From a presentation for the Myofunctional Research Company by Dr. Barry Raphael, September 2014. All rights reserved.

1. My Journey in Orthodontics
Toronto, Sept 13, 2014
Rancho Cucamonga, Sept 21, 2014
Barry Raphael, DMD!
!
The Raphael Center for Integrative Orthodontics
The Raphael Center for Integrative Education
!
Clifton, New Jersey
!
!
www.alignmine.com
www.learnairwayortho.com

2. RO since1983 (31 years...yikes)
Bucknell University 1974
University of Pennsylvania DMD1978
(Three Years in General Practice)
Fairleigh-Dickenson University Ortho 1983

3. Right out of school

4. Functional Orthodontics
Frankel
Bionator
Twin Block
MARA
Herbst

5. 2008
Soft Tissue Dysfunction
is THE cause of
malocclusion

6. Myofunctional Research Co.

7. Spring, 2009 MRC meeting, Chicago > Terry Carlyle
September, 2009 MRC conference, Coral Gables, Fl.

8. Myofunctional Orthodontics
Chris Farrell
John Flutter
German Ramierez
Damien O’Brien
Myofunctional Research Co.
Rancho Cucamonga
2008-2012

9. Oral Myology
Oral Myology: Levels 2, 3
Kim Benkert
Clifton 2012
Habit Cessation
Shari Green
Clifton, 2013
Joy Moeller
NYC 2011
San Diego 2012

10. Biobloc Orthotropics
BBO Mini-residency
Bill Hang
Agora Hills
2012-13
BBO Intensive
Drs. John and Mike Mew
LSFO
2013

11. Breathing and Sleep
Buteyko Mentorship
The Breathing Center
Woodstock
2010
Breathing Well Programme
John Flutter
2010
Sleep Dentistry
Michael Gelb, et.al
Ortho-Postural Training
Roger Price
2013
NYU
2012,2013

12. Cranial Osteopathy
Advanced Dento-cranial Orthopedics
Bob Walker
2014
Cranial Academy: Basic
ALF, The Team Approach
Jim Bronson
2013
Course
January 2014

13. Teaching
Mt. Sinai Pedo Residency
Ali Attaie
2010-2014
Montefiore Ortho Residency
Tony Maganzini
2012
2009-Present

14. Airway and Facial Development
Collaborative Webcast
Mark Cruz

15. Myobrace Activity
Center
Myofunctional
Therapy
Bodywork
Ortho-Postural
training
Public and
Professional
Education

16. learnairwayortho.com

17. Bass players do it from the bottom up

18. My greatest dysfunction
“It’s all about
Barry
And The World
of
Mouthbreathing

19. Paradigm Shifts
• Malocclusion as a symptom
• STD as THE etiology
• Facial morphology as a risk factor
• The Child attached to the teeth

20. Paradigm Shifts
• Malocclusion as a symptom!
• STD as THE etiology
• Facial morphology as a risk factor
• The Child attached to the teeth

21. Malocclusion as a symptom
Malocclusion is the body’s solution
to provide equilibrium and homeostasis.

22. Malocclusion as a symptom
Perfect alignment is the
most stable.

23. Malocclusion as a symptom
Malocclusion is the
body’s solution to
provide equilibrium and
homeostasis
Upper Jaw and Teeth
Lower Jaw and Teeth
Tongue, MM, TMJ,Cranium
Posture, Breathing, Body

24. What’s the Rule?
Perfection Adaptation
Place the blue block where it will
balance the stack against gravity
or
Place the blue block directly on
top of the yellow block
The Angle classification

25. If we seek Perfection using the wrong rule (ie.Angle Class I)…
…we may “rebalance” the occlusion, but disturb the equilibrium

26. Orthodontic’s Solution
Retainer
Long-term retention is the
orthodontic’s solution to
provide equilibrium and
homeostasis…

27. Orthodontic’s Solution
Retainer
Long-term retention is the
orthodontic’s solution to
provide equilibrium and
homeostasis…
…but holding balance in
one part of the system
may aggravate an
imbalance elsewhere.

