A series of lectures by Dr. Barry Raphael on Airway-focused orthodontics from 2013. Chapter 2: About Soft Tissue Dysfunction and how it affects the growth and adaptation of facial growth in children.

1. Airway Orthodontics
A lecture series prepared by
Dr. Barry Raphael
Of the
Raphael Center for Integrative Orthodontics
Clifton, NJ.
www.alignmine.com
www.myobracenj.com
“Soft Tissue Dysfunction and Facial Growth” - 2013
1Thursday, June 6, 13

2. •Animations are not included in this archive and may
affect the meaning or intent of the slide
•As the information in these presentations is
constantly evolving, please consider the date of creation
when reviewing the material.
2Thursday, June 6, 13

3. Soft Tissue
Dysfunction is
THE etiology
in a majority of
malocclusions
3Thursday, June 6, 13

4. Egil
Harvold
A History of Myofunctional Orthodontics
George
Catlin
1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020
Norman
Kingsley
Julius
Wolff
J. Sim
Wallace
Edward
H.Angle
Andresen
and Haupl
Alfred P.
Rogers
Chris Farrell,
John Flutter
You
Allan G.
Brodie
Westin
Price
Bimler,
Balters,
Frankel
Tom
Graber
Melvin
Moss
Donald
Enlow
Charlie
Tweed
Daniel
Garliner
Robert
Little
John
Mew
4Thursday, June 6, 13

5. There is Nothing New
Under the Sun
5Thursday, June 6, 13

6. Norman William Kingsley
•Stockholm, NewYork
•“The Father of Orthodontics”
• A Treatise on Oral
Deformities (1880),
•The first to recommend that
etiology, diagnosis, and
treatment planning should be the
foundations of practice
• The Bite Jumper
•Vulcanite with “pull-forward”
bite ramp
1829-1913
6Thursday, June 6, 13

7. Julius Wolff
•1892 :The Law of Bone Remodeling
•Bone will adapt to the loads placed upon it.
•Increased load leads to increased
trabeculation internally and then increases in
the cortical thickness externally.
•Converse: lack of use or stress leads to a
diminution of bone strength and thickness due
to turnover.
7Thursday, June 6, 13

8. George Catlin
• Lawyer, artist, amateur anthropologist
•Documented native populations in North and
South America
•1870
•“Shut Your Mouth and Save Your Life”
• Book recommended by Edward Angle in 1925
8Thursday, June 6, 13

9. George Catlin - 1870
•The cause of modern man’s maladies is his lack of “a quiet and natural sleep”.
•Proper breathing regulates digestion and circulation to every part of the body.
•Improper breathing brings imbalance and disease.
•The nostrils are intended to measure and temper the air in support of proper
breathing.
9Thursday, June 6, 13

10. George Catlin - 1870
On mouth breathing at night:
“That man knows not the pleasure of sleep; he rises in the
morning more fatigued than when he retired to rest - takes
pills and remedies through the day, and renews his disease
every night.”
10Thursday, June 6, 13

11. James Sim Wallace - 1904
• Natural suckling and chewing exercises the
muscles of the jaws and tongue.
•The tongue stimulates the maxilla, the alveolus and
the teeth during growth.
•A lack of spacing in the primary teeth is due to lack of
outward pressure on the arches by a fully developed
tongue.
•Without primary spacing, permanent anterior teeth
will surely be crowded, and the posterior teeth will be
seen to “fall inwards”.
11Thursday, June 6, 13

12. James Sim Wallace
Soft food>lack of chewing>
unopposed eruption>excess vertical
height> increased lip and muscle
incompetence>mouthbreathing>
deterioration of nasal airway>more
mouth breathing>more vertical
growth...
12Thursday, June 6, 13

13. Edward H.Angle
•1898 Treatment of malocclusion of the teeth and fractures of the maxillae
•KNOWN for:
•The Angle Classification
•The Edgewise bracket and rectangular wire
•Non-extraction orthodontics:“The Angle School”
•Organizing the Specialty of orthodontics
•All “TOOTH-CENTRIC” concepts, but...
•“... more often than is recognized, the
peculiarities of lip function may have been
the cause of forcing the teeth into the
malpositions they occupy”.1855-1930
13Thursday, June 6, 13

14. 14Thursday, June 6, 13

15. Alfred P. Rogers
•Angle School, 1903
•taught at Harvard
•private practice in Boston
•past president of the ASO (AAO)
•total-child approach and advocated
muscular exercises to improve neck,
head, and tongue posture and
encourage nasal breathing
•treated many “skeletal Class II”
cases ONLY with exercise.
1873-1959
15Thursday, June 6, 13

