the cause of - reading the face

8/20/2019 The Cause of - Reading the Face

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4Reading the Face

CHAPTER 4

READING THE FACE

The Influence of the Soft Tissues onFacial and Occlusal Characteristics.

Many of our patients are referred becausehey or their dentist is concerned that theircial proportions are not ideal. This is a

elicate matter to discuss, as most parentsve their children as they are and any

uggestion of change can cause anxiety.he strength of the emotion can be judgedy the acceptability of the following twoatements “your daughter has irregular

eeth” and “your daughter has an unattractivece”. Many parents think that a slightly

at face or protruding chin is an attractiveature of their child’s face but I warn them

that if their child does not look quite like theirfriends they should watch out for increasingdisproportion as they get older.

The mother of nine year old Louisa (figureIV/1) came to see me with a photograph ofher as a six year old in her hand. Her motherhad watched the lengthening of her face with

mounting concern but remained unawareof its cause or what she could do aboutit. Clearly there had been a lot of verticalgrowth which was much more obvious froma lateral view (figure IV/2). The majority ofparents fall into this category being unawarethat early action is required and sadly theirdentists and orthodontists usually offer little

help. My main objective in writing this bookis to encourage the whole dental team toprovide simple guidance which at the age ofsix can easily reduce and often prevent suchproblems. I am equally confident that thesame approach could prevent most Ear Noseand Throat problems.

Because orthodontists initially train asdentists they usually place more emphasis onthe teeth than the face, and as a result maybe unaware of subtle changes in the profilethat can occur naturally or sometimes followtreatment. Orthodontists in particular relyon their referring dentists for most of theirpatients. They often say to me “if I don’tget nice straight teeth the dentists will stopreferring patients to me”. However the publicas a whole certainly think that the face ismore important than the teeth. The troubleis that neither group find it easy to assesschanges to the face. Following a systematicreview Bondemark and his colleagues (2007)came to the conclusion that it is “astonishingthat only a few studies were found onpatient satisfaction in the long-term, andfurthermore most of them showed lowscientific evidence and no conclusions couldbe drawn”. They finally concluded “Thisreview of the literature has thus exposed agreat need for future studies in this area”.

While all orthodontists accept that

adverse facial change is possible followingorthodontic treatment the majority feel it israre and only follows inappropriate treatment.However there is poor consensus aboutwhich treatments are appropriate especiallyfor severe cases. Of more importanceresearch has confirmed (Faure 1998) thatvertically growing faces are especially at risk.Downward growing faces are those that tendto look unattractive before treatment andcan often look worse afterwards regardlessof how they have been treated. Logic wouldsuggest that the only way the face can besaved is to convert the Vertical growth toHorizontal and currently it seems that onlyBiobloc Orthotropics is able to do that.

My research with identical twins (to

be discussed later) and my contacts withunhappy patients suggests to me that adversefacial changes following orthodontics arecommon and I have been quoted as saying“30% of orthodontic patients suffer slightfacial damage and a further 20% suffernoticeable damage”. In my opinion the worstof this damage is caused by fixed appliances.These carry a particular risk of worseningfaces that are already growing vertically.However many Functional and Orthopaedicappliances also carry this risk and I am verysure that all these appliances are likely tocause more damage to a vertically growingface than good to the teeth. We will discussthe evidence for this later.

Not surprisingly some orthodontists areangry with me for saying this but it is reallytheir responsibility to carry out clear cutresearch to find out the truth one way or theother. Currently as Bondemark says (2007)we just don’t know.

I quote below a few of the letters and

e-mails sent to me, showing that rightly orwrongly the public have real concerns aboutthis.

‘Laurie’ age 49. I unfortunately hadtraditional ortho with head gear and all. Allmy life I knew something was wrong withmy face, tongue and everything. My parentsthought I was crazy to question it all. Wellnow at 49, to discover you, it shows myinstincts were right. I also feel it effectsdepression, that I am struggling with.


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Reading the Face 4Reading the Face

‘RN’. 29. “I asked him to just fix the gap bute insisted on fixing everything”. “Now myce has sunken in I have a flat face and no

heeks”. I’m a TV presenter, is there anythingcould do?

‘OF’ my son, age 14. “I’ve been to visit threefferent orthodontists over the last three

ears and I have had conflicting advice andm deeply suspicious of the recommendedeatment options”. “He told we would need

o consider Maxillofacial Surgery”. “He wasuch a good looking child until about 10, nowe is frequently called names such as Buckyeaver.” “He’s gone from being a confidentnd happy child to feeling ugly”. “I am so angrynd will not forgive myself for having listenedo the advice of so called professionals.” “I

ound the website pertaining to Orthotropicreatment and then the penny dropped!”

‘TS’ I am just looking to reverse what haseen done to my mouth and face. I would likey teeth to go back to the way they were

rior to orthodontic treatment.

‘C.S’. Mother of 11 year girl. Let mepen by saying that I stumbled across theOrthotropics” website after years ofruggling with the knowledge that my

aughter needed more attention than sheas getting with her teeth and jaw line.

When I first read about your approachshed a few tears because finally I found

omeone who was saying the things I neededo hear. At age 3 we started taking Caseyo a Paediatric Dentist Over the 4 years ofeeing her regular Paediatric Dentist nothingas said to me about her teeth or jaw.

When she was 7 a “locum dentist” fillingfor her Paediatric Dentist brought her

oncerns to me and suggested I send Caseyo an orthodontist but she did not think earlyeatment made sense.

‘WF’ “I recently had 4 extractions done andcan see my profile starting to change!”

‘TS’ “I am having an awful experience withrthodontic treatment. I am noticing that mycial structure is changing”. “My jaw seems

o have moved forward, my face has becomeatter”. “This face is not mine”.

‘LD’ Age 27. “I feel my face has been

damaged with the procedure which includedfour extractions. I fear if I go to the doctoror dentist for an opinion, I will get a verydefensive answer, as is common amongprofessionals who do not wish to point thefinger at one another”.

‘PJ’ age 20. “I used to be a very goodlooking guy when I was of 18. I went for anorthodontic consultation but damn it provedto be the worst decision I had ever made inmy life. My orthodontist asked me to get 4healthy 1st premolars extracted and due to myenormous faith on my orthodontist I did whatI was advised. This has really affected my self-esteem and my confidence. My doc pushedmy front teeth backwards which resulted indegradation of my facial aesthetics.

‘WF’ age ? “I recently had 4 extractionsdone and I can see my profile staring tochange!! I told the ortho that and he says itwill be fine. I don’t want have a flat face!!Is there something I can do? I just started 2months ago? Can he push the teeth forwardinstead? Please help!!”

Provided patients cooperate the facialimprovements with Orthotropics are likely tobe positive and frequently dramatic, but thisneeds to be balanced against the superiorabilities of fixed appliances to align teeth. Itis important to consider faces and teeth as asingle unit; and wise to assess the face firstfor if it is wrong then the teeth will be wrongand if facial growth is not corrected, long-term dental goals will rarely be achieved.

We now live in a consumer driven worldand our patients come to us to improvetheir appearance. We may naively believethat aligning their teeth will achieve thisbut if patients are given the opportunity

of comparing facial changes followingtreatment at the same time as dental changes,then a small improvement in the former willoverwhelm those in the latter (Mew 2010).This would suggest that we need to pay moreattention to facial changes during treatment.

The Psychology of the Face.

Facial beauty is arguably the most powerfulgenerator of human emotion. In addition toserving the obvious function of attractingthe sexes to each other it has also served to

inspire great works of art, prompt sadisticacts, initiate ferocious wars, and reputedlylaunch a thousand ships. Is it inherited? If itis, why do attractive parents often have plainchildren and vice-versa?

Great beauty is undoubtedly a very specialasset, bestowed on very few people. Such isits power that those who possess it find italmost impossible to lead a normal life. Eventhose who are slightly more attractive thanaverage appear to have many advantagesin life while the less attractive are likely tosuffer repeated discrimination and rejection.

Children grow up to believe that heroesare good looking, heroines are beautiful,and bad people are ugly. While many would

assume that these stereotypes are fictionalthere is substantial evidence to suggestthey are based on truth. Attractive babiesreceive more affection and attention fromtheir parents and other adults, and aremore likely to grow up to be well-balancedadults themselves (Bull and Rumsey 1988).Unattractive children are more likely to bebullied at school (Lowenstein 1978) andless adept at interacting socially. Good-looking people are likely to be perceivedas more intelligent (Bull and Stevens 1979).Surprisingly they may actually be moreintelligent (Clifford 1975)), possibly becausethey receive more attention at school. Theyare also likely to get better jobs, rise tohigher positions, and earn more money (Bulland Rumsey 1988). You are considered tohave a higher status if your partner is goodlooking than if they are plain (Hartnett 1973).

Handsome cadets achieve higher rankby the time they graduate (Ackerman1990). A judge is likely to give an attractivecriminal a shorter sentence (McFatter 1978).

