Dental-Cranial functional model and the understanding of cranial facial distortions in dentistry: A Commentary.
Revista Brasileira de Quiropraxia - Brazilian Journal of Chiropractic
Dental-Cranial functional model and the understanding of cranial facial distortions in dentistry: A Commentary.
The purpose of this presentation is to facilitate an understanding of cranial facial distortion (CFD) patterns as a reaction to compromised growth and development of the cranial facial structures, along with the results of these patterns on the whole bodyâ€™s kinematic chain. There are various factors that will be discussed which include cervical headgear (CHG) and its effect on craniofacial growth and development, the orthotropic paradigm, related sympathetic nervous system overload and stress, and suggestions for interdisciplinary treatment and prevention.
Cervical headgear (CHG) has been most commonly used to treat anteroposterior (class II) malocclusions for over a century1 . In its most common iteration, headgear attaches to the braces on the teeth via metal hooks or a facebow. Straps or a head cap anchor the headgear to the back of the head and/or neck. Elastic bands are used to apply pressure to the bow or hooks with the purpose of restricting maxillary growth so that the mandible is not too far posterior relative to the maxillary dentition. In general its purpose is to inhibit the upper jaw from growing, thereby preventing or correcting an overjet (maxillary incisors too far forward relative to the mandibular incisors).
While CHG may maintain an aesthetic maxillary and mandibular incisor positioning there are other secondary iatrogenic factors that many in the dental field have referred to as the â€œHeadGear Effectâ€ (HGE)2 . The (HGE) causes a cranial facial distortion (CFD) associated with alterations in the growth and development of the facial structures and due those modifications in craniofacial growth
and development compensations and distortions are subsequently developed throughout the entire musculoskeletal system. In order to better understand this phenomenon, the HEGâ€™s dental cranial relationship will need to be explored and discussed. As Isaac Newton noted there is always a cause and effect, an action and reaction3 ; in sacro occipital technique (SOT) terminology DeJarnette called this â€œresistance and contractionâ€ (R+C) factors4 .
There is published literature that discusses the effect of cervical headgear on the cranial base and the convexity of the maxillary profile. AliÃ³-Sanz et al noted that â€œcervical headgear treatment induced cephalometric flattening of the cranial base and a decrease of the angle measured from the anteroposterior relationship of the maxillary basal arch on the anterior cranial base5 .â€ Also Kirjavianen noted that â€œCervical headgear treatment in Class II correction is associated with a decreased facial convexity caused by the restriction of forward growth of the maxillary A-point, while the rest of the facial profile, including the mandible, continue to grow forward at a normal rate6 .â€
In traditional or orthodox orthodontic care, â€œheadgearâ€ conjures up an image of a childâ€™s face with straps that wrap around the head to some sort of metal bar that attaches to braces and mouth piece. As previously stated, the primary purpose of this is retraction and/or intrusion of maxillary teeth (pulling them toward the back of the head). Historically the orthodontic approach tended to focus on the belief that there are too many teeth (or the teeth are too big) for the mouth. Protocol in traditional orthodontics recommends the extraction of four bicuspids7 or premolars 8.9 to reduce crowding and make space so that they can then pull teeth together and straighten them.
However, there is significant concern amongst functional orthodontists that removing teeth can lead to various secondary issues aside from facial morphology10. For instance Broadbent noted that, â€œmost occlusal "chewing" function occurs with the first molar and premolar teeth. It is reported that 90% of chewing function occurs at the first molar and bicuspid region. Physiologically oriented orthodontists must consider: soft tissue profile and facial esthetics, incisal misguidance (interference), narrow or constricted maxilla, underdeveloped or retruded maxilla, overdeveloped or prognathic mandible (Class III actual of effective condition relative to maxilla), crowding or displacement of teeth, and (TMJ) temporomandibular joints must be considered11.â€
The functional dental approach as described by Broadbent believes traditional orthodonture creates posterior pressure on the remaining six front teeth, maxilla, cranium, and compromises the airway space12. A primary goal of traditional orthodontics is helping the patient to achieve an attractive smile with straight teeth along with an improvement in facial aesthetics. These traditional orthodontic modalities utilized are predominately braces and sometimes headgear. While traditional orthodontic perspectives support their methods of treatment,13 physiological based or functional dentistry questions the long-term effects of removing teeth.
