0.6 Jaw surgery – Is it becoming more frequent?

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Estimates of the number of British children and young adults receiving orthognathic surgery have varied widely over the last twenty years. Previously it was thought to be less than 1000 a year but in 1999 a survey suggested that 7% of a consultant Orthodontist’s workload was related to Orthognathic treatment. In 2009 it was estimated that 1.5 million people would warrant orthognathic treatment. I think that this change in treatment selection has been driven by the difficulty in correcting class II malocclusions by non-surgical means.

Twenty years ago most overjets treated by surgery were over 7 millimetres but currently many cases are less than 5 millimetres. This may be due to the realisation that correction by functional and dental-orthopaedic appliances is uncertain even when the overjets are small. There are few accurate figures to tell us what the current number might be and anyway the figure is distorted by the number of children who are advised to have surgery but who are too frightened to accept. These may outnumber those accepting surgery by two to one, leaving many children with disfigurement that no one can cure satisfactorily.

Information about orthognathic surgery is largely supplied by individuals who publish successful cases but of course this is always slightly unsatisfactory as one is left wondering what might have happened had another method been used. As a result there is little evidence to show if some methods get better results than others. Although modern surgery is very safe there is always the chance that things can go seriously wrong and certainly surgery should always be avoided if possible.

Most orthognathic surgery these days it a sequence of orthodontic treatment using fixed appliances and surgery, usually in that order but sometime with a second cycle of orthodontics. This can make overall treatment quite a lengthy process. Non-surgical methods such as Fixed, Functional and Herbst Appliances have been used but there is a risk of only partial improvement as a result of unattractive facial lengthening (Faure, J. 1998). Some success has been reported using Orthotropic treatment on cases previously recommended for surgery suggesting that it could be an effective alternative (see below).

Although these cases have been shown to the GDC they have said orthodontists need not “inform a patient of alternative treatments which, in the dentist’s opinion would not be appropriate”. Some readers might think that patients should be informed about all realistic alternatives especially if they can avoid invasive surgery so they are able to decide for themselves.

 

0.4 The Tongue – What part does it play?

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The Tongue: What Part does it Play?

It is hard to comprehend the full difference between the correct and incorrect action/posture of the tongue. The teeth are resistant to short-term force during biting or swallowing but they are very sensitive to light long-term force/posture, including the touch of the tongue. If you place a blob of resin on the lingual side of an unopposed molar it will move away from the light contact of the tongue because it is continuous while the strong push from the tongue during swallowing lasts barely a second and so has little influence.

The shape of the dental arch is determined primarily by the tongue but also by the cheeks and lips, all of which have far more influence than the genes. That is why the arch shape of all animals and our primitive ancestors reflects the shape of the tongue. That does not apply to people who have any malocclusion because all of them have displaced tongues. Usually children from industrialised countries rest their tongue to a greater or lesser extent between the teeth. In fact about 95% of civilised children do this, leaving the teeth and lips apart for varying periods which of course is why malocclusion is endemic.

William Profit’s research at South Carolina, showed very clearly that teeth erupt when out of contact and intrude when in contact (Proffit et al 1993). From this research it is obvious that teeth need to be in contact 4 to 8 hours a day for them all to meet evenly with the face the correct height. But if the tongue rests between the teeth this balance is distorted.

The problem has been that few clinicians who work in the mouth have realised how influential the tongue is for the growth and development of the jaws and face. This includes many Dentists, Ear Nose and Throat Specialists, Orthodontists, Speech Therapists, Orthognathic Surgeons, Oral Myologists and to some extent Beauty Specialists and Plastic Surgeons all of whom are involved in the shape and function of the facial skeleton. We could also include Anthropologists who study the historical shape of the face as well as the Cranial Osteopaths, and Chiropractors who treat internal deformation of the skull. Many of them visualise the tongue as a soft structure which adapts to the form of the tissues around it, rather than seeing it as the large powerful muscle it is.