16. “Our teachers have recognized the
importance of muscular pressure in its
normal conduct as well as in its abnormal
conduct, but here we seem to have
stopped, assuming that with the correction
of the faulty osseous formation and cusp
relation, nature, somehow or other, would
establish the correct muscular tone and
muscular habits…”
Alfred P. Rogers, 1918 to the A.S.O
Alfred P. Rogers, 1918 to the A.S.O
16Thursday, June 6, 13

17. Tom Graber
AJO, 1963
“The Three M’s:
Muscles, Malformation, and Malocclusion
The Two Groups of Disciples:
Edward Angle: Edgewise Expansionists
Calvin Case: Extractionists
This tooth-focused battle rages on
even today.....
Must take muscles into account...
1917-2007
17Thursday, June 6, 13

18. Melvin Moss
• Professor at Columbia U.
•Functional Matrix Theory
•AJO 1966 :“The Primary Role of
Functional Matrices in Facial
Growth”
•Periosteal Matrix: the pull of muscle
on bone
•Capsular Matrix: the function of a
space stimulates bone
1923-2006
18Thursday, June 6, 13

19. Donald Enlow
•U. Mich, Case Western
•1975: Handbook of Facial Growth
•“Area Displacement”
Sutural and Bone growth in
the face is the RESPONSE
to soft tissue displacement,
not the CAUSE of it.
19Thursday, June 6, 13

20. Egil Peter Harvold
•Norwegian Orthodontist
•Cleft Palate
•Professor
•Brought Functional Treatment to N.A.
•1981 Primate experiments
• Blocked nasal passage
• Skeletal malocclusion resulted
1912-1992
Block the nose> posture changes and teeth get crooked
20Thursday, June 6, 13

21. Plugged Nose changes Posture
21Thursday, June 6, 13

22. Posture changes Teeth
Lowered mandibular posture, tongue protrusion,
and open bite
Open mouth posture retained for 1 year after nose
reopened. Facial features retained
22Thursday, June 6, 13

23. John Mew
•“Orthotropics”
•Normal growth of maxilla > Down
and Forward
•Dysfunctional growth > Down
•BioBlock Therapy to reestablish
Forward component
www.orthotropics.com
www.facefocused.com
23Thursday, June 6, 13

24. The Tropic Premise
“ If the tongue at rest is against the
palate with the lips lightly sealed and
the teeth in or near contact, there will
be ideal facial and dental
development.”
“Something RARE in industrialized
societies…”
24Thursday, June 6, 13

25. The Tropic Premise
“Because the genetic control of skeletal
growth is not precise, the articulation
of the teeth and jaws depends upon
additional guidance from oral
posture.”
25Thursday, June 6, 13

26. Normal Eruption
•Tongue rest on palate
•Erupting teeth slide into the
space between the tongue and
cheeks/lips (path of least
resistance)
•Cuspal contacts guide teeth
into position
26Thursday, June 6, 13

27. Dysfunctional Eruption
•Tongue rests in between teeth
• Maxillary alveolus collapses medially
and fails to grow fully forward (change
of shape)
•Teeth erupt without guidance or...
•With poorly directed pressures from
hyperactive muscles
• Cuspal contacts misdirect final
settling of teeth
27Thursday, June 6, 13

28. Orthodontics:
Current Principles and Techniques (3rd ed.)
Graber andVanarsdall
• Equilibrium Theory: Stability is the sum total of forces
and lack of force over time.
•Tongue Resting Posture is more important than
tongue function.
•Whatever determines resting tongue posture, for
long enough, will influence the position of the teeth.
• Respiratory Pattern
• Head posture
• Jaw Function and posture
28Thursday, June 6, 13

29. Homeostasis
•The Body Seeks Balance
•Against gravity
•Temperature
• Blood pH
• Oxygen : CO2 balance
• Dynamic Equilibrium
•A System in a Steady State where loss is equal to gain
•There is change, but no NET change
•Blood glucose
•Tooth Position
29Thursday, June 6, 13

30. G. David Singh
• Epigentic Orthodontics
•Genetics is important in
the way genes react to
stimuli
"Malocclusion is one solution for the complex adaptive
orofacial system to be in equilibrium."
30Thursday, June 6, 13

31. Epigenetics
31Thursday, June 6, 13

32. How DNA works
1. Direct protein synthesis
2. Through switches that turn those genes on and off. (Histone
switches and epigenetic factors)
3.Through sequences of D.N.A.'s chemicals that control those
switches.
4. Gene switches can change a characteristic by changing the
timing, intensity or duration of the same gene..like the
difference between a fin or a limb.
32Thursday, June 6, 13

33. Brian Palmer
•From Kansas City
•(Mal)occlusion begins at birth
• Breast Feeding critical to
formation of palate
• Short Frena limit suckling and
proper tongue posture
Genetic response begins at birth
And can be influenced.
33Thursday, June 6, 13

