Download Orthodontics has become the largest single item of normal expense

Orthodontic Care with Chris Norton, DDS
at Fast Tracks Orthodontics
Orthodontics has become the largest single item of normal expense that parents can
expect to encounter in raising a child prior to college (United States Health and Human
Services Department 1999). Since this is a large family expense, I believe you should be
highly informed to make your decision. Your decision also affects the future health and
appearance of your child. For this reason, I have put together some information that
explains how I use multiple modalities to give my patients a beautiful smile while
producing the most pleasing facial appearance genetically possible.
Some families’ decisions are driven by costs, location, and personality of the practitioner
and staff. These factors are very legitimate in the decision process. I would like to put
forth my philosophy of treatment, backed by scientific research whenever possible, to aid
in your decision process. I want to explain how our treatment is fast, affordable, safe and
technologically advanced.
I like to consider myself a functional jaw orthopedist (bone moving) with a knowledge of
orthotropics (bone growing). This means that I treat to the face. I will shy away from
treatment I think will damage the beauty of the face such as extractions and headgear.
Instead, I take a course that will enhance the facial features such as expansion, posture
and airway. As an orthotropist, I am concerned about the growth of the face in to it’s
genetically most desirable position. I fit my orthodontics (straight teeth) into this equation
as a third component. I do not let my orthodontics cause harm to the esthetics of a face.
Some call this technique full face orthodontics.
Chris Norton, DDS
Born in Richardson in 1958, Dr. Norton attended Highland Park High School 1976, SMU
1980, and Baylor Dental School 1984. He has practiced general dentistry in Dallas and
Santa Fe, New Mexico. He is past Chairmen of the Dental Program at Amarillo College.
Married to wife Susie, they have two teenage children, Mitchel and Claire. The Norton’s
currently live in Fairview, and are remodeling a home in the Historic District of
McKinney.
Aside from remodeling houses, Dr. Norton enjoys golf, and attending high school sports.
Dr. Norton began his orthodontic training in 1984, and incorporated orthodontics into his
general practice. He has attended numerous continuing education hours in orthodontics.
In 2002, he took a big step and decided to limit his general practice to Orthodontics. This
required leaving academia and general dentistry behind to start practicing orthodontics
exclusively. He has started and completed about 250 to 300 cases a year since 2002.
Orthodontics lead to an interest in facial growth, orthopedic development, TMJ treatment,
and snoring/sleep apnea. He finds a common thread which runs through treatment of
these areas.
The Difference in Orthodontic Care
Orthodontic techniques fall broadly into two groups that reflect the differing views about
the cause of the irregularity of the teeth. Practitioners of Traditional Treatment hold the
view that the dimensions of the jaws are largely predetermined at birth. As a result they
extract teeth in crowded arches and use ‘traditional’ fixed appliances to align the teeth
within the existing dimensions of the jaws, resorting to orthognathic surgery if the
disproportion is severe. A second group believe that changes in our environment and diet
over the last 30,000 years have lead to an increase in malocclusion and point out that that
the genes have not changed significantly during that interval (Sykes 2001). They use a
combination of ‘Expansion’ appliances to widen narrow jaws, and ‘Functional’
appliances to reduce inter-arch differences. This approach is called ‘DentofacialOrthopedics’ meaning ‘moving bone’ or ‘Orthotropics’ meaning ‘growth guidance’.
As I will discuss later ‘Traditional Treatment’ tends to be empirical (based on observed
experience rather than scientific principles) and treats the symptoms of malocclusion
rather than the cause. Possibly because of this, its long-term success record is less certain.
Dentofacial Orthopedics and Orthotropics may have greater potential for a long-term
correction but are very dependent on the cooperation of the patient which makes them
unpopular with traditional orthodontists. It takes a special dentist-patient relationship to
produce good patient compliance. Both groups accept that the teeth and their supporting
bone are in a position of balance between the soft tissues (lips, cheeks, tongue) and are
aware that adverse oral posture is likely to be associated with disruption of growth.
Unfortunately oral posture is difficult to measure, diagnose or treat, which may be why
few ‘Traditional’ orthodontists try to correct it. Orthotropists go to great efforts to correct
the environmental problems by means of appliances that strengthen the jaw muscles and
train the patients to keep their mouths closed in the expectation that this will encourage
forward growth of the face instead of the more usual downward or vertical growth. They
claim that if this is achieved while the child is young, they will grow up with a good
looking face and at least 28 teeth in good alignment. Many clinicians use a mix of the two
systems but there is concern that the treatment objectives may sometimes conflict.
