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What Goes Wrong in Growth and How Can an Adult Fix it

ThaGangsta
Eminent Member

In my last post, I talked about how in young people the primary growth mechanism is sutural, and the older they get the less sutural and more dependent on peripheral resorption and deposition it becomes.  Eventually you are left with a "non-growing" adult, where the craniofacial skeleton merely remodels completely once per decade to maintain the mass and shape of the bone, under normal circumstances (we will touch on this more later).  We must first understand what goes wrong in growth.

 

What happens in good growth:

 

In a child who has been breastfed and weaned to direct hard foods, has no nasal obstruction, and follows the tropic premise (tongue on palate, teeth in gentle contact, lips gently sealed), and swallow properly, growth will happen in a very good direction.  We know how orthodontists superimpose growth on the S-N line  to calculate a growth direction (Picture shown).  The SN line is still an imperfect superimposition point, as it is not as stable as once believed.  In a well growing individual, they will grow from 35-40 degrees down and forward direction from this line, producing a well balanced face with good occlusion. 

This is growth from the age of 5 to 13, with the dotted line being age 5 and full line being age 13

(Sutural growth of the upper face studied by the implant method, Arne Björk, European Journal of Orthodontics, Volume 29, Issue suppl_1, April 2007, Pages i82–i88,)

 

This is my superimposition of a face that has grown 35-40 degrees instead of the average of 51 degrees shown here, in purple

 

 In these individuals the cranial base angle is also likely to be acute, since the entirety of the lower face swings forward with growth and the cranial base length also tends so be small, making them more likely to be brachycranial.

(Enlow and Hans 1996)

 

Their mandible also rotates in a forward rotation during growth centered in the area of the lower incisor tip, which makes the ramus longer and the chin project more anteriorly.

 

Their palate and dental arches take the form of the tongue resting on it, with a nice broad smile, no crowding and space for the teeth. Since the teeth are in unobstructed gentle contact the occlusion will also be good.

Thanks to Professor John Mew, we have two ways to quickly measure this.  The indicator line will be 38 in a boy and 36 in a girl at the end of growth (give or take up to 2 mm in different ethnicities due to nose shape variation) and their cheek line will run parallel to their nasal bones (the solid bone in-between the eyes). 

 

Indicator and Cheek line:

The indicator line is an approximation that measures the degree of vertical growth (and therefore the horizontal growth as well) and is done with an approximation of how when the face grows vertically, the upper incisors drop twice as much as the tip of the nose does, therefore for every millimeter you are away from the ideal in measurement, means you have double the difference in vertical growth, and perhaps that amount of the difference in midface deficiency (at least according to this paper: https://stamforddentist.com/wp-content/uploads/2018/09/facial-growth-part-2.pdf).  

For example, If my indicator line as a male is 46 instead of 38, the difference is 8.  This means I have an excess of 16mm of vertical growth, and possibly a sagittal midface deficiency of 8mm.

The cheek line measures the sagittal strength of the infraorbital rims, paranasal area, and malar bones, perhaps even pointing to a better pneumatization of the maxillary sinuses.

Credits to Professor John Mew for both charts

 

 

What happens in bad growth:

In bad growth, the child has not been properly breastfed, they leave their tongue off the palate, the teeth are unlikely to be in contact, and are likely to leave their lips open and swallow involving their facial musculature disrupting their occlusion and growth.  They grow very much in excess of 40 degrees, often in the region of 90 which lengthens and shallows their maxilla.  

 

Their cranial base angle is likely to be more obtuse, bringing the mandible back and rotating down leading to a weak,receding, long chin and short ramus.  Their cranial bones are likely to be mis-placed and their cranial base is likely to be longer, leading to a more dolichocranial headform (distance from S to N).  It can even be argued that the frontal sinus (brow bone) size increases in these individuals, as these frontal sinuses respond to greater respiratory demands such as larger noses and lungs in males, and maybe even an airway restriction. This includes their sphenoid bone, where the point Sella (S) is based on.  This bone is likely to be placed and rotated too far down.  According to John Mew this makes the S-N plane too unreliable as a plane of reference, a far better one would be the F-N plane (Frontal-Nasion).  This point F lies 50 mm above the nasion, so as to avoid the big frontal sinuses discrepancies (so called ‘brow bones’)especially found in males.  

(Enlow and Hans 1996)

Comparison of vertical vs horizontal grower in S-N line by Bjork

 

See how superimposing on the S-N line fails to show most vertical differences:

 

This is John Mew's F-N plane, which attempts to illustrate this better:

Their cranial base angle is likely to be more obtuse, bringing the mandible back and rotating down leading to a weak,receding, long chin and short ramus.  Their cranial bones are likely to be mis-placed and their cranial base is likely to be longer, leading to a more dolichocranial headform (distance from S to N).  It can even be argued that the frontal sinus (brow bone) size increases in these individuals, as these frontal sinuses respond to greater respiratory demands such as larger noses and lungs in males, and maybe even an airway restriction. This includes their sphenoid bone, where the point Sella (S) is based on.  This bone is likely to be placed and rotated too far down.  According to John Mew this makes the S-N plane too unreliable as a plane of reference, a far better one would be the F-N plane (Frontal-Nasion).  This point F lies 50 mm above the nasion, so as to avoid the big frontal sinuses discrepancies (so called ‘brow bones’)especially found in males.  

