Fast Trax Orthodontics

 

When to begin Treatment and
What to Look For

THE SIMPLE TRUTH ABOUT CROOKED TEETH

Teeth become crooked if the jaws grow incorrectly. The most common causes are simple things like thumb sucking, bad swallowing habits, or hanging the mouth open (airway problems). Bad growth of the jaws will also spoil the look of the face. This can be avoided if the jaws can be encouraged to grow correctly from a young age.
Scientists have known this for ages (evidence provided later) but most orthodontists are currently taught that it is too difficult to alter the growth of the jaws, or not worth the effort, and prefer the more reliable option of fixed braces, often accompanied with extractions and sometimes jaw surgery. This form of traditional treatment has been used for about 100 years and orthodontists are fully aware that it can damage the teeth and face and also the crowding tends to return later. Despite this, braces and extractions are still widely used all over the world because that is how they were trained. In America, currently over 60% of the cases in “traditional treatment” involve extraction of usually four to eight teeth. In England, over eighty percent of the orthodontic cases involve extraction. Austin Powers pokes fun at the English smile in his movies. Treatment in my office involves extraction less than 1% of the time and typically only adult patients.

What Are the Early Signs of Future Problems

So many attractive children grow up to be plain teenagers. This was the concern which brought me into the study of full face orthodontics and early treatment. General dentists and orthodontists have combined together to advise parents about early growth guidance or 'orthotropics'. The most important thing is for parents to be aware that the growth of the face can go wrong and that this can be avoided if early action is taken. If your child's face does not look quite like the other children’s, you should be concerned. Watch for flattening of the cheeks or an unusual shape around the mouth because these will almost certainly get worse. Look for dark circles under the eyes and slumping shoulders.

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Additionally topics to be concerned about:

Hanging the mouth open
. This is probably the most important single factor. Open mouth postures will cause the face to grow down to an extent that a child may have difficulty in closing their lips at all. Once this has happened, it can be very difficult to correct other than by surgery. Try to persuade your child to keep their mouth closed at rest. Check out the child above to see that his lips are parted in both pictures.

Adverse Growth. The downward (vertical) growth of the face tends to set the jaw back and restrict the size of the throat. In order to breathe more easily, the head is tilted back. Try dropping your jaw an inch and you will see why this is. To restore the balance of the spine the neck is tilted forward. This unbalances the whole vertebral column and osteopaths, physiotherapists and chiropractors find this is a common cause of headaches, neck aches, and long term back trouble.


A horizontally growing face and a vertically growing face, note how the head is tilted back to enable them to breath.

Sucking Habits If your child's face does not look quite like the other Children do seek advice. Strange sucking habits, or swallowing with the tongue showing, can also distort the teeth and jaws, and may precipitate a speech impediment. Remember that the only thing that guides the teeth into position are the lips, the cheeks, the tongue and the other teeth and any faults in these will be reflected by irregularity of the teeth, followed later by facial disfigurement.

Spaces. At the age of five there should be spaces between the front teeth. Their permanent successors which should arrive about the age of six, are a lot larger, and if there is no space they will crowd. It is easier to prevent crowding by creating space than to correct it afterwards.

Crowding. If the lower front teeth are crowded at six years of age take advice and do not accept a ‘wait and see approach’. At the very least, your child needs to improve their mouth posture.

Unattractive Eyes. If the top jaw grows down, the eyes look prominent and the outer corner of the eyelids will sag making them look tired with too much white-of-eye showing. The lower eyelid will develop a ridge rather than slope smoothly into the cheek.

Weak Chin. Look at your child sideways and see if you like the position of the chin. It is likely to be set back if their mouth is open a lot and they will have a double chin.

Prominent Chin. Children who fidget or are overactive, may suffer from too much growth of the lower jaw, even more so if they stick their jaw forward and work it from side to side. Excessive jaw growth can be very difficult to correct when they are older.

Excessive Gum. You will notice that good looking people do not show a lot of gum when they smile. The more gum that shows the less attractive the face. If a young child
shows a lot of gum their face is growing downwards.

Speech. The tongue should be in the palate for most sounds and if it protrudes sideways or forwards between the teeth, the teeth are likely to become displaced. A lisp usually indicates that the tongue is between the teeth. The lips should come into contact between most syllables. Ask your child to count up to five and see how far apart their lips are after the 'five'. If it is more that 3mm there is a mild problem if more than 7mm a severe problem.