Differences Between General Dentist Practicing Orthodontics
Exclusively and Orthodontist
An orthodontist and a general dentist practicing orthodontics, are both dentists. They are
both given the same license to practice. There is no additional special certificate required
to be able to practice orthodontics. The two doctors are differentiated in how they learn
orthodontics. An orthodontist is awarded a postgraduate degree after taking two years or
more of orthodontic study at a dental school sanctioned by the ADA. They usually have
made very good grades in dental school in order to secure this competitive internship, and
should be admired for their hard work. A general dentist can obtain comprehensive
orthodontic knowledge by taking postgraduate courses, most of which are sanctioned by
the ADA. Nevertheless, general dentists should not do orthodontics if they have not taken
enough postgraduate courses to adequately treat cases. (Source: American Dental
Association, American Association of Orthodontists) Nowhere in the field of dentistry is
there more controversy than in orthodontics. What techniques should be used and who
should be doing it are areas that can confuse a patient in the process of deciding which
office to go to. At Fast Trax Orthodontics, Dr. Norton is a general dentist practicing
orthodontics exclusively. We have a policy of not criticizing another dentist or technique.
It is not necessary. We will provide you with information about us, our philosophy, and
techniques. After many years of practicing orthodontics we feel very confident about
what we can do and about our final results. Thousands of satisfied patients speak volumes
as to whether or not high quality prevails with Dr. Norton’s techniques at Fast Trax
Orthodontics. We therefore let our history of patient satisfaction speak for itself.
What Makes Us Different
The balance of the face and the airway are respected with straight teeth being a third part
of the overall treatment goal. Primary (baby) teeth are not extracted to alleviate crowding
and jaws are developed to accommodate the teeth. Permanent teeth are not extracted to
alleviate crowding for children and adolescents and only in very rare cases for adults.
Instead, space is made for the teeth. (Wisdom teeth are a separate, unrelated issue.) We
believe a broad smile is more attractive, and treatment to accommodate the teeth helps
keep the airway from being compromised. Headgears are NEVER used to push the upper
teeth back and upper teeth are almost never too far forward relative to the rest of the face!
It's the lower jaw that is too far back making the upper teeth appear to be too far forward!
Treatment for children and adolescents is done as early as possible to achieve the best
result in the shortest amount of time. Parents are busy and kids don't want or need to be in
braces longer than necessary! Malocclusions (crooked teeth) and unfavorable facial
development are caused by altered oral posture (the way the tongue, teeth, and lips are
held at rest). Because breathing through the mouth rather than the nose is frequently the
cause of altered oral posture, we try to find the reason someone is a mouthbreather and
change the pattern to nosebreathing. In turn, this supports proper dental and facial
development and stability of the orthodontic result. Based on the research Dr. Norton has
studied, impacted cuspids (eye teeth that are in the roof of the mouth and do not erupt)
can usually be prevented. Impacted cuspids naturally occur in 2-3% of the population including Shaquille O'Neal! It is critical to see children long before all the permanent
teeth are in if we are to prevent this serious problem. (Canine Impaction Identified Early
with Panoramic Radiographs - American Dental Association Journal, March, 1982)
Adults who had extractions for orthodontics can often have improved facial balance and
an improved airway by orthodontically reopening the spaces and replacing the extracted
teeth. This often also helps reduce headaches and symptoms from TMJ.
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. 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, usually 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 usually involves 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.
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.
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.
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.
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 over react and they can become permanently sensitized, not only to the original
agent but to other concurrent foreign proteins such as cows 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 grandparents 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.
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 home work or watching
TV. Some dentists can provide an 'Oral Screen' which prevents a child mouth breathing
during the night. 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.
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)
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).
Paula, aged 14
Paula, aged 16
Status. You will be considered to have
higher status if your partner is good
looking than if they are plain (Hartnett
1973).
She was told she would need to have her jaws Personality. Although many people
cut and repositioned, but was treated with
claim to judge personality by the shape
orthotropics (growth guidance) instead.
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
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.
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, surgeons are refusing to tell 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 most safe 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 learn to keep their mouth
closed.
Pros and Cons of Differing Treatment
Braces and Extractions “Traditional Treatment”
Advantages. Will reliably achieve good alignment of the teeth within 18 to 30 months.