28. Orthodontic’s Solution
Relapse
Occlusal Wear
Occlusal Trauma
Bruxism
Joint Derangement
Referred Pain
Sleep Apnea
Assorted physical ailments

29. Integrative Ortho
Teeth and Occlusion
Tongue, MM, TMJ
Cranial and Cervical
Whole Body (resp,
circ, musc-skel, etc)

30. Malocclusion as a symptom
The Toothberg
Instead of crooked teeth being The Problem,
They are just a SYMPTOM of something larger

31. Paradigm Shifts
• Malocclusion as a symptom
• STD as THE etiology!
• Facial morphology as a risk factor
• The Child attached to the teeth

32. “….there is much circumstantial evidence that
jaws and faces do not grow to the same size
that they used to…” - Daniel Lieberman

34. The “Modern” Maxilla
The Gothic Arch The Roman Arch

35. How do you build an arch?
The Roman Arch

36. No scaffold?

37. 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

38. Those children who breathe 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.

39. Harvold’s Monkies

40. Posture changes Teeth
LOowpeerne dm mouatnhd pibouslatur rpeo rsetutarein, etodn fgoure 1 p yroetarur saifotne,r annods eo preeon pbeitneed.
Facial features retained

41. John Mew’s 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.”

42. John Mew’s 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…”

43. The Tropic Premise
If the tongue is chronically held away from the palate…
…the maxilla collapses in all three dimensions.

44. Then the Mandible Adapts
If the mandible keeps up: Class I Crowded

45. Then the Mandible Adapts
Mouthbreathing and/or tongue thrust hinders growth : Class II

46. Then the Mandible Adapts
Low Tongue keeps mandible growing forward: Class III

47. The Tropic Premise

48. The Tropic Premise

49. Craniofacial Dystrophy
Insufficient Mid-Facial
Support
Nasal Cartilage
Collapse
Maxilla is
Down and Back
The Mandible is
Retrognathic

50. 2008
Soft Tissue Dysfunction
is THE cause of
malocclusion

51. Soft Tissue Dysfunction
issue”
the tissue is Cranimofaalcoicalc malocclusion tone but Dluyssiotrnophy
Bone sets the “- Mark Cruz
is THE cause of
The Maxilla and Upper Dentition take the
Shape of the Muscles and Muscular Functions
that Surround them.

52. Open Mouth Posture !
is the most common and significant
Soft Tissue Dysfunction
In children today.

53. Chronic hyperventilation
Hypocapnia
Craniofacial Dystrophy!
Reverse swallow
Facial muscle dysfunction
Lymph swelling
Nasal obstruction
Frequent ear infection
Snoring
SDB, UARS, OSA
Learning Dx
Heart rate variability
Enuresis
Poor posture
Malocclusion
Gingivitis
Halitosis
Open Mouth Posture
Birth trauma
Cranial strains
Poor posture
Bottle feeding
Soft diet
Processed foods
Immune challenges
Oxidative stress
Heat
Hyperventilation
Stress reactions
Habits
Dental pain
Ankyloglossia
Macroglossia

54. The Missing Link in Orthodontics Today...
It’s not just
Growth and Development
!
It’s
Growth, Development and
Adaptation

55. If Malocclusion is caused by
Growth and Development...
Total Growth
Genetics Epigenetics

56. If Malocclusion is caused by
Growth and Development and Adaptation...
Total Growth
Genetics Epigenetics

57. An example of “adaptation”

58. Identical twins with different habits
Dr. John Mew
orthotropics.co.uk

59. An example of adaptation
Two sets of twins…

60. Another set of twins
One of them has crooked teeth.

61. RHYHS -o 10wY 1d1Mid these teeth get this way?
3 August 2003 3 August 2003
Different genes than his brother?…

62. RHFYSo -u 1r4 Yy 5eMa rs later, after successful MFO
1 March 2007 1 March 2007
Text
(Treatment by Dr. Chris Farrell)

63. RHDYSi d& KgYeLEn - e13tYic 8sM make the teeth crooked?
RHYS - 16 AUGUST 2007 KYLE - 16 AUGUST 2007
Did genetics fix the face?
TRAINER BWS MYOBRACE MINIMAL SWA

