel to a busy public environment such as a shopping mall, restaurant or school observe how people hold their mouths at rest.  Observe if you can draw any conclusions between how much their mouths are left open and how they look, or rather the shape of their faces. This is especially apparent in children under puberty as they have yet to gain such a strong social awareness so are not trying to conform to any social pressures and when people are fully relaxed such as at home watching something that fully engages their consciousness such as their favourite TV show. The next time you are in a movie theatre look backward at all the staring faces fixated on the screen, compare the faces with their mouth closed with those that are really open. The conclusion could not be more dramatic, people who hang their mouths open really don’t look so good, and you don’t have to be a scientist to work that out.

Mouth always closed, or almost closed- good cheekbones, excellent face shape	Mouth slightly open- lower cheekbones	Mouth resting wide apart- very low cheekbones, nose appears to be large and forehead is slopping back in comparison to facial complex.

Snoring is due to vibration of the ‘soft palate’ (the flap of tissue at the back of your mouth). It is caused by air passing either side of this flap when the mouth is open, rather like a flag waving from side to side. Obviously it will not flap if you breathe through your nose only but many people find this difficult especially at night because their nose blocks. The snoring sound is unpleasant for others and many partners are unable to sleep in the same bed. Naturally this is the cause of many matrimonial problems.

The main reason for snoring, is sleeping on the back, because the jaw drops down and the tongue falls to the back of the mouth. This is often coupled with being overweight which makes it difficult to sleep on the side. The best self-cure is to lose weight and learn to sleep on your side with one leg drawn up. If this is difficult try sewing a tennis ball between the shoulders at the back of your night wear.

The most common medical cure is either to cut a slice out of the ‘soft palate’ to reduce the vibration, or to wear a night brace to hold your jaw forward. Severe cases may need to wear a mask to provide additional oxygen, but this is very inconvenient and many patients give it up. Night Braces have an unfortunate side effect. Initially they make breathing easier but after a while they pull the upper jaw back which was part of the initial problem, so that the patient actually gets worse in the long run.
Because of this we strongly disapprove of these Night Braces and treat patients with Orthotropics, first widening their upper jaw and nose slightly to improve their breathing and then giving them an appliance which trains them to keep their mouth closed. This is hard work but it approaches the basic cause and so can permanently cure the problem.

Make your face beautiful with correct oral posture

Ever since the work of Eva Fraserpeople have been aware that the function and posture of the muscles of the face can influence the shape of the face and that the shape of the face was not set in stone. Under the skin are muscles that are susceptible to changes in size due to changes in function (as Arnie Schwarzenegger could tell you). The assumption was that faces progressively drop, this can be slowed but it is inevitable. This is clearly demonstrated following injuries to the nerves that innovate the face, although no one has questioned if the reverse could also be true, if by gaining the reverse effect the face could rise up.

The science of training the muscles of the face is known as Orofacial Myology. The most essential part is for the tongue to be pushing up forcing the upper jaw up and forwards giving support to the eyes and moving the cheekbones forwards. Although the forces of these muscles are small and their duration of action short, over time, day in and day out the force of the tongue on the roof of your mouth adds up. Increasing the muscle forces can help to give shape and definition to the jaw bone but risks making a face look a little masculine.

In the 1800’s, parents began to be concerned about the increasing number of children developing with crowded and irregular teeth and set back jaws.

In the US, a dentist named Edward Angle, developed a method for straightening teeth by fixing wires to them and pulling them with screws and ligatures onto a larger wire, which he called Angles E arch. This proved very popular and it is from this that fixed appliance developed.

This diffident boy’s life changed once his appearance was changed with Orthotropics

In the early twentieth century a European dentist named Vigo Andresen, working in the northern reaches of Norway developed a block of plastic hollowed out for the tongue that sat inside the mouth and dictated where the child could bite, and thus brought forward under developed jaws. He called this an activator and it has since been known as the Andresen activator.

 

At more or less the same time a dentist in the United States called Edward Angle developed a range of wire appliances that were fixed to irregular teeth so that they could be moved into a straight line. Unfortunately towards the end of the century it was realised that these sometimes damaged the enamel and the roots of the teeth and after a few years the teeth became crooked again. To overcome this problem orthodontists would recommend ‘retainers’ for a year or two to hold the teeth straight after treatment. However the teeth still recrowded and almost all orthodontic schools now recommend that the teeth should be retained with either removable retainers or fixed wires for the rest of the patient’s life.