They are widely available. Registered orthodontists are University trained. Treatment can
be delayed until twelve or fourteen.
Disadvantages. They tend to involve extractions to alleviate crowding. They usually
retract the upper jaw to match the lower and this tends to increase the vertical growth of
the face. This may be barley noticeable. In cases where the face is already too long the
damage may be severe. The teeth often tend to re-crowd in the years following treatment
unless they are held straight indefinitely. The braces cause damage to the roots and
enamel of the teeth but these are usually considered acceptable. Some clinicians believe
that patients are subsequently liable to headaches, snoring/sleep apnea and joint damage
when extractions are employed, but there is conflicting evidence about this.
Functional Jaw Orthopedics
Advantages. Brings the lower jaw forward and widens the upper jaw. Reduces the
number of extractions. Causes less damage to the teeth. Treatment can be started earlier if
required.
Disadvantages. Usually requires braces to gain the final alignment but causes less
damage to the teeth and face provided the treatment is started early. Requires a longer
period of day and night treatment. Takes back the upper jaw slightly, and lengthens the
face especially if crowding is severe. Teeth often require holding straight afterwards.
Growth Guidance, (Orthotropics).
Advantages. Takes both jaws forward. This should produce an improvement in facial
appearance. Brackets and extractions only required in severe cases started late. Short
treatment period in mild cases. Almost no damage to the teeth. Teeth do not need holding
straight after the patient has corrected their mouth posture. The facial improvements
achieved by Orthotropics have not been matched by any other technique.
Disadvantages. More difficult for the operator. The teeth are not as perfectly aligned at
the end of treatment but usually improve subsequently (the reverse of braces). Treatment
best started before eight (earlier in severe cases). Requires high levels of co-operation
from the patient who must wear inconvenient appliances for long periods and learn to
keep their mouth closed and swallow correctly. If patient can not achieve this, night time
wear may last several years. However it is a ‘fail safe’ option and even a slight
improvement of mouth posture is likely to provide a better long-term result than braces.
Can it avoid the need for surgery? Yes often. Patients who have already been told that
they will have to have their jaws cut, have a strong incentive to co-operate and the
success rate of Orthotropics and dento-facial orthopedics in these circumstances, is good
even if some of them are considerably older. However they are treated, it is still
important that patients are able to correct their mouth posture, and failing this many will
relapse. Some cases involving hyper growth of the lower jaw are only corrected by
surgical approaches no matter the technique used.
Age seventeen and a half and nine months later, she was treated with
orthotropics.
She had been told that cutting her jaws was the only possible treatment.
Even with conventional surgical cases it is still important that the patients are
able to correct their mouth posture, and failing this about 30% will suffer the
same long term relapse.
Adult Orthodontics
Adult orthodontics has become a large segment of our practice at Fast Trax Orthodontics,
almost forty percent. Treatment at Fast Trax usually takes about a year. This is acceptable
to many adults when compared to two years average at other offices. Dr. Norton
especially enjoys the challenges of adult orthodontics and the opportunity to work with
exceptional dentists and specialists to achieve the best results for his patients. Dr. Norton
has taken a phenomenal amount of continuing education outside of orthodontics so that
he knows what is possible for his patients and what he can do to assist the general or
cosmetic dentist and any other specialists in achieving optimal results. This may include
preparing for implants, crowns, veneers, bonding, or repositioning of the jaws.
After
treatment
We see many adults who for one reason or another have never had orthodontics and want
a better smile. Even for the most crowded situation, we seldom recommend having teeth
extracted.
We also see many adults who have had orthodontics before and are unhappy with their
result. Many of these cases have had teeth extracted in the past and the profile has a
"dished in" appearance. Many have functional concerns like headaches or sleep problems.
Opening spaces to have the teeth replaced is often an option which can result not only in
an improved profile, but an improved airway and a dramatic decrease in headaches.
Before treatment
TMJ Treatment
The temperomandibular joint(TMJ) is a joint next to each ear. The diseases which affect
the TM Joints are no different, really, than the diseases which affect other joints in the
human anatomy. Rheumatoid, and Osteoarthritis; Inflammation of the Joint capsule;
inflammation of the Synovium; torn ligaments; perforation, or tears in the Articular
Disks; internal derangement of the Condyle Head, and or Disk, in the Joint space, and
etc.