Unattractive people are associated withundesirable personalities and deeds. (Miller etal 1974), they are also perceived as deviants,feminists, homosexuals, and political radicals(Unger et al 1982). Criminals who have theirappearance improved by facial surgery areless likely to re-offend (Lewison 1974).

Physiologically facial attractiveness, bodysymmetry and even intelligence are thoughtto be linked (Furlow et al 1997). The interplayof these variables merits further research.

Which Faces are Most Attractive?

In the last chapter we discussed howorthodontists find a ‘straighter’ (vertical)profile more attractive than the general publicwho prefer a more horizontally growingface. It is important that these differencesare born in mind when debating the impactof treatment on the face. We should askourselves why orthodontists prefer flatterfaces. Most orthodontic students are taughtthe Steiner analysis recommending an SNA ofabout 82° degrees and SNB of 78° (Fig IV/3A)but I think this looks rather flat.

Johnston (et al 2005) experimented bymoving the mandible of the Steiner profilebackwards to an SNB of 68° (Fig IV/3 B) and

forward to 88° (Fig IV/3 C). and found that102 social science students preferred therecommended Steiner Profile with a 78°mandibular position. However they made noattempt to move the maxilla and if this is takenforward to 91° using a graphics program, thenit matches quite nicely with the 88° mandible(Fig IV 3D). In fact it looks not dissimilar tothe late Paul Newman the actor when he wasa young man. Perhaps the answer to our initialquestion about orthodontist’s preferences isbecause they have come to prefer the flatfaces that their treatment tends to create.

The Golden Proportion.

Attractive appearance is a matter ofproportion and ancient mathematicianssuggested that the most aestheticallypleasing ratio of height to width was 1.6(more accurately 1.61803398…). This is alsoreferred to as the ‘Devine Proportion’ or‘Golden Ratio’ usually denoted by the Greekletter φ (phi) and is actively promoted as atreatment goal by many clinicians who go to

great lengths to demonstrate its veracity.Ricketts (1982) was particularly keen to

establish the merit of the ‘Golden Proportion’which he applied to facial appearance. Itis certainly an aesthetically pleasing ratiowhich fits the height and width of manyattractive faces however it will also fit manyunattractive faces. Moss and his colleagues(1995) have shown that faces that fit thegolden proportion are at times associatedwith both skeletal and dental malocclusionand I remain less than convinced that its


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gid application assists in valuing facialroportions.

How Are Faces Judged?

The ability to recognise good looksarts very early in life. Its appreciation is

ndoubtedly influenced by cultural valuesnd many people believe that ‘beauty lies

the eye of the beholder’. However theassic study by Samuels and Elvey (1985)

howed convincingly that babies as young six months have a strong preference for

he same good looks that adults appreciate,uggesting that these aesthetic values arerobably specific and innate. This was firstoticed many years ago when readers ofnewspaper were found to agree closely

bout which individuals from a range ofctures looked most attractive (Illiffe 1960).

Subsequently Cross and Cross (1971) usedmpartial judges to compare photographs of

range of faces of different nationalities.

Each Judge placed them into approximatelythe same rank-order of beauty, regardlessof the race, colour, or background of eitherthe subjects or surprisingly of the judgesthemselves. Many people find this hard toaccept as personal preferences about facialbeauty vary so widely, however my ownresearch (below) suggests that our personalpreferences only start to diverge whenconsidering less attractive faces within thegeneral population around us and this isprobably the reason why so many peoplebelieve that “beauty lies in the eye of thebeholder”. It was to clarify this point that Iundertook the research.

The Skeletal Foundation.

Facial form is obviously dependent onthe facial skeleton and the soft tissues, theformer providing the sculptor’s armatureover which the latter are draped. We havediscussed how changes in the size or positionof the bones, especially the maxilla, can make

a substantial difference to the appearance ofthe face. The position of the maxilla is alsoused by cartoonists to portray good or evil.

As it would seem from the e-mails quotedon the previous pages, many people believethat human maxillary growth can be affectedby orthodontic appliances. Some of thesefacial changes are unfortunate even if theteeth are improved (figure IV/6).

The direction of maxillary growth has astrong effect on the teeth and Platou andZachrisson. (1983) found that if the jawsgrow ‘horizontally’ the teeth are less likelyto become crowded, and Woodside (1996)found that this was especially true for thelower incisors. Franchi (et al 1997) agreedwith this, saying “increased facial verticalrelationships appear to be a skeletal featurecorrelated with higher degrees of incisorcrowding” and suggested that crowdedlower front teeth in any seven-year old child

were a certain sign of current and probablyfuture vertical growth. Woodside (1996)repeated the warning saying “anything thatcauses facial lengthening will increase incisorcrowding” continuing, “Those faces whichstart to crowd after treatment are thosewhose faces have lengthened”. It is clear thatcrooked teeth are closely and constantly

linked to vertical facial growth at all ages.

The Frequency of Adverse FacialGrowth.

It is exceptionally rare for mature adultsliving in industrialised cities to have all 32teeth in perfect alignment with space behindthe third molars, although this was routine


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mongst our direct ancestors. Clearly adverseertical’ growth is now commonplace andeal ‘horizontal’ faces are rare. It is almost

mpossible to gather an equal number ofertical and horizontally growing facesuring research into facial beauty. Because ofhis most facial research has been undertakenn skewed samples of vertical faces.

As we discussed in the last chapter aertically growing face can be recognisedecause the maxilla swings down and backaving the nose looking more prominent and

he teeth crowded. Frequently the droppingf the maxilla is followed by a hinging back ofhe mandible which creates a weak chin (figV/7 A and B) and this moves the tongue to theack of the pharynx. This in turn will partiallyock the airway making breathing difficult.described these changes many years ago

Mew 1983) and explained how most peoplet their head back to restore the airway (Fig

V/7 C. In that article I also suggested thatDisproportionate facial growth is to somextent disguised by this backwards tiltingf the head, which maintains the facial plane

while permitting major adaptive changesto occur in other parts of the cranium”.This disguises the weak chin and causes theforehead to slope back but results in the noseprojecting even further, producing whatorthodontists call a ‘convex’ face (figure IV/7C). Although this article was prophetic theinformation it contained was largely ignoredand unfortunately this is still often the case.We discussed the inappropriate treatmentof ‘Brian’ in chapter 3 which was due to thewidespread misunderstanding about suchfacial changes.

Psychological Assessment of FacialAppearance.

Classically, psychologists have usedfrontal photographs when assessing facialappearance. Horizontal and vertical linesare drawn across the facial features andthis framework has been used to suggestspecific rules for ideal facial proportion,involving the so called ‘Golden’ and otherproportions. However, the changes in profilethat we have just described are not easily

distinguished when looking at the frontalview of the face. If figure IV/8 is studied itcan be seen that tilting the face forward orbackwards can make a substantial differenceto the proportions of the facial features. Thisproblem was pointed out many years agoby Lucker and Graber (1980) who suggestedthat psychologists should rely more on lateralviews. Surgeons and orthodontists havetended to use a lateral view, as this allows theimage to be rotated in order to compensatefor this type of distortion. In my opinionfrontal photographs are not appropriatefor assessing facial beauty, especially if thesubject is smiling as this distorts the facialcontours.

Psychologists are now increasingly usingcomputer generated three dimensionalimages which can be rotated at will to givea much better idea of skeletal relationshipswith the soft tissues. The side view (Fig IV/2)shows the same girl as figure IV/1 but givesa much better idea of whether the face isgrowing horizontally or vertically.

Reading the Personality from the Face.

Although most of the public think that theycan assess the personality of an individualfrom their face, there is little scientificsupport for this belief. Indeed Cunningham(1977) suggested that “The pseudo-sciencesof phrenology and physiognomy may havemade measuring the face seem disreputableto some scientists”. This may have discredited

the concept of judging the personality ofan individual using objective measurementof their facial structures. A study by apsychologist and myself (Squires and Mew1981) was one of the very few to have founda significant relationship between facial formand personality characteristics. It concluded,amongst other things, that people withvertically growing faces tend to be lessconventional than those with horizontallygrowing faces. We know that reduced motortone is associated with vertical growth andpossibly unconventional people are morerelaxed with a lower muscle tone than their


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ore conventional colleagues.

There has been recent interest in the usef imaging systems that are able to ‘mix’wide range of natural facial variations. Ifcial appearance were genetic then beautyould be randomly distributed throughout aopulation and one might expect a digitallyeated ‘mean’ to look more attractive

han the extremes. However, Edler (2001)xpressed doubts about the use of theseomposite averages, saying “The process ofroducing composites from a large numberf individuals inevitably eliminates facial skinemishes including creases, wrinkles, etc.,

hus providing the composite face with annfairly’ clear complexion”.