It appears that both concepts which underpin modern orthodontics were not treating the causes of the problem but the symptoms. At that time it was thought that crooked teeth were inherited although modern thinking increasingly believes that the environment plays a big part.

History
Over the last 100 years the consensus of professional opinion, in regard to extracting teeth has swung from almost never extracting teeth to almost always extracting teeth and halfway back with possibly a more mixed standpoint in today’s more diverse and international society. At each swing practitioners holding the opposing view were considered outcasts. Current opinions vary between countries and ideologies. Most patients would be surprised at the polarization, even animosity, between these groups and it is unfortunate that little open scientific debate occurs between them.

Philosophical overview
It has been assumed for most of the existence of orthodontic practice that malocclusion (crooked teeth) is an entirely genetic condition.  You are born with either too many, too few or the right number of teeth to fill the dental arches. Without good scientific data this assumption has persisted relatively unchallenged. Philosophical reasoning for extracting teeth was that if there were too many teeth to fit them some would need removing. Once all the adult teeth have arrived in the mouth, between 12 and 14 years of age, an assessment could be made whether to extract teeth or not.
Interestingly little general reasoning was made and the fact that no vertebrates exist with additional teeth to requirements and that none of our ancestors had additional teeth was overlooked. Only 1000 years ago in Scandinavia several studies reported that all the skulls examined had a full compliment of teeth present and correctly aligned, including the wisdom teeth and showed no signs of additional teeth.

Alternatives to orthodontic extraction
Many alternatives to extracting teeth have been put forward and some are currently used in orthodontic treatment:

Distalizing upper molars-
Pushing the upper molars teeth backwards makes space for the front teeth, using appliances such as the distal jet and headgear. This is an effective method of creating space on the front of the mouth but teeth are still lost at the back of the dental arch near the hinge which tends to magnify the tendency to facial lengthening.

Slimming teeth-
Teeth can be ground on both sides to create more space in mild to moderate cases of crowding allowing space for the remaining teeth to be aligned. Natural slimming of the teeth as they move against each other, known as Attrition, is a normal process and it is estimated by some that the native Australians lost the equivalent of a whole tooth width during their lifetimes.
Tooth slimming is often recommended when there is a little crowding in the lower arch while the teeth in the upper arch are well aligned in a situation known as a Bolton discrepancy.

Expansion
Widening the dental arches laterally (sideways) can also provide additional space, however unless tongue position is affected to maintain this expansion it is often unstable.

Who extracts the teeth?
In most countries the orthodontist will refer a patient back to the general dentist who will undertake the extractions. This may be done by an oral surgeon who is a specialist, trained to extract teeth, especially if the extraction is predicted to be difficult or the patient is compromised medically. General dentists with experience in Orthodontics will often extract the teeth themselves.

Which teeth are extracted?
Common adage in orthodontics is that you must extract closest to where the space is required, also aesthetically you should avoid extracting any of the front six teeth, the incisors or canines. This has made tooth number 4, the first permanent premolar (first bicuspid) the most common tooth to be extracted. At the height of the extraction philosophy the phrase “all fours on the floor” was a common nickname for this approach, when it was often felt wise to extract teeth in cases where there was no crowding, to prevent future crowding.
Some orthodontists concerned about the “dishing in” aspect of facial damage have taught to extract the tooth number five, the second permanent premolar (second bicuspid). Although it is more difficult to close the spaces, the extraction of tooth number six (the first permanent molar) or even seven (the second permanent molar) have also been advocated and in mild cases a single lower single incisor may be removed. The choice of extraction is also determined by the prognosis (health) of individual teeth and those with large fillings (especially if with root fillings) should be extracted in preference to perfectly healthy teeth, where possible.

