John Mew’s Lectures Part 9: Early Posture

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At birth all babies are obligate nasal breathers. This is because it would be fatal for them in the womb if they inhaled amniotic fluid. However many of them subsequently develop short or long-term nasal obstruction and are forced to breathe through their mouth.  For some this is temporary, but for others it develops into a long-term or even permanent open mouth posture.

There is some debate about the reason for the nasal obstruction but I am sure it is primarily related to household allergies. It is very important that mothers make every effort to encourage their child to keep their mouth closed. Many people are unaware that mouth breathing itself increases nasal congestion. So this can become a vicious circle. When I first suggested that lips could be taped, nearly 30 years ago, I was accused of child cruelty or worse. At that time I suggested two vertical strips of non-allergic tape, merely to act as a reminder.

There is much contradiction about how best to open the airway. The traditional treatment has been to remove the tonsils and adenoids which are presumed by many to be the cause. However I was influenced by the work of Brian Preston (1979) who used tomography to show than the upper airway is rarely obstructed by even large tonsils or adenoids. Instead I found that if my Stage 1 appliance was expanded at the semi-rapid rate for ten millimetres the airway would always enlarge enough for normal nasal respiration.

However there is a snag. If the child does not learn to breathe primarily through the nose the nasal airway will block again within eighteen months. This is why expansion must be coupled with training, but in my opinion the removal of tonsils and adenoids is usually unnecessary. Recent research has shown this ring of lymphoid tissue is an important part of the immune system and in any case usually shrinks as the child passes the age of ten.

I have no doubt that a lot of long-term facial damage is done in the first three years of open mouth growth. Babies look attractive anyway and it is often not until the pre-pubertal growth spurt at the age of 7 or 8 that the true vertical growth is exposed (see illustration below). Sadly by then it may be too late to restore a natural closed lip posture.

 

 

 

 

 

 

 

Quite apart from the lip posture, by the age of 8 it is often too late to restore the structural damage that has been done to the maxilla. This is why the majority of children from highly civilised countries are doomed to grow up with flat cheeks and big noses. The sad thing is that this could be avoided if only their parents realized the importance of keeping the mouth closed and I constantly recommend that treatment should start before the age of 8. The influence of an open mouth posture is huge even as late as 10 years old (see picture below).

I have been surprised that the orthodontic specialty has been so slow in recognising this damage. It was not really accepted until 1997 when Trotman, McNamara, Dibbets and Th van der Weele published their seminal paper. Even now I find many orthodontists give little importance to lip training .

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John Mew’s Lectures 8 – The Stage 1

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My father taught me the advantages of maxillary expansion which in his day was routine for 5 year olds unless they could place a 2mm coin between each front tooth, but when I graduated 30 years later, I was taught not to expand as it always relapsed. However the research of Skieller in 1964, using metal implants told me that most of the widening of the suture remained stable; it was the teeth and alveolus that relapsed. I then did my own research and found that if the tongue was resting in the palate, then there was very little relapse.

Unfortunately the dental authorities did not agree and I was fined large sums for expanding patients. This created my first confrontation with the British authorities and I had to take the Minister of Health to the High Court to justify expansion. At the time this changed the whole pattern of UK orthodontic treatment but most of my colleagues were using fixed appliances which are not ideal for expansion and so they soon forgot.

I designed the Stage 1 (see illustration below) in 1974 to achieve a range of objectives. It was constructed in Acrylic resin a very safe material, with one tooth cribbed on each side, with rests on the teeth in front and behind. This created a very stable appliance and with the use of Crozat clasps a child under the age of eight was not strong enough to remove it. It was in effect a fixed removable appliance, with the result that every adjustment was effective.

Stage 1 Appliance

After a lot of experiment I decided the best rate of expansion was 1/16th of a millimetre each side per day. I based this rate largely on the work of Storey 1973, who suggested that this rate widens the suture at a natural rate preventing the formation of scar tissue that often makes Rapid Expansion so damaging and unstable. So I adopted the 1/8th of a 1mm turn of the screw each day so that there was always blood flow to the periodontium. Research shows that small intermittent movements are less damaging than a gentle continuous force.