On the basis of a series of ‘average’ces Perrett (et al 1994) concluded thatdeed they look more attractive than mostdividual faces. However he found that

highly attractive faces are systematicallyfferent in shape from average” and tended

o be at one end of the range of variation.his conclusion was supported by Edler 2001ho similarly found that “There were a few

exceptionally attractive individuals, whowere more attractive than the composites

This strongly suggests that facial beauty isnot randomly distributed within the genes.It is of interest that one of the featuresthat Perrett found to be associated withattractive faces was prominent cheek bones.This is a constant feature of horizontalgrowth, and the attractiveness was ratedeven higher if this was emphasised by meansof digital technology, strongly supportingthe belief that the attractive faces areassociated with a forward placed maxillae.This concept is further supported by the workof Sforza and his colleagues who comparedattractive children with less attractive onesand concluded “The soft-tissue facial profile

was more convex in attractive children,with a more prominent maxilla relative tothe mandible”. However both Perrett andEdler appear to believe that these featuresare related to inheritance rather than theenvironment.

In their search for the ‘ideal’ face,psychologists have often studied accepted

beauties. However, dental crowding, iscommon, even amongst beauty queens (FigIV/9) which raises a number of queries. If weaccept that crowding is linked to incorrectskeletal growth then either skeletal formis not related to beauty or Beauty Queensare just the best of a skewed sample froma population most of whom are a long wayfrom the ‘ideal’.

More recent research suggests thatconcepts of beauty are ever changing.Iglesias-Linares and her colleagues (2011)after studying attractive black and whitesubjects according to ‘People Magazine’during previous 10 years, concluded thatthe concept of beauty and facial balance isevolving, with a predilection for increases

in facial convexity and lip protrusion. Thoseconsidered beautiful had strikingly similarcharacteristics. However the authors had nocontrol to represent past facial standards andthe broad evidence suggests that protrusivefaces have always been popular.

To answer some of these questions Idesigned a study to see how judgementsabout facial appearance are affected by smallchanges in facial form. Judgements are easierwhen comparing real faces but it would beextremely difficult to find a group of peoplewith small specific skeletal differences thatcould be compared. Most research has beenconducted using computer graphics orsilhouettes but these do not always providelifelike faces and so ¾ view outline drawingswere used instead.

Method and Material.

This research was undertaken to examinethe impact of aberrant ‘vertical’ growth,on facial attractiveness. Unfortunately

neither a frontal or profile picture shows thecheekbones, which are so crucial to goodlooks and are so damaged if the maxilla failsto grow horizontally. It is also easy for skinquality, hair colouring and facial expressionsto influence judges trying to assess facial


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ppearance. To eliminate any factors thatight detract from the facial contours, ¾ ew outline drawings were used in thisroject in preference to computer generatedctures.

One hundred and seven adults, selected atndom and aged between 16 and 60, were

hown ¾ view outline drawings of five facesig IV/10) and asked the following questions.

1/ “Which girl’s face do you think is mosttractive?”

2/ “Which girl’s face do you think is secondost attractive?”

The drawings were intended to illustratefferent features of ‘vertical’ facial growth

nd this is in marked contrast to mostervious research, which has looked atcremental variations around a mean. Face’ was traced from a photograph of a patientho had actually been treated with Bioblocrthotropics to convert her vertical growth

o horizontal (Fig IV/11). In each of the otherepictions one feature was manipulated by 5

m on the life size scale. ‘A’ had thick lipsuch as would have been occasioned by aara-functional swallow commonly foundith ‘vertical’ growers. ‘C’ had a large nose,type of deformity that does not normally

xist on its own as ‘large’ noses are the naturalonsequence of a vertical growing maxilla buthis picture was modified to assess the effectf a large nose in isolation. ‘E’ had flat cheeks seen with a vertically growing maxilla,

ote that the eyes, nose and chin also lookfferent, although they are unaltered. ‘D’

ad an undersized mandible. This would notormally exist without a ‘vertical’ growing

maxilla but again it was desired to assess thisfeature on its own.

Results.

Face ‘B’ was preferred by 74%. 13%preferred face ‘D’, 8% preferred face ‘C’, 3%preferred face ‘A’, and finally 2% preferredface ‘E’. When judging the second mostattractive face, all but four who did notplace ‘B’ first, placed it second. Face ‘D’ wasselected by 24%, face ‘C’ by 23%, face ‘B’ by19%, and ‘A’ and ‘E’ were both selected by17%.

Discussion

In agreement with many previous studies,the results suggest that most people findhorizontally growing faces attractive and anyaspect of vertical growth is judged harshly.It would also seem that small changes in onefeature may alter the appeal of the wholeface and that a flat maxilla does specialharm to a female face. This is followed in aless damaging sequence by thick lips, largenoses, and receding chins, all of which areassociated with vertical growth and para-functional habits. It could be argued thatthe constructed drawings did not fairlyrepresent such environmental variations,however the face was taken from real life andevery effort was made to mimic the changesseen in vertically growing faces. Of greatersignificance the near equal distribution of thesecond preferences would suggest that thefacial model was a fair one.

These findings support those of Crossand Cross (1971) who found that there isclose agreement when judging faces whichare perceived as attractive, however thepresent study in addition suggests thatour personal preferences diverge when

considering less attractive faces within thegeneral population who have been affectedby vertical facial growth. Sadly, as we havediscussed, the majority of industrialisedpopulations fall into this latter category, andtheir individual preferences concerning flatfaces, receding chins, large noses and thicklips clearly differ, with a similar proportionin favour of each feature. This may explainhow the mistaken belief that “Beauty lies inthe eye of the beholder” has arisen. We allagree about good looking faces but havedifferent preferences when judging the lessthan perfect faces within our society.

Sadly I have been unable to get this researchpublished, I think because psychologists, likeorthodontists, see facial variations as geneticrather than environmental.

Surface Anatomy.

Reading the face should be one of themost important aspects of Orthodonticsand before examining any new patient, itcan be beneficial to spend a few momentsstudying their surface anatomy. The musclebulges give a good indication of activity andas most orthodontists accept, it is primarilythe soft tissues that determine the positionof the teeth and alveolus. Unfortunately fewcurrent post-graduate students are givensuch guidance.

At the London School of FacialOrthotropics, students are taught todiagnose the dental malocclusion before thepatient has opened their mouth. Surprisingly,with a little practice; the Indicator Line (to bedescribed shortly), Overbite, Overjet, Anglesrelationship, crowding, cephalometric anglesand even palatal width can be estimatedquite accurately. This teaches students howto estimate the influence of various musclebulges and the additional functional/postural

information which can be assessed if thepatient is then asked to talk or swallow.

Aesthetic and Functional Indicators.

The forehead.

If we start at the top of the face, wefind there are often contrasts between theinclination of the forehead and the facialplane. Some minor variations are probablyinherited but most sloping foreheads arerelated to the extension of the cranium onthe vertebral atlas (tilting the head back). Aswe have already discussed, this is due to anincrease in the Saddle angle following a lackof lower facial development and a resultingpharyngeal airway restriction which causesthe patient to tilt their head to restore theirairway. Many researchers (McDonagh et al1997), and (Mclntyre and Mossey 2003) haveshown that the forehead is one of the moststable areas of the face and eminently suitablefor superimposition. We also discussed howthe angle between the frontal bone and thebase of the skull frequently changes duringboth growth and treatment (Singh at al1997). This is because; over time the face willmove independently from the cranial vault(Fig III/8).


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Let us look at an individual case. Fig IV/12eft) shows a five year old girl with the earlygns of facial flattening. Not only are herheeks noticeably flat but the lower palpebralarsus is prominent under both her eyes, this

one of the first signs of lack of forwardaxillary growth and may be recognised in

n infant as young as a year old. It is obvioushat she has a resting open mouth posture ofbout four millimetres and this will certainlycrease the collapse of her maxilla.

Figure IV/13 right shows her facial form athe age of 63. By then she was suffering fromevere Temporo Mandibular Dysplaisia (TMD)ogether with neck and spinal difficulties.owever the excess of vertical growth is notery obvious because her good muscle tone

as ensured a forward placed chin. Manyinicians misdiagnose such cases as ‘convex’rofiles but the signs of vertical growth canill be recognised by her sloping forehead,

urved neck and increased ‘Indicator Line’ (toe described shortly). She has extended heread on the atlas to open her airway and asresult the whole cranial vault is tilted back.he now has a class I malocclusion; but theowding is not particularly marked because

f her good muscle tone. Unfortunately onop of these developmental problems sheas an intermittent clenching habit which, ase will discuss later, may explain her currentMD.

As we mentioned in the last chapter herfacial plane has remained almost uprightdespite the fall back of the maxilla and it is notuntil the slope of her forehead is appreciatedthat the true extent of the lack of lower facialdevelopment becomes obvious (Figure IV/14)

The nose.

Large noses are a constant feature ofsevere malocclusions: think about it. The noseis supported above by the paired nasal boneswhich are firmly attached to the frontal boneand below to the septal cartilage, vomer andmaxilla. Vertical growth of the maxilla is

therefore reflected in the shape and positionof the nose as it ‘hinges’ down from the loweredges of the nasal bones.

Robinson (1986) noticed that the size of thenose was inversely related to the size of themaxilla and considered that for some patientsthis was a genetic association however hedoes not appear to have considered thepossibility that the nose might look largerby contrast when maxilla is set back andcases such as figure IV/23 show an apparentincrease of nasal size as the maxilla falls back..

