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From a presentation for the Myofunctional Research Company by Dr. Barry Raphael, September 2014. All rights reserved.
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My Journey in OrthodonticsToronto, Sept 13, 2014
Rancho Cucamonga, Sept 21, 2014 Barry Raphael, DMD!
!The Raphael Center for Integrative Orthodontics
The Raphael Center for Integrative Education !
Clifton, New Jersey !!
www.alignmine.com www.learnairwayortho.com
RO since1983 (31 years...yikes)
Bucknell University 1974 University of Pennsylvania DMD1978
(Three Years in General Practice) Fairleigh-Dickenson University Ortho 1983
Right out of school
Functional Orthodontics
Frankel
Bionator
Twin Block
MARA
Herbst
2008
Soft Tissue Dysfunction is THE cause of
malocclusion
Myofunctional Research Co.
Spring, 2009 MRC meeting, Chicago > Terry Carlyle
September, 2009 MRC conference, Coral Gables, Fl.
Myofunctional Orthodontics
Chris Farrell
John FlutterGerman Ramierez
Damien O’BrienMyofunctional Research Co.
Rancho Cucamonga 2008-2012
Oral Myology
Oral Myology: Levels 2, 3 Kim Benkert Clifton 2012
Habit Cessation Shari Green Clifton, 2013
Joy Moeller NYC 2011
San Diego 2012
Biobloc Orthotropics
BBO Mini-residency Bill Hang
Agora Hills 2012-13
BBO Intensive Drs. John and Mike Mew
LSFO 2013
Breathing and SleepButeyko Mentorship
The Breathing Center Woodstock
2010
Breathing Well Programme John Flutter
2010
Ortho-Postural Training Roger Price
2013
Sleep Dentistry Michael Gelb, et.al
NYU 2012,2013
Cranial Osteopathy
Advanced Dento-cranial Orthopedics Bob Walker
2014
ALF, The Team Approach Jim Bronson
2013
Cranial Academy: Basic Course
January 2014
TeachingMt. Sinai Pedo Residency
Ali Attaie 2010-2014
Montefiore Ortho Residency Tony Maganzini
2012
2009-Present
Airway and Facial Development Collaborative Webcast
Mark Cruz
Myobrace Activity Center
Myofunctional Therapy
Bodywork
Ortho-Postural training
Public and Professional Education
Bass players do it from the bottom up
My greatest dysfunction “It’s all about Barry
And The World of
Mouthbreathing
Paradigm Shifts
• Malocclusion as a symptom • STD as THE etiology • Facial morphology as a risk factor • The Child attached to the teeth
Paradigm Shifts
• Malocclusion as a symptom!• STD as THE etiology • Facial morphology as a risk factor • The Child attached to the teeth
Malocclusion is the body’s solution to provide equilibrium and homeostasis.
Malocclusion as a symptom
Malocclusion as a symptom
Perfect alignment is the most stable.
Malocclusion is the body’s solution to
provide equilibrium and homeostasis
Upper Jaw and Teeth
Tongue, MM, TMJ,Cranium
Posture, Breathing, Body
Lower Jaw and Teeth
Malocclusion as a symptom
What’s the Rule?Perfection Adaptation
Place the blue block directly on top of the yellow block
Place the blue block where it will balance the stack against gravity
or
The Angle classification
If we seek Perfection using the wrong rule (ie.Angle Class I)…
…we may “rebalance” the occlusion, but disturb the equilibrium
Orthodontic’s Solution
Retainer
Long-term retention is the orthodontic’s solution to provide equilibrium and homeostasis…
Orthodontic’s Solution
Retainer…but holding balance in one part of the system may aggravate an imbalance elsewhere.
Long-term retention is the orthodontic’s solution to provide equilibrium and homeostasis…
Relapse
Occlusal Wear
Occlusal Trauma
Bruxism
Joint Derangement
Referred Pain
Sleep Apnea
Assorted physical ailments
Orthodontic’s Solution
Integrative Ortho
Teeth and Occlusion
Tongue, MM, TMJ
Cranial and Cervical
Whole Body (resp, circ, musc-skel, etc)
The ToothbergMalocclusion as a symptom
Instead of crooked teeth being The Problem, They are just a SYMPTOM of something larger
Paradigm Shifts
• Malocclusion as a symptom • STD as THE etiology!• Facial morphology as a risk factor • The Child attached to the teeth
“….there is much circumstantial evidence that jaws and faces do not grow to the same size that they used to…” - Daniel Lieberman
The Gothic Arch The Roman Arch
The “Modern” Maxilla
How do you build an arch?
The Roman Arch
No scaffold?
When the tongue rests in the roof of the mouth the teeth erupt around the tongue forming a normal shaped and sized jaw.
The tongue is the scaffold for the upper jaw
Those children who breathe through the mouth or have the lips apart at rest will not have the tongue in the roof of the mouth.
All of these children will have an underdeveloped upper jaw.
It will not be big enough for all of the teeth and when the adult teeth erupt they will be crooked.
