John Mew’s Lectures 6 – Diagnosis

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Precis.  Diagnosis for orthotropics is very different from orthodontics. You are measuring the shape of the face and deciding what has caused any unattractive features. An orthotropist needs to learn how to recognise poor development and decide on the best way to correct it which is almost always to encourage forward growth of the Maxilla and Mandible.

Lecture 6. Diagnosis for orthotropics is very different from orthodontics. With a young patient the orthotropist is not very concerned with the position of the jaws or teeth because these can easily be changed. The posture of the mandible and tongue is of far more concern. Many orthodontists criticise orthotropists for sloppy diagnosis but the clinician only needs to note the position of the jaws so he can estimate how long it will take to re-position them. The position of the teeth is of less concern as their correction will depend primarily on the age and the co-operation of the patient.

I can usually diagnose the problem as the patient walks into the room and have judged what will be needed before they have sat down. I say that to draw attention to the simplicity of diagnosis. Apart from the 4% of genetic deformities such as a cleft lip, which are usually very obvious, all malocclusion is due to poor oral posture. There are just three things you need to look at their jaw, lips and tongue. You can then measure how far they are from the ideal and decide the extent to which you can restore it, knowing that a full correction is rare over the age of six.

The first and most basic measurement is the Indicator Line. This is simply the distance between the tip of the nose to the incisal edge of the upper incisors. It can be measured with an indicator line ruler, obtainable from www.johnmeworthotropics.co.uk . It is a way of measuring how far back and down the maxilla and incisors are from the ideal. It only gives an ‘indication’ but this has proved a simple and surprisingly accurate way of assessing the severity of any malocclusion. It should be about 28mm at the age of five and increase 1mm per year until puberty when it should be 38 for a man and 36 for a girl. (see picture below)

There is also a lower Indicator line measured between the incisor tip and the soft tissue vertically below it. It is suggested that this should be 2mm less than the upper Indicator Line. It is very rare to find someone with correct Indicator Lines, but it is also very rare to find anyone with room for 32 teeth with 10mm of spare space behind the wisdom teeth. They are usually the same people.

One needs to assess the shape of the face and especially the slope of the forehead to understand the head posture and growth direction (See illustration).

Also record the postural features such as how much the lips are apart. To do this I ask the patient to count up to six and watch the average separation. A natural seal is rare and research suggests that healthy 4 to 5 year old children in developed countries, leave their mouth open more than 80% of the time (Glatz-Noll,E & Berg,R. 1991).

In some groups with bi-maxillary protrusion the mouth can be open 15 to 20mm. There are many other postural features which can be recorded relating to various muscle bulges, which indicate para-functional activity. The most important records are facial photographs from the front and side. Three-quarter views are also useful for showing Maxillary change (see illustration). For record purposes these should be taken with a 5cm marker or ruler in the sagittal plane so that subsequent growth can be measured.

I may take X-rays of the teeth, but I do not find lateral skull X-rays helpful for forecasting growth or even of much use for recording changes. We will talk later about measuring growth and growth direction with a Gnathiometer.

 

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John Mew’s Lectures 5 – Facial Aesthetics

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Facial appearance is hugely important for everyone’s success in life. Mothers often feel their child’s  face is God given and should be accepted, however many teenagers are more concerned about their facial appearance than anything else. I have done a lot of research on facial form and in one project I traced the changes that I had achieved when treating a young girl and recorded them on a sheet of paper. I then reproduced the change of the lips, the nose, the cheeks and the chin separately and put them on a past board with the end result of all the changes in the centre. (See girl and tracings below).

I asked 106 lay people which face they preferred. The percentages are shown with the tracings and you can see that flat cheeks were by far the most unattractive feature. Interestingly receding jaws are not as big a drawback. Certainly those with forward growing cheeks and chins are considered far more attractive than anyone else.

In another project, I researched the judgements of lay people, dentists and orthodontists and was surprised to find orthodontists were less concerned about flat faces than the others. I wondered why that might be and found three other research papers had found the same thing, I suppose it is because orthodontists tends to flatten the face and they get used to a “straight profile”.

In another paper of mine Kieferorthopädie 2015;29(4):1–15, I collected 16 ‘Excellent’ results achieved by orthodontics and compared them with 16 ‘excellent’ results achieved by orthotropics. I was really surprised that twelve dental and lay judges found the faces and teeth of the orthotropics cases were “Highly Significantly” better than the orthodontic cases. When looking for reasons I think it must be the retruded and flattened cheeks created by fixed appliances.

John Mew has been working on a lecture series going into more depth on his thoughts, ideas and what inspired them. In this episode he talks about facial appearance, some research that he has undertaken and what make a face attractive.

 

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John Mew’s Lectures 4 – An Actual Case

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After I had conceived the Tropic Premise’ I started to apply it to many aspects of human development especially of course the face. I found that lay people could usually understand the concept of Growth Guidance quite easily but dentists had more difficulty and I found many orthodontists quite unable to grasp the concept. I suppose like surgeons, they are used to ‘fixing’ problems and the idea of encouraging natural growth is quite foreign to them.

