I am an osteopathic physician and what is that?? Well it start with a man named AT Still was an MD born in 1828 and lived in Missouri. At that the medicine we had was considered crude and included blood letting and giving small doses of poisons. Antibiotics were not discovered yet. Dr. Still had lost many of his family members to various illness and he began to question what was missing in his medical training. AT Still was also trained as an engineer and a minister. He began to look at the human body from his mechanical perspective and saw that it’s a whole functioning unit with the individual parts forming in a specific shape to create a specific function. Like a bridge has a specific form to hold the function of carrying cars across. So when a pateint had pneumonia he started assessing rib movement under the theory that the structure/function of the ribs are related to the function of the lungs. He began to get fabulous results with his patients. He named the method of which he treated the body with his hands Osteopathy and began the first school in 1892. Talk about Upledger teaching out of Michigan State Univeristy started “cranio sacral therapy” in 1983. Talk about difference

Philosophy of Osteopathy

Body is a functioning unit.

The body possess a self regulatory mechanism, having the inherent capacity to heal itself.

Structure and Function are reciprocally interrelated.

As The Twig Bends The Tree Grows

AT Still said “as the twig bends the tree grow.” So when treating children we are looking at the forces that bend the little twig. Dysfunctional breathing, swallowing, chewing, birth injuries, childhood falls are just a few of the dysfunctions. The body will contort itself to breath and be well oxygenated. Just like a plant will bend and grow towards the light.

(1)We have talked about the development of the cranium and face from embryo into adulthood and we have a sense of some of the dynamics that play a part in growth. Joy has introduced us to some of the myofunctional components that affect growth. We have been introduced to the ideas and palpatory feel of the importance of the swallow. Now we are going to talk more about some of the influences that can affect facial growth.

(37) Paloma before side view. It’s and underdeveloped maxilla. Talk about what the traditional treatment is.

(38)Paloma (11-07) present cases from Jim of under bite. This is an example of an underdeveloped mandible. Causes genetic, mandible from german father and maxilla from asian mother. Fluid field lesion in maxilla. Restriction to anterior growth of the middle face or anterior cranial fossa, trauma to forehead, or nose, or maxilla

(39)Paloma (5-08) 5 mos later

(40)Paloma (5-08) after side view

Team Approach to Facial Development

Team approach.... it’s takes a village to raise a child... many of us have had this experience. It also takes a team of a functional dentist, osteopath and myofunctional therapist to most efficient treat facial dysfunction's.

Dr. Darick Norstrom... tell story of the ALF. How it was created and intended to be used. What do the osteopath do.... remove obstacles... soften the tissue so the appliance can work in the dentist most predictable ways. Diagnosis and treat underlying issues such as pelvic asymmetries, cervical somatic dysfunction's. Also assure that the adjustments are biocompatible with the patient.

(21) Darick and I treating-Teamwork. We are using the ALF to enhancing and stimulate growth of the face which is also augmenting inherent motion. Coming from the parts for a dentist would be simply looking at teeth and how they are aligned in relationship to each other. Looking at the disease in a tooth and not assessing the movement of the soft tissue in the mouth. Not taking into account the dynamic movement of the TMJ or the functioning of the swallow or an assessment of breathing or the asymmetries of the face or the birth and trauma histories to the head.To come from the part for an Osteopath is the treat the body without awareness and skill to assess the motions created by the teeth coming together in occlusion and its affect on the whole body. Coming from the part for an osteopath would be to be aware of the somatic dysfunction in the neck and not to check how the bite plays into the dysfunction or not. To be aware of cranial somatic dysfunctions and not to see how the occlusion plays a part of the dysfunction.The Osteopath needs to have the skills to look into the mouth and put together what they see in the mouth with what they feel. We can learn how to describe what we feel to dentist. We can learn how to evaluate swallow and breathing and feel the affects on the palate and the whole. We can learn how to feel individual teeth and treat them.Dentist could develop basic palpatory skills that would give them more feedback about the forces that are being introduced into the palate and cranium. By having the skills to assess the dynamics soft tissue movements the dentist will have a wider understanding of why a particular force introduced onto the teeth will create a certain responds.

Myofunctional Therapy

(24) Myofunctional therapy- Talk about value of working with a functional facial specialist. Example of Gabriel and father-finishing the case. Talk about Michaela

Natures Intent

(2) We start with always looking at the health. We must have an intimate relationship with Health, Nature to be able to feel, see, and sense dysfunction. We can only heal from our health, from what is working. So we started by studying embryology to look at what is Natures intent in terms of the human structure and function. We study embryology to see and understand natures intent. As osteopaths and functional dentist we are interested in the process of nature unfolding as seen in growth and development. We need to be able to see, sense and touch this Health that we work with not only our patient but everywhere in life.

Talk about why study the formative forces. The formative forces also called embryonic functional growth movements are present at birth and continue to grow a human being. This is what we call inherent motion. If we develop a close relationship with the embryonic growth movements we can feel them present and working in a biodynamic process creating structure and health. If we want to input a force into the human being it will be most effective if it stimulates inherent motion. That is to say we would like to augment the embryonic growth forces to help stimulate growth in a child and an adult.

(56)Overall growth and development of the face is in an anterior and inferior direction

Any insult that disrupts normal growth and development causes facial