Stack described how historically â€œproviders of orthodontic services were solely concerned with esthetic/cosmetic considerations of the teeth. In more recent years emphasis has been placed on the interdigitation of the teeth in centric occlusion combined with the absence of occlusal interferences in sliding/gliding jaw movements with the teeth in partial contact with each other (protrusive, cuspid disclusion, etc.)14.â€ He continued that, â€œstill more recently true jaw function, or, function of the entire stomatognathic system, as opposed to the more limited functional movement of the teeth as influenced by their inclined planes when in partial occlusion, has come to the fore14.â€
So in conjunction with removal of teeth and use of headgear, the term â€œheadgear effectâ€ (HGE) has been used in dentistry to describe the â€œdownward and backward growthâ€ of the oral facial structures even without the use of cervical headgear. This pattern of growth and/or development in SOT cranial terminology would be called a â€œcranial facial distortionâ€ (CFD), which can have a relationship to the cranial-sacral and the musculoskeletal systems as well as the oral facial structure.
Clinically it is believed that the CFD is associated with restricted or distorted growth patterns of the upper jaw inhibiting normal growth patterns, restricting upper arch width and/or length. Since the lower dentition will attempt to fit within the shape of the upper dental arch this upper arch restriction may lead to decreased growth and advancement of the lower jaw, commonly resulting in a narrowing and elongation of the face.
John Mew, DDS described a model of the growth and development of the oral facial structure which utilizes an â€œorthotropicâ€ (growth guidance) paradigm15. According to Mew, treatment to straighten crooked teeth treats only the symptoms, not the cause Mew proposes this is the reason there is commonly a relapse following completion of treatment. Often by removing teeth, this narrows and shortens the oral cavity ultimately hindering orofacial growth and development16.
Orthotropic paradigmâ€™s orthodontic objective is to facilitate growth of maxilla up and forward versus down and back. Mew believes that some types of malocclusion are related to vertical growth instead of horizontal. He suggests that cases should be started by eight years old, since it is around that age that maxillary growth and its affect on the cranium is most optimally controlled17. Instead of aesthetics, Mew believes that the most important factor to focus care is to change (expand) the shape of the dental arch as a means to restore nasal breathing and eliminate mouth breathing. By reestablishing a more protrusive mandibular position, this helps bring the tongue forward opening the airway space therefore helping to optimize TMJ position and function18.
Sympathetic Nervous System Overload and Psychogenic Stress
With the stresses or tensions associated with iatrogenically induced CFD and its affect on craniofacial growth, secondary effects such as temporomandibular joint disorders (TMD) and airway space compromise can create a cascade of clinical presentations. Research appears to have found a relationship between TMD and psychogenic or stress disorders19,20 that are experienced by orthodontic patients21.
From a chiropractic perspective it does seem reasonable to assume that stress to the craniofacial and cervical region could have an inhibiting factor on the parasympathetic system22 due to its compromise on the craniosacral autonomic outflow. So it is not unreasonable to find clinically that TMD patients who have had orthodontic care presenting with a HGE/CFD would be challenging chiropractic patients to treat. Clinically, patients presenting with HGE/CFD often, due to chronic nature of their condition, tend to be difficult, sensitive and psychologically challenged, due to their heightened sympathetic response that leads to reduced coping skills. In fact, at times this subset of patients may be so sensitive that typical high velocity, low amplitude manipulations are not possible due to patient guarding, necessitating that treatment focuses on only passive or indirect manipulations. Once HGE/CFD patients can be separated into their own specific subset, then specialized care can be rendered, ultimately making them (as a group) easier to manage.
However, what appears interesting is that similar psychogenic stressed patterns have also been found with non-orthodontic patients. Therefore while TMD patients are often hypersensitive and psychogenically challenged, those with HGE/CFD-- particularly with dental extractions -- appear to have significantly stressed systems. HGE/CFD can be present in patients with TMD with or without the use of cervical headgear, though those TMD patients with HGE/CFD will tend to have a lower pain threshold23,24 and increased fear avoidance behavior25.
Wahlund et al compared adolescents [n=60] with chronic TMD to a healthy control group evaluating sensitivity to all types of somatic and emotional stimuli. In their study â€œthe results showed that adolescents with TMD pain reported significantly greater sensitivity to all types of somatic and emotional stimuli. In their study â€œthe results showed that adolescents with TMD pain reported significantly greater sensitivity (p(p<0.05) to aversive somatic and pleasant somatic stimuli than the controls26. Their findings suggested â€œchronic TMD pain states in adolescents are accompanied by amplification of bodily, but not purely emotional stimuli and that cognitive systems are implicated, not only an alteration of the nociceptive systems26.