My early research convinced me that therewas a fairly constant relationship betweenthe apparent prominence of the nose and thecollapse of the maxilla and this encouragedme to look for a linear measurement whichcould express this relationship.

The Indicator Line.

This is the distance from the tip of thenose to the incisal edge of the lowest uppercentral incisor (Fig. IV/15). The tip of the noseis defined as the furthest point from theTragus of the ear. The length of the IndicatorLine is then related to average values forCaucasians (Table IV/16), Scandinavians tendto be about 1mm greater and Orientals about1 or 2 mm less, but as the values are onlyapproximate this is hardly significant. We usea steel ruler to measure this distance (FigureIV/17 and 18). One caution is necessary whenthe maxilla is very retruded; the ruler mustnot be pressed against the nose but placed ata tangent to it and the line from the Tragusextended to where both lines meet figure

IV/19). If desired the line can be measured ona lateral skull x-ray but do not forget to allowfor enlargement. Clearly this measurement isno more than an ‘indication’, nevertheless itis surprisingly accurate.

This unlikely measurement is now usedto assess maxillary position throughoutthe world and is especially helpful forepidemiological studies where X-rays maynot be possible. It provides an approximateguide of the relationship of the mid-face andthe frontal bone, representing the ‘fullness’


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f the facial profile. I have used the Indicatorne for over twenty five years and have

ound it invaluable. Not only does it providen immediate assessment of maxillaryosition but it guides me during treatment,specially when deciding how far to advancehe incisors or the maxilla and when to acceptcompromise.

Peter Bushgang and his colleagues (1993)uperimposed X-rays on SN and noticedhat the “The upper dorsum (the area ofhe nasal bone) rotates upward and forwardpproximately 10 degrees between 6 and 14.”hile “The lower dorsum (the area of the

artilage) rotates downward and backwardpersons who show greater vertical and

ss horizontal growth changes”. Thesee relative changes but the most logical

xplanation must be because the saddle anglepens up increasing the angle between frontalone and SN. Both Robinson and Bushgangresumed the nose was growing forwardhereas I think the maxilla was rotating back.hese changes can easily be measured by thecrease in the Indicator Line.

It does appear that orthodontic retractionf anterior teeth emphasizes and perhapscreases the size of the nose, especially if

ccompanied by extractions. This pattern ofeatment was common between 1940 and

1960 when many faces were badly damagedincluding my own. Sadly there are still manyoperators who extract and retract.

If the central incisors are not fully erupted,an assessment can be made using the occlusalplane. For a five year old it should ideally beabout 28 and increase at approximately 1mmper year until puberty. In general girls areabout 2mm less than boys. A simple rule is toadd 23 to the age for a boy or 21 to the agefor a girl. For instance if a boy is nine yearsold add twenty three and you know that hisIndicator Line should be around thirty twomillimetres.

It must be emphasized that these are idealsand are very rarely observed in industrializedsocieties as even good looking faces are likelyto be increased by several millimetres. Someidea of ‘ideal’ values can be gained fromvarious authors. Platou and Zachrisson (1983)studied a population of 568 twelve year oldScandinavian children but were able to findonly 15 boys and 15 girls with class I occlusionsand less than 1mm spacing or rotation.Reworking their material, I found that theseboys had a mean indicator measurementof 43.9 (SD 2.79) while the girls were 41.5(SD 2.62). The paper reported that the 30selected children with ideal occlusion were“brachyfacial with somewhat procumbentincisors” compared with cephalometricnorms and noted that “Remarkably the lowerincisors were not behind the APO plane in anysingle case with ideal occlusion” suggestingthat the mandible was also further forward.However the Indicator Lines of these boys andgirls with ‘ideal occlusion’ were still nearly 4millimetres higher that that suggested by thesuggested ‘ideals’ and I am sure that this is ameasure of the distance that the maxilla hasto fall back before a malocclusion even starts

to develop. Certainly my research with thoseliving in more primitive environments hasshown higher ratios of individuals with near‘ideal’ Indicator Lines.

My belief is that it was the advent ofcooking, circa 70,000 years ago, that led tothe slow but progressive degeneration of thehuman occlusion and that any modern childwho was brought up on a diet of unrefined,uncooked food, would develop normalocclusion. Living outdoors might also reducethe risk of allergies.

An unpublished study of my own, on 72randomly selected twelve year old Britishschoolchildren (17 boys and 54 girls), showedthat the Indicator Lines averaged 43.8millimetres for the boys and 41.5 for thegirls; remarkably similar figures to Platouand Zachrisson’s group. It is surprising thatthe British group, a number of whom hadmalocclusions, did not score higher. Kerrand Ford’s work (1986) would suggest thatScandinavians Indicator Lines are probablyabout 2 millimetres larger than Britons whichmay explain this but a number of children inthe Scandinavian group had problems suchas Bimaillary protrusion or lip apart postureswhich may have introduced confoundingfactors.

Kitafusa’s work (2001) suggests thatJapanese ideals are about 2 millimetres lessthan British. Clearly the contrasts createdby tall Scandinavians would also apply tosmall individuals from other populations.All this emphasises how difficult it is to findideal faces and occlusions in industrialisedpopulations.

I recently researched faces of the Masai tribein Kenya. The average indicator line was justover 40mm, but several of them had IndicatorLines in the region of 37 millimetres. Deeperanalysis of Platou and Zachrisson’s materialshows that some conditions such as openmouth postures, and Bi-maxillary Protrusions

are clearly related to maxillary position whichcan be identified using the Indicator Line. Allorthodontists have experienced the irritationof children leaving their teeth and lips apartwhen the lateral skull X-ray is taken and I findit unsurprising that these particular childrenwill have higher indicator lines. In Platou andZachrisson’s case the Indicator Line was onaverage 2mm higher for the 10 boys and 8girls who had their lips apart when the X-rayswere taken, remembering that despite this allof them had ‘ideal’ occlusion.

Five girls were separately classified by theseauthors as having Bi-maxillary Protrusion,because their lips were “forward by morethan 2 standard deviations”. Despite thistheir Indicator Line was on average almost

2mm higher showing that despite the teethbeing substantially too far “forward”, themaxilla was back and in fact their increasedIndicator Lines suggests that this well knowncondition ought to be labelled “Bi-dentalProtrusion” with the maxilla displaceddown and back. In the same way nearly allpatients with Anterior Open Bites havehigher Indicator Lines (Figure IV/20). Theseexplanations may seem confusing until it isrealised that in all these situations (as well asin class II division 1 and 2) the teeth may bedisplaced in one direction while the maxillacan be displaced in another, a very importantconcept to understand.


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Logically the Indicator Line should stopcreasing when growth ceases, however theork of Rolf Behrents (1985) suggests thatcial changes (mostly lengthening) continue

hroughout life. While this may be true, thetuation is complicated by difficulties inchieving accurate superimpositions overng periods. Behrents was using the base

f the skull as his reference plane which cane affected by long-term changes in theaddle angle. My own research suggests thathe majority of this change is due to verticalmodelling of the facial bones, rather than

rowth. There is a strong tendency forcreased vertical changes in old age as theuscle tone degenerates allowing the maxilla

o drop back; which is why old people’s noseso often appear to grow. This is associated

ith a flattening of the saddle angle as theyet older.

Problems with vertical growth.

Most orthodontic treatment tends tocrease vertical growth by retracting theaxilla (Lundstrom et al 1980), (McDonagh et2001), (Melson et al 1999), (Ruf et al.2001)

ut clinicians are often unaware of themount of vertical growth. As Battagel (1996)

says, “Both fixed and functional appliancetreatment of Class II division 1 malocclusionsare accompanied by exaggerated verticalfacial growth” and adds that “vertical changesare not easily detected by conventionalcephalometric investigations”. Althoughthere are several short-term studies of biteplanes and high pull headgear that showreductions in vertical height, I do not knowof one long-term study that suggests thesechanges are other than temporary.

It concerns me how few orthodontistsappreciate the frequency of increasedvertical growth following treatment andits consequences in terms of facial damage,and long-term dental relapse. This is wherethe Indicator Line can provide on-the-

spot information and we will discuss laterhow Biobloc appliances have the primaryobjective of moving the maxilla forward toavoid vertical growth.

While it normally takes two sequentialX-rays taken a year or more apart to detectthe direction of growth, the Indicator Lineis quickly able to identify excessive verticalgrowth in quite young children, thus warningparents of the risk of future adverse growth.

We started this chapter with Louisa at theage of six (Figure IV/1) when her indicatorline was 38 mm (seven millimetres too high),suggesting a downward pattern of growth,despite her attractive facial appearance (notethe gum line). She received no treatment atthat point and by the age of nine Louisa’sIndicator Line was 42 (nine millimetres toohigh), and the previously hidden vector ofvertical growth became very obvious. Wewill discuss Louisa’s treatment later under‘difficult cases’ (Chapter X). Table IV/15 showsthe relationship between the Indicator Lineand vertical growth. It is only approximatebut can be helpful in anticipating verticalchanges.