Should teeth be removed for orthodontics?
Few areas within orthodontics (and possibly in dentistry) seem to have caused as much passion and polarization of viewpoints. This argument has raged since before “The extraction debate of 1911”. Careers have been made, reputations been dashed and there is still no consensus within the profession. The current view within the “Establishment” including the most teaching hospitals and the majority of Orthodontists trained within them is that; in some cases extractions are certainly required and in others they are unnecessary and when the correct decision is made there are few if any adverse side effects. Standing back a little from the details of this argument it has been noted that until recently none of our ancestors for 220,000 years, nor their ancestors for millennia, nor for that matter any of the other mammals through history have had extra teeth that require extracting. However currently a significant proportion of children in modern societies present to the orthodontist without sufficient space for all their teeth and extracting is often the simplest and most expedient approach, usually without any noticeable or immediate side effects or facial damage. Many individuals live a long and healthy life, with permanently well aligned dental arches having had extractions. Despite the numbers who eschew extractions this argument cannot be claimed to be clear-cut by either side.

Side effects of extractions in orthodontics- I
The debate against extractions in orthodontics has long been based around the supposed side effects of extractions. There are five traditional effects of extractions that have been proposed and denied without a clear consensus:

Dark corridors: When some individuals smile a dark space is present either side of their dental arches, between the white teeth and the outer corner of the lips. It is suggested that this is created or increased by orthodontic extractions that reduce and narrow the dental arches. The research undertaken by the “Establishment” suggests this is untrue, but this is criticised since it excludes unsuccessful cases. Case studies show evidence both to support and disprove this belief.

Reopening of extraction sites: The stability of orthodontics is discussed elsewhere (orthodontic stability) however one particular concern is that spaces sometimes open up where teeth were extracted. The spaces tend to be smaller than a single tooth suggesting that some slimming might have been a better treatment plan.

Aesthetic line and lip position: By considering the dental arches in isolation, contemporary orthodontics has focused on the effect of extractions on the support of the lips, but may have missed the larger picture. In there is crowding, aligning the teeth without extractions will require an arch of greater circumference, expanding the teeth either side and pushing them forwards at the front, pushing the lips forward. The opposite is true when extracting teeth and reducing lip support allowing them to flatten. In orthodontic assessment of the face the aesthetic line is drawn from the front bulbosity of the chin to a point, halfway between tip of the nose and its base where is meets the upper lip. This is known as Rickett’s E-Line and it is against this that an assessment of the lips are made and it is a simple exercise to make this assessment.  If a friend holds a camera taking a profile shot while a ruler is held in this position both lips should be approximately on this line. Some reasonably good quality research has been done this area. It would appear that problems do occur but are due to a poor treatment plan of extractions. Good treatment planning can correct protrusive lips and avoid collapse when the lips are normal. Unfortunately this ignores the vertical effect of orthodontics and the loss of bone supporting the roots of the teeth.

Nasiolabial angle: In orthodontic assessment an angle is drawn at the intersection of the flat section of the upper lip and a flat section at the base of the nose, referred to as the nasolabial angle. The normal range appears to be approximately 90° to 120°, with a modern average somewhere between 95° and 100°. This angle can increase dramatically and look aesthetically displeasing when unnecessary extractions are performed pulling back the upper lip.

Side effects of extractions in orthodontics- II
In addition to the five traditional insights into facial damage, in orthodontic therapy there are two that do not seem to have been greatly recognised or given much consideration within orthodontic literature.

Facial support from teeth: Anecdotally it has been suggested that the bone surrounding the roots of the upper teeth, in particular, is lost after the removal of these teeth. This suggestion lacks quality research however some case reports appear to show a relationship.

Facial lengthening: One of the most consistent observations of orthodontic treatment is that the anterior facial skeleton (the mid-third of the face) lengthens during orthodontic therapy, usually following fixed appliance therapy, retractive headgear, class 2 elastics and any distalizing therapy. This appears to be true in almost every single controlled research paper on the subject and is possibly one of the most consistent finding within orthodontic literature. It has also been observed that in general, facial lengthening is unattractive. From an Orthotropic perspective this is worsening the underlying problem while treating the symptoms. Although this observation has not become a widespread topic of interest, it has caused much deliberation for a few notable authors. A. Lundström and D. G. Woodside noted that there was not a single incidence of late mandibular growth in the Bulington growth study and suggested that “Horizontal increments of mandibular growth are usually seen following orthodontic treatment which has retracted the maxilla, and this probably represents a recovery from a downward and backward mandibular rotation created during the treatment.“ Individual variation in growth directions expressed at the chin and the midface Eur J Orthod (1980) 2 (2): 65-79 and Birte Melsen has written extensively on the loss of vertical control even appearing on national television to suggest headgear use should be banned, (Effect of cervical anchorage studied by the implant method EOJ 29 (2007) i102–i106) showing a dramatic increase in facial height for some individuals.
It is not fully understood what is causing this process however the suggested causes of facial lengthening are:

    Conning: once the brackets had been placed on each tooth a thin arch wire usually made of nickel titanium is placed, running through all the brackets that works to level and align the dental arch. The arch wire will be bent so that it can engage into each bracket. This sets up a force that aims to push the brackets (and the teeth attached to them) into alignment. This is the main principle of fixed appliance orthodontic therapy. This first phase known as “leveling and aligning” produces some of the largest movements of teeth with some very complex mechanical interrelationships (statically indeterminate force systems) between the teeth. The teeth, especially the root tips, move in a very unpredictable pattern often round tripping (making a circular movement to return to the original position- often due to the movement of another tooth close by). All the sideways (lateral) forces are reciprocated by other sideways movements and are cancelled out, however the vertical forces must be reciprocated by the biting forces, muscle tone and it is often the very individuals without these that have the most crooked teeth. In addition to this, since teeth naturally erupt and naturally resist intrusion (pushing into the bone) the net result of this first phase of orthodontics is to vertically erupt the teeth lengthening the anterior facial height.

    Sensitive teeth: The process by which a tooth moves through the bone due to fixed appliances is quite remarkable, part of the process is a chronic inflammatory reaction that removes the preceding bone before new bone is formed behind the teeth. As with all chronic inflammatory processes, this can be a painful process and during movement the teeth tend to be sensitive to bite on. Due to this the biting forces and resting muscle tone tends to be reduced, thus lengthening the face, as discussed in the section on “Causes of crooked teeth”.

    Damage to oral posture: Any appliance that occupies space within the oral cavity can affect the postural and functional position of the soft tissues such as the tongue and lips. The work of Harvold in his monkey experiments (Primate experiments on oral sensation and dental malocclusions, AJO Volume 63, Issue 5, May 1973, Pages 494–508) shows how simply placing a piece of plastic in the palate can have a dramatic effect on the direction of growth of the face. Fixed appliances by their nature seem to damage the natural lip seal and large braces in the roof of the mouth such as hyrax, quad helix or bulky removable appliance often damage the resting tongue position, thus worsening the underlying problem.

    Direct affects on the position of the maxilla or mandible: Retraction headgear (the traditional type that pulls backwards) and class II elastics (the ones in the mouth that fit onto fixed braces to encourage the lower jaw to grow forwards) both tend to pull the upper jaw back and down, lengthening the anterior facial height. In addition bite raising appliances lengthen the resting muscle length of the face, once lengthened at this sensitive age there is a good chance that the effect will be permanent. Research consistently suggests that all of these appliances seem particularly consistent in increasing facial height especially for the individuals where this is not desired.
The effect of facial lengthening is often known as “unfavourable facial growth” and it is suggested that this is a natural genetic response rather than an effect of orthodontic treatment. There is little good evidence to support either argument however circumstantial evidence would suggest that this is the effect of most orthodontic treatment.

Responsibility of the general dentist
Although the general dentist extracts teeth under prescription from the orthodontist, responsibility tends to live with the individual who undertakes an action. As such it has been suggested that general dentists may share joint liability for problems associated with extractions for Orthodontic reasons. Sensible advice for general dental practitioners would be to check the treatment plan with the orthodontist, confirm that the side effects outlined have been reasonably considered and finally to take some quality lateral and facial photographs prior to commencing the treatment. (see Orthodontic outrage, info for dentist).

All problems are a mix of genes and the environment. The genetic influence on facial development is obvious and environmental things such as thumb sucking has long been recognised. It is not often appreciated how influential the environment is and what a dramatic effect on facial shape changing this can make.

Interestingly all our ancestors had perfectly straight teeth, as all the other 5,400 species of mammals except some domesticated cats and dogs, some feral foxes (in Europe) and zoo animals. Over the last 10,000 years, while our genes have not changed at all; whenever, and wherever our ancestors became civilised they developed crooked teeth (malocclusion).The irregularity has been in proportion to the level of civilisation with the last hundred years have seeing a dramatic rise in the levels of malocclusion.