There are two basic types of treatment for TM Joint disorders: surgical and non-surgical,
but it is generally agreed that in most cases the non-surgical approach should be taken
first in an effort to restore comfort, and improve jaw function to an acceptable level.
TMJ function is not well understood by modern medicine. Therefore, patients with TMJ
Dysfunction are often given drugs, referred for psychological counseling and/or told they
might grow out of the problem or have to learn to live with it. Interestingly, conservative
non-surgical dental TMJ treatment is very effective in helping those with TMJ problems
ranging from severe headaches to ear problems.
What makes the TMJ different from other joints is the relationship the jaw has with teeth.
Teeth out of alignment can be a bumpy road for the TM joint which must act as a shock
absorber. Often there is a fight between the chewing muscles and the misaligned teeth as
to where the lower jaw should rest against the skull. Through the use of splints and
orthodontics a harmony is created between these muscles and the teeth creating an
atmosphere where the joint can heal and function with less pain. We do only non surgical
treatment in our office.
Snoring and Sleep Apnea
Sleep apnea is a condition characterized by episodes of choking or not breathing during
sleep. In normal conditions, the muscles of the upper part of the throat keep this passage
open to allow air to flow into the lungs. These muscles usually relax during sleep, but the
passage remains open enough to permit the flow of air. Some individuals have a narrower
passage, and during sleep, relaxation of these muscles causes the passage to close, and air
cannot get into the lungs. Loud snoring and labored breathing occur. When complete
blockage of the airway occurs, air cannot reach the lungs.
For reasons that are still unclear, in deep sleep, breathing can stop for a period of time
(often more than 10 seconds). These periods of lack of breathing, or apneas, are followed
by sudden attempts to breathe. These attempts are accompanied by a change to a lighter
stage of sleep. The result is fragmented sleep that is not restful, leading to excessive
daytime drowsiness.
Older obese men seem to be at higher risk, though as many as 40% of people with
obstructive sleep apnea are not obese. Nasal obstruction, a large tongue, a narrow airway
and certain shapes of the palate and jaw seem also to increase the risk. A large neck or
collar size is strongly associated with obstructive sleep apnea. Ingestion of alcohol or
sedatives before sleep may predispose to episodes of apnea.
The classic picture of obstructive sleep apnea includes episodes of heavy snoring that
begin soon after falling asleep. The snoring proceeds at a regular pace for a period of
time, often becoming louder, but is then interrupted by a long silent period during which
no breathing is taking place (apnea). The apnea is then interrupted by a loud snort and
gasp and the snoring returns to its regular pace. This behavior recurs frequently
throughout the night.
During the apneas, the oxygen level in the blood falls. Persistent low levels of oxygen
(hypoxia) may cause many of the daytime symptoms. If the condition is severe enough,
pulmonary hypertension may develop leading to right-sided heart failure or cor
pulmonale.
This is a relatively new field for Dr. Norton. He has spent the last eighteen months
studying the dental and orthodontic roles for this menacing disorder. He has attended
over 100 hours of post graduate training and visited offices in Dallas, Denver, West
Virginia and Milwaukee that limit their practice to sleep apnea and snoring.
Forty million Americans suffer from some sort of chronic, long term sleep disorder, and
20 million suffer occasional sleeping problems. People with sleep apnea have an eight
times greater chance of auto accident, and it is estimated that forty percent of truckers
have sleep apnea. SDB (sleep disordered breathing) has relational, functional, behavioral,
and medical consequences. I will pick only one to address in this forum. Hung et al, 1991
looked into independent predictors of myocardial infarction. The odds ratio of this study
were as follows:
Risk Factor
Odds Ratio
Standard
1.0
Overweight
7.1
Hypertension
7.8
Smoking
11.1
OSA (AI>5.3)
23.3
OSA is obstructive sleep apnea and AI>5.3 is the mildest form os OSA. If you have
sleep apnea, then you are 23 times more likely to have a heart attack. Therefore snoring
and sleep apnea patients have twice the risk of heart attack as a smoker.