To give an example of what I mean, I will quote Stanley a 13 year old boy with a severe impaction of his upper left canine. I was treating his younger sister and his mother casually mentioned that she had been told he needed surgery to remove or reposition the canine. I offered to help him and saw from the X-ray that the canine was impacted behind the middle of his upper right Central incisor; quite severe.

I said to his mother “I think I might be able to correct this without surgery”. Stanley was enthusiastic although I did warn him “it will be inconvenient and you will have to do exactly what I say, but it will not be painful” he agreed and I started a standard course of orthotropic treatment. I first widened the maxillary suture with a Stage 1 Biobloc by about 10 millimetres and proclined his incisors. This made room for his tongue and took just over three month by when he was 14 and starting at a new school.

I then fitted a Stage 3 with a ‘timer’ and asked him to become accustomed to it during the day, for a week or two, before wearing it for 20 hours day and night. He wore it well and within three or four appointments had got used to what we call the ‘Tight Locks’, meaning that the flanges on the Stage 3 were set to touch if he dropped his jaw at all. This of course meant that he had to keep his teeth in or near contact the whole of the time and the timer told me that he was wearing it for about 22 hours a day.

After another four months the Canine erupted in the palate just in front of the first premolar. Most people would not believe this possible but I have seen it several times before. You can see from the photograph that his whole face has grown forward about 15 millimetres within a couple of years. The Cell Volition Theory and the Tropic Premise both suggest that every cell in the body including those in the canine know where they should be, and provided the posture is correct, they go there.

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John Mew’s Lectures 3 – Tropic Premise

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Orthotropics 3. Tropic Premise

Why do human jaws and teeth often have poor growth when other parts of the body are rarely affected? Occasionally a child will have ‘Club Feet’ or perhaps ‘an extra finger” but in contrast, more than half will have malocclusion. I was much impressed by the research of Horowitz on Identical Twins way back in 1960. He found that the jaws varied more than any other part of their body despite the genes being identical.

I spent a long time trying to work out why this was. I experimented with tropisms which guide plants to grow towards light or gravity and saw how identical plants with the same genes, would grow differently depending on where the sun was. I coupled this with my thoughts on the large contrasts in the growth of human jaws that sometimes occur between individuals or within the same individual over time. I then wondered if there was some kind of compensation mechanism.

Obviously it is essential for the teeth of all mammals to mesh perfectly, so perhaps the jaws are adaptive to a greater extent than other parts of the body? Based on this thought I created the ‘Tropic Premise’ which suggested that if “the tongue rests on the palate with the lips sealed and the teeth in or near contact then the growth and position of the jaws would be ideal”. This Tropic belief has subsequently proved popular and has been adopted by many millions of youngsters as ‘mewing’.

Around this time I had a nice-looking young patient with slightly prominent front teeth. Having been trained by ‘Willy’ Grossman at University College Hospital to use Funtional Appliances, I gave her an ‘Andresen Monobloc’. From the start she wore it awkwardly with her lower incisors underneath the appliance. I stopped treatment within two months but she continued to hang her mouth open. To my horror her face continued to grow down quite spoiling her appearance.

I was very concerned and took her to see my Professor but after many tests no cause was found. I now know that the appliance had disrupted her posture and with my present knowledge could have quickly reversed her growth. However at that time I could do nothing but watch and ever since have had deep feelings of guilt which have driven me to help others to avoid this. This stimulated me to design a new system of four appliances which I called the Biobloc System. Stage 1 provided room for the tongue by encouraging the suture itself to widen rather than moving the teeth and the other appliances helped to train the patient to correct their tongue and jaw posture to ensure natural growth.

Happily I got the design more or less right to begin with and they have only been changed slightly since. Many clinicians have created other expansion appliances since such as the ALF, the AGGA, and the MSE but in my opinion, few have really understood the Tropic Premise and the idea that the teeth and jaws know where they should be and only need guiding into position with the right posture. I strongly believe that they should not be pushed or pulled. Interestingly I find that the teeth often align themselves if the posture is right, although in reality I am doing no more than copying the natural growth of most mammals. Remember every cell knows where it should be and it only needs correct posture to be able to grow to that position. This is an entirely different concept of growth but I feel confident is the right one, or very close to it.

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John Mew’s Lectures 2 – Facial Growth

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If we apply the “Cell Volition Theory” to human growth we need to remember the importance of ‘position’ or in its long-term context ‘posture’, as this is what enables the cells to grow naturally to the right place with no pushing or pulling. I was taught that during evolution the genes changed slightly over the years and that most malocclusion is due to changes in the genes, caused mainly by alterations in our diet’, is that true?

The evolution of the Giraffes long neck took over ten million years. This is a minute amount each generation, but many orthodontic text books teach that that evolution changed the shape of human jaws from near ideal to almost universal malformation in the last 18.000 years. This just did not make sense to me and when I looked closer I found that the different types of malocclusion did not first appear in a certain area and gradually spread, but every type of malocclusion appeared in different places around the world wherever and whenever the standard of living rose above a certain level.