34. •Open Mouth
Posture
•Mouth breathing
•Tongue Resting
position
•Obstructive Sleep
Apnea
•Upper Airway
obstruction
•Adenoids
•Allergies
•Nasal obstruction
•URI
•Recurrent Otitis
Media
•Early Feeding
• Breast vs Bottle
•Hard vs soft
•Tongue Thrust
•Reverse swallow
•Delayed
maturation of
infantile suckling
•Finger habits
•Hypomobility
•Short Frenum
•Scarring
•Premature Tooth
Loss
•Stress
•Overheated houses
•Oxidative stress
•Nutritional
Deficiencies
•Nutritional Excesses
•Nutritional Toxins
•Breathing Habits
•CO2 stores
•Posture
•Birth Trauma
•Cranial Strains
Environment Influences Homeostasis
34Thursday, June 6, 13

35. Perpetuation
Form Function
Makes...
Grows into...
•Soft tissue dysfunctions cause malocclusion
•Malocclusions encourage Soft Tissue dysfunctions.
•The Spiral continues
35Thursday, June 6, 13

36. The Stack of Blocks
36Thursday, June 6, 13

37. The Stack of Blocks
37Thursday, June 6, 13

38. The Stack of Blocks
Malocclusion: one
solution to be in
equilibrium
38Thursday, June 6, 13

39. Soft Tissue
Dysfunction is
THE etiology
in a majority of
malocclusions
As stated by Dr. John Flutter
39Thursday, June 6, 13

40. “So why do some children develop
crooked teeth and some children develop
straight teeth?”
40Thursday, June 6, 13

41. “For normal growth and development
the growing child needs to:
1.breathe through the nose,
2.have the lips together at rest, and
3.have the tongue sitting in the roof
of the mouth.”
41Thursday, June 6, 13

42. “When the tongue rests in the roof of the
mouth the teeth erupt around the tongue
forming a normal shaped and sized jaw.
When this happens the teeth will
erupt into a straight line.”
42Thursday, June 6, 13

43. “Those children who breath through the
mouth or have the lips apart at rest will not
have the tongue in the roof of the mouth.
All of these children will have an
underdeveloped upper jaw.
It will not be big enough for all of the teeth and when
the adult teeth erupt they will be crooked.”
43Thursday, June 6, 13

44. Arch Forms
The Gothic Arch The Roman Arch
44Thursday, June 6, 13

45. How do you build an arch?
45Thursday, June 6, 13

46. Building a Stable Arch
The Roman Arch
46Thursday, June 6, 13

47. When the tongue rests in the roof of the
mouth the teeth erupt around the tongue
forming a normal shaped and sized jaw.
The tongue is the scaffold
for the upper jaw
47Thursday, June 6, 13

48. Mechanism of Sutural Activation
THE TONGUE-TEAT COMPLEX
APPLIES PRESSURE ANTERIORLY
HERE AT THE INCISIVE
SUTURE
THE TONGUE ALONE APPLIES
PRESSURE UPWARDS/
LATERALLY HERE AT THE MID-
PALATAL SUTURE
THE TONGUE ALONE APPLIES
PRESSURE UPWARDS/POSTERIORLY
HERE AT THE TRANSVERSE-
PALATAL SUTURE
During Breastfeeding and Postural Rest Position
48Thursday, June 6, 13

49. Bones Adapt to Spaces
49Thursday, June 6, 13

50. With Support of the Tongue
50Thursday, June 6, 13

51. SOFT TISSUE DYSFUNCTION
When the palate is NOT supported by the tongue.
51Thursday, June 6, 13

52. SOFT TISSUE DYSFUNCTION
Comparison of Unsupported vs Supported Growth
52Thursday, June 6, 13

53. SOFT TISSUE DYSFUNCTION
Comparison of Unsupported vs Supported Growth
53Thursday, June 6, 13

54. Everyday in my practice...
54Thursday, June 6, 13

55. The Missing Link...
It’s not just
Growth and Development
It’s
Growth, Development and
Adaptation
55Thursday, June 6, 13

56. If Malocclusion is caused by
Growth and Development
Genotype Phenotype
Total Growth
56Thursday, June 6, 13

57. If Malocclusion is caused by
Growth and Development and
Adaptation
Genotype Phenotype
Total Growth
57Thursday, June 6, 13

58. The Missing Link…
The Moral of the Story
The Face you have
May not be the face
That Genetics intended for you
58Thursday, June 6, 13

59. The Missing Link…
The Moral of the Story
Crouzon’s
59Thursday, June 6, 13

60. The Missing Link…
The Moral of the Story
60Thursday, June 6, 13

61. Is this the face her genetics gave her?
What is the appropriate question to ask?
The Missing Link…
The Moral of the Story
61Thursday, June 6, 13

62. Do any of us have the face that we were intended to have?
The Missing Link…
The Moral of the Story
62Thursday, June 6, 13