 

Many cases of vertical growth also have very crowded teeth, narrow palates, and poor maxillomandibular relationships.

Their indicator and cheek lines are several millimeters and degrees too far from the accepted ideals.  They can have many distinguishing features to their face. 

 

What can we do as non growing adults?

 

In children the treatment consists of changing rest oral posture and guiding the direction of growth, and perhaps even changing some of the bone itself via expansion, protraction, intrusion, and alveolar reformation to aid in this process (this can still be done to a small extent with devices for adults).  Since the vertical component is limited in a child, growth must come out horizontally.  Picture a clay ball that is being squished from the bottom, it must splay out.

As adults, there is no growth to guide so we are playing a completely different game here.  The sutures are tremendously hard to open and keep open and the cranial base has fused.  The peripheral deposition and resorption have slowed down to approximately 10 percent of what they were in children.   They have passed the phase of growth and entered into the phase of bone homeostasis, where osteoblasts and osteoclasts work in harmony to preserve the shape and mass of the bone.  But these same cells may be able to adapt to the demands placed on them, albeit much slower.  Therefore, this is not growth, but adaptation.

Let us first look at what is done during major bimaxillary surgeries:

 

 

The lower maxilla (primarily alveolar portion) is moved forward and up in a counterclockwise fashion.  The rotational element is either done via removing bone from the top of this segment (especially in cases of a gummy smile) or it is done by bringing the back of the maxilla down.  Personally, I don’t believe bringing the back of the maxilla down is the way to go, rather this is simply a way the surgeon compensates for the excess of basal vertical growth in the maxilla (lengthening of the mid face, which no surgery can truly correct) and lack of incisor centered forward growth rotation of the mandible. 

The mandible is then brought forward and up via incision.  The patient is then given a sliding genioplasty for the chin and sometimes a procedure like a bone graft or distraction for the ramus. These two latter elements are done to simulate that incisor-centered forward rotation that occurs during good growth.

 

The patient is then often given cheek (malar/paranasal) cosmetic augmentation along with a rhinoplasty (nose surgery), and this can be done with implants and cartilage resectioning and fillers. 

 

 

How can we do this nonsurgically?:

What is absolutely amazing is that even these major surgeries that literally cut and reposition bone and bolt it to a new position with plates and screws often STILL relapse after several years, due to the muscular tensions and incorrect posture pulling them back over the years.  This shows that nonsurgical change is definitely possible in an adult.

A shows presurgical, B shows immediately postsurgical, C shows 2 years after the surgery.  You can already see some relapse and its effect on the face.  If this proceeds for more years, the patient will look just like they did before surgery.

 

Another example of change being possible in adults is certain tumors of the bone that grow tremendously slowly and with soft force that push the bone out of its position and shape.  Mike Mew mentioned this in his hard vs soft mewing Q&A with this website.

 

This is a cross section of the skull, the spongy parts are trabecular bone, whereas the sheet-like thinner parts are cortical bone.

 

 

We know that the maxillary alveolus is modifiable. FAGGA attempts to modify the alveolus, albeit in my opinion in a dangerous way. The best way to achieve change in the position of the lower maxilla is to keep one’s teeth in gentle contact (for the vertical posterior component via intrusion of the molars and slow reformation of the basal cortical bone in the back of the maxilla), and the tongue on the palatal ruggae near the incisive papilla (the “spot”/ “n” positon) to push the alveolar bone and the trabecular bone of the lower maxilla up and forward (this portion includes the base of the nose).  This will happen through positional remodeling from the tongue pushing.  This takes care of the lower maxilla and parts of the upper maxilla due to proximity of force (especially the cheek, eye, paranasal and nasal area) and can give that CCW-like effect, and may also help the shape of the nose due to the base of the nose also being the same as the upper palate.

 

(Gif)

 

Now comes the length of the midface and some elements of sagittal projection.  This would come from forces from the back third of the tongue and the teeth in gentle contact.  Over time, these gentle forces will cause greater sagittal projection and vertical reduction (mid face shortening) of these areas.  Since this area is made up mainly of cortical bone, the changes will be slower.

 

(Gif)

 

Now we have a nice shaped and placed maxilla, but what about the mandible? Since the teeth are in contact, the mandible will swing up.  But often there will still be a large overjet.  This is where jaw jutting comes in, where the mandible is held in a forward position for most of the day and functionally performs there, thereby allowing the TMJs to reform in the new position, even in adults! See this video by Dr. Derek Mahony (link) for more on this.  Often even this is not sufficient for a good ramus length or chin projection, as incisor-centered forward rotation has not happened, and cannot happen since the adult is non-growing.  This is why I propose the following to mimic this.  It will have to be a combination of lower incisor retraction (from both lip seal and pushing up against the upper incisors with the lowers, resembling a jaw surgery decompensation) and chewing to increase the masseter size, such that this muscle’s attachment on the lower ramus creates a gonial eversion by pulling on the bone which resembles a long, properly grown ramus.