64. Paradigm Shifts
• Malocclusion as a symptom
• STD as THE etiology
• Facial morphology as a risk factor!
• The Child attached to the teeth

65. Snoring
8-10%
The Spectrum of SDB
Normal
Prevalence:
OSAS
1-3%
UARS
?

66. • Short maxilla means smaller
airway
• Narrow maxilla puts
nasopharynx at risk for collapse
with loss of muscle tone
Anatomic Determinants of SleepDisordered Breathing Across the Spectrum of Clinical and Nonclinical Male Subjects*
Jerome A. Dempsey, PhD; James B. Skatrud, MD; Anthony J. Jacques, BS; Stanley J. Ewanowski, PhD; B. Tucker Woodson, MD; Pamela R. Hanson, DDS, MS; and Brian Goodman, PhD
CHEST September 2002 vol. 122no. 3 840-851

67. Which is easier to breathe through?

68. Which would you trust most?

69. Which would you rather have?
Analysis of anatomical and functional determinants of obstructive sleep apnea.
Aihara K, et. al ,Sleep Breath. 2012 Jun;16(2):473-81. Epub 2011 May 15.

70. Narrow Airway Dynamics
Narrow, irregular airway >
> increased shear forces >
> negative pressure pulls on soft tissue >
> tissue pulling and trauma (snoring) >
> impairment of mechanoreceptors >
> uncoordinated diaphragm and upper airway muscle contraction >
>DISORDERED BREATHING
Powell N, Guilleminault C. “Abnormal pharyngeal airflow in obstructive sleep apnea using computational fluid dynamics:
Feasibility study.” Proceeding of the 9th World Congress on Sleep Apnea (Seoul, Korea) 2009

71. Morphology and SDB in children
“Abnormal craniofacial morphology, but not excess
body fat, is associated with an increased risk of
having SDB in 6–8-year-old children.”
Ikävalko, et.al.,Eur J Pediatr (2012) 171:1747–1752

72. Everyday in my practice...

73. Damage to Cognitive Function
Childhood OSA is associated with
•Deficits of IQ
•Deficit of executive function
•Possible neuronal injury in the
hippocampus and frontal cortex.
Childhood Obstructive Sleep Apnea Associates with Neuropsychological Deficits and Neuronal Brain Injury
Ann C. Halbower, et.al, PLoS Medicine,August 2006 | Volume 3 | Issue 8 | e301

74. Breathing distress
• Constricted airway
• Head Extension
• Congestion
• Soft tissue collapse

75. Airway-Related Craniofacial Dysfunctions
•Chronic Naso-pharyngeal Obstruction
•Tongue form aberrations (Frenum and tongue-tie)
•Open Mouth Rest Posture
•Myofunctional disorders (Swallowing, chewing,etc.)
•Chronic Hyperventilation and Hypocapnia
•Breathing Disordered Sleep (OSA, UARS, snoring)
•Bruxism and parafunctions
•TMD and facial pain components
•Cranial and postural issues
• Malocclusion

77. Remember the Airway!
“Consequently the most important missing
diagnosis is the airway.
!
Nevertheless, breathing is the most
important action for human beings to live;
we forgot the airway to make a diagnosis
of the orthodontic patients.”
Orthodontic treatment in children to prevent sleep-disordered breathing in adulthood
Makoto Kikuchi, Sleep and Breathing Published online: 17 November 2005©

78. Treating the Cause
• Adult SDB and OSA
• Narrow Jaws and Faces
• Soft Tissue Dysfunction
• Early Parafunctional Habits, esp Open Mouth Posture
• Environmental Stressors
• CPAP, MARA,UPPP, Surg
Where’s the best
place to start
treatment? Here?
Or Here?

79. Paradigm Shifts
• Malocclusion as a symptom
• STD as THE etiology
• Facial morphology as a risk factor
• The Child attached to the teeth

80. The Child attached to the teeth
We treat the teeth attached to the child
AND
we treat the child attached to the teeth.