Orthotropists believe that the natural growth and appearance of the face is largely guided by the position of the tongue, but no one has yet found an accurate way of measuring tongue posture and so this suggestion is as yet hypothetical. It is theorised that the forward growth of the maxilla (the mid face) depends to a large extent on support from the tongue but although there is incidental evidence to support this concept it is not widely accepted by orthodontists. Sadly because it can’t be measured, university researchers have shown little interest in tongue posture so we have little idea whether it is crucial or unimportant.

The illustration below shows the effect of enlarging the maxilla and taking it forward.

0.5 Can orthodontics damage faces?

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The big majority of orthodontics in Britain is carried out with fixed appliances which achieve excellent alignment of the teeth but several scientific papers have suggested the possibility of adverse facial changes (Battagel 1996). I think orthodontists are embarrassed about this but believe that by avoiding discussing the subject, the public will not be worried.

The father of the girl shown below was a medical doctor and asked for non-extraction treatment for his daughter hoping this would avoid damage. After a year of retractive Headgear there was little change and she then had 4 teeth extracted. After another year the orthodontist said she would need jaw surgery. The picture below shows the change to her face at that point.

The next patient (below) received a nice improvement from Biobloc Orthotropic treatment but then decided to have the alignment improved with fixed appliance. See the vertical growth that followed.

Early Treatment Options ages infant to 6

Early Treatment Options ages infant to 6

Hands-on seminar hosted Spring 2018 in Grand Rapids, MI

partnered with AAGO

Presented by Wyland Gibbs, DDS, MS &
Karen O’ Rourke, DDS

 

Why Early Treatment Options?

• Redirect improper facial growth
• Enhance airways and improve health
• Gain self-worth and confidence

 
Before
 
Dr. Karen O’Rouke on the importance of early intervention

Register Here

 
After
HANDS- ON SEMINAR INCLUDES:

• Literature based reasons for treating early*
• Discover underlying causes for breathing and growth disorders
• Methods to prevent malocclusion and airway issues
• Learning the use of appliances for early intervention

• 14 CE credits, breakfasts, lunches and a group dinner

*Sleep Breath, 2012 Mar; Brockmann PE1, Urschitz MS, Schlaud M, Poets CF. Primary snoring in school children: prevalence and neurocognitive impairments.

 

 

Friday lecture and Saturday clinic
March 9 – 8am – 5pm | March 10 – 8am – 3pm$1250 for doctors ($1050 prior to
2/9/2018) $190 for auxiliaries.Details and early bird pricing until February 9:
WMIOrthotropics.org | Questions
email: info@WMIOrthotropics.org

Dsmile Body Balance Training

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0.2 Growth Direction – Can it be changed? by Prof. John Mew

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Growth Direction – Can it be Changed?

At the 2005 Northcroft Memorial Lecture, Professor Nigel Hunt said “Of all the problems that confront us, it is abnormalities in the vertical dimension, whether they be in the growing child or the adult, which still present the greatest difficulties both in treatment itself, as well as maintenance of the treatment outcome”, The big majority of orthodontics in Britain is carried out with fixed appliances and the evidence suggests that these routinely increase vertical Growth, usually slightly but sometimes severely (Battagel 1996). Lengthening the face makes it less attractive (Lundstrom et al 1987). I think orthodontists are embarrassed about this but accept it as unavoidable.

To establish the facts, two UK orthodontists compared the direction of growth in a closely matched group of people with 10mm overjets and downward growing faces, treating them either by conventional fixed appliances or by appliances designed to change their oral posture. 10 millimetre overjets are rare and only twelve subjects were available. They were divided into two groups and treated prospectively by the alternate methods at two different centres. The X-rays were traced by the authority providing the fixed appliances. The pogonions of the patients undergoing fixed appliances cases were found to have grown at an angle of 74.4° (range 59° to 90°) to the SN plain, while for the posture group the average was 50.6° (range 37° to 65°).