 

(Gif rotation) 

(Gif jutting)

 

(Gif incisor retraction, forward movement, and gonial eversion)

 

Because the jaw is jutted and remodeled forward and upward (postural tensions from the temporalis at play here as well) and the maxilla is in the optimal position, the remainder of the cranium such as the sphenoid, cranial bones, will slowly remodel into the right position.  The cranial base area known as the spheno-occiptial synchondrosis which is the fusion (shortly after puberty ends) between the sphenoid and occipital bone  and makes up the cranial base angle, will slowly remodel into a more acute angle since it is consisting of trabecular bone.

 

(Gif changes in the cranial bones)

 

Keep in mind, all of these changes involve gentle, long-term and consistent forces.  This is not about pushing the maxilla up, but rather, shortening it with long-term gentle force as well as optimizing its position and shape in other ways.  All of these components will happen all at once too so at no point will the face look oddly imbalanced.  Are there devices that can do some of this or assist? Sure, but keep in mind that they assist you and they will likely relapse if you fail to maintain a good oral posture.  Plus, many devices can move too fast and hard for the bone to handle, but it is rare for posture to do the same.

 

It may also be possible to speed up the remodeling of this bone, but more research must go into that.

 

 

Quote
Topic starter Posted : 08/02/2021 7:56 pm
skethoskope, MewYouSinners, smot and 3 people liked
ThaGangsta
Eminent Member

Continued:

The video by Dr Mahony is this: https://www.youtube.com/watch?v=QRgrZ45B9J8&ab_channel=DrDerekMahony

Starting at 01:02:19 he goes into this concept of condylar remodeling and the muscles adapting to a new mandibular position.

 

Coming back to the surgical example used:

If this young lady had grown well, she'd have looked more like this compared to her surgery result

And this is compared to her presurgical face

 

Some appliances that can help are the

Biobloc stage 1 which expands the maxilla making more tongue space and this expansion alone can result in a millimeter or two of forward movement itself, reforms the alveolus, through pushing the upper incisors very gently (much lighter force than FAGGA) allowing for slow changes to the alveolus.

Any other expander that can disarticulate sutures can do as well such as MSE

A facemask that pulls in a proper vector which can maybe give a couple milimeters of the needed change

A Biobloc stage 3, which can help train to keep the mouth closed and held forward without pulling the maxilla back as reciprocal action, especially in those with large overjets.

But I don't think any appliance beyond long term posture will achieve significant changes. 

 

ReplyQuote
Topic starter Posted : 08/02/2021 8:46 pm
Loliboly, mr.mewing, TGW and 1 people liked
ThaGangsta
Eminent Member

And now a comparison between the skull I demonstrated on from beginning to end:

 

ReplyQuote
Topic starter Posted : 08/02/2021 10:09 pm
Progress
Member Moderator

Excellent post! 👍 

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Posted : 09/02/2021 6:07 am
Progress
Member Moderator

Perhaps instead of the S-N or F-N plane we could create useful superimpositions by using the orbital, lambdoid suture and possibly the TMJ as anchor points? This results in a fairly stable comparison:

 

ReplyQuote
Posted : 09/02/2021 4:24 pm
mr.mewing
Estimable Member

Good post! but I have a question what about a double jaw surgery where they put metal plates in the jaws to keep it together do those cases also see relapse?

ReplyQuote
Posted : 09/02/2021 5:21 pm
ThaGangsta
Eminent Member
Posted by: @progress

Perhaps instead of the S-N or F-N plane we could create useful superimpositions by using the orbital, lambdoid suture and possibly the TMJ as anchor points? This results in a fairly stable comparison:

GIF 09 02 2021 20.50.49

Perhaps.  One needs to note the TMJ position can change based on cranial base angle changes. The orbital rim is a possibility, especially the upper right portion, which isn't affected much by maxillary, zygomatic, or "brow bone" (Frontal sinus) position.  The lambdoid suture is another possibility, the thing is that I don't know if the occipital bones move intraskeletally or if it is just a change in head posture or both.

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Topic starter Posted : 09/02/2021 6:47 pm
ThaGangsta
Eminent Member
Posted by: @mr-mewing

Good post! but I have a question what about a double jaw surgery where they put metal plates in the jaws to keep it together do those cases also see relapse?

A couple pics I found.  These cases relapse due to the muscular forces from their previous jaw alignment pulling the jaws slowly back over time.  Another example of this phenomenon is if you turn the MSE too slow, the screws literally move through the bone.

ReplyQuote
Topic starter Posted : 09/02/2021 7:00 pm
auxiliary
Reputable Member

This isn't a bad thread, but it's based on too much theory. The problem with jutting or keeping your teeth together is that you're more likely to just push your teeth deeper into their gums instead of actually changing the face.

 

It's good that you noticed that the relative position of the lower teeth to the mandible has a huge effect on the position of the mandible, but what you don't know is that in most people the teeth are already packed all the way to the ramus. The ramus directly prevents the teeth from moving backward.

 

The only way to achieve the movement of the lower teeth that you mentioned is to expand the front upper and lower palate sideways:

 

Image result for prehistoric man palate

Image result for prehistoric man palate

 

Image result for palate

 

 

Image result for palate

 

Notice the difference between the palates. It's the width in the front that makes all the difference.

 

BY WIDENING THE FRONT PALATE, YOU WILL PUSH THE FRONT TEETH BACKWARDS:

 

 

This will push your mandible forward relative to your palate.