Eating Habits. Many children avoid hard foods. This allows their muscles to become weak and can be a principal cause of vertical growth. These habits often develop when the child is first weaned, try to encourage them to chew hard things but remember that too much persuasion can have the reverse affect.

Where should the teeth be?
To measure the correct position of the upper front teeth simply put a pencil mark on the most forward point of the nose, and measure from there to the edge of the upper front teeth. Ideally it should be 28mm at the age of five and increase one mm each year until puberty, when it should be 38 to 42mm for a girl of 16 and 40 to 44 for a boy of 17. If it is more than five millimeters over this there will be some irregularity of the teeth and disfigurement of the face, and if more than eight millimeters the child is certain to grow up with an unattractive face. We can take this measurement in our office for you.

What Can Mothers Do?

JAWS & BREASTFEEDING
During breast suckling, the undulating rhythmic elevation and lowering of the jaw stimulates lower jaw growth, during the most rapid period of jaw growth.
(SOURCE: Van der Linden's Handbook of Facial Orthopedics--1982)
Your Jaws ~ Your Life (page 46)
Breastfeeding helps jaws and airways to develop properly. Bottle and pacifier use can deform jaws and airways. Breast suckling promotes good forward jaw growth and development. Bottle, pacifier and finger sucking put backward forces on the jaws during one of the most important periods of rapid forward growth. Dentists should advocate breastfeeding for about 6 to 12 months. Sivty percent of the face’s growth occurs by age four. Research shows breastfed infants have considerably less illness and fewer lifelong health problems. Some of the health benefits of breastfeeding are due to better jaw and airway formation, although most credit has been given to the content of a nursing mother's milk.

Pottenger has shown that bottle feeding with processed milk may be harmful to infants .There are other major concerns with bottle feeding.

The shape and texture of latex nipple is vastly different than natural breast nipple. 
The shape and texture of latex nipple is vastly different than natural breast nipple.

The shape and texture of latex nipple is vastly different than natural breast nipple.

Infants suckling on unnatural latex nipple develop unnatural swallowing patterns and possible tongue thrust which can cause abnormal facial and dental growth and development.

Allergies. Allergies and blocked noses can start soon after birth. They are a response to tiny particles of dust in the air, and are becoming increasingly common in industrial countries. The most common allergy is to house dust. You can see how much there is when a shaft of sunlight crosses a bedroom.

If a newly born infant is exposed to high levels of dust their immature immune system may overreact and they can become permanently sensitized, not only to the original agent but to other concurrent foreign proteins such as cow’s milk. For instance children born at times of the year when the pollen count is high tend to have more hay fever. The consequences can be - blocked noses - mouth breathing - ear infections - crooked teeth - enlarged tonsils - enlarged adenoids - sinusitis - and later on unattractive faces.

Can allergies be avoided? NEVER LEAVE A NEW BORN IN A DUSTY ATMOSPHERE. Attempting to remove dust by dusting or vacuuming can be counter productive as it tends to stir it up. An electrical gadget called an 'ionizer' which generates an electric field can help to lay bedroom dust and these can be coupled with a filter. Or one can adopt our grandparent’s habit of leaving a baby in fresh air for some hours each day. Alternatively you could go and live in the mountains or by the sea, where there is less dust/pollution and allergies are less frequent. All these alternatives are difficult to implement. The important thing is to realize is blocked noses lead to open mouth postures and that these destroy faces.

Thumb sucking, together with other finger, dummy and blanket sucking habits will, if severe enough distort the growth of the face and teeth. It is very important that babies and young children are discouraged at every opportunity as it can cause severe damage to both the face and teeth (see below). Don't accept it as a passing phase, be gentle but firm.

Aged 6 before she started sucking her thumb and aged 8 afterwards.
Note the facial damage as well as the teeth. The chin has become more recessive

Tonsils and adenoids can make it difficult for a child to breath through their nose. However, we are not sure if they are the cause or the result of the mouth breathing. Either way, their removal will occasionally result in a dramatic spontaneous improvement in nose breathing, facial appearance, and self confidence.

