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916-786-4TMJ Advanced Dental Concepts 916-786-4865 Routine Extraction of Four Bicuspid teeth should not be done! This statement is bound to create great controversy and is considered heresy and false by a large number of orthodontists. However, the dental profession, including a growing number of orthodontists, is awakening to the dangers that patients treated with this technique are exposed to throughout their lives. Females are especially compromised due to the greater joint laxity, the physiologic differences in joints and lesser muscle mass overall compared to men. The biologic basis for this claim is that patients with the healthy bicuspid amputated are forced into a forward head posture. This forward head posture predisposes patients to a variety of musculoskeletal stressors, anyone of which may, if aggravated, force the patient out of their physiologic adaptive range into pain and dysfunction. These concepts will be discussed in detail in the future on this website. Orthodontic textbooks state that the vast majority of crowded orthodontic cases involve an upper jaw (maxilla) that is too small, as opposed to a lower jaw (mandible) that is too large. If that is true, why do we make the already small upper arch smaller by extracting teeth? Logic and common sense tells us that it would be better to help the maxilla grow to its proper size. Techniques to do this are readily available and have been used in Europe since the early 1900’s. These techniques have been growing in popularity in the United States for the past thirty years. Ask your general dentist or orthodontist about non- extraction orthodontics. If they insist that healthy bicuspid teeth have to be taken out without considering non-extraction methods, find a different doctor. Dentists who use the patient’s own growth to eliminate crowding may be found through the American Association for Functional Orthodontics or the International Association for Orthodontics. Please contact our office for more information. Thank you. (916) 786-4TMJ (786-4865) |
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ADVANCING THE CAUSE OF INTERCEPTIVE ORTHODONTICS The foundation for dental mal-occlusion and disfigured faces is established within the first five years of life. Though genetics plays a part, research in craniofacial development points to extrinsic factors as the most influential in abnormal facial growth.
THE CONTROVERSY Although credible studies demonstrate significant benefits in early treatment to correct skeletal discrepancies, others have shown that relapse is common in multi-phase treatment, and posit that ultimately, single-phase adolescent treatment is the more time and cost effective. Non-professionals in the insurance industry have taken this controversy as an opportunity to further limit costs / benefits through re-defining covered orthodontic services. In some areas of the country, the integrity and motives of those suggesting interceptive treatment has been questioned. What is the truth about interceptive treatment? What are the causes of malocclusion and abnormal facial growth? To what extent can these causes be influenced by treatment? What are the risks of delaying treatment? Why is there relapse? How could it be prevented or reduced? Can we make treatment more predictable, with fewer esthetic compromises. Recently a family traveled to our office for evaluation of a 15-yr. old daughter who had completed orthodontic treatment a few years previously. Her bite had since opened, and the asymmetry in her mandible put her chin >15mm off midline. They had been meeting with surgeons. Before discussing treatment options, we spent time explaining the physiology and process of developing the presenting deformity ... to which the mother, a nurse, excitedly responded that now, for the first time, she understood her daughter’s problem. This knowledge is a powerful force that we will need to draw from to successfully complete the treatment. THE DEVELOPMENT OF MID AND LOWER FACIAL DEFORMITIES STATES: "The infantile swallow is characterized by: 1) a positioning of the tongue between the gum pads holding the jaws apart as the swallow is completed, 2) a stabilization of the mandible by contraction of the "facial" muscles and the interposed tongue, and 3) a swallow which is initiated, and to a great degree guided by, the sensory interchange between the "lips" and the "tongue." This infantile swallow is normally given up sometime during the first year of life. (Handbook of Facial Growth) And, later adds: "The orofacial and jaw musculature is responsible for the vital positional relationships that maintain the airway. All learned jaw functions are built around and accommodated to the mandibular and tongue positions which make possible a clear air-way." If the airway is clear, and there are no related genetic or traumatic defects, the infant successfully nurses (with nasal breathing), as its oral musculature, digestive, and nervous system mature. The pressure of the tongue on the palate stimulates the mid-facial bones, and the A-P jaw movement pumps the small Eustachian tubes, as its oral musculature, digestive, and nervous system begin to mature. "During the latter half of the first year of life, several maturational events occur that alter markedly the orofacial musculature’s functioning. The arrival of the incisors cues the more precise opening and closing movements of the mandible, compels a more retracted tongue posture, and initiates the learning of mastication. As soon as bilateral posterior occlusion is established (usually with the eruption of the first primary molars), true chewing motions are seen to start, and the learning of the mature swallow begins. Gradually, the fifth cranial nerve muscles assume the role of muscular stabilization during the swallow, and the muscles of facial expression abandon the crude infantile function of suckling and the infantile swallow and then begin to learn the more delicate and complicated functions of speech and facial expressions."