I introduced a ‘shelf’ on each side of the appliance, so that the lower teeth, which I do not expand at this point, would still be supported after 10mm of expansion. This had several advantages; it was sloped towards the midline so it guided the mandible to the centre and widened it slightly. Also It was smooth so it allowed the mandible to slide forward. At the same time biting on the lower teeth ensured the appliance was well seated. Many clinicians and other appliances do not use the shelves and I think it lessens their success. I strongly disapprove of any acrylic covering the teeth as this opens the bite.

To make sure that the arch form is correct, the Catenary wires behind the incisors are re-contoured forward 1mm every two weeks, lengthening the arch as well as widening. This coupled with the contact of the appliance against the soft tissues of the vault ensures a near ideal maxillary form. Appliances which only expand create distorted arches which relapse later. The Indicator Line is adjusted at the same time, this process will be described later.

Catenary
Catenary

There is an ‘Approximating Wire’ on each lateral incisor to enable the clinician to bring the incisors together with all of them facing forward in the centre of the arch,. A rest on the distal tooth each side ensures that the appliance does not tilt forward or aft and there is a hook each side of the Canines for forward pull headgear which can also be used to align the incisors with elastics but this should only be done when the incisors are supported behind by the Catenary Wire. Almost routinely I expand patients under nine 8 millimetres and older that 10 millimetres. This will usually move the maxilla forward two or three millimetres.

 

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John Mew’s Lectures 7 – Informed Consent

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As you all know, every patient attending for treatment should be informed about both the
advantages and disadvantages of every treatment. This is not as easy as it sounds and we must be
careful not to pass our own convictions on to patients without mentioning any drawbacks. For
instance almost all orthodontics these days is done by fixed appliances. We ‘know’ they are precise
and are probably the best way of aligning teeth.


What about the disadvantages? Yes fixed appliances can cause some root resorption but we can’t
treat patients without that risk. However we must remember to mentions alternatives like
removable appliances even if we don’t use or agree with them, although we are allowed to say if in
our opinion onr or the other is more suitable. It is the same with stability. Orthodontic results will
almost always relapse unless the teeth are retained indefinitely. Do we say or believe there are no
alternatives or is it that we don’t accept the claims by orthotropists that they can create permanent
stability without root resorption. We must be even handed.


A major issue is facial appearance. Many papers and individuals have suggested that damage by
fixed appliances is possible and not so many have said that this does not happen.

 

In fact there is very little comparative research on this very sensitive subject.

Certainly it is of great importance to the public and we need to be honest about this.


Possibly the most important issue is the widespread use of minor or major facial surgery to improve
facial appearance. Major surgery and is usually delayed until the patient is over 18 and the results
vary with many successes but some failures. This is acceptable provided the patients are warned of
possible failure but many of these operations are elective which raises the stakes. Patients who are
offered irreversible surgery must be told of every possible risk or alternative treatment.


In 2012 I conducted a survey of 1059 members of the public asking them “Imagine for a moment
that you have a child who suffers from abnormal jaws and face. Typically major corrective surgery is
the recommended treatment. A non-surgical treatment using removable appliances is also available
but most surgeons do not consider it appropriate. When deciding on a treatment for your child
would you wish to be told of non-surgical alternatives?”. 93% said they would like to know about
non-surgical alternatives even if their surgeon did not think them appropriate.


Orthotropists claim to be able to avoid most jaw surgery (see illustration below), should every
patient be told about this? Some surgeons might be reluctant to mention rival methods but it is their
responsibility to know of and mention all alternative methods that have at any time claimed to be
effective. This information should be based, not on what the surgeon believes but on what the
patient might wish to know. Currently very few surgeons tell prospective patients that there are any
non-surgical alternatives.  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 informed consent. If there are any other topics you want us to cover please let us know. Engage with Prof John Mew or Dr Mike Mew on this topic;

Professionals (of any medical/health discipline); https://www.facebook.com/groups/Ortho… or https://www.facebook.com/groups/Ortho…

Non Professionals; https://www.facebook.com/groups/crani… or https://www.facebook.com/groups/crani… To see the text version please visit; https://orthotropics.com/

Please consider joining our Patreon Community: https://www.patreon.com/orthotropics

Particularly if you have;

1) gained any benefit from the information that we have provided (usually for free).

2) wish to have the benefits of being a patreon member.

3) believe in, and wish to support our mission to gain full, free and fair debate (engagement) on these issues within the orthodontic and dental community. Currently the full proceeds of the patreon is directed to the video team, who donate the rest of their time for free. Please help in spreading this message.