As a dentist, I cannot diagnose sleep apnea. Only an MD can do this following a
polysomnogram. A polysomnograph is a test of sleep cycles and stages through the use of
continuous recordings of brain waves (EEG), electrical activity of muscles, eye
movement (electrooculogram), breathing rate, blood pressure, blood oxygen saturation,
and heart rhythm and direct observation of the person during sleep. You typically spend
the night in a sleep center with dozens of electrodes attached to various and sensitive
parts of the body. If during the study you test positive for sleep apnea, they will wake you
and fit you with a CPAP machine. Nasal CPAP delivers air into your airway through a
specially designed nasal mask or pillows. The mask does not breathe for you; the flow of
air creates enough pressure when you inhale to keep your airway open much like blowing
up a baloon. CPAP is considered the most effective non-surgical treatment for the
alleviation of snoring and obstructive sleep apnea.
Polysomnogram and nasal CPAP are the gold standard for treatment of sleep apnea.
However, many people cannot comply with their use.
Medical doctors have very little sleep training in school, but this is still more than most
dental students receive. It has fallen on the ENTs and pullmonologists to tackle this
prevalent disorder. Their answer is sleep labs to do polysomnograms and CPAP
machines. Both are very expensive and profitable for the people who work this form of
treatment. Results of an 11 year study at Milton Kramer, Bethesda Hospital Cincinnati,
Ohio as to why patients do not receive adequate care for SDB(sleep disordered breathing)
are as follows:
Total referred to lab
7025
Refused PSG (sleep study) 1755
25%
Did not have OSA
1686
24%
Refused treatment
921
13%
Chose other treatment
717
10%
Rejected CPAP at trial
545
8%
Stopped CPAP
584
8%
Poor compliance
441
6%
Those receiving
adequate treatment
576
6%
The CPAP machine is the gold standard of the sleep industry, yet more than 50% of the
patients receiving CPAPs will not use them. Successful use of CPAP is considered as
between four and five hours per night five nights a week. Even with this low patient
compliance there are 1.5 million PSGs per year, 1.0 million new OSA patients per year,
and 750,000 CPAPs sold each year at a cost of about $4,000 each. The number of sleep
labs and tests is growing at a rate of 40% per year.
What I can offer. At Fast Trax I can screen for the possibility a patient has sleep apnea.
Since I cannot diagnose, I cannot bill medical insurance for the procedures I perform.
Those wishing to use their insurance should seek dual treatment with my office and a
sleep lab with a medical doctor. I have a home monitoring device with three leads that
has a 97% correlation rate with polysomnograms. I can fabricate a mouthpiece that is
recommended for snoring and mild to moderate OSA. I can also treat patients who do not
tolerate CPAP with the same oral appliance. The appliance I make holds the lower jaw
forward during sleep which keeps the airway more patent and lowers the number of
apneas, or choking experiences, one has during the night.
Common Sense in Science
Established beliefs are maintained until they can be convincingly displaced, and even
then tend to linger on. This is especially true in the medical sciences, where the rash
introduction of untried methods can have disastrous consequences. The increased
incidence of litigation has also hindered the introduction of many promising new
techniques.
As modern specialties have developed they have formed their own governing bodies, and
assumed responsibility for monitoring their own standards. Examples are The American
Dental Association and The American Academy of Orthodontics. Naturally they base
training on their own beliefs, so their pupils tend to think alike. While this helps to
establish a common viewpoint, it can reach a point where change is resisted for no other
reason than it is change. This can result in separate specialties dealing with similar areas
of the body, having contrasting beliefs. For instance Orthodontists and Ear Nose and
Throat surgeons have different terminology, reach contrasting diagnoses and offer
alternate treatments.
In years gone by, such issues could be debated in an open forum such as the British Royal
Society, where a wide range of views would be expressed by separate scientific
disciplines and obvious inconsistencies addressed. However, there is now no authoritative
body to oversee common sense in science. The orthodontic establishment are by no
means the only ones that face this problem.
The examination system forced onto students often slows down change, because they are
primarily given the established view. Postgraduates on the other hand should be
encouraged to balance the merits of treatment alternatives for themselves but in medicine
unorthodox lecturers are usually disapproved of for fear that naive students will believe
them and fail their exams. This is likely to prevent their exposure to alternative
techniques until their pattern of reality has formed, thus perpetuating established beliefs.
Balance the Evidence
It is not easy to balance the two sides of an argument, and remain uninfluenced by the
number of people supporting each viewpoint. Because this debate is so crucial for the
orthodontic establishment, they have always presented a united front.