Many people believe farming led to the content of our food changing but I believe that food consistency is more important. Farming started over ten thousand years ago, however I think more important changes have occurred since, as in the middle ages we started to move into houses that were better and better insulated. This undoubtedly has increased the allergens floating in the air and the allergies we have developed to them which often precipitate mouth breathing. Research suggests (Glatz-Noll & Berg 1991) that healthy four to five year old civilised children leave their mouths open over 80% of the time. This can have a profound effect on facial growth (see picture of mandible below) within as little as four years.

We should not forget the reduction in breast feeding over the last two to three hundred years. This has undoubtedly increased the ratio of those with poor tongue posture. The cumulative effect of these various changes on our pattern of living has been huge and almost everyone now has relatively flat cheek bones compared to our ancestors of just a few hundred years ago. Sadly the main effect is to lengthen the face and as faces lengthen the jaws are moved back, this automatically shortens the dental arch, creating the crowded teeth which are so common today.

To those who ask me how to prevent this happening to their children I say “Sell your house and buy a cave in a mountain. Then live on raw food that you find for yourself”. Not many people are going to do that so what else can we advise?

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John Mew’s Lectures 1 – The Cell Volition Theory

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Before we talk about the best way to correct malocclusion we should really discuss why it occurs and before even that we should think about what creates a good occlusion. This means looking at growth and how all organisms grow from a single cell. In 1958, I was very interested in John Gurdon’s experiments with cloning. He was able to take the nucleus from a somatic cell of a tadpole and implant it into an enucleated egg cell.

This then developed into a twin of the original tadpole or frog. This told me that every cell in the body contained all the necessary information to make a complete individual.

 

 

 

 

A Hydra is a water living animal that is only a few millimetres long and consists of a tube with a sticker at the bottom and tentacles at the top. If you cut off a tentacle it will grow again showing that the cells around it know it has gone and needs to be replaced, even if you cut the Hydra in half the larger bit or sometimes both bits will grow into a complete Hydra. It has no brain or control system so each cell must know what has happened and what to do.

The same applies to humans, although we cannot grow another leg or arm, we can replace a lobe of the liver. If it is removed, the remaining cells will restore it to the same size and shape it was before. We might ask how this growth is controlled. I was taught it was by either a control system or hormones or something else we were not sure about. However it seemed obvious to me that nothing could instruct the millions of cells in a palisade like the periosteum of the mandible, how can each of them be given separate instructions to perform the subtly different tasks necessary when remodelling takes place?

To answer this I put forward my “Cell Volition Theory” where I suggested that during our evolution, when cells first joined together to form multicellular organisms, the individual cells still maintained their own volition even if they worked together for the good of the whole. The only additional information they needed was, where they were in the organism.

Let’s look at a butterflies’ wing, each of the colour cells develops in the neural crest and then migrates to where it displays its colour. Although it is not motile it wriggles its way between all the other cells (millions of them) until it arrives at the right spot. How can it have the ability to do that? It must have a map of the whole body and know exactly where it should be. That is why position and its association with posture is so important. We can next look at how humans grow.

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John Mew’s lectures 0 – History of Orthotropics

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My father was an orthodontist practicing in the times of Edward Angle who is considered by many to be the Father of Orthodontics. Although Angle was best known for developing non-extraction orthodontics he also believed in the influence of the soft tissues saying “Orthodontic treatments are very unlikely to succeed, if the functional disorders are still going on”; a philosophy very similar to my own Tropic Premise.

I never met Charles Tweed although I knew many people who had. He was a free thinking student of Edward angles and the two of them often had heated debates, especially over extractions. He refused to accept Angle’s view that if you followed the rules the case would be stable.

So he tried extracting first premolars and at a famous meeting in 1940 showed 100 non-extraction cases using Angles technique methods all of which had relapsed. So he had retreated then with premolar extractions to show successful results. Following this Charles was nick named “Four on the Floor.”

However many of his cases were only just out of retention. This presentation had a huge impact on American and later, world orthodontics. To start with he was thrown out of the Angle Orthodontic society like both my son and I have been, but following that almost all orthodontists adopted his techniques.

What interests me is that in his later life he almost completely reversed his opinions and would only accept patients in the early mixed dentition saying “Knowledge will gradually replace harsh mechanics”, However most of his followers have continued with fixed appliances.

I was fortunate to have been trained by Willy Grossmann who followed Viggo Andresen’s ‘Functional’ treatment. This again relied more on the activity of the Soft Tissues. My first case went well and I was sold.

It was in 1967 that I heard of Rolf Frankel. I went to Germany to see how he influenced the Soft Tissues with his Buccal Shield and Lip bumper. In many ways it was similar to Andresen’s but neither of them encouraged the mouth to close.

In the 1970s I created my own theory which I called the Tropic Premise saying that malocclusion was a Postural Deformity. To restore natural posture, I designed an appliance based on many others but unlike any of them added lingual ‘Locks’ to train children to keep their mouths closed.

This has proved to be the Missing Link and appears to prevent almost all malocclusion.

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