 

ReplyQuote
Posted : 10/02/2021 5:53 am
Progress
Member Moderator
Posted by: @auxiliarus

BY WIDENING THE FRONT PALATE, YOU WILL PUSH THE FRONT TEETH BACKWARDS:

Or is it the other way around, i.e. by pushing the front teeth backwards, you will widen the palate? This would be in line with John Mew's view of individuals with proper lip seal having wide and straight arches. Assuming that the dental arch functions like a roman arch, pushing the keystone and the surrounding stones (=anterior teeth) inward would have a widening effect on the whole arch.

 

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Posted : 10/02/2021 7:39 am
toomer
Estimable Member
Posted by: @mafiagang

A shows presurgical, B shows immediately postsurgical, C shows 2 years after the surgery.  You can already see some relapse and its effect on the face.  If this proceeds for more years, the patient will look just like they did before surgery.

This is very interesting, and is in-line with what a lot of the "neuromuscular" TMJ folks will say - that in the long-term, muscles will win out over bone.

Of course, the oral surgeons think that's hogwash.  But this relapse case really kind of proves it.

Do you have more detail/background on this case?

ReplyQuote
Posted : 10/02/2021 9:58 am
ThaGangsta
Eminent Member

@auxiliarus

Hence why light contact is key, clenching the teeth just intrudes them, but keeping them in that 'butterfly bite' allows for much slower forces that travel and compress bone.  I am not against the posterior maxilla going up/compressing, so long as the anterior maxilla goes even further up/compresses.  One must note that the molars are right next to the cheekbones and eye support, you can feel it in your mouth itself

 

@auxiliarus 

 

@progress

 

If you actually push the lower teeth back, be it with jutting or mechanics, you may actually widen the lower arch a little (as ironic as it sounds) due to the sagittally compressive forces splaying them transversally see this pic:

 

The ramus may also remodel and upright in some cases (due to its remodeling potential) when teeth are pushed towards it.

 

@toomer

https://www.researchgate.net/publication/329505571_Recurrence_of_the_Anterior_Open_Bite_After_Orthognathic_Surgery_3D_Analysis_of_Dental_Soft_Tissue_Skeletal_and_Airway_Changes_in_Unravelling_the_Aetiology_of_Relapse

Here is the paper I found this in.

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Topic starter Posted : 10/02/2021 1:40 pm
auxiliary
Reputable Member
Posted by: @progress
Posted by: @auxiliarus

BY WIDENING THE FRONT PALATE, YOU WILL PUSH THE FRONT TEETH BACKWARDS:

Or is it the other way around, i.e. by pushing the front teeth backwards, you will widen the palate? This would be in line with John Mew's view of individuals with proper lip seal having wide and straight arches. Assuming that the dental arch functions like a roman arch, pushing the keystone and the surrounding stones (=anterior teeth) inward would have a widening effect on the whole arch.

 

This is a very interesting point actually.

 

Assuming what you say is true:

1) Maxilla will be pulled backwards, along with the whole palate.

2) The mandible will stay in the same place relative to the head, thus relative to the maxilla, the mandible will move forward.

 

But what is a proper lip seal? My mouth is always closed/my lips are always closed and I still have lower teeth protrusion. Not only that, but my lower teeth are already jammed up against my ramus. Of course the teeth can still widen, which can pull them backwards slightly .

 

I even tried to fix my lower teeth protrusion, it worked for a while, then it relapsed There's just simply no way for me to put my lower teeth back without widening my lower arch, seeing that my rear teeth are already jamming against my ramus.

Here is what I mean with lower teeth protrusion:

And my ear angle has only worsened with all the forward growth I've gotten. My ears look Elven as hell.

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Posted : 10/02/2021 1:49 pm
auxiliary
Reputable Member

@mafiagang What about the devastating effect of shortening the face on the skin around it? The skin becomes saggy and thick, no?

 

Also have you considered that the tongue is able of vacuuming the lip seal towards the teeth?

 

I find that with jutting my teeth keep sliding off forward, only by vacuuming the lip seal with my tongue am I able to jut without the sliding. But I can't maintain tongue posture if I do this vacuum, it's impossible.

ReplyQuote
Posted : 10/02/2021 2:00 pm
ThaGangsta
Eminent Member

 

Posted by: @auxiliarus

But what is a proper lip seal? My mouth is always closed/my lips are always closed and I still have lower teeth protrusion. Not only that, but my lower teeth are already jammed up against my ramus. Of course the teeth can still widen, which can pull them backwards slightly .

How about pushing the lower incisors against the uppers gently?  That can definitely help.

Posted by: @auxiliarus

What about the devastating effect of shortening the face on the skin around it? The skin becomes saggy and thick, no?

Yeah that can happen.  But if its done slowly, you won't have much of that. Just like weight loss, the faster the weight is lost the more loose skin is left.  With a positive change the soft tissues like skin and cartilage will both stretch in some areas and contract in others.

Posted by: @auxiliarus

 

 

Also have you considered that the tongue is able of vacuuming the lip seal towards the teeth?

 

I find that with jutting my teeth keep sliding off forward, only by vacuuming the lip seal with my tongue am I able to jut without the sliding. But I can't maintain tongue posture if I do this vacuum, it's impossible.