Counseling. Every effort should be taken to encourage nose breathing. Place a paper clip or cocktail stick between the lips for long periods when doing homework or watching TV. The best source for these problems is the Oral Motor Therapist. Encourage them to eat hard food.

Treatment. Occasionally a simple appliance to widen the upper jaw will have the same effect as removing tonsils. This is because the nose is attached to the top jaw and widens with it, making it easier to breath. In more severe cases treatment should begin by the age of six. In mild cases, an excellent result can be achieved in the teens or later. Unfortunately, unless the child learns to keep their mouth closed, treatment will not last a long time, and the problem will tend to return afterwards. If correct growth and oral posture can be achieved there can be a dramatic improvement in the appearance of the face and no extractions should be necessary.

When to Bring in Your Child

We like to see children as young as 4 years old if they are mouthbreathers or their upper teeth are inside the lower teeth when your child bites down. Actual treatment often begins in the 6-10 year age group if there is crowding or less than ideal facial balance. If the child is not a mouthbreather and has proper dentofacial development, we will wait for all 28 teeth (all teeth but the wisdom teeth) to be in the mouth before orthodontics. This minimizes the time children are in braces.
We would much prefer seeing a child early before it is the appropriate time for treatment than having to tell a parent it is too late for ideal treatment.

Reasons to treat early:
If space is made for the permanent teeth to erupt into relatively good positions they will tend to be more stable in those positions.
Improper skeletal relationships, poor facial balance and gummy smiles can be corrected at an early age with orthopedic appliances. By the time a child is over 10 the window of opportunity is starting to close on females, and a year later for males.
A narrow airway can be expanded 4-5 times in area with the use of orthopedic appliances at a young age. Establishing a good airway contributes to good facial development, stability of the orthodontic result, and a healthier child. An ideal airway can become of critical importance in later years since obstructive sleep apnea (a life threatening problem) is a direct result of a reduced airway! Posture also improves with the proper development of a restricted airway.

Does Airway Matter?

An adequate airway is THE most important factor in a child's facial development. Genetics determines factors such as hair color, eye color, and height. In contrast, it is altered oral posture usually caused by an altered nasal airway which determines whether or not the face will be well balanced.
Too often children grow up as mouthbreathers due to allergies, obstructions in the airway such as enlarged tonsils or adenoids, or sinus problems. Mouthbreathing allows the child to get the air he or she needs, but it alters "proper oral posture" and causes changes in the child's growth pattern.
If a child grows up as a mouthbreather without proper oral posture the growth tends to be in a downward and backward direction rather than a forward and downward direction. Downward and backward growth results in a long lower face and recessive chin. Different alterations in oral posture produce facial and tooth changes that are unique and different from the genetically determined pattern for an individual.
Pictured below is a 10 year old boy who was developing normally. He was a nosebreather, and his face is well balanced. Not long after this picture was taken he was given a gerbil which he kept in his room. Unfortunately, he was very allergic to the gerbil and went from being a nosebreather to a mouthbreather. Note the changes in his face by the time he is 17: the chin is back (recessive), the cheeks are flat, the lips are flaccid, and the nose appears to stick out.


Age 10

Age 17

Age 17

Studies have been done with monkeys to show the effects of mouthbreathing on growth. When the noses of perfectly normal growing monkeys were plugged, their faces began to grow backward and downward rather than forward and downward. ("Neuromuscular and Morphological Adaptations in Experimentally Induced Oral Respiration" Nasorspiration Function and Craniofacial Growth )

Mouthbreathers continue to have facial changes occur throughout life. Depending on the extent of the mouthbreathing, the chin may continue to become more recessive bringing the soft tissue drape of the cheeks and nose downward. This can result in the cartilage of the nose being pulled down making it appear as if there is a bump in the nose where the nose becomes bony. Some of the downward & backward change may be masked by tilting the head in an unconscious effort to open the airway. This results in a forehead that slopes backward, but the chin does not appear as recessive.
Mouthbreathing also contributes to an unstable orthodontic result because the forces of the tongue and cheeks are unbalanced.
Check out this adult. Note her sloping forehead caused by forward head posture tilting to open the airway so she can breath. Notice the lack of cheekbones. Cheekbones only develop when a person breathes through their nose. Mouthbreathers tend to lose their chin anatomy and develop the “turkey gobble” look.