81. Don’t be a Barker

82. Don’t be a Barker

83. The Broken Door

84. The Broken Door

85. The Broken Door

86. The Broken Door

87. The Broken Door

88. The Broken Door
Persistant Organic
Polutants (POPs)
Chronic Autonomic Stressors
Post-Industrial Diet

89. Treating the Cause
TRAINING the Cause
• Early Feeding and Nutrition
• Allergies, Asthma, URT infections
• Posture and Cranial
• Airway, Breathing, and Sleep Disorders
• Soft Tissue Dysfunctions (Tongue Thrust, Open Mouth)
Instead of crooked teeth being The Problem,
They are just a SYMPTOM of something larger

90. It’s NOT about the Trainer
Part 1

91. It’s NOT about the Trainer
You mean I have to pay $7 for this?

92. It’s NOT about the Trainer
Now that’s a bowl of oatmeal! Yum!

93. It’s NOT about the Trainer
It’s about the VALUE you’re adding
Habit Training
Better Breathing
Nutrition
Trainer and
straight teeth
Overall health

94. It’s NOT about the Trainer
Part 2

95. It’s NOT about the Trainer
Which Hammer should I use?

96. It’s NOT about the Trainer
Which Trainer should I use?

97. It’s not the Trainer…
!
It’s the Training

98. The Child attached to the teeth

99. Batting Average?
Double:
Good Trainer Wear.
Braces 18mo, Easy Non-X
Triple:
Good Trainer Wear.
Braces 12 mo or
aligners to touchup
Home Run:
Great Trainer Wear.
No Braces Needed
Single:
OK Trainer Wear.
Braces 24 mo. Crowding
or OJ remain
Walk: Tries Trainer.
Can’t/Won’t do it.
Do Conventional Tx.
Strike out: Poor Wear. Case
Drags On.
Gets nowhere.
Braces are a compromise

100. Cases

101. July 2010
9-10y F
Class II div 1
Excess OJ/OB
Narrow arches
Lip Incompetence
STD
Mouth breathing

102. 12 month progress

103. 8 month progress

104. 12 month progress

105. Class II w rotated U6’s
Narrow and mild crowding
Lower midline to right
Crowding at LR4
Tight labial musculature

106. Upper BWS 4mos
T4K Soft, then Hard 9 mos
Lower BWS 2 mos
• Better arch width and form
• No crowding
• Molars still rotated

107. Upper BWS 4mos
T4K Soft, then Hard 9 mos
Lower BWS 2 mos
• Better arch width and form
• No crowding
• Enough space for LR4 (with leeway and midline shift)
• Available space on left to correct midline

108. Upper BWS 4mos
T4K Soft, then Hard 9 mos
Lower BWS 2 mos
• Reduced overbite
• No crowding
• Enough space for LR4 (with leeway)

109. C.F. 7-6F
OJ=7mm, Lost c-space, Open Mouth Posture

110. Developing the Arch
7-6yo
8-7yo
9-2yo 10-1yo

111. Recover Lost c-space
7-6yo
8-7yo
9-2yo 10-1yo

112. Recover Lost c-space
7-6yo
10-1yo

113. Better Lip Competence
7-6yo 10-1yo

114. C.F. 10-1yoF
Perm dentition. Still Class II Right

115. C. R. 10-8yo F
Late Mixed Dent
Crowded incisors
FaMu active swallow
Hypermentalis

116. 10-8yo
13-0yo
11-6yo
12-0yo

117. 10-8yo
13-0yo
11-6yo
12-0yo

118. 10-8yo
13-0yo
11-6yo
12-0yo
.012 Niti Wire Microbond
Composite Stops

120. J.S. 11-8yo F
I want
braces...
Just try it for a
coupla’ months...

121. Deep Bite Corrected
11-6yo
12-4yo

122. Class II Improved
11-6yo
12-4yo

123. Still want braces?

124. C.G. 9-10yo M

125. •

127. Thank you.
Fight the good fight!
drbarry@learnairwayortho.com