Apart from the jutting, most of this should be very subconscious/bordeline subperceptible such as a very light vacuum seal.  That may help you

ReplyQuote
Topic starter Posted : 10/02/2021 3:55 pm
auxiliary liked
toomer
Estimable Member

@mafiagang 

Thanks for the link to the relapsed orthognathic surgery case.  Seems they blame it solely on airway, and that the patient continued to mouth breathe.  Amazing that even with titanium pins in there, if breathing isn't right the body still bent the jaws back to where it wanted them to be.

Biobloc stage 1 which expands the maxilla making more tongue space and this expansion alone can result in a millimeter or two of forward movement itself, reforms the alveolus, through pushing the upper incisors very gently (much lighter force than FAGGA) allowing for slow changes to the alveolus.

Would you put Vivos DNA into this category as well?  Similar to Biobloc I think in terms of lateral expansion - which as you point out, should also get you a mm or two of forward movement.  And there are the light force springs on the front, six of them - one per tooth - so that each interaction is customized to each tooth.  These are pushing very very lightly at rest, and they cycle a bit more force intermittently when the patient swallows or bites/clenches, and then they go back to very light force at rest.  It's believed that this intermittent cycling of force (unlike a fixed constant force like a FAGGA) is better at creating bone growth (wear time for DNA is only 12-16 hours in order to give the body and oral structures time to rest).

 

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Posted : 10/02/2021 4:11 pm
ThaGangsta
Eminent Member
Posted by: @toomer

Would you put Vivos DNA into this category as well?  Similar to Biobloc I think in terms of lateral expansion - which as you point out, should also get you a mm or two of forward movement.  And there are the light force springs on the front, six of them - one per tooth - so that each interaction is customized to each tooth.  These are pushing very very lightly at rest, and they cycle a bit more force intermittently when the patient swallows or bites/clenches, and then they go back to very light force at rest.  It's believed that this intermittent cycling of force (unlike a fixed constant force like a FAGGA) is better at creating bone growth (wear time for DNA is only 12-16 hours in order to give the body and oral structures time to rest).

I think a good analogy of intermittent force can be to the swallowing that we do a few times a minute.  That may have some kind of effect, perhaps micro fracture to the bone?  I know FAGGA can be downright dangerous because of how much force and speed it uses and it can push incisors through the bone, essentially killing the teeth.  Plus all that force can kill the bone tissue by stopping circulation to teeth/bone by compressing it, I think that is why biobloc and similar appliances are removable so that blood circulation can be restored in the time they are out of the mouth daily.   A much slower force would push the teeth from the apex/incisal tip, allowing them to tilt rather than bodily move, then supporting them in that forward position while a lip seal uprights them and allows for new alveolar bone to grow around them while they upright.

I used to think DNA was a scam but I've changed my opinion.  There are clear visible facial changes from DNA/Homeoblock and they are positive changes even if they are subtle.  There are also very clear sutural changes from MSE, but you would have to show me a result that has created positive aesthetic change, I am yet to find one.  I have seen both MSE and DNA/Homeoblock create positive functional change though.

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Topic starter Posted : 10/02/2021 4:32 pm
greyham liked
toomer
Estimable Member

@mafiagang Exactly.  Depending on which numbers you buy into, we either swallow around 700 times a day, or 2,000.  And supposedly the force generated by a swallow is about 4lbs - not sure where it's measured though.  So for a patient wearing a DNA Appliance, each swallow creates a small pressure signal against the teeth for an split second - I wouldn't say it's a "micro fracture" as that's thinking too mechanically.  Dr. Singh believes that there are pressure-sensitive cells in the peridontium which pick up on this and over time create a genetic response.  When you think about it, teeth are unbelievably sensitive.  Got some egg shell in your scrambled eggs?  Your teeth pick up on it in an instant.

The body of the DNA is intentionally spaced off of the palate, so that there's a small gap between the top of the appliance and the roof of the mouth.  Saliva collects there, and then with each swallow this - according to the inventor's beliefs - creates a negative pressure differential on the mid-palatal suture.  So each swallow creates both a forward signal on the front six teeth (independent to each tooth) as well as a simultaneous downward pull on the suture.  Hundreds of times a day, every single day.

And that's where DNA is quite different from FAGGA.  FAGGA is 24x7 constant force.  DNA is intermittent during the wear hours, and then there are non-wear hours to allow a bit of relapse ... as the alternating between expansion and relapse is actually also believed to contribute to bone growth.

And with each expansion of the appliance's screws - over time, what DNA seems to end up doing is tricking the body into believing it's got an ever-growing tongue.  If/when the top of the appliance starts making contact with the palate, the provider shaves it back down at the next adjustment appointment.  And so the body just adapts to that ever-growing tongue and alters the jaws by the same type of adaptation you're seeing here with this patient.  Not much (if anything) about what happened to that poor girl by the 3rd photo had anything to do with the mid-palatal suture.  The body literally bent the front of the maxilla back upwards again.

ReplyQuote
Posted : 10/02/2021 4:51 pm
auxiliary
Reputable Member
Posted by: @mafiagang
Posted by: @toomer

Would you put Vivos DNA into this category as well?  Similar to Biobloc I think in terms of lateral expansion - which as you point out, should also get you a mm or two of forward movement.  And there are the light force springs on the front, six of them - one per tooth - so that each interaction is customized to each tooth.  These are pushing very very lightly at rest, and they cycle a bit more force intermittently when the patient swallows or bites/clenches, and then they go back to very light force at rest.  It's believed that this intermittent cycling of force (unlike a fixed constant force like a FAGGA) is better at creating bone growth (wear time for DNA is only 12-16 hours in order to give the body and oral structures time to rest).