Airway Compromise, Head Posture, and SOT
Patients presenting with CFD patterns display a relationship between the upper cervical spine and chronic TMD or HGE affecting airway function. This was initially described by Casey Guzayâ€™s Quadrant theory, in which he determined that the forces of the mandible and the bite rotate around a point in the sub-occipital region in the cervical spine27. The lever action of the mandible and associated musculature create an inferior pressure, distorting the cranial sutures and dural membranes via the temporalis, masseter and pterygoid muscles. This also results in a tilting of the entire head forward and downward to help to open airway space, creating a forward head posture as a reaction and compensation. This attempt to maintain airway space, proper dental occlusion, condylar position, and tongue position can lead to sleepâ€“apnea/open mouth breathing habits along with bruxism, parafunction, and grinding patterns28.
The mechanics of the mouth breather is often related to the compromise of the airway and associated musculature in and around the mouth. The head, neck, and TMJ relationships tend to be more balanced with nasal breathing and with the lips closed (lip seal). Ultimately the pressure coming from outside the teeth (lips & cheeks) needs to match the pressure from inside the teeth (tongue) to maintain the maxillary dental arch. So, when the mouth is open a significant part of the day and/or night to breath, the tongue tends to not reside within the maxillary arch but more commonly in the lower mandibular region. With this lower tongue placement it will significantly decrease any upward and outward pressure on the maxilla and the lingual surface of the teeth, thus inhibiting the necessary craniofacial growth and development29,30.
With mouth breathers, not only will the tongue not stimulate upper arch development but inward forces from the cheeks and lips will not be counter balanced, further causing the dental arch to â€œcollapseâ€ inward, down, and backward. This will lead to the maxillary arch becoming narrower, the palate becoming higher, and the maxilla will be restricted from expanding anteriorly or laterally. This maxillary arch restriction can be associated with craniofacial suture tension31, trigeminal nerve irritation32, and TMD changes leading to posture and compensations throughout the musculoskeletal system33-35.
With mouth breathing patterns, bruxism and grinding can be an attempt by the patient to unconsciously find a way maintain good airway space and still have adequate dental occlusion. Airway space and proper dentition cannot adequately function independently, so when there is airway compromise or obstructive apnea the dentition is commonly challenged and results in clenching, bruxism, and parafunctional activities. This pattern is associated with the need for adequate oxygenation, excessive stimulation of pain receptors, and leads to increased systemic stress load.
From a clinical cranial SOT perspective, the CFD patterns associated with narrowing of the face and skull5,17 keep the cranial system restricted (extension phase) and unable to release all the way into its flexion phase (inhalation). This restricted growth and development has a functional affect on the cranial suture system reducing cranial compliance, limiting cranial motion associated with CSF pulsations or cranial rhythms. With cranial motion limited, this can lead to an increased predisposition for the craniofacial and craniosacral systems to have cranial extension restrictions or fixations.
In SOT the narrow face and high narrow upper dental arch are associated with what is called cranial internal rotation or extension (SB+). The ability of the craniofacial and craniosacral system to enter into internal rotation or extension (SB+) and external rotation or flexion (SB-) allows for a balanced functional system36. This can have far reaching implications since cranial internal/external rotation or flexion/extension is associated with the ability of CSF pressure variants, pulsations, or fluctuations to be buffered as the cranium moves through increased and decreased pressure changes in response to these pressure variants37. Also the ability to have this craniofacial bone or suture flexibility allows muscular forces, most particularly associated with mastication, to be distributed throughout the craniofacial system and not focused at one point of muscle insertion. For instance, Buckland-Wright has noted that small movements have been observed between facial bones in animals, indicating the presence of a flexible component within the skull, thus allowing large forces to be exerted during biting without overstressing the facial bones38,39.
In addition, cranial meningeal tensions are reflected to the sacral region via the pia (filum terminale) and dura (internal attachments at S2) so that the craniosacral system is responsive caudally to tensions found cranially. Therefore if the craniofacial system is restricted in only one phase of flexibility, such as extension, this may have an adverse affect on the functional motion at the sacrum, affecting sacral nutation (extension) and counternutation (flexion) 37,40
This imbalanced sacral nutation is believed to have a physiological effect since normal sacral nutation plays an important role in CSF circulation from the lumbosacral cistern, cranialward41. Also it is purported that a stressed craniofacial craniosacral system may also lead so inhibition of parasympathetic nervous system activity. This reduced parasympathetic activity tends to lead to increased sympathetic stimulus42 creating a persistent state of musculoskeletal tension43 as an adaptive and compensating mechanism in the body.