In order to support their case many unorthodox clinicians will quote long lists of
supporting evidence some of which is of indifferent quality. This is quickly dismissed by
established experts and the strength of their case is weakened. To avoid this error only
evidence that is broadly accepted by all sides has been quoted. That a case has been made
for Orthotropics and dento-facial orthopedics on this basis must justify it to some extent,
but much of it will be dismissed as irrelevant.
All orthodontists accept that the teeth and their supporting bone are in a position of
balance between the lips and tongue but for some reason they are reluctant to accept that
mouth posture plays a significant role in facial development. It is difficult to measure the
posture of the jaw or tongue and it will be said that there is no proof that posture
influences facial growth, this is not true, as several of the enclosed references have
shown. Orthopedic surgeons and osteopaths freely accept that posture will influence bony
form, it is only orthodontists that reject this.
They draw attention to many negative findings but do not be mislead by this. Jonathan
Sandler, publicity officer for the British Orthodontic Society, recently published an
article entitled "Fact and Fantasy" (British Dental Journal:2004 196:143) in which he
claimed that "there is insufficient evidence to show that ‘Functional’ (similar to
Orthotropic) appliances work" but neglected to mention that there is also insufficient
evidence to show that they do not. Misleading statements like this do much to confuse
readers. There is currently no research to show that oral posture does not influence facial
growth or that orthopedic appliances do not work.
Orthotropic results are sometimes criticized because the teeth are not in perfect
alignment. Orthotropics treatment is primarily aimed at improving the growth of the face
and at the end of treatment the teeth are allowed to find their own ‘natural’ position. All
patients are told "if your mouth posture does not improve the treatment will relapse," and
those who hang their mouth open after treatment do relapse. However it is important to
realize that this applies to all methods of treatment and is why the teeth of most
orthodontic patients re-crowd in the years following treatment (Little et al 1988) unless
they wear a retainer for the rest of their life. Those orthotropic patients who cooperate
should maintain straight teeth for their lifetime and if an orthotropic result does relapse
the patient themselves does not complain as they know where the blame lies.
The possibility that orthodontics could damage faces will be firmly denied although it
might be accepted that inappropriate treatment can, at times, cause damage. The real
question is "what is appropriate?" Research projects have found that patients in general,
are satisfied with the appearance of their face after treatment, however most of these have
relied on the opinions of the patients themselves or others involved in the treatment.
Modern protocol would consider personal views unacceptable. Other projects have
excluded "poorly treated" patients or those who leave their mouths open after treatment
(Bishara and Jakobsen 1997). Subtle selection of this type can produce deliberately
misleading results. There does not seem to have been any significant long-term research
into the risk of facial damage, a quite unacceptable situation in this age of public
accountability.
Many parents are aware that their own or their children’s faces have been damaged by
orthodontic treatment, but say nothing to avoid their child’s embarrassment. Do not be
mislead by smiling faces, only a passive expression with the lips in contact, will display
the true shape of the face. Make sure that photographs are all taken from the same angle,
and look closely for drooping eyelids, flat faces and thick lower lips. In general, you will
find that faces look worse after conventional orthodontic treatment, this is because the
teeth and face are taken back while orthotropics and dentofacial orthopedics takes them
forward. Until the public becomes aware of the true situation, the existing patterns of
treatment based on surgery and mechanics, are likely to be maintained.
A
Ackerman, D. "A natural history of the sences". Cornell University. 1990.
Alexander SA 1993 The effect of fixed and functional appliances on enamel decalcifications in
early Class II treatment Am J Orthod Dentofacial Orthop 103:45-7.
B
Battagel, J.M. 1996. "The use of tensor analysis to investigate facial changes in treated Class
II division 1 malocclusions". European Journal of Orthodontics. 18: 41-54. (Steve this one is
already in list just provide link please.)
Bishara,SE, and Jakobsen, JR. 1997. "Profile changes in patients treated with and without
extractions: Assessments by lay people". American Journal of Orthodontics and Dento-facial
Orthopedics. 112: 639-644
Bjork, A. "Sutural growth of the upper face studied by the implant method." Acta Odont
Scand. 24:109-127. 1966.
Bresolin, B. Shapiro, G.C. Shapiro, B.A. Dassel, S.W. Furukawa,C.T. Pierson, W.E.
Chapco,W.E. & Bierman,C.W. "Facial characteristics of children who breath through the
mouth." Pediatrics 73:622-625. 1984.
Bull, R. & Rumsey, N. "The social psychology of facial appearance." Springer-Verlag, New
York. 1988.