How useful is the Indicator Line?

The criticism has been made that becausethe Indicator Line is a linear measurement itcan not assess a three dimensional change. Aswas discussed in the first chapter, becauseany movement has to be recorded with twopairs of X and Y co-ordinates it is difficult touse cephalometric X-rays to assess maxillarychanges. However it will be appreciated thatwhen the maxilla falls back it does so alongthe same vector as the Indicator Line itself(Figure IV/9) and this is probably why it issurprisingly accurate.

Another factor which increases its accuracyis that the nose also falls back in the samedirection but less so than the maxilla, thusthe distance from the nose to the teeth (theIndicator Line) represents about two-thirdsthe total increase (Figure IV/21) which almostdoubles its accuracy.

Lower Indicator Line.

It was Tweed who many years ago noticed

that straight lower incisors were usually at90º to the mandibular plane. This encouragedgenerations of orthodontists to retract theupper incisors to match this angulation andwas in my opinion the cause of much facialdamage. I have no doubt that the widevariations we see in lower incisor angulationare due to tongue and lip postures, althoughhabits, function and inter-incisal lockingalso play a part. We will discuss shortly theprecise soft tissue factors responsible forthe retraction and protraction of the lowerincisors but in almost all instances the incisors

themselves over-erupt. An increase in lowerfacial height is almost always aestheticallyunpleasing and sadly a common sequel tofixed orthodontic treatment. To assess thiswe use the “Lower Indicator Line”.

This is defined as “The distance inmillimetres between the incisal edge of thehighest lower central and the soft tissue of

the mandible below it, measured at rightangles to the occlusal plain” (Figure IV/22).Again it sounds rather simplistic but issurprisingly accurate. In a well balanced facethis will be about 2 millimetres less than theUpper Indicator Line. The upper beak of thecalliper should be in line with the occlusionand the lower beak in light contact with thetissue vertically below the incisors.

The Duke of Wellington (Fig IV/23) providesa good illustration of an increase in both theupper and Lower Indicator Line. It can be seenthat in relation to the frontal bone, the nasalbones themselves remain relatively staticcausing the nose to become progressivelyhooked as the nasal cartilage drops backwith the maxilla. This is sometimes calleda Roman nose and if, as was suggested in

Chapter I, facial mal-development is relatedto social standards and soft food; its initialmanifestation in Roman high society whomay well have had a very different diet fromthe plebeians they ruled, could have givenrise to this expression. Certainly a large nosedoes not guarantee a satisfactory airway; infact the reverse is usually true.

Centuries ago a large nose could be anasset because of the link between wealth andlife style. To quote from William Seymourdescribing King Henry II, “he was a man of


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lip swallow. Many long face class I’s have asimilar problem and yet orthodontists havetraditionally been afraid to procline thelower incisors because it was believed thatthis would cause fenestration of the alveolarbone which is often quite thin in these cases.This was due to a misunderstanding of theaetiology of the problem, as the thinness ofthe bone is not inherited but due to long-term force from the mentalis muscle.

More recent work suggests that the riskof fenestration or ‘clefting’ due to incisorproclination is small (Woodside 1996) andRuf and his colleagues (1998) concludedthat. “Orthodontic proclination of lowerincisors in children and adolescents seemsnot to result in gingival recession”. However

I do think it is wise to use a ‘Purley Wire’ toreduce contraction of the mentalis muscle(See chapter VIII appliances)

In my book Biobloc Therapy (1986),chapter IV, I described a father and sonwho demonstrated the progression of thiscondition from severe retro-clination, to apoint where the apices of the father’s lowerincisors were actually projecting throughboth bone and gingeva. The same chapterdiscussed many other aspects of ‘myotherapy’or Oral myology’ as it is sometimes called andwould make good adjunctive reading. This isdiscussed in Chapter VII.

As the lower incisors tilt back they usuallycontinue to erupt until they reach the limitof bony support (figure I/4). Proclining theteeth to reduce the Lower Indicator Line cando much to improve the appearance of theface especially in class III cases with pointedchins, although this does require taking themaxilla an additional distance forward (FigureIV/24).

The Cheek Line.

This is the angle between the bridge of thenose and a line running sagitally down fromthe centre of the lower eye lid at a tangentto the soft tissue. If the maxilla is set backthe angle may be as high as thirty degrees(Figure IV/25). Again this is not a precisemeasurement but is very helpful in assessingthe face and is one of the first features of thesurface anatomy that I note when a patientwalks into the office. The Cheek Line of amildly flat face will be at about 10° to the

edium height and strong build with delicateands and a handsome head enhanced by arong nose”.

It can be seen that the Iron Duke’s lowerdicator Line also increased excessively.he retroclination of the lower incisors gavem a prominent chin and the correction of

he Lower Indicator Line will often restore aamaged profile Figure IV/24.

An increase in the lower Indicator Line isery common in class III cases (describedter) and is principally due to a low tongueosture coupled with a tongue to lower

bridge of the nose and a more obvious onewill be at 20°.

It must be remembered that the maxillaprovides three-quarters of the support forthe eye and a retruded maxilla is likely tobe associated with other features such as a

prominence of the lower palpebral tarsus(Figure IV/26) and an increase of the whitesclera showing below the Iris of the eye.

In addition the lateral margins of themaxilla below the eye seem more liable todrop more than the mesial, causing the outer


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orner (canthous) of the eye to drop morehan the inner (Figure IV/27). In severe caseshis may create an open space of one towo millimetres between the sclera and theteral margin of the eyelid. Psychologistsave found the eyes are the most importantngle feature in facial beauty and if anyoneas doubts that the position of the maxilla isucial, they should look at figure IV/28 andsess the personality of the girl on the left

ompared with the one on the right. Do thisow and then read the next paragraph.

It is the same girl before and afterurgery to move her maxilla forward. As

emonstrated above (figures IV/4 and IV/5.),artoonists are well aware of the importancef the maxilla but orthodontists often doot realize the degree of facial change that

maxillary position can create. Sadly mostcurrent orthodontic treatment actuallyretracts the maxilla which exacerbates theseproblems.

Muscle Bulges.

For the purposes of this chapter we willconsider three muscle groups and their effecton the dental skeleton. Firstly, a reminder ofthe discussion in chapter I concerning thetype 1 and type 2 muscle fibres; the fast acting(Type 2) are thicker and more powerful butare unable to maintain a pull for long periodsbecause oxygen can not reach them whilethey are contracted. The slow acting musclefibres (type1) are much thinner which enablesoxygenation even if they are contracted andso they can maintain low levels of contractionfor long periods. Essentially the fast actingfibres do the short-term powerful work likechewing while the slow ones maintain long-term posture, such as keeping the sphinctersof the alimentary canal closed, including thelips.

The relationship between muscle fibretype and facial shape is shown in Figure IV/29.Professor Nigel Hunt who kindly lent methis slide, initially felt that fibre types wereinherited but there is increasing evidence tosuggest that these fibres can change fromone type to the other or perhaps that newfibres can grow so that the ratio betweenthe two types can change to meet differentlevels of activity required.

Because of the difference in thickness, theapproximate ratio of each type of fibre withinany muscle can be recognised by changes inits shape. If we look at an example (figureIV/30) we can immediately see that the upperlip is too thick and as a result the vermilion

boarder between the skin and the mucosa isa rounded curve, whereas it should form anattractive raised ridge outlining the lip (seefigures IV/36 and IV/37). It has thickenedbecause there is a higher ratio of short actingfibres, a clear indication that her lips at restare several millimetres apart and that sheswallows with her tongue pushing against herlips. It can also be seen that the lower lip isthickened and a thickening of both upper andlower lips is a common feature in people withbi-maxillary protrusion. One might expectthat powerful lips would cause retractionof the teeth but no; the tongue is more

powerful but only at intervals. Her indicatorLine is raised showing that the upper incisorsare in fact too far down and back suggestingthat incisor retraction might not provide thebest result.

We can notice that her buccinators are

also thickened showing that she has a tonguebetween tooth swallow. The buccinatormuscles are enlarged in suckling infantswhose cheeks are described as ‘cherubic’(figure IV/31) but should begin to becomethinner after the age of fifteen months,following the eruption of the deciduousbuccal teeth at which point the adult swallow


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hould develop with the tongue against thealate. However as we discussed previouslyarly weaning often encourages children toevelop tongue-between-tooth swallows forlife time.

A correct swallow is obtained by sealinghe margins of the tongue against thealate to achieve the necessary negativeuction but this is impossible if the tongue isartially between the teeth as air is sucked

between the contact points. To preventhis, the buccinators have to be contractedo seal these spaces and this contraction cane seen by a movement of the modiolus (theecussation between the Orbicularis Orisnd the Buccinator) whenever such a patientwallows. This is a very important clinical

bservation as the force and bulk of theuccinators will tend to collapse the teethngually while the tongue-between-toothosture will tend to disrupt the occlusalontacts as can be seen with this girl (figure

V/30).