I think a good analogy of intermittent force can be to the swallowing that we do a few times a minute.  That may have some kind of effect, perhaps micro fracture to the bone?  I know FAGGA can be downright dangerous because of how much force and speed it uses and it can push incisors through the bone, essentially killing the teeth.  Plus all that force can kill the bone tissue by stopping circulation to teeth/bone by compressing it, I think that is why biobloc and similar appliances are removable so that blood circulation can be restored in the time they are out of the mouth daily.   A much slower force would push the teeth from the apex/incisal tip, allowing them to tilt rather than bodily move, then supporting them in that forward position while a lip seal uprights them and allows for new alveolar bone to grow around them while they upright.

I used to think DNA was a scam but I've changed my opinion.  There are clear visible facial changes from DNA/Homeoblock and they are positive changes even if they are subtle.  There are also very clear sutural changes from MSE, but you would have to show me a result that has created positive aesthetic change, I am yet to find one.  I have seen both MSE and DNA/Homeoblock create positive functional change though.

That's because those appliances are made for functionality such as improved breathing. Aesthetically wise it would be best to expand the front palate. Also aesthetically wise forward growth matters much more than lateral expansion.

 

Another issue is that the expansion is so fast with those devices that the zygos simply don't follow the increase in width in a linear fashion.

 

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Posted : 10/02/2021 4:55 pm
ThaGangsta
Eminent Member
Posted by: @toomer

@mafiagang Exactly.  Depending on which numbers you buy into, we either swallow around 700 times a day, or 2,000.  And supposedly the force generated by a swallow is about 4lbs - not sure where it's measured though.  So for a patient wearing a DNA Appliance, each swallow creates a small pressure signal against the teeth for an split second - I wouldn't say it's a "micro fracture" as that's thinking too mechanically.  Dr. Singh believes that there are pressure-sensitive cells in the peridontium which pick up on this and over time create a genetic response.  When you think about it, teeth are unbelievably sensitive.  Got some egg shell in your scrambled eggs?  Your teeth pick up on it in an instant.

The body of the DNA is intentionally spaced off of the palate, so that there's a small gap between the top of the appliance and the roof of the mouth.  Saliva collects there, and then with each swallow this - according to the inventor's beliefs - creates a negative pressure differential on the mid-palatal suture.  So each swallow creates both a forward signal on the front six teeth (independent to each tooth) as well as a simultaneous downward pull on the suture.  Hundreds of times a day, every single day.

And that's where DNA is quite different from FAGGA.  FAGGA is 24x7 constant force.  DNA is intermittent during the wear hours, and then there are non-wear hours to allow a bit of relapse ... as the alternating between expansion and relapse is actually also believed to contribute to bone growth.

And with each expansion of the appliance's screws - over time, what DNA seems to end up doing is tricking the body into believing it's got an ever-growing tongue.  If/when the top of the appliance starts making contact with the palate, the provider shaves it back down at the next adjustment appointment.  And so the body just adapts to that ever-growing tongue and alters the jaws by the same type of adaptation you're seeing here with this patient.  Not much (if anything) about what happened to that poor girl by the 3rd photo had anything to do with the mid-palatal suture.  The body literally bent the front of the maxilla back upwards again.

I believe a lot of what you're saying is true as well.  One needs to look more into intermittent vs light constant forces to see the applications of both on bone shape and remodelling.  I think there is too much of a focus on sutural change when in fact much of it is through remodeling on a cellular basis (bone resorbed from one surface and deposited on another) and maybe a small amount of sutural change.

 

Posted by: @auxiliarus

That's because those appliances are made for functionality such as improved breathing. Aesthetically wise it would be best to expand the front palate. Also aesthetically wise forward growth matters much more than lateral expansion.

 

Another issue is that the expansion is so fast with those devices that the zygos simply don't follow the increase in width in a linear fashion.

I agree entirely!  Maxillary arch width has poor correlation with aesthetics, so long as it isn't excessively narrow.  I see many people with narrower than optimal arch widths who are otherwise still beautifully forward grown.  I think John Mew once said that the main purpose of expansion in the biobloc was to increase tongue space and for the reciprocal 2mm of forward movement that comes with it, instead it is the arch length and maxillary sagittal position being modified by the appliance that contributes most to the facial appearance.  

The zygomatic arch/bone won't follow the expansion much because cause these are some of the strongest points on the skull and the main resistance to expansion.  Thus, a high force and speed will simply jam the maxilla against it but maybe a slower speed would push the maxilla transversally against the zygos which will adapt and remodel to this.

 

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Topic starter Posted : 10/02/2021 5:21 pm
toomer
Estimable Member
Posted by: @mafiagang

One needs to look more into intermittent vs light constant forces to see the applications of both on bone shape and remodelling.  I think there is too much of a focus on sutural change when in fact much of it is through remodeling on a cellular basis (bone resorbed from one surface and deposited on another) and maybe a small amount of sutural change.