Battagel J.M "The use of tensor analysis to investigate facial changes in treated Class II
division 1 malocclusions". European Journal of Orthodontics 18:41-54. 1996.
C
Cavior, H. , Hayes,S. and Cavior,N. "Physical attractiveness of female offenders". Criminal
Justice and Behavior. 1:321-331. 1974.
Clark,JD, Kerr,WJS, and Davis,MH. 1998. "Surgery, Growth Modification or Orthodontic
Camouflage? Brian's case". Dental Update. 25:12-17.
Corruccini,R, Keul.SS, Chopra.SRK, Karosas.J, Larsen.MD, and Morrow.C. . 1983.
"Epidemiological survey of occlusion in North India". British Journal of Orthodontics 10: 44-47.
Cross, J.F. and Cross,J. "Age sex, race, and the peception of facial beauty". Developmental
Psychology. 5: 433-439. 1971.
F
Frankel R,1, and FrankeI C. 2001. Clinical Implication of Roux’s Concept in Orofacial
Orthopedics. Journal of Orofacial Orthopedics. 62 1-21.
Fushima,K., Kitamura,Y, Mita,H., Sato,S, Suzuki,Y and Kim,Y.H. 1996. "Significance of the
cant of the posterior occlusal plane in Class II division 1 malocclusions". European Journal of
Orthodontics. 18: 27-40.
G
Glatz-Noll, E & Berg, R. "Oral disfunction in children with Down's Syndrome:an evaluation of
treatment effects by means of video-registration." European Journal of Orthodontics. 13; 446451. 1991
H
Harris, E.F. & Johnson, M.G. "Heritability of crainiometric and occlusal variables: A longitudinal
Sib analysis." American Journal of Orthodontics and Dento-facial Orthopedics. 99: 258-268.
1991.
Hartnett, J. & Elder, D. "The princess and the nice frog. Study in perception". Perceptual and
Motor Skills.37:863-866. 1973.
Harvold, E, Chierici, G. and Vargervik, K. "Experiments on the development of dental
malocclusion." Ammerican Journal of Orthodontics. 61:38-44. 1972.
Horowitz, E.P. Oxbourne, R.H. & de George, F.C. "Chephalometric study of crainiofacial
variations in adult twins". Angle Orthodontist30:1-5. 1960
Howe, R.P. Macnamara, J.A. & O'Connor, K.A. "An examination of tooth crowding and its
relationship to tooth size and arch dimensions". American Journal of orthodontics 83:263273.1983.
J
Johnston L.E. 1990 Fear and loathing in orthodontics: notes on the death of theory. D S
Carlson (Ed). Craniofacial Growth Series 23. The University of Michigan Ann Arbor
K
Kahl-nieke B, Fischback H, and Schwarze C.W. "Post retention crowding and incisor
irregularity: A long term follow- up evaluation of stability and relapse". British Journal of
Orthodontics 22:249-257. 1995.
Kraus, B.S. Wise, W.J. & Frei, R.M. "Heredity and the crainio-facial complex." American Journal
of Orhtodontics 45:172-217. 1959.
Kurol,J., Owman-Moll,P and Lundgren,D. 1996. "Time related root resorption after application
of a controlled continuous orthodontic force". American Journal of Orthodontics and
Dentofacial Orthopedics. 110: 303-310.
L
Lee, L.F. & Proffit, W.R. "The daily rhythm of tooth erruption". American Journal of
Orthodontics and Dento-Facial Orthpedics. In press 1994.
Lewison, E. "Twenty years of prison surgery: An evaluation." Canadian Journal of
Otolaryngology. 3:42-50. 1974.
Linder-Aronson, S. Woodside,D.G. Hellsing,G.& Emerson,W. "Normalisation of incisor position
after adenoidectomy". American Journal of Orthodontics and Dentofacial Orthopedics.
103:412-427. 1993.
Little, R.M. Riedel, R.A. & Artun, J. "An evaluation of changes in mandibular anterior alignment
from 10 to 20 years post-retention." American Journal of Orthodontics and Dento-Facial
Orthopedics. 93:423-428. 1988.
Lundstrom, A. Woodside, D.G. & Popovich, F. "Panel assessments of facial profile related to
mandibular growth direction". European Journal of Orthodontics. 9: 271-278. 1987.