 

What is Proper Oral Posture

Proper oral posture means that at rest the tongue is to the roof of the mouth, the teeth are touching or slightly apart, and the lips are together without strain. When a child grows up with proper oral posture the face develops in good balance - the way it was meant to develop. There is proper balance between the forces of the tongue and the cheeks and lips The teeth tend to come in to relatively good positions. Proper oral posture also contributes to a more stable orthodontic result.
Improper oral posture manifests in numerous ways including mouthbreathing with the tongue low and teeth and lips apart or posturing the tongue between the back teeth.
When the tongue is low and the teeth and lips are apart at rest the result is crowded teeth, gummy smiles, recessive chins, and long faces. If the tongue is positioned between the back teeth the upper front teeth over erupt or come down too far, resulting in a deep bite situation (upper teeth covering all or most of the lower teeth) and often a gummy smile.
Changes in the balance of the face and the teeth vary in severity depending on the severity of the departure from proper oral posture. There appears to be a strong relationship between the distance the lips are apart at rest and instability of an orthodontic result as well as continuing facial changes throughout life.
These changes have been well documented by such scholars as Dr.Weston Price author of "Nutrition and Physical Degeneration" and Dr. Robert Corruccini author of "How Anthropology Informs the Orthodontic Diagnosis". As early as the 1920's and 30's, Dr. Price was documenting the changes in facial balance and dentition that occurred in one generation in various primitive peoples all over the world. He found that the common link in going from a generation with good facial balance and broad jaws with little or no crowded teeth to the next generation with poor facial balance and narrow jaws with crowded teeth was a change to a Western diet which included refined sugar and flour. A genetic adaptation does not occur in one generation nor can the change be classified as an adaptation when there is no advantage to the change of crowded dentition, long face, and mouthbreathing. The following pictures are of sisters a year apart in age. Can you guess which one is a mouthbreather and which has good oral posture?

Improper oral posture and poor facial balance

Proper oral posture and good facial balance

Does Facial Appearance Matter?

Babies. Babies as young as three months strongly prefer attractive moms to unattractive moms (Samuels 1985). Attractive babies receive more affection and attention from there parents and other adults, and are more likely to grow up to be well balanced adults themselves.
Children. Children grow up to believe that heroes are good looking, heroines are beautiful, and bad people are ugly. These stereotypes remain with us all our lives.
Teenagers. Although they may not admit it, young teenagers are more concerned about their appearance than their relationships with their parents, their siblings, their friends, their work, or their pastimes. Handsome cadets achieve higher rank by the time they graduate (Ackerman 1990).
Criminals. A judge is more likely to give an attractive criminal a shorter sentence. Unattractive people are more likely to become criminals, four out of five females committed for aggressive offenses were rated as unattractive (Cavior 1974). Criminals who have their appearance improved by facial surgery are less likely to return to prison. (Lewison 1974)


Paula, aged 14

Paula, aged 16

She was told she would need to have her jaws cut and repositioned, but was treated with orthotropics (growth guidance) instead.

Intelligence. Good looking people are likely to be perceived as more intelligent. Surprisingly good looking people are actually found to be more intelligent, possibly because they receive more attention at school. They are also likely to get better jobs, rise to higher positions, and earn more money (Bull 1988).

Status. You will be considered to have higher status if your partner is good looking than if they are plain (Hartnett 1973).

Personality. Although many people claim to judge personality by the shape of a face, most studies have dismissed this possibility. However, one study (Squires and Mew 1981) of long and short faced people concluded that the former tended to be less conventional while the latter were more so.
Does Beauty Lie in the Eye of the Beholder? The answer is no, research has shown that we all tend to put peoples appearance into approximately the same rank and order, regardless of their race, color, or background. (Cross 1971). Recent research (Mew 1993) would suggest that while we generally agree about who is very good looking, opinions differ when we are considering the less good looking who populate the real world around
us. In fact we tend to prefer people who look like ourselves.

Can orthodontic treatment change faces?
 While it is certainly possible to damage a face, most orthodontists do not believe it is possible to improve the shape of the face with appliances. This may be true with traditional treatment but it does seem that Orthotropics can achieve changes in facial appearance, as well as oral posture.