The environment has a great influence over the tooth positions and shape of the face shape.

1) It is universally accepted within dentistry that the teeth and bone occupy a space between the soft tissues of the tongue and the lips and cheek. In an ideal swallow, the lips and cheek should be completely passive. The problem appears to be that individuals never fully convert from an infantile suckle to an adult swallow. The change from breast to baby feeding has long been suggested to be the cause of this,but lacked evidence. A more contemporary view is that by feeding infants very soft food that they can physically suckle before they have gained the reflex to swallow, encourages them to adapt the suckle with their tongue between the teeth and never fully convert.

Anyone whose facial muscles can be seen to move when they swallow are not in balance, sometime the teeth resist these forces but usually they are affected. The face should be completely passive during swallowing.

2) A change from a very hard diet that was very low in calories to a very soft diet that is exceptionally calorie dense, just at the time that far less calories are needed. It is estimated that while we are using our bodies about 30% as much as our ancestors

we are using our jaws some 3% as   much, and as every astronaut returning to earth knows, you use it or lose it. For example muscular dystrophyand muscle wasting diseases, such as Stephen Hawkins has (pictured), who grew normally before the onset of the disease that has dramatically changed the shape of this face.

3) Change in the oral and body posture. Nearly all children experience at least one blocked nose in early infancy, most have complete nasal blockage for days at a time, when they are forced to lower their tongue and open their mouths to breath. This becomes a habit during the very period that they are learning to walk and program their postural centres. This picture shows the effect of this on a child who was almost fully grown but developed a blocked nose causing his face to grow down, the effect on younger developing children is even greater.

By changing the environment it is possible to change the direction of growth and the more horizontal the growth then the more space there is for the tongue to move up out of the airway to allow a normal head , neck and tongue function, and allowing the teeth to align naturally without mechanical intervention.

Most people are unaware that the orthodontic profession openly admits that it does not know the causes of malocclusion, except for less than 5%, which are the cases of syndromes, diseases, infections and trauma. For the everyday normal health child the profession has no idea what the cause of the problem is.

Does Facial Appearance Matter?

Attractiveness has become a double-edged sword in the skin deep modern society. Whereas the drive for beauty has certainly lead to physical and emotional casualties it is also important to be objective and consider that beauty is a sign of health in which humans are hard wired to be attracted to more healthy individuals.

Babies: Babies as young as three months strongly prefer attractive mums to unattractive mums (Samuels 1985). Attractive babies receive more affection and attention from their parents and other adults, and are more likely to grow up to be well balanced adults themselves.

Children:Children grow up to believe that heroes are good looking, heroines are beautiful and bad people are ugly. These stereotypes remain with us all our lives.

Teenagers:Although they may not admit it, young teenagers are more concerned about their appearance than their relationships with their parents, their siblings, their friends, their work, or their pastimes. Handsome cadets achieve higher rank by the time they graduate (Ackerman 1990).

Criminals:A judge is more likely to give an attractive criminal a shorter sentence. Unattractive people are more likely to become criminals, four out of five females committed for aggressive offences were rated as unattractive (Cavior 1974). Criminals who have their appearance improved by facial surgery are less likely to return to prison.(Lewison 1974)

She was told she would need to have her jaws cut and repositioned, but was treated with Orthotropics (growth guidance) instead.

Intelligence:Good looking people are likely to be perceived as more intelligent. Surprisingly good looking people are actually found to be more intelligent, possibly because they receive more attention at school. They are also likely to get better jobs, rise to higher positions and earn more money (Bull 1988).

Status:You will be considered to have higher status if your partner is good looking than if they are plain (Hartnett 1973).

Personality:Although many people claim to judge personality by the shape of a face, most studies have dismissed this possibility. However, one study (Squires and Mew 1981) of long and short faced people concluded that the former tended to be less conventional while the latter were more so.

Does Beauty Lie in the Eye of the Beholder? The answer is no, research has shown that we all tend to put peoples appearance into approximately the same rank order, regardless of their race, colour, or background.(Cross 1971). Recent research (Mew 1993) would suggest that while we generally agree about who is very good looking, opinions differ when we are considering the less good looking who populate the real world around us. In fact we tend to prefer people who look like ourselves.

The ethics of affecting facial appearance are discussed separately at “The Ethics of Changing faces” page.