Lundstrom,A. &Woodside,D.G. 1980. "Individual variation in Growth Direction Expressed at
the Chin and Midface". European Journal of Orhtodontics. 2:65-79.
Lundstrom,A. Woodside,D.G. & Popovich,F. 1987 "Panel assessments of facial profile related to
mandibular growth direction". European Journal of Orthodontics. 9: 271-278
M
Melson B, Hansen K and Hagg U. 1999. Overjet reduction and molar correction in fixed
appliance treatment of class II division 1 malocclusions: Sagittal and vertical components.
American Journal of Orthodontics and Dentofacial Orthopedics 115:13-23.
Mew, J.R.C. "Facial form, head posture, and the protection of the pharyngeal space" The
clinical alteration of the growing face. J.A.Macnamara, K.Ribbens, R.P.Howe. Eds. Monograph
14. Crainiofacial Growth Series. Center of Human Growth and Development. Ann Arbor.
Michigan. 1983. (see also papers published by John Mew)
Mew, J.R.C. "Suggestions for forecasting and monitoring facial growth" American Journal of
Orthodontics and Dento-facial Orthopedics. 104: 105-120. 1993Faces 1993. (see also papers
published by John Mew)
Mew J R C. 2004. The Postural Basis of Malocclusion: A philosophical Overview. American
Journal of Orthodontics and Dentofacial Orthopedics. In press July or August.
Mew JRC. 1999. A New form of Orthodontic Treatment Tested on Identical Twins. European
Journal of Orthodontics. 21: 605.
Mirabella, A.D. and Artun, J. 1995 "Prevalence and severity of apical root resorption of
maxillary anterior teeth in adult orthodontic patients". European Journal of Orthodontics. 17:
93-99
More, W.J., Lavelle,C.L.B. & Spence,T.F. "Changes in the size and shape of the human
mandible in Britain." British Dental Journal. 125: 163. 1968.
O
Ogaard B, Rolla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1.
Lesion Development. Am J Orthod Dentofacial Orthop 1988 Jul;94(1):68-73
Ogaard B. Prevalence of white spot lesions in 19-year-olds: a study on untreated and
orthodontically treated persons 5 years after treatment. Am J Orthod Dentofacial Orthop 1989
Nov;96(5):423-7.
P
Proffit, W.R. and Fields, H.W. 1993 "Occlusal forces on Long and Normal Face children".
Journal of Dental Research. 62; 571
Peck, H. & Peck,S. "A concept of facial aesthetics". Angle Orhtodontists. 40: 119-127. 1970.
Platou, C. and Zachrisson, B.U. "Incisor position in Scandinavian children with ideal occlusion".
American Journal of Orthodontics. 83:341-352. 1983.
R
Richards Derek. Director of Evidenced Based Medicine at Oxford. 2000 ‘The London Based
Symposium’. , Evidenced Based Dentistry 2: pages 3-4.
S
Sackett,D. Professor of Evidenced Based Research at Oxord. 1994 "Nine years later; a
commentary on revisiting the Moyers symposium". CraniofacialGrowth Series, Center for
Human Growth and Development, University of Michigan, Ann Arbor.
Samuels, C.A. & Elwy, R. "Aesthetic perception of faces during infancy". British Journal of
Psychology. 3:221-228. 1985.
Shaw, W C, 2000. How relevant is the evidence based process to Orthodntics? Evidenced
Based Dentistry 2: pages 7-8
Squires, R, & Mew, J.R.C. "The relationship between facial structure and personality
characteristics." British Journal of Social Psychology. 20: 151-160. 1981 (see also papers
published by John Mew)
T
Toth LR, and McNamara JA. 1999. Treatment effects produced by the twin-block appliance and
the FR2 appliance of Frankel compared with an untreated Class II sample. The American
Journal of Orthodontics and Dentofacial Orthopedics116:997-609.
Trotman,C, MacNamara,J, Dibbets,J, & Th van der Weele, L. 1997. "Association of lip posture
and the dimensions of the tonsils and sagital airway with facial morphology". Angle
Orthodontist. 67:425-432
W
Walpoff, W.H. "Deturminants of mandibula form and growth." Centre for Human Growth and
Development. University of Michigan Ann Arbor.
Much of this information comes from Dr. John Mew and his website, www.orthotropics.
com. Another resource is Dr. William Hang and his website www.facefocused.com. I
have had the good fortune to attend lectures from both men.