Characteristic features of the mature swallow are; (1) the teeth are together (although they may be apart–with a liquid bolus); (2) the mandible is stabilized by contractions of the fifth cranial nerve muscles; (3) the tongue tip is held against the palate above and behind the incisors; and (4) minimal contractions of the lips are seen during the swallow. Harvold demonstrated with primates the development of anterior open bite as the result of nasal obstruction. The mandible reflexively drops, and "learns" to reposition, arcing downward to open the airway, the lips contracting to simulate the nares function, the buccinators returning to the infantile mandible-stabilizing role, and the tongue bunching forward to humidify the air like the turbinates. The result is an underdeveloped maxilla (due to the orofacial muscle pressure and lack of occlusal and lingual stimulation), apertognathia, and long face. When the tonsils are swollen and/or tender, the tongue moves down and forward to avoid contact and to open the airway. This results in minimal stimulation of the maxilla (causing an underdeveloped maxillary arch), and excessive forces on the mandible, causing cross-bite and prognathism.
From these principles, one can further apply the fundamentals of facial development to under-stand the pathogenesis of most facial dysmorphisms. THE CASE FOR INTERCEPTIVE TREATMENT.
Interceptive orthodontics has the potential to halt and reverse the progressive aberrant growth in two ways.
Although treatment is initially unstable, the tooth-together swallow is self-supportive, and the cyclic vertical occlusal pressure facilitates maturation of the alveolus around the newly aligned dentition. In early interceptive treatment, getting the patient "on track" in this way allows the natural down-and- forward growth of the face and mandible to occur coupled together. This normally occurs with the growth of the tongue, but this potential will not be realized with an infantile swallow due to the tongue not being contained within the arch. The downward force also occurs in the sinuses, which will generally continue after the tongue completes development.
"The most crowded case (with a mature swallow) is easier than a slightly crowded mouth breather." AVOIDING RELAPSE. Comprehensively diagnose and educate. (2.) Use appliances: a.) that will continue to stimulate orthopedically until nature fully "kicks-in," b.) that can be adjusted periodically following initial active treatment to insure that the arch keeps up with growth, and c.) that are minimally invasive and easy to clean (can be safely left in without complaint while new growth and function mature) (3.) Work to establish the mature swallow, get patient functioning on the dentition, and maintain function over time.
The included case demonstrates a young patient with compromised nasal breathing. He is already developing a long face with a lateral distortion. Both arches are crowded (the reason for referral), the premaxilla is particularly underdeveloped, the lips compress the arch as they form a small breathing aperture, and the tongue bunches inferiorly. The plan is to develop both arches and premaxilla, allowing the mandible to autorotate closed and forward (which necessitates adequate tongue space.) The ALF appliances are placed and activated. After there is adequate arch length for uncrowding, brackets are placed on the "1"s. In this case, the buccal tubes have Clear Triad "plugs" in the distal, and the light arch wire is cut slightly long to provide labial pressure (the proximity of the tubes to brackets precludes wire problems and controls force vectors). The laterals are then tied in, and the arch levels. Brackets help reduce the lip pressure. The ALF continues to be activated past that necessary for uncrowding until there is adequate space for a mature swallow conversion, and every effort made to insure adequate nasal breathing. Occlusion is tested regularly to assure that it is balanced.