 

@greyham here has done a bit of that in a blog entry he wrote on bone remodeling and touches on intermittent cycling mentioned in research: https://cfs-survivors.org/blog/2020/09/19/does-the-vivos-dna-appliance-really-work-via-epigenetics/

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Posted : 10/02/2021 5:37 pm
Progress
Member Moderator
Posted by: @auxiliarus

But what is a proper lip seal?

Posted by: @toomer

The body of the DNA is intentionally spaced off of the palate, so that there's a small gap between the top of the appliance and the roof of the mouth.  Saliva collects there, and then with each swallow this - according to the inventor's beliefs - creates a negative pressure differential on the mid-palatal suture.  So each swallow creates both a forward signal on the front six teeth (independent to each tooth) as well as a simultaneous downward pull on the suture.  Hundreds of times a day, every single day.

It sounds like the DNA is successfully replicating the natural forces that would come into play with competent lip suction, or intra-oral vacuum if you will:

1. the springs mimic the lower arch pressing against the upper anterior arch.

2. the aforementioned negative pressure differential is a result of glossal-palatal suction (the posterior seal of the oral vacuum).

Both of these (should) take place once one attempts to vacuum the lips against the teeth. Beyond this, lip suction has a stabilizing effect on neck musculature, even engaging muscles below the occiput. It's fascinating how by focusing on just this one thing the rest of oral & cervical posture will almost magically fall into place.

This is partly a reply to your question too Aux.

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Posted : 10/02/2021 5:40 pm
toomer
Estimable Member
Posted by: @progress

It sounds like the DNA is successfully replicating the natural forces that would come into play with competent lip suction, or intra-oral vacuum if you will:1. the springs mimic the lower arch pressing against the upper anterior arch.2. the aforementioned negative pressure differential is a result of glossal-palatal suction (the posterior seal of the oral vacuum).Both of these (should) take place once one attempts to vacuum the lips against the teeth. Beyond this, lip suction has a stabilizing effect on neck musculature, even engaging muscles below the occiput. It's fascinating how by focusing on just this one thing the rest of oral & cervical posture will almost magically fall into place.

I'd say that's a fair assessment.  That's why the inventor typically describes it as a "biomimetic" appliance - it's basically trying to mimic the proper interactions of all the things you just mentioned, but for those of us with collapsed arch forms our tongues just won't get up there and we won't ever be able to replicate that.  We can't just "mew" our way out of where we might be at.

So along comes this thing, it mimics a tongue ... things space out a bit, then suddenly the tongue gets a little bit wider and longer every week or two ... and the body keeps adapting and adapting on its own with each and every swallow, until you (hopefully) achieve what you're generically capable of in terms of upper and lower arch shape, form, etc.

At least, that's the theory.  But unfortunately the inventor has been a bit too obsessed with buzzwords (epigenetic, biomimetic, pneumopedic) and that causes some to think it's just snake oil.  But he's spent 20 years studying sutures and airways, I don't think he's peddling a bogus cure.  Will it work for everyone and every situation?  Probably not - they are targeting it specifically for OSA patients like me.

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Posted : 10/02/2021 6:13 pm
ThaGangsta
Eminent Member
Posted by: @mafiagang

The zygomatic arch/bone won't follow the expansion much because cause these are some of the strongest points on the skull and the main resistance to expansion.  Thus, a high force and speed will simply jam the maxilla against it but maybe a slower speed would push the maxilla transversally against the zygos which will adapt and remodel to this.

 

@toomer

 

Went through Greyham's post and found this research done on slow maxillary expansion and facial changes:( https://www.sciencedirect.com/science/article/pii/S1808869415300513) ( https://pubmed.ncbi.nlm.nih.gov/16951848/).  Interesting stuff and would recommend a read.  

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Topic starter Posted : 11/02/2021 6:58 pm
greyham
Eminent Member
Posted by: @toomer
Posted by: @mafiagang

One needs to look more into intermittent vs light constant forces to see the applications of both on bone shape and remodelling.  I think there is too much of a focus on sutural change when in fact much of it is through remodeling on a cellular basis (bone resorbed from one surface and deposited on another) and maybe a small amount of sutural change.

 

@greyham here has done a bit of that in a blog entry he wrote on bone remodeling and touches on intermittent cycling mentioned in research: https://cfs-survivors.org/blog/2020/09/19/does-the-vivos-dna-appliance-really-work-via-epigenetics/

Hmmm... interesting. I'm learning a lot here, so thanks @ThaGangsta for kickstarting the discussion.

This post also covers research I did on intermittent cyclic forces: The Optimal Daytime Usage Pattern For Adult Oral Expansion Appliances

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Posted : 11/02/2021 8:39 pm
Basim
Eminent Member
Posted by: @mafiagang

@auxiliarus

Hence why light contact is key, clenching the teeth just intrudes them, but keeping them in that 'butterfly bite' allows for much slower forces that travel and compress bone.  I am not against the posterior maxilla going up/compressing, so long as the anterior maxilla goes even further up/compresses.  One must note that the molars are right next to the cheekbones and eye support, you can feel it in your mouth itself

 

@auxiliarus 

 

@progress

 

If you actually push the lower teeth back, be it with jutting or mechanics, you may actually widen the lower arch a little (as ironic as it sounds) due to the sagittally compressive forces splaying them transversally see this pic:

 

The ramus may also remodel and upright in some cases (due to its remodeling potential) when teeth are pushed towards it.