Overclosed bites will frequently showngival recession and possibly clefting at

oint ‘B’. This is assumed by many to be dueo a convoluted fold in the lower lip. Howeveris more complex than that as deep bites are

ue not only to powerful muscles but alsoo the tongue resting between the buccaleeth. This posture intrudes the buccal teethut allows the anterior teeth to over eruptith an increase of the Lower Indicator Line

despite the reduction in the height of thelower face. This aspect is discussed in greaterdetail below under ‘Tongue Posture’ wherethe soft tissue postures relating to eachcategory of malocclusion will be described.

If the patient has or develops a correcttongue-to-palate swallow the buccinatorswill become quite thin, creating ‘hollowcheeks’ which are said to be essential foranyone wanting to be a successful model(see figure IV/32). It is interesting to notethat attractive men and women often havea narrow face with these ‘hollows’ (FigureIV/32) and the greater the hollows the moreattractive the face is judged (Figure IV/33).Despite the narrow cheeks the dental archesare likely to be wide, giving a ver y attractive

smile. Tongue to palate swallowing is alsoessential for forward growth of the maxillaand long term dental stability.

The Tropic Premise would suggest that

ideal oral posture would create ideal facialaesthetics. We discussed earlier how thepublic appreciation of facial aesthetics is

remarkably uniform but that few faces arejudged perfect; for instance figure IV/9showed an imperfect Miss World. All thisgoes to confirm the conclusion we came toin chapter I, that ideal facial development israre.

We have been discussing the diagnosisof facial and dental anomalies by assessingthe surface anatomy of the face but someanomalies can be created by inappropriateorthodontic treatment. As we discussedin the previous paragraph, these may be

recognised by the surface anatomy. A largeproportion of modern orthodontic treatmentis retractive in nature and sometimes leads toa restriction of forward growth and increasein vertical (IV 6). These changes can certainlyaffect resting oral postures. For examplefigure IV/34 shows a pair of identical twinsone of whom (Anne) was treated with theextraction of one second premolar andthree second molars to avoid retracting the

dentition or face. Her identical sister (Jane)had no treatment.

A panel of ten lay judges decided that Annewas the better looking before treatment by8 to 2 but after treatment they thought Janewas the better looking by 9 to 1. The faces ofidentical twins can help us to identify someof the subtle long-term changes that can takeplace following treatment. What featureswere they looking at? The most obvious isthe enlargement of the buccinators. This isbecause Anne now swallows with her tongue

partly between her teeth, probably becauseof the reduction in arch size, a commonconsequence of orthodontic treatment. Shenow has to recruit the buccinators to seal thespaces between the contact points so that shecan suck and swallow, this has caused them toenlarge. It also appears from the photos thatthe nasio-labial angle has increased despitethe efforts of the orthodontist to avoidretracting the face by extracting posterior

teeth. Certainly the lower palpebral tarsusis more obvious suggesting that the maxillahas fallen back and the inevitable sequel tothis has been some retrusion of the mandiblewhich is why she now has a ‘double chin’. Thisplus the enlarged buccinators make Annelook fatter, although she is actually 6 pounds(2½ Kilos) lighter than her sister.

Many might protest that this is a singlecase and the changes could have been dueto chance. While this is possible, they wereidentical twins and so whatever the cause,


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he changes are presumably environmental.owever such changes are a commonequel to a reduction in arch size followingrthodontic treatment even if care is takenot to retract the incisors. For instance amilar pattern can be seen with another pairf identical twins Ben and Quinton (Figure

V/35). Note how Ben’s buccinators enlargedollowing the start of fixed applianceeatment.

I have little doubt that similar changesake place whenever tongue room is reducednd once they have occurred the chancesf long-term stability are severely reducedr lost, committing the child to a life timef retention. Sadly this sequence is notncommon in post orthodontic patients.ntil we can measure tongue posture weill never be sure but in my estimation the

equence was

1/ Reduction of tongue space followingxtractions.

2/ Development or increase of a tonguebetween tooth swallow.

3/ Enlargement of the Buccinator muscle.

4/ Maxilla dropping due to lack of tonguesupport.

5/ An increase in ver tical growth (or verticalremodelling in adults). This sequence appearsto be quite common during many forms oftreatment.

Lip Form.

Most orthodontists believe that lip form isinherited, however I have been surprised howmuch the shape of the lip can change overtime, with or without treatment and thishas led me to believe that lip form is largelydetermined by lip posture.

I have heard many clinicians describe thecharacteristics of perfect lips and especiallythe perfect smile, but few of them relate

this to the position of the maxilla which tome is more influential. As we discussed earliersome use the ‘Golden Proportion’ but I donot find this helpful. Hunt and her colleagues(2002) found that “More attractive ratingswere awarded to those smiles where theamount of gingival exposure was within 0-2mm” and this measurement is closely linkedto the vertical position of the maxilla and thetilt of the maxillary plane.

Kim and Gianelly (2003) compared dentalcasts of 30 patients treated with extractionand 30 patients without extraction, andfound rather surprisingly that “the extractiongroup was 1.8 mm wider in the mandible and1.7 mm wider in the maxilla”. This is initiallyhard to rationalise until one realizes that

the incisors were probably retracted in theextraction cases, giving them a relativelygreater width in the second premolar area.

Shafiee and his colleagues (2008) suggestedthat smiling photographs are better thaneither frontal or lateral photographs.However, they used the faces of 45 patientswith relatively mild malocclusions and Isuspect that if the cases had been moresevere the lateral views would have had mostpower. My own view is that smiles distort theface, making valid comparisons difficult butwe need better evidence.

Perhaps we should define attractive (ideal?)lip form. Figure IV/36 shows the maturationof a young girl as she learnt to keep her lipsclosed. On the left her lower lip is thick andprotrudes slightly in front of her upper lip.Note that her buccinators are also quite thicksuggesting that she has a tongue-between-tooth swallow. As she grew she learnt to

keep her mouth closed with a correspondingimprovement in lip form. As an adult in theright hand picture she has almost perfect lipform, while at the same time the buccinatorhas thinned to give her ‘hollow cheeks’. Thereader should work out how and why this hashappened?

Like many of the sphincters in the alimentarycanal, the lip has a dual enervation; partvoluntary and part autonomic. The voluntaryenervation facilitates speech and masticationwhile the in-voluntary control maintains thelip sphincter at rest. I remember a visit to thepremature baby unit in the town of Soweto,South Africa where there were twenty four‘premature baby’ cots each containing ababy, many of whom were close to death.

Despite this, every one of them had their lipsin contact. I have been told that if you pinchthe nostrils of a new born, they will suffocateas they do not know to open their mouth.

Sadly, if this automatic lip seal is lost,it is frequently never regained. As wediscussed in the last chapter young childrenin industrialised countries leave their mouthsopen over 80% of the time which is whydamaged lip form is routine rather thanoccasional. As these children grow up many,will leave their mouths open for the rest oftheir lives, only closing them voluntarily forfunctional or social reasons. It is exceedinglydifficult for a child who has lost theirnatural lip seal, ever to regain it and yet agood lip seal is essential for maintaining agood occlusion either natural or followingorthodontic treatment. Think about it: anoverjet or reverse-overjet of more than 2 or 3millimetres can not exist if there is a lip seal.

If the lips are held together intermittently,the thick type 2 muscle fibres tend to be

generated (figures IV/29 and 30). A natural lipseal requires minimal activity and this is whythose with a natural seal have quite thin lipsand the vermilion boarder is slightly raised(Figures IV/36). An example of this is givenby two sisters who received exactly the sametreatment (Figure IV/37). From the beginningKelly made a great effort to keep her mouthclosed (you can see the contraction of theMentalis muscle) while Samantha neversucceeded. It is salutary to see how the shapeof Kellie’s lip has improved while Samantha’shas become worse. Situations like this are


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uite common and have convinced me thatp form is volatile and far more dependentn posture than inheritance. If the upper lipin front of the lower when the head is held

pright (figures IV/4 and III/15), it can beafely assumed that the lips are sealed at restnd vice versa (figure IV/5).

It is not easy to interpret resting liposture and many clinicians make the mistakef using terms such as ‘competent’ andncompetent’. These are rather misleading they are measures of potential rather thanality and involve the subjective assessment

f the contraction of the Mentalis muscle. Irefer to measure the distance the lips arepart at rest.

The most reliable way to do this is to askhe patient to talk (I ask them to count fromne to six). During speech the tongue and lips

tend to return to the rest position betweeneach syllable. For instance someone with goodocclusion and facial form will bring their lipsinto contact after most words (Figure IV/38)while some one with poor occlusion willsometimes speak an entire sentence withouttheir lips touching (Figure IV/ 39) note

especially how her tongue remains away fromher palate. It is simple to observe these twocontrasting patterns when watching a goodlooking television commentator interviewsomeone with poor posture.

