John Mew’s Lecture Part 10 – Measuring Facial Aesthetics

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Orthotropics 10. Assessing Facial Aesthetics

In session five we discussed the benefits of an attractive face and how they were related to forward growth and in session six, how the Indicator Line will measure facial development. There are many other ways of recognising facial features. Almost all authorities agree that symmetry is important and many orthodontists and especially surgeons base their treatment on this although most of us are bilaterally different to a greater or lesser extent.

In terms of facial shape, Robert Ricketts attached great importance to the Divine Proportion of just over one point six to one. This is actually the shape of the paper sizes A3, A4, and A5. It is a pleasing ratio and Ricketts showed that it fitted selected features of good looking faces but it also fits many unattractive faces too and I do not think it is very relevant. Another orthodontic measurement is the Nasio-Labial Angle, which looks better if it is near a right-angle and progressively worse as the upper lip drops back.

I personally use the “Cheek Line” which runs down sagittally from the centre of the lower eyelid just touching the soft tissue below. See illustration below. Ideally it should be parallel with the bridge of the nose but if the maxilla drops may run at 15 to 30 degrees to it. Cartoonists use the cheek line to great effect (see Illustration below).

Some orthodontists (Robinson 1986) believe the nose frequently grows after treatment and Behrents (1985) thinks it continues to grow in old age, but I believe both are wrong and it is the visual effect of the maxilla dropping.

In my experience the human eye is better at judging faces than any measurement. When I was assessing the changes to the appearance in identical twins following different types of treatment, it frequently took me some time to see any difference at all. However I was surprised to see that most of the judges agreed with my judgement although they must have had the same difficulty.

We know from the work of (Samuels & Elwy.1985) that even 1 year old babies can recognize a good looking face, suggesting that this appreciation is inborn and not developed as we grow up. My own research has shown that although we all agree about which faces are best looking, we have different preferences when faces are not perfect. This probably accounts for the common belief that “Beauty is in the eye of the beholder”.

Some people are convinced that using 3D images will make assessment easier. I think it may help to measure any changes but despite colour coding will not make it easier to judge attractiveness. Some Far Eastern populations have more prominent zygomatic processes which can look very attractive. However this advantage is soon lost if the maxilla is set back or contracted.

It has taken me years to realise that the prominence of the cheek bone needs to be coupled with the fullness of the alveolar support for the upper incisors and canines. This is only seen when they are well forward and near upright. I am told that alveolar bone does not count as it is only there because of the teeth, but this is semantics as it all goes together to form an outstanding face.

Undoubtedly Good Cheek bones Can give you a great advantage. See below.

Is it possible to scientifically asses facial attractiveness? Prof Mew discussed some aspects of this and suggests that the cheek line shows great promise. He has previously described Beauty as NOT being in the eye of the beholder, in this lecture; https://youtu.be/kC_sjWV-zhc.

Faces that grow well work well and are incidentally attractive. For too long this has been dismissed as a seemingly random event which was just inherited. As it becomes very clear that this is far from true it is important to apply science to the subject and making an objective assessment is part of this. If there are any other topics you want us to cover please let us know.

As a general rule neither Prof or Dr Mew have time to engage in the comments section, their focus must be to gain as much real change and scientific engagement as possible, and this would otherwise consume all their time. If you want to engage with Prof John Mew or Dr Mike Mew on this or other topics then follow these links (if you want a personal opinion on your situation then please book an on-line consultation at https://orthodontichealth.co.uk/book-…

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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 .

If there are any other topics you want us to cover please let us know.

As a general rule neither Prof or Dr Mew have time to engage in the comments section, their focus must be to gain as much real change and scientific engagement as possible, and this would otherwise consume all their time. If you want to engage with Prof John Mew or Dr Mike Mew on this or other topics then follow these links;

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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;

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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.

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 diagnosis of the face.

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);

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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.

 

If there are any other topics you want us to cover please let us know.

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To see the text version please visit; https://orthotropics.com/john-mews-lectures-5-facial-aesthetics/

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Best wishes,

Orthotropics Video Team.

 

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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