Can Orthodontics Damage Your Face?
The attractiveness of a child's face depends largely on two things:
• The shape of their parents faces
• Whether their face grows forwards or downwards.
While the first is fixed at conception, the second displays a range between 'horizontal' which orthodontists label favorable and 'vertical' which is considered unfavorable. Horizontal growth is associated with good looks, square jaws and straight teeth, while vertical growth produces the reverse, and the effects of this may range from the barely perceptible to the markedly unattractive. The direction of growth can be affected by a range of simple things like thumb sucking or hanging the mouth open, both of which encourage 'vertical' growth and the degree of damage will depend on the severity of the habit.

Facial Damage.
The public have a strong preference for 'horizontally' growing faces. Unfortunately there is clear evidence that almost any kind of orthodontic treatment encourages an increase in the unattractive 'vertical' growth (Battagel 1996).
It is interesting to note that orthodontists seem to prefer the flatter profiles seen with 'vertically' growing faces. (Peck and Peck)
Recent evidence (Clark et al 1998) would suggest that the large majority of orthodontists in Britain are not interested in the relationship between oral habits and the direction of facial growth. Furthermore that 91% are prepared to extract teeth, even if there is no crowding and 63% to pull teeth back despite strong evidence to show that this encourages 'vertical' growth. Not only is this approach likely to damage facial appearance but the teeth often re-crowd after treatment despite the extractions. This approach plays right into the hands of Austin Powers who mocks the bad teeth found in Great Britain.

Vertical Growth

Horizontal Growth

Picture showing how vertical growth can damage a face

Picture showing horizontal growth

This child’s face was damaged by vertical growth following orthodontic treatment. Vertical growth is associated with thick lips, receding chins, protruding noses, sloping foreheads and tired eyes.

This boy received Orthotropics. Although his front teeth stuck out both jaws were encouraged to grow forward. Few other techniques achieve this and most pull the teeth back. Horizontal growers retain naturally straight teeth for a life time. Notice the more forward position of the chin.

Extraction versus Non-extraction

The treatment of irregular teeth has evolved over the last century, largely by trial and error. Many types of treatment have been tried during this period, most of which have been superseded. Most treatment has been based on two underlying alternatives.
• Accept that the jaws are too small and extract teeth to provide the space.
• Enlarge the jaws to accommodate the teeth.
Over the last 100 years, treatment has alternated between these two concepts and there have been decades when no orthodontists extracted teeth and decades when they all extracted teeth. At the moment most countries are leaving a period of extraction but some are moving towards it. This might suggest a degree of discontent with both methods.
Both methods work well in the short term but unfortunately tend to fail in the long term with re-crowding of the teeth. In Europe teeth are extracted in around 75% of cases while at the moment in the USA it may be closer to 60%. Most orthodontists will say they extract teeth only when absolutely necessary, but clearly there is considerable disagreement about when this might be so. Whatever the treatment, very few patients treated by these methods finish with all their teeth and a large proportion loose eight teeth as there is not room for the wisdoms.
Some orthodontists avoid extractions by pulling the side teeth back with a strap aground the back of the head or neck, so making room to straighten the front teeth. However this tends to reduce the room for the wisdom teeth. It also encourages downward growth of the face and there is no doubt that this can damage the face, sometimes severely.


Child aged 10 and 12; extractions and fixed braces

 

However it can not be assumed that extractions will damage the face.
Catherine Zeta-Jones (Michael Douglas' wife) has lost two pre molars

Why was there no damage in her case? Perhaps it has something to do with her lip-seal and tongue to palate posture.

 

Orthotropics aims to find room for all 32 teeth
and at the same time optimize the growth of the face.

Before during and after orthotropic treatment, aged 9, 11, and 14. Note how the teeth are pushed forward, although conventional treatment usually pulls them back which may flatten the face. Note the improvement in the eyes and face.