A difference of 24.8⁰ in growth direction is unusual especially considering this is an average and that many orthodontists struggle to achieve any reduction in growth direction. The Bolton study found that the normal direction of growth of people without malocclusion is about 55⁰, showing that these very vertically growing faces finished better than average. As a matter of interest one of the cases with a 10mm overjet returned to the clinic concerned about a small diastema and the picture below shows the long term result of changing oral posture.

Growth direction

Oral Posture and Faces

“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.

Orthotropics--Orthodontics-Oral-posture-and-faces1 Orthotropics--Orthodontics-Oral-posture-and-faces2 Orthotropics--Orthodontics-Oral-posture-and-faces3
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.

Facial Shape and Sleep Apnoea

Within this site are several well-supported texts discussing how external influences in the modern environment are leading to a lengthening of the anterior facial skeleton. This is well illustrated if you compare the tracing of a primitive skull shape with a modern average such as is used by orthodontists when they are planning treatment (see below). The reduction in the muscular effort and a lowering of the tongue from its habitual position on the roof of the mouth have effected a large change in anterior facial skeleton.

Orthotropics--Orthodontics-Facial-shape-and-Sleep-apnoea
  • Individuals with any form of malocclusion will have longer faces, often much longer

As the craniofacial complex lengthens, the mandible hinges back and downwards carrying the tongue down into the airway. If a face is longer it is going to be narrower and shorter, reducing the cross sectional area. This area contains the tongue, teeth and airway and if there isn’t space for the teeth then your airway is at serious risk. The most statistically significant single measurement in the diagnosis of sleep apnoea is the distance from the insertion of genioglossus (just behind the chin point) to the hyoid bone (the Adams apple), which is more significant that obesity and body mass index. The more the mandible hinges back the smaller this area becomes.

Orthotropics--Orthodontics-Facial-shape-and-Sleep-apnoea2
  •     This image of the airways give a graphic representation of the difference between a vertical and horizontal growth pattern.  When Poiseuille’s Law is considered, where the resistance is equal to the radius to the power of 4, then it would seem that a small increase in the vertical growth pattern can disproportionately increase the resistance in the airway.

When awake, we usually make two subconscious postural adjustments to cope with this situation. One is to extend the head and neck, opening the airway in a similar manner to the tipping the head back for Cardiopulmonary Resuscitation (CPR) or when giving an anaesthetic, the other is to move the mandible and tongue, for example lowering the mandible slightly while the tongue is held a little forwards, moving some of the bulk of the tongue forwards out of the airway. It is also possible to increase the motor tone of the muscle in the airway and those holding the base of the tongue. Such compensatory functions can be very effective at maintaining a patient airway, however they take a level of conscious command that is inevitably reduced during sleep, when the tongue falls back into the airway causing nocturnal sleep apnoea which is exacerbated by sleeping face upwards.

The next time you 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 they are fully relaxed at home watching something that fully engages their consciousness. 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.

 

Orthotropics--Orthodontics-Oral-posture-and-faces1 Orthotropics--Orthodontics-Oral-posture-and-faces2
Mouth always closed, or almost closed- good cheekbones, excellent face shape Mouth slightly open- lower cheekbones

Orthotropics--Orthodontics-Facial-shape-and-Sleep-apnoea4

To move the mandible and tongue, for example lowering the mandible slightly while the tongue is held a little forwards, moving some of the bulk of the tongue forwards out of the airway. It is also possible to increase the motor tone of the muscle in the airway and those holding the base of the tongue. Such compensatory functions can be very effective at maintaining a patient airway, however they take a level of conscious command that is inevitably reduced during sleep, where the tongue then falls back into the airway causing nocturnal sleep apnoea which is exacerbated by sleeping face upwards.
The systemic effects of sleep apnoea cannot be understated, it has been suggested that it is involved in the pathogenesis of heart disease, Attention Deficit Hyperactivity Disorder (ADHD) and even obesity (which suggests a pathological vicious circle may exist).

Stop Snoring

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

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.

Orthotropics--Orthodontics--Make-your-face-beautiful

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.

Orthotropics--Orthodontics--Make-your-face-beautiful2