Brackets are eventually removed and the arch form maintained from the lingual appliance, which is evaluated briefly for activation at the 6-month hygiene visits. Pictures are also included to show use of the extended buccal tube (on an omega wire) assembly which is soldered to bands placed on the primary molars. This auxiliary facilitates control over vertical positioning and R-L slant. The appliance is readily adjusted intraorally with a Weingard pliers, but is cemented with EBA cement to allow easy removal and re-cementation (small bonded "ledges" on the cuspids stabilize the appliance against accidental dislodging.) This design carries into full arch treatment and allows (as shown) correction of sloping occlusion (caused by face sleeping or similar trauma.) Using uneven omega tubes to correct canted occlusion. The ability to diagnose and intercept facially disfiguring and functionally compromised and unstable malocclusions with a high degree of success is the most exciting dental achievement of our time. The impact of facial form and esthetics on self esteem has been demonstrated in numerous studies. There is still so much work to be done to further increase the level of predictability, educate, and broad-en the access to this service – and technology is expanding the potential at the moment we need it! by Dr. Darrick Nordstrom Featured speaker at the American 0rthodontic Society Foundation meeting. |
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An additional extrinsic factor in developing
malocclusions is abnormal sleep posture. Stomach sleeping with the face into the pillow,
the mouth forming a pocket in the pillow to humidify and warm the air during mouth
breathing, exerts the heaviest traction on the lower face. When the teeth are separated by
the tongue, there is little to prevent the mandible from sliding to the opposite side ...
compressing the TM Joint, and placing stretching traction on the ipsilateral hemimandible.
During deep sleep, there is no proprioception from the joint until the patient cycles into
a lighter level, during which time, the pain typically signals for a temporary shift in
sleep posture, or a period of bruxing.
Schellhas, Boering, and others have demonstrated the
prevalence of internal derangements of the TMJs in the pediatric population, along with
their contribution to retrognathia and asymmetry. Fortunately, studies have demonstrated
the potential for repair or healing during the early stages of degenerative change,
especially in youth. Unaddressed, these degenerative and maladaptive changes continue
actively into the second decade of life. It is my opinion that the majority of these cases
develop due to the mandibular instability that is the result of mouth breathing, retained
infantile swallow, and face-sleeping.
In many cases, patients have been able to convert to
nasal breathing following aggressive maxillary arch development (especially in the
pre-maxilla / cuspid area), and establishment of stable occlusal contacts at correct
vertical (with discs properly on condyles). In others, this treatment must be complemented
by dietary changes and ENT surgery. Once nasal breathing is established, treatment can
develop both arches to contain the tongue volume comfortably (neutral zone), allowing a
tooth-together swallow, and also develop anterior coupling to complete the oral functional
matrix.
In contrast, adolescent (late)
treatment suffers from multiple compromises; among which are: 1.) Significantly reduced
potential for midface anterior development due impacted sinuses and near completion of
tongue growth with-out the functional oral matrix. 2.) The development of the basal bone
of the mandible is near mature and narrow, limiting the potential for arch development, or
correction of the angle and corpus length. 3.) The learned, deviate swallow habit has
matured; lip size and position are now fixed, and have become a part of the persona. 4.)
Slow, chronic remodeling has occurred around the TMJ and mandible to accommodate the
internal derangement (if present). 5.) The patient is rarely willing to be involved in the
extensive extra treatment required (including changing sleep posture).
The ALF appliance was developed
to address #2. and #3). It has the power necessary to gain the necessary arch dimension in
a short period. Its powerful forces in the premaxilla facilitate nasal breathing. It can
be converted to manage anterior brackets to effect alignment and coupling with small
elastic wires, etc. It can be left in place for extended periods while new arch
development matures, and is easily tweaked to activate for facial growth. The triomega
loop design occupies minimal space, yet reminds the tongue of its posture. The design has
proven itself for well over a decade, and is readily adapted to each individual’s
technique or requirements.
The initial changes occur in a
matter of months. A lip bumper may need to be added to the lower appliance, but, due to
primary tooth anchorage, is small, stable, and effectively generates new keratinized
tissue.