 

@toomer

https://www.researchgate.net/publication/329505571_Recurrence_of_the_Anterior_Open_Bite_After_Orthognathic_Surgery_3D_Analysis_of_Dental_Soft_Tissue_Skeletal_and_Airway_Changes_in_Unravelling_the_Aetiology_of_Relapse

Here is the paper I found this in.

So you shouldn’t have teeth contact unless you good occlusion because I am doing teeth contact and I am wondering if this is bad while you are Mewing with a malocclusion and overbite.

 

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Posted : 16/02/2021 11:50 am
ThaGangsta
Eminent Member

@basim

Teeth should still be in gentle contact as long as you are class 1 (no overjet/excessive deep bite).  You have a lot of spaces in your teeth so it is very likely you're pushing on the teeth with the tongue at rest and especially when swallowing. 

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Topic starter Posted : 17/02/2021 5:37 pm
Basim
Eminent Member
Posted by: @mafiagang

@basim

Teeth should still be in gentle contact as long as you are class 1 (no overjet/excessive deep bite).  You have a lot of spaces in your teeth so it is very likely you're pushing on the teeth with the tongue at rest and especially when swallowing. 

Well I have a class 2 bite with a deep bite in the back and a slight overbite in the front. Plus I have my wisdom teeth erupting. But I am quite recessed. So should I still keep my teeth in contact.

 

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Posted : 19/02/2021 11:16 am
ThaGangsta
Eminent Member

@basim

I'd advise keeping teeth in very gentle contact, they should barely be touching.  Since your bite is deep your incisors will touch before your molars, try to get all the teeth to just barely touch.  That's what I'd recommend.

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Topic starter Posted : 19/02/2021 10:28 pm
Basim
Eminent Member

@mafiagang

I see, I still have a few issues on this, as my posterior 2nd molars( top and bottom) still don’t touch all the way down and have a cross bite on my left side where my premolars don’t touch since my maxilla significantly wider than my mandible but also have a vaulted palate. So I do wonder having a light contact on teeth would change my occlusion where it can be straight or should I get insvilagin to solve this issue? Explain how this would effect on a person with a malocclusion?

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Posted : 20/02/2021 5:22 pm
ThaGangsta
Eminent Member

@basim

Do you have a pic of your natural bite?  I think it'd be helpful to see a pic before specific recommendations.  

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Topic starter Posted : 21/02/2021 11:07 pm
Basim
Eminent Member

 

 

@basim

Do you have a pic of your natural bite?  I think it'd be helpful to see a pic before specific recommendations.  

Sure, here is my bite

 

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Posted : 23/02/2021 11:34 am
ThaGangsta
Eminent Member

@basim

You do have a considerable midline shift.  But from what I can see this midline shift seems mostly dental, unless you have actual asymmetry of your jaw/chin that isn't visible in the pic.  If you are having specific teeth erupting problems, it is very possible it is because the tongue a little bit wedged between those teeth or your maxillary arch is just excessively wide relative to the mandibular arch with space between teeth, perhaps from tongue also pushing on the teeth, so these gaps would have to slowly close.  While good oral posture can fix this problem, it can take many years and may be unpredictable. Since your case is a bit more complex, I would say you don't have anything to lose by consulting a orthodontist, so long as they aren't pulling teeth and using restrictive mechanics.

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Topic starter Posted : 23/02/2021 5:40 pm
Basim
Eminent Member
Posted by: @mafiagang

@basim

You do have a considerable midline shift.  But from what I can see this midline shift seems mostly dental, unless you have actual asymmetry of your jaw/chin that isn't visible in the pic.  If you are having specific teeth erupting problems, it is very possible it is because the tongue a little bit wedged between those teeth or your maxillary arch is just excessively wide relative to the mandibular arch with space between teeth, perhaps from tongue also pushing on the teeth, so these gaps would have to slowly close.  While good oral posture can fix this problem, it can take many years and may be unpredictable. Since your case is a bit more complex, I would say you don't have anything to lose by consulting a orthodontist, so long as they aren't pulling teeth and using restrictive mechanics.

I see, I do have a slight asymmetry of my jaw of my right being slightly higher than my left side. And I have my wisdom teeth erupting without any pain. My posterior 2nd molars on both sides are not touching and not fully erupted. My IMW is about 38-39 mm and my palate is very vaulted. Would getting Invisalign be a good option for straighting my teeth and fixing my bite and occlusion to be my teeth in natural contact? Since I have consulted my orthodontist and said that my case was pretty mild and I didn’t necessarily need braces to fix my bite expect for my overbite which you can see in the photos where my upper teeth are quite deep into my lower teeth. So do you think Invisalign or getting a palatable expander would be the best option to improve my situation and mewing.

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Posted : 25/02/2021 10:48 am
ThaGangsta
Eminent Member

@basim

I think invisalign is a good choice for you.  Make sure you aren't pulling the upper teeth back with the movement or opening the bite up with overextrusion of the molars, they can have bad effects too.  Look into palatal expansion too (though 38-39 is decently wide).  It is hard to wait/allow those 2nd molars to naturally erupt due to the possibility of the tongue wedging them preventing eruption.

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Topic starter Posted : 02/03/2021 4:42 pm