Having observed the patient count in thisway the lips should be re-postured in whatseems to be their most natural rest positionand an accompanying adult can be asked ifit seems natural. It is not difficult to traindentists and their staff to assess lip seal inthis way with acceptable repeatability. Ifthe panel of judges system (Shaw 1981) is

used, the opinions of three people (judges)will convert this subjective judgement into ascientific measurement which can be used forresearch into many aspects of malocclusion. Ilook forward to seeing an increasing numberof papers by various workers on this subject.Hopefully my own research using thesemethods will be ready soon.

Many features of ideal lip form are obviousenough, however they have been misreadby some specialists in facial aestheticswho believe that attractive lips are moredependent on inheritance than lip activity.The Tropic Premise would suggest that theheight of the embrasure is dependent on thebalance of upper Orbicularis and Mentalisactivity. If the lips are sealed at rest then


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he embrasure will be about ⅔ of the wayetween the nose and the chin. On the otherand if the lips are apart at rest the Mentalisas to assist in obtaining lip seal and thisctivity will tend to lift the embrasure to aosition of over three-quarters of the wayp (See figure IV/40). Fortunately the re-stablishment of a good lip seal will restorehe lip form and position to the two thirdsosition within a year or so in any youngatient but it can be hard work.

The Four Millimetre Rule.

This simple rule divides lip seal into fiveroups.

1/ Lips naturally sealed at rest. Rarely seenindustrial society and always associated

ith excellent appearance and occlusion.

2/ Lips up to 4 mm apart at rest.ssociated with mild lower crowding.

3/ Lips 4 to 8 mm apart at rest.ssociated with more general crowding

4/ Lips 8 to 12mm apart at rest. Will have aevere skeletal malocclusion.

5/ Lips over 12mm apart. Extremeertical growth and will require surgery orternatively Orthotropics from a young age.

This information is of crucial importance

for the prediction of stability or relapseand can be given to parents of children asyoung as three or four years old, who muchappreciate guidance before bad habitsbecome established. Interestingly parentsare more likely to be forgiving about relapseof dental crowding if it has been forecast onthis basis, as the responsibility of achievinglip seal can be seen to rest with the patientrather than the clinician.

Before I used Orthotropics I can rememberretreating fixed appliance patients who hadrelapsed, free of charge, only to have themreturn two or three years later saying, “DrMew it was so kind of you to retreat littleJohnny but I am sorry to say his bottom frontteeth are becoming crooked again”. By then‘little Johnny’ was probably at universityand did not want re-treatment. Now I have

parents returning saying” “I am so sorry but‘Johnny’ is still leaving his mouth open and ithas undone your work” and I say “so it has, Ican retreat him for you but they will crowdagain unless he can learn to keep his mouthclosed”. I also charge them.

Many patients are concerned about havingthin lips although they are not always able tovocalise this. It is normally the upper lip thatis thin and this is usually due to a tongue tolip swallow, associated with a class II division2 malocclusion. This posture and habit suckstheir mid-face inwards and if I want to provide

patients with an incentive to improve, Iremind them of the witch in Walt Disney’s‘Snow White’ who was an extreme exampleof the long-term effect of mid-face retrusion.The long-term consequence is distalisationof both maxilla and mandible leaving the chinand nose protrusive, however an early signmay be no more than a thin upper lip (FigureIV/41).

Tongue Form and Posture.

The Tropic Premise says that the occlusalcharacteristics of malocclusion are largelydetermined by “inherited muscle patterns,

primarily of the tongue”. While many considerthe shape and size of the tongue to be specificfor each individual it is an amorphous organthat can change its form substantially withina short period. Harvold (1981) experimentedwith monkeys that had their noses blockedand noted that this created changes intongue shape which did not revert untilafter the airway had been restored. He alsonoted that “Remodelling of the bones wasmost pronounced in the animals with a moreconsistently low postural position” of thetongue, a feature that is reflected in Class IIIhuman subjects. I am constantly amazed that

the observations of this brilliant thinker andresearcher are so ignored.

Unfortunately it is almost impossibleto measure tongue posture over time, asthe smallest instruments tend to disruptits position. To assess tongue posture itcan again be helpful to watch the patienttalk or swallow. When talking the activityof the tongue can be divided into fivecategories (Figure IV/42). These may beeasier to recognise if the patient is alsoasked to swallow, observing any conjunctivecontraction of the buccinator, modiolus orlip.

Orthotropic Scale of Resting tonguePosition.

1/ Against palate.

These patients will have ‘Ideal Occlusion’

2/ Touching upper teeth.

These patients may have ‘Slight Crowding’.

3/ Covering the lingual cusps.


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bite or a bi-maxillary (bi-dental) protrusion,depending on the reciprocal action of thelips.

The Tropic Premise suggests ‘the occlusalcharacteristics of 95% of malocclusionsare determined by a complex mix ofinherited tongue postures superimposedon environmentally precipitated verticalgrowth’. Orthotropists accept that this is thecause of most malocclusion and that the only

These patients will have ‘Lingual Inclination’.

4/ Covering lower buccal cusps.

These patients will have a Deep or Opente depending on tongue position and

calloping.

5/ Against lower teeth.

These patients will have ‘Class III’ (figureV/43).

Clinically I find that there are virtuallyone in group 1. Many deep bite patients

ill claim to swallow with their tongue onheir palate but if asked to swallow withheir teeth biting together will say thisels strange. This is because they normally

eparate their teeth slightly and push theongue between them, sucking as they doo. These ‘tongue-between-tooth swallows’ill usually be accompanied with varying

mounts of scalloping on the margins of theongue depending on the forces involvedigure IV/44). In addition the tongue may be

ostured forward between the teeth and thislikely to be associated with either an open

long-term cure is to correct the oral posture,preferably before the age of eight other wisethe skeletal damage may become irreversible.

Correct maxillary arch developmentrequires good muscle tone and broad tongueto palate posture (figure IV/42 -1). Goodmuscle tone without tongue-to-palateposture is able to maintain quite a broaddental arch but will not take the maxillaforward and is likely to be associated withclass I deep bite, class II division 2 or a classIII malocclusion. Many Japanese and Koreanpeople have this problem with a broadpalate but retruded maxilla. In these casesthe maxilla will be back with an increasedIndicator Line. This is another importantconcept to understand and may be related tolanguage as well as ethnicity.

Class III cases universally have a low tongueposture which fails to support the maxilla.Those with good muscle tone will developa reverse over bite rather than an open-bite.Those with poor muscle tone will develop along face with a reduced or open-bite.

It is not difficult for anyone to confirmthis pattern of class III growth; try restingyour tongue on the lower incisors with yourteeth ten millimetres apart. You will find anatural tendency to advance your mandible1 or 2 millimetres. This will trigger the long-term forward posture that leads to increased

mandibular growth and it amazes me thatI can find no reference for this constantobservation in the literature.

Mild Class III patients are often treated bytilting the lower incisors back which is likelyto lead to a pointed chin and unattractivelengthening of the lower face height. Moresevere cases may be referred for surgicalcorrection but unfortunately this has a highrate of long-term relapse. This is probablywhy many experienced clinicians believe thatclass III growth is genetic and uncontrollable.To be sure of a long-term correction it isessential to re-establish a tongue-to-palaterest position. I have observed that speechpatterns in Japan and Korea require lesstongue-to-palate contact and in my opinion

this is associated with the high ratio of classIII patients in this part of the world despitetheir good muscle tone and wide upperarches.

Occlusion.

Although the science of orthodonticsis essentially that of occlusion there is adegree of woolly thinking on this subject.Firstly occlusal inter-digitation is an entirelyunnatural concept, as our ancestors wore thecusps of their teeth flat within two or threeyears of eruption. This does not necessarilyinvalidate the need to balance the occlusionbut it is important to realize that conceptssuch as ‘cuspal guidance’ and ‘oppositeside contacts’ are man made and relate toan artificial situation. Although the current‘rules’ of occlusion may fit some situationsthey are unlikely to have natural validity.

Secondly, as we discussed in chapter 1, BillProffit’s work on eruption leaves little doubtthat teeth will continue to grow until their

eruptive potential is exhausted or they comeinto contact with opposing teeth or perhapsa tongue, thumb or pencil. There are threevariables, the period of contact, the force andthe height to which the teeth have alreadyerupted. The level of everyone’s occlusaltable depends on the product of the first twobalanced against the third. Proffit’s figuressuggest that light contact for between fourand eight hours a day will maintain a constantheight of eruption. These facts enable us tomake a series of logical conclusions aboutdental occlusion.


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any alternative logical explanation and weshould remember ‘the truth in retrospect isusually simple’.

There is a clear message here for all dentistsas well as orthodontists. If the occlusion doesnot ‘sock in’ after treatment, either thereis a tongue-between-tooth posture or themouth is open too much. Vertical elasticswill rarely overcome these forces and eventhen only temporally. As will be explainedlater Orthotropics makes little attempt toestablish occlusion other than correctingcrossbites, all you need is correct oralposture and the natural forces will completeyour correction. We will discuss this furtherin chapter VI.

The Aetiology of the Various Malocclusions.

Class I.