Harvold’s Monkies
Posture changes Teeth
Lowered mandibular posture, tongue protrusion, and open biteOpen mouth posture retained for 1 year after nose reopened. Facial features retained
John Mew’s Tropic Premise
“Because the genetic control of skeletal growth is not precise,
the articulation of the teeth and jaws depends upon additional guidance from oral posture.”
John Mew’s Tropic Premise
“ If the tongue at rest is against the palate with the lips lightly sealed and the teeth in or near contact, there will be ideal facial and dental development…something RARE in industrialized societies…”
The Tropic Premise
If the tongue is chronically held away from the palate… …the maxilla collapses in all three dimensions.
Then the Mandible Adapts
If the mandible keeps up: Class I Crowded
Then the Mandible Adapts
Mouthbreathing and/or tongue thrust hinders growth : Class II
Then the Mandible Adapts
Low Tongue keeps mandible growing forward: Class III
The Tropic Premise
The Tropic Premise
Craniofacial Dystrophy
Maxilla is Down and Back
The Mandible is Retrognathic
Nasal Cartilage Collapse
Insufficient Mid-Facial Support
2008
Soft Tissue Dysfunction is THE cause of malocclusion
Soft Tissue Dysfunction is THE cause of malocclusionCraniofacial Dystrophy
Soft Tissue Dysfunction is THE cause of malocclusion
“Bone sets the tone but tissue is the issue”
- Mark Cruz
The Maxilla and Upper Dentition take the Shape of the Muscles and Muscular Functions that Surround them.
Open Mouth Posture !is the most common and significant
Soft Tissue Dysfunction In children today.
Chronic hyperventilation Hypocapnia Craniofacial Dystrophy!Reverse swallow Facial muscle dysfunction Lymph swelling Nasal obstruction Frequent ear infection Snoring SDB, UARS, OSA Learning Dx Heart rate variability Enuresis Poor posture Malocclusion Gingivitis Halitosis
Open Mouth PostureBirth trauma Cranial strains Poor posture Bottle feeding Soft diet Processed foods Immune challenges Oxidative stress Heat Hyperventilation Stress reactions Habits Dental pain Ankyloglossia Macroglossia
The Missing Link in Orthodontics Today...
It’s not just Growth and Development
!
It’s Growth, Development and
Adaptation
If Malocclusion is caused by Growth and Development...
Genetics Epigenetics
Total Growth
If Malocclusion is caused by Growth and Development and Adaptation...
Genetics Epigenetics
Total Growth
An example of “adaptation”
Two sets of twins…
An example of adaptation
One of them has crooked teeth.
Another set of twins
3 August 2003 3 August 2003
RHYS - 10Y 11MHow did these teeth get this way?
Different genes than his brother?…
1 March 2007 1 March 2007
RHYS - 14Y 5M Four years later, after successful MFO
Text
(Treatment by Dr. Chris Farrell)
RHYS - 16 AUGUST 2007 KYLE - 16 AUGUST 2007
TRAINER BWS MYOBRACE MINIMAL SWA
RHYS & KYLE - 13Y 8MDid genetics make the teeth crooked?
Did genetics fix the face?
Paradigm Shifts
• Malocclusion as a symptom • STD as THE etiology • Facial morphology as a risk factor!• The Child attached to the teeth
The Spectrum of SDB
Snoring 8-10%
Normal Prevalence:
OSAS 1-3%
UARS ?
• Short maxilla means smaller airway
• Narrow maxilla puts nasopharynx at risk for collapse with loss of muscle tone
Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects* Jerome A. Dempsey, PhD; James B. Skatrud, MD; Anthony J. Jacques, BS; Stanley J. Ewanowski, PhD; B. Tucker Woodson, MD; Pamela R. Hanson, DDS, MS; and Brian Goodman, PhD
CHEST September 2002 vol. 122no. 3 840-851
Which is easier to breathe through?
Which would you trust most?
Which would you rather have?
Analysis of anatomical and functional determinants of obstructive sleep apnea. Aihara K, et. al ,Sleep Breath. 2012 Jun;16(2):473-81. Epub 2011 May 15.
Narrow, irregular airway >
> increased shear forces >
> negative pressure pulls on soft tissue >
> tissue pulling and trauma (snoring) >
> impairment of mechanoreceptors >
> uncoordinated diaphragm and upper airway muscle contraction >
>DISORDERED BREATHING
Narrow Airway Dynamics
Powell N, Guilleminault C. “Abnormal pharyngeal airflow in obstructive sleep apnea using computational fluid dynamics: Feasibility study.” Proceeding of the 9th World Congress on Sleep Apnea (Seoul, Korea) 2009
Morphology and SDB in children
“Abnormal craniofacial morphology, but not excess body fat, is associated with an increased risk of having SDB in 6–8-year-old children.”
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752
Everyday in my practice...
Damage to Cognitive Function
Childhood OSA is associated with •Deficits of IQ •Deficit of executive function •Possible neuronal injury in the hippocampus and frontal cortex.