So this HGE/CFD, airway compromise, parasympathetic inhibition, and other subsequent related physiological effects will over time create a multifactorial condition with secondary compensations or body distortions. The internal craniofacial tension caused by altered dentocranial growth and development can create increased stress in all of the cranial sutures while concurrently affecting the shape of the cranium. The muscle tension secondary to TMJ disorders or airway compromise increases tensions in the suboccipital muscle region, creating a forward head posture28,44,45
As this tension pattern persists it can lead to increased tension along the falx cerebri to the internal aspect of the frontal bone creating an inferiorward tension which transmits throughout all of the facial bones and sutures. The maxilla, zygoma, and mandible are under a craniofacial tension drawing the bones inferiorly, posteriorly, and medially. This starts a cascade of changes, beginning with increased muscle tension in muscles of mastication, compromised stomatognathic function, and a tendency for clenching and/or bruxism.
Clinically it has been found that the CFD subset of patients tends to have the following types of presentation:
1. Loss of cervical curve, increased forward head posture and increased tension in cervical musculature28,44,45.
2. Suboccipital tension27.
3. TMD/CMD (craniomandibular disorder) â€“ symptoms46,47.
4. Decreased lumbar curve and/or increased lumbosacral disc angle48.
5. Unstable or dysfunctional sacroiliac joint33,49,50.
6. Pain in feet and metatarsals, poor foot mechanics â€“ collapse of arches51,52.
7. Muscle tensions may be present in any of the areas mentioned above.
The narrow craniofacial with a high hard palate or extension distortion leads to a diminished nasopharynx cavity and reduced air flow and oxygenation. It also reduces and decreases nasal breathing, while increasing the tendency to mouth breathe and sustaining these vertical growth patterns of the oral facial structures. This tendency is perpetuated because the tongue has no ability to locate itself in the upper hard palate that is considered the tongueâ€™s physiological rest position. As the tongue rests downward it forces mouth breathing and subsequent retro-positioning of the mandible, or a dental class two position.
The basic concepts of proper craniofacial growth and development as described by Mew15 or Chinappi46 consider craniofacial and stomatognathic system as necessitating function to allow for proper physiology locally and distally affecting the whole kinematic chain. This relationship is far reaching since there appears to be airway compromise affecting oxygenation as well as increased sympathetic nervous system function.
Dental therapeutic interventions (orthodontic, restorative, etc.) from a physiological perspective need to consider growth and development, TMJ (occlusion and condylar position), airway passages, and stomatognathic function. If not, it is possible that they could contribute or cause some CFD patterns by not addressing whole-body relationships. Therapies have to consider the various stressors to the system, along with the myriad of secondary problems associated with apnea53,54 and possible sympathetic overload55,56.
The reduced oral cavity created by reduced size of the upper dental arch, lingual tipping of the mandibular dentition, retro-positioning of the mandible, and relative size and position of the tongue all creates airway compromise, reduced oxygenation, and excessive sympathetic nervous system stimulation. The musculoskeletal system will develop adaptive compensation distortions, and it is not uncommon for the patient to have increased fear avoidance behavior25, low pain thresholds57,58, and a limited physiological adaptive range59.
Within the subset of patients with CFD, generalized pain can aggravate and complicate this pattern. The compromised airway and oxygenation along with sympathetic stimulus will eventually overload the patientâ€™s physiologic adaptive mechanisms. Ultimately the body will attempt to compensate and adapt to the imbalanced stressors until it begins to fail. As the body begins to fail to compensate there will be alteration in sub-optimal posture, compromise of musculoskeletal function, osteoarthritis, degenerative joint diseases, decreased flexibility or joint hypermobility, as joints are challenged muscles will increase tension to maintain support, and lowered pain thresholds leading to generalized pain syndromes.
There are various methodologies available to deal with CFD associated with HGE or poor growth and development. One aspect can be incorporating dentistry and chiropractic (SOT cranial techniques)47 preventatively to facilitate a childâ€™s growth and development allowing for upper dental arch development and good orofacial behavior. From a dental perspective this incorporates focusing on upper dental arch expansion, leading to optimal dental occlusion, good condylar position, and appropriate tongue to oral cavity space and function. It is not about a focus on removing teeth (bicuspids) or using head gear to retroposition a mandible60.