Muscle Tone

This influences the depth of the overbite,the Gonial angle, the arch width, the facialheight and even the facial width. Workby Kiliaridis (1991 and 2003) shows thatmaxillary and mandibular widths are affectedby muscle tone and this can even extend upto the eyes and cranial vault. Muscle Tonewill also support the maxilla vertically but inmy opinion has only a marginal effect on itsforward development. In those patients withreduced motor tone there is a progressivereduction in the depth of overbite as themaxilla and mandible swing down and backtowards the class II relationship.

Tongue position.

In class I cases the tongue is between mostof the teeth, ranging from half a millimetre

over the lingual cusps (figure IV/42, 43 or 44)to 8 or more millimetres between the teeth.When these patients swallow the tonguesucks against the teeth with a reciprocalcontraction of the Buccinator, and OrbicularisOris which are in turn supported from behindby the Superior Constrictor to form the‘Buccinator Sling’ (Figure IV/45). This activityhas a distalising effect on the whole arch andincreases the inward and backwards collapseof the dentition already initiated by thetongue-between-tooth posture.

The Buccinators and Orbicularis Oris willbe enlarged to varying extents causing thebuccal and incisal teeth to incline lingually,the greater the retroclination of the incisorsthe thinner the vermillion boarder will be,giving the patient an unattractive thinlipped appearance (figure IV/41). There hasbeen much debate on the damaging effectof extractions but regardless of whetherpremolars or second molars are extracted theevidence shows that the anterior teeth will fallback during orthodontic treatment and thismay damage the facial appearance. Howeverit can not be assumed that extractions willdamage a face. Catherine Zeta-Jones is one ofthe worlds accepted beauties (Figure IV/46),and yet her close-up shows that she is missingher premolars. A good lip seal and tongue-to-

palate posture will save almost any face.The increase in vertical growth that results

from conventional orthodontic treatmentalso reduces the arch length and thisincreases the risk of long-term crowding.In addition the archwires have a retractiveeffect which will cause a further reductionof tongue space. Long-term dental stabilitywill almost certainly be prejudiced if tonguespace is reduced.

Despite a small maxilla some patients learnto rest their tongue evenly between theupper and lower teeth so that it acts as a splintand the teeth remain well aligned despitethe reduced arch size but scalloping of thetongue will usually be visible (Figure IV/44).

The interposition of the tongue betweenthe teeth inevitably disrupts the occlusalcontacts and will often make it difficult fororthodontists using fixed appliances to ‘sockin’ the occlusion at the end of treatment. Lipand cheek bulges will confirm this but alsoserve to emphasise the need to analyse thecomplex variables involved.

The larger the buccinators, the greater isthe likelihood of a cross-bite on one or bothsides. It always surprises me that there is suchconfusion about the cause of the cross-bites.The maxillary width collapses due to lack oftongue support, compounded by buccinatorcontraction and the lower dental archbecomes too wide for the upper. The cuspsclash (usually the canines) and the unfortunate

patient is forced to choose one or other sideto chew on. They quickly learn to deviate tothe side that fits best and if continued for along time the postural deviation may becomea functional one; almost always on the sideon which they prefer to eat. Treatment bychanging posture while young is simple, quickand remarkably permanent but do rememberto expand enough (see chapter VII).

Maxillary position.

Although class I occlusions are definedas having normal skeletal relationships themaxilla is usually back with an associatedincrease of the Indicator Line and CheekLine. Forward development of the maxillarequires constant contact from the tongue.Figure IV/47 shows how the pressure of thetongue will remove indicator paste from therugae. The absence of this contact in class Imalocclusions is the main reason why theyhave a retruded maxilla. It is worth examiningthe rugae, for they will be flattened if there isgood contact but remain proud if the tongue

does not regularly compress them. Thedegree of mid-face retrusion will be greaterif there is also poor motor tone.

Lip posture.

Although many patients with mild class Imalocclusions will have ‘competent’ lips theywill often be 3 or more millimetres apart atrest. Their class I relationship depends on areasonably good lip seal as a large positive ornegative overjet can only exist when the lipsare some distance apart. Lip seal is related to

Teeth that are out of contact will eruptto occlusion unless something stops themr they run out of er uptive force. Converselyver-erupted teeth will intrude if they are

contact for sufficient time and force.herefore all teeth should meet evenlynless something intercedes or the eruptiveotential of the tooth is exceeded.

Why then are unbalanced occlusions andng faces so common? Because tongue-

etween-tooth swallows and open–mouth-ostures are the rule rather than thexception in industrialised society and as asult most people have their teeth out of

ontact or contacting soft tissues such ashe tongue for long periods of time. Theseles apply primarily to centric occlusion but

primitive environments the teeth wouldave worn to suit the full range of mandibularxcursions as is seen in most omnivores andodern human bruxers.

On this basis occlusal equilibration haslimited validity. If the tongue is not

terfering and the patient can be taughto keep their teeth in light contact for fouro eight hours a day, then all the teeth willeet evenly regardless of age. The presence

r absence of cusps should make littlefference to this equation. Many cliniciansnd this hypothesis hard to accept but it isot so much a question of evidence as logic.f more significance, I have never heard of


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otor tone and with severe malocclusionshe lips will be further apart with an increasingendency towards a class II or III relationship.

Jaw position.

The mandible has huge plasticity dependingn the posture in which it is normally held andable to change shape, shrink or enlarge by

everal centimetres in different directions.ee chapter I fig 7 & 8). The freeway spaceill be increased depending on how far the

ongue spreads between the teeth at rest.this is coupled with increased motor tone,

he patient is likely to bite gently on theongue leaving small indentations which

we call ‘scalloping’ (figure IV/44). This mayintrude the teeth and reduce the facialheight. If the motor tone is low the reversewill apply. The lowered rest position of themandible restricts the pharyngeal airway(Mew 1983) and the posterior margin ofthe vertical ramus will resorb flatteningthe gonial angle. At the same time a co-ordinated deposition of new bone on theanterior margin will result in the verticalramus moving forward. This will shorten ofthe arch length resulting in dental crowdingwhich characterises this malocclusion (figureIV/48). The arch shortening will have mostimpact on the last teeth to erupt in each areaof the arch, the wisdoms, the canines and thesecond premolars.

Figure IV/49 shows this situation inreverse, as this patient received Orthotropictreatment which caused the vertical ramusto remodel distally within the relatively shortperiod of nine months, providing room fora previously impacted wisdom tooth. Notealso the changing relationships between theupper and lower teeth, sadly orthodontictreatment tends to have the reverse effect,opening the gonial angle rather than closingit and as a result shortening the arch lengths.This illustrates the contrast betweenOrthotropics and almost all other approachesto treatment.

CLASS I Anterior open-bite.

Motor Tone.

There are two types of class I open bite,depending on motor tone. The first grouphave a higher tone with a good looking faceand when they were infants, suckled thebreast and/or their thumb very firmly. Thishas given them a near normal facial height,usually with their tongue between theirteeth, mostly the anterior teeth. The second

group have a low muscle tone with a thinMasseter muscle and an increased cheek-lineangle. Many of this latter group never suckedtheir thumb but if they did so, used littleforce.

Tongue Posture. With both types thetongue will be postured forward betweenthe teeth and not against the palate. Duringspeech and swallowing the tongue will beseen to move forward and they are likely tospeak with a lisp or ‘blunt S’. It is the long-term tongue-between-tooth posture that islikely to maintain the open bite even if theystop thumb sucking. Essentially the thumballows the posteriors to over-erupt ratherthan prevents the anteriors from eruptingand frequently the upper central i ncisors are

the only teeth in the correct position.

Maxillary position.

The high motor tone group will be one ofthe few situations when the Indicator Lineis almost ideal. This is why it is incorrect toextrude or retract the upper incisors in thesecases.

Figure IV/50 shows a six year old girl whowas about to start a course or Orthotropicsto create room for her permanent anterior


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eeth (left picture). Sadly her father waslled in a road accident and the treatmentas never started. However the emotionalauma caused her to start sucking her thumbthough she had not done so before. She wasot seen again for nearly two years a time gaphich enabled the effects of an uncontrolled

humb sucking habit to become apparent. Notnly did she develop a severe malocclusionith an open-bite but the damage to her faceobvious (centre picture).

She had developed a forward tongueosture but fortunately it was not too lateor a course of Orthotropics to reversehe changes to both teeth and face (rightcture). Note the maxilla was expanded toake room for the tongue; this moved the

uccal teeth up and following some tongueaining the incisors to came into contactithout lengthening the face. The occlusionas then re-established by training her to

eep her mouth closed and her tongue on heralate. CLASS I Deep bite.

Motor tone.

These patients will have a motor tone ofor 2 on the Orthotropic scale, which willsult in a low MM angle and quite a goodheek Line. Apart from the lower incisors

he crowding in these cases is unlikely to be

severe because their Oral Posture is quitegood. They respond very well to Biobloctreatment as it can correct the deep bitewithout lengthening the face.

Tongue Posture.

The tongue will be between the buccalteeth rather than between the anteriors butless so than with class II division 2 (See FigureIV/42 position 2 to 3). The action of thetongue depresses the buccal teeth an

the cause of - reading the face

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