Childhood Obstructive Sleep Apnea Associates with Neuropsychological Deficits and Neuronal Brain Injury Ann C. Halbower, et.al, PLoS Medicine,August 2006 | Volume 3 | Issue 8 | e301
Breathing distress
• Constricted airway • Head Extension • Congestion • Soft tissue collapse
•Chronic Naso-pharyngeal Obstruction
•Tongue form aberrations (Frenum and tongue-tie)
•Open Mouth Rest Posture
•Myofunctional disorders (Swallowing, chewing,etc.)
•Chronic Hyperventilation and Hypocapnia
•Breathing Disordered Sleep (OSA, UARS, snoring)
•Bruxism and parafunctions
•TMD and facial pain components
•Cranial and postural issues
• Malocclusion
Airway-Related Craniofacial Dysfunctions
Remember the Airway!“Consequently the most important missing
diagnosis is the airway. !
Nevertheless, breathing is the most important action for human beings to live; we forgot the airway to make a diagnosis
of the orthodontic patients.”
Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood Makoto Kikuchi, Sleep and Breathing Published online: 17 November 2005©
• Adult SDB and OSA
• Narrow Jaws and Faces
• Soft Tissue Dysfunction
• Early Parafunctional Habits, esp Open Mouth Posture
• Environmental Stressors
• CPAP, MARA,UPPP, SurgWhere’s the best
place to start treatment? Here?
Or H
ere?
Treating the Cause
Paradigm Shifts
• Malocclusion as a symptom • STD as THE etiology • Facial morphology as a risk factor • The Child attached to the teeth
The Child attached to the teeth
We treat the teeth attached to the child AND
we treat the child attached to the teeth.
Don’t be a Barker
Don’t be a Barker
The Broken Door
The Broken Door
The Broken Door
The Broken Door
The Broken Door
The Broken Door
Persistant Organic Polutants (POPs)
Chronic Autonomic Stressors
Post-Industrial Diet
Treating the Cause
Instead of crooked teeth being The Problem, They are just a SYMPTOM of something larger
• Early Feeding and Nutrition • Allergies, Asthma, URT infections • Posture and Cranial • Airway, Breathing, and Sleep Disorders • Soft Tissue Dysfunctions (Tongue Thrust, Open Mouth)
TRAINING the Cause
It’s NOT about the Trainer Part 1
You mean I have to pay $7 for this?
It’s NOT about the Trainer
Now that’s a bowl of oatmeal! Yum!
It’s NOT about the Trainer
It’s about the VALUE you’re addingHabit Training
Better Breathing
Nutrition
Overall health
Trainer and straight teeth
It’s NOT about the Trainer
It’s NOT about the Trainer Part 2
Which Hammer should I use?
It’s NOT about the Trainer
Which Trainer should I use?
It’s NOT about the Trainer
It’s not the Trainer… !
It’s the Training
The Child attached to the teeth
Batting Average?
Home Run: Great Trainer Wear. No Braces Needed
Triple: Good Trainer Wear. Braces 12 mo or aligners to touchup
Double: Good Trainer Wear. Braces 18mo, Easy Non-X
Single: OK Trainer Wear. Braces 24 mo. Crowding or OJ remain
Walk: Tries Trainer. Can’t/Won’t do it. Do Conventional Tx.
Strike out: Poor Wear. Case Drags On. Gets nowhere. Braces are a compromise
Cases
July 2010 9-10y F
Class II div 1 Excess OJ/OB Narrow arches
Lip Incompetence STD
Mouth breathing
12 month progress
8 month progress
12 month progress
Class II w rotated U6’s Narrow and mild crowding
Lower midline to right Crowding at LR4
Tight labial musculature
• Better arch width and form • No crowding • Molars still rotated
Upper BWS 4mos T4K Soft, then Hard 9 mos
Lower BWS 2 mos
• Better arch width and form • No crowding • Enough space for LR4 (with leeway and midline shift) • Available space on left to correct midline
Upper BWS 4mos T4K Soft, then Hard 9 mos
Lower BWS 2 mos
• Reduced overbite
• No crowding
• Enough space for LR4 (with leeway)
Upper BWS 4mos T4K Soft, then Hard 9 mos
Lower BWS 2 mos
C.F. 7-6F OJ=7mm, Lost c-space, Open Mouth Posture
Developing the Arch
7-6yo
10-1yo9-2yo
8-7yo
Recover Lost c-space
7-6yo
10-1yo9-2yo
8-7yo
Recover Lost c-space
7-6yo
10-1yo
Better Lip Competence
7-6yo 10-1yo
C.F. 10-1yoF Perm dentition. Still Class II Right
C. R. 10-8yo F
Late Mixed Dent Crowded incisors FaMu active swallow Hypermentalis
10-8yo
13-0yo
11-6yo
12-0yo
10-8yo
13-0yo
11-6yo
12-0yo
10-8yo
13-0yo
11-6yo
12-0yo
.012 Niti Wire Microbond
Composite Stops
J.S. 11-8yo FI want braces...
Just try it for a coupla’ months...
Deep Bite Corrected11-6yo
12-4yo
Class II Improved11-6yo
12-4yo
Still want braces?
C.G. 9-10yo M
•