Chiropractic (SOT cranial) care is focused on maintaining good anterior sacroiliac joint (sacral nutation â€“ category one) motion and posterior sacroiliac joint (weightbearing ligamentous integrity â€“ category two) support. Assessment and treatment is directed to the whole body kinematic chain from an ascending (feet, knees, hips, pelvis, spine to craniofacial and TMJ regions) as well as a descending (TMJ, craniofacial, spine, to the pelvis) orientation62,63 SOT craniofacial treatments facilitate growth and development, improve TMJ function, and help integrate these changes into the patientâ€™s entire neuromusculoskeletal kinematic chain47,60,61-64. Autonomic nervous system balance is important and can involve balancing viscerosomatic/ somatovisceral reflexes to help the patient cope with any sympathetic nervous system overload of parasympathetic nervous system inhibition65.
Oral myofunctional therapy (OMT) can be incorporated into care with resistant TMD and CFD cases66,67. OMT involves a neuro-muscular re-education of the oral facial muscles, is a modality that promotes the stability of the stomatognathic system. OMT treatment commonly consists of jaw stabilization exercises, habit elimination and behavior modification, and repatterning the oral facial muscles and changing their function for optimal tongue rest position, chewing and swallowing so that the tongue does not drop into the airway68,69
The interdisciplinary relationship between the dentist, chiropractor and OMT therapist incorporates myofunctional aspects regarding internal and external pressures to the dental arch and its affect on function and growth and development. For instance the pressure pushing out on the dental arch from the tongue is supposed to match pressure pushing inward from the lips and cheeks. With a mouth-breathing patient, their mouth is open a large part of the day and night due to the lack of ability to get enough oxygen through the nasopharyngeal and this position allows the lips and cheeks to have a slow consistent long term sub-optimal effect on the dental arch. With a mouth breather it is found clinically that the tongue does not press into the maxillary arch, and so this arch slowly collapses inward, backward, and down or a combination of these distortions. This pattern becomes persistent since when the tongue is not in it physiological rest position (upper dental arch) aside from growth and development being affected the back of the tongue closes off the airway space leading to airway compromise.
Another preventative factor that can be investigated is the use of nutrition to facilitate proper stomatognathic function and dental growth and development This was studied in animals by Pottinger. Pottinger demonstrates in his book â€œPottinger Cats70.â€ how a compromise in the developmental patterns of cats can be attributed to moving away from raw to cooked food diets. Pottinger found that cats moved from raw to cooked food diet had a significant loss of teeth, poor dental arch development, swollen organs, fertility, hair loss, skin problems, and significant behavioral changes70. Pottinger also, through radiographic study, noted a relationship between mandibular underdevelopment and microtrauma and fracture in the feet suggesting a possible relationship between these distal osseous boney structures70.
In humans, this concept is further investigated by considering â€œdevelopmental nutrition70.â€Developmental nutrition as discussed by Price in his book â€œNutrition and Physical Degenerationâ€ examines how diets of processed food can significantly alter oral facial structure as well as general development. Price, a dentist, performed anthropological studies in the 1930s traveling globally and studying the diets and nutrition of various cultures. His book concluded that aspects of a modern Western diet (particularly flour, sugar, and modern processed vegetable fats) cause nutritional deficiencies that are a cause of many dental issues and health problems. The primary dental issues he observed from a â€œmodern Western dietâ€ included the improper development of the facial structure (overcrowding of the teeth) in addition to dental caries71.
The significance to dentists and cranially trained chiropractors or osteopaths is the realization that there is a common pattern of compromised craniofacial growth in a subset of our patients. Looking at the body as a matrix of structure and function, with the dental growth and development, airway, and autonomic nervous system balance as integrated aspects of a patientâ€™s health, can be an essential aspect of healthcare treatment or prevention. This concept of a comprehensive, whole body approach to diagnosis and can facilitate the treatment of myriads of problems that are seen clinically.
Examples can be patients presenting with migraine headaches, teeth grinding, bruxism or clenching, TMD/CMD, tinnitus, vertigo, general loss of strength, chronic fatigue, snoring, sleep apnea, low pulse oxygen levels, and loss of cervical curve or forward head posture. It is not uncommon to find with the CFD subset of patients cervical and lumbar muscle tension from the resulting compromised or compensatory posture, predisposing them to thoracic outlet syndrome, carpel tunnel syndrome, and other upper extremity type disorders. Therefore these patients may have interrelated disorders throughout their entire neuromusculoskeletal system and kinematic chain.
Ideally the future for these patients will be more hopeful if interdisciplinary relationships can be developed between dentists, chiropractors, osteopaths, OMT, podiatrists, nutritionists, and other healthcare practitioners. The ultimate goal is to improve dental or craniofacial growth and development as well as airway space, and reduce related secondary apnea or upper airway resistance syndromes and excess sympathetic nervous system activity. This field of study and care should warrant significant further research since it may represent a large, understudied portion of our patient population.
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