Craniofacial Dystrophy – The hidden epidemic under our noses – Why are teeth crooked?
by Dr Mike Mew
Sometimes a simple question can lead to a journey connecting a wide range of “modern” disease, which gets very personal. The suggestion is that the facial form of few, if any, modern humans fulfil their full genetic potential; due to changes in the environment; and faces which are not the right shape do not work correctly. All our ancestors from the dawn of time, and all the other 5,400 species of mammals, gained and maintained near perfectly aligned teeth, for their entire lives without any orthodontics. They never had “too many teeth” for their jaws.
Craniofacial Dystrophy (CFD) proposes that crooked teeth, sleep apnea, jaw joint disorders, many otolaryngic diseases and forward head posture, are all symptoms of the same underlying problem. There is now also evidence linking this to MS and Alzheimer’s Evolutionary medicine in its clearest for.
Changing faces, and with this curing malocclusion and associated symptoms like OSA (obstructive sleep apnea), will give a better start in life for children and a better approach to treating adults and furthermore it is evidence-based and improves health.
It is more comfortable to believe that the way that your craniofacial form has developed, and the arrangement of your teeth is genetic. However, the hard scientific evidence clearly shows that this is false. This issue is highly controversial and challenges 100 years of orthodontic theory and dogma. None of our ancestors, none of the members of the other 5,400 species of mammals and few truly indigenous peoples have malocclusion. For hundreds of thousands of years everyone attained and maintained 32 perfectly aligned teeth for their whole life.
Modern melting faces: there is now a considerable mismatch between the environment that we evolved to live in and the one that we do live in.
The effort required to masticate our food is a fraction of what it was.
Transient nasal obstructions are now normal forcing postural modifications which become habits.
Pureed foods and a lack of breast feeding interrupt the natural change from an infantile suckle to an adult swallow.
Use it or lose it, modern faces are not fulfilling their full genetic potential, and faces that are not the right shape do not function correctly. We have an endemic of malocclusion, OSA, middle ear infections, deviated nasal septums, sinusitis, forward head posture and temporomandibular disorders. No one can demonstrate the causes, pathology or cure of any of these. It is estimated that 10% of 60 year olds will die a decade earlier from OSA alone, and 40 years ago it was almost unheard of; what will this percentage raise to in a decade or two?
You will learn:
The aetiology, epidemiology, pathology, treatment and cure of Craniofacial Dystrophy.
The underlying problem of which malocclusion and obstructive sleep apnea are symptoms.
I have already mentioned some of the consequences of orthodontic treatment such as facial damage and root resorption but there are other longer-term risks such as re-crowding and some such as gum damage which have only recently been recognised. Because patients prefer to avoid extractions Orthodontists currently go to great effort to avoid extracting teeth where possible. Some orthodontists and many general dentists use a screw appliance or an ‘ALF’ to expand the upper jaw to provide enough space for all the teeth. However this does not usually provide room for the wisdoms which they may say are unnecessary.
These are a simple way of avoiding extractions but the teeth usually re-crowd a few years later. This is avoided by many clinicians who give the patient a retaining appliance or attach fixed wires to their teeth either permanently or until they brake or are removed. Other clinicians avoid extractions for a while by pushing the side teeth back to make room for the front teeth but this tends to result in a flat looking face, it is then more likely that the wisdom teeth will become impacted and have to be extracted which can involve complex surgery.
Few if any orthodontists seem to use the Orthotropic method of lengthening the jaw as well as widening it. This makes much more room for the teeth and provided it is done by the age of 8 or 9 should always provide room for the permanent teeth including the wisdoms. This of course also takes the whole upper jaw forward improving the appearance of the cheek bones, sometimes dramatically. See the picture below.
Another long-term problem is gum damage which has more recently become recognised as a matter of concern. As we explained earlier the teeth and their supporting bone are normally supported by the tongue, lips and opposing teeth. But if the teeth are moved and held in a different position for a long time, such as with a retainer, the bone around them remains unstable and tends to resorb. The blood supply to the gums is carried through the bone and if it resorbs the gum often recedes or dies leaving what are called ‘fenestrations’ or holes which can severely shorten the life of the teeth.
Many clinicians from different disciplines offer explanations and cures for TMJ and it is widely assumed that there is no ‘One Size Fits All Treatment Guarantee’. However when part of the body goes wrong there is usually only one direct cause, although by coincidence two or possibly three causes could occur simultaneously. Most of the other factors are either, resultant, coincident, predisposing, or unrelated, but not causative. It is wise therefor to consider each one separately and then try to select the real culprit.
My research in anthropology convinced me that the jaw joints of our ancient ancestors rarely showed any signs of damage, so why does this joint cause so much trouble now? Things have changed since then and many jaw bones are now set back as much as 20 to 30mm from where they were back then. Most TMD clinicians agree that this distalization, causes pressure on the joint but there are few suggestions about how to improve it and surgery has not so far proved a reliable cure.
There are many recommended treatments but about 20% of patients continue to suffer whatever is done. Good cures usually surface quickly and the single most effective treatment appears to be a dental splint (orthotic) which separates the teeth somewhere between 1 to 8 millimetres. While the relief can be dramatic, and permanent the problems often return after a few weeks or months. This suggests to me that the splint may rest the joint in the short-term but the underlying cause remains. This explanation fits the fact that thickening the splint often provides a further period of relief but again the problem returns. Splints can also have side effects such as intruding teeth and despite what is done 20% or so of patients continue to suffer.
Other cures exist such as physiotherapy which can be almost as effective as splints, but again they seem ineffective for about 20% of patients. A number of clinicians and patients consider changes in the content and consistency of our diet is important, but ‘cures’ on this basis are rather unspecific and it not appear to have a high ratio of success.
With orthotropics we try to reverse the life-style changes because we believe that modern living has encouraged many children to leave their mouths open and also to swallow with their tongue between their teeth. Research shows that this is a major reason for both jaws failing to grow forward which in turn disrupts the way the teeth and jaws meet and effects the position and form of the TMJ. Orthotropic treatment is based on the ‘Tropic Premise’ which says “correct oral posture is with the tongue resting against the palate, the lips sealed and the teeth in light contact for about six hours a day”. Orthotropic treatment aims to train children to keep their mouths closed which increases forward growth improving the teeth and face. This seems to reduce their susceptibility to TMJ problems later but is only fully effective with growing children. However adopting the Tropic Premise can often cure TMD pain in young adults possibly reaching that last 20%. see the picture below.
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.
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.
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.
• 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
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A new perspective in craniofacial functional medicine
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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.