Are Extractions Necessary?
Orthodontic clinicians in the past have been severely criticized by scientists for ignoring the scientific evidence. Here are some of the comments about orthodontics from world scientific heavyweights they are “behind homeopathy and on a par with scientology” (Sackett 1985), their work is “based on trial and error” (Johnston 1990), the schools “teach technical skills rather than scientific thinking” (Richards 2000), “Sadly it is hard to see this situation change unless the inadequacy of current knowledge is acknowledged” (Shaw 2000), their treatment of crowding “treats a symptom, not the cause”. (Frankel 2001).
Traditional Orthodontists are taught that the size and shape of the jaws is inherited and most of their treatment is based on this belief. Clearly if the teeth were too large for the jaws some teeth would have to be extracted but there is almost no evidence to show that this is true.
Many orthodontists consider crowded teeth are caused by interbreeding between humans with different sized jaws. Biologists do not support this view, and even if a 100 kg Great Dane were crossed with a 1kg Chihuahua the offspring would be unlikely to have a malocclusion. There is evidence to suggest that the size of the teeth and jaws is inherited, but little to suggest that disproportionate growth is.
Some orthodontists believe that evolution has caused jaws to become smaller over the last few thousand years (Walpoff 1975). Certainly crowding has become worse, but this has been mostly within the last 400 years (More 1968), which is far too short a period for an evolutionary change. Also an evolutionary change would have to start in one area and spread, but irregular teeth are found all over the world, wherever people take their standard of living above a certain level.
Despite this overwhelming evidence, most orthodontic treatment is still carried out on the basis that disproportionate jaws are inherited and that little can be done to change them. Based on this belief and in contradiction to the evidence the teeth are moved into line mechanically usually coupled with the extraction of either four or eight permanent teeth. If the jaws are in the wrong position orthodontists may recommend that they are cut and corrected surgically. Many thousands of children and young adults have this surgery each year although a substantial proportion of those who have been told that surgery is the "only answer" have subsequently been corrected with Orthotropics and dento-facial orthopedics. Despite this, the dental profession are not informing their patients that there might be an alternative, or they are not aware of alternative treatment.

Iatrogenic Damage caused by Braces.
Scientists have clearly shown that braces can damage both the roots and the enamel. "Over 90% of the roots of the teeth show signs of damage following treatment with fixed appliances". (Kurol, et al 1996). "40% of patients show shortening of more than 2.5mm". (Mirabella and Artun 1995). This is a substantial proportion of the root length and must shorten the life of the teeth. Enamel damage, with fixed appliances, is rapid, widespread and long-term. (Ogaard et al 1988) (Ogaard 1989) (Alexander 1993). According to the AAO Orthodontist’s Journal, the type of bioeffecient non-friction bracket system used at Fast Trax Orthodontics is the safest on the market.
All orthodontists accept that faces can be damaged by inappropriate treatment but they disagree about which approach will cause least damage. "The maxillary retraction associated with braces (Edgewise) contributes to the poorer aesthetic result." (Battagel 1996) and may be "accompanied by exaggerated vertical facial growth".

It is known that Braces tend to lengthen the face (Lundstrom,A. &Woodside,D.G. 1980) and that longer faces look less attractive’ (Lundstrom et al 1987). However there is little sound research to establish how often or how severe the damage may be.
Twins, who are genetically identical, still show more contrast in the shape of their jaws than any other part of their skeleton (Krause 1959) proving that much of the variation is due to non-genetic environmental factors such as open mouth postures and unusual swallowing habits that distort the growth of the jaws. Orthodontists in the past have found it difficult to explain why modern children have so much malocclusion, but the following new hypothesis appears to fit the known facts better than those put forward previously: -
"Environmental factors disrupt resting oral posture, increasing vertical skeletal growth and creating a dental malocclusion, the occlusal characteristics of which are determined by inherited muscle patterns, primarily of the tongue" (Mew 2004).
Most children with upper front teeth sticking out are treated by pulling them back. However, if you look at the side of such a child's face, you can see that the fault is often their lower jaw which is too far back (see Antonia below). Almost all orthodontists pull back the top teeth in this situation risking an increase in downward growth with subsequent damage to the face. It is important that prospective patients are warned of this risk, because little research is being done to establish how often it occurs. However Antonia had Orthotropics to take both her upper and lower jaws forward.

In conclusion, space to align the teeth can be provided by extractions and braces but the crowding is likely to return, especially of the lower front teeth (Little 1988). There is also a risk of damage to the teeth and face. Orthotropics aims to avoid extractions by early correction of the cause rather than later treatment of the result, but is highly dependent on the ability of the child to comply with wearing appliances and learning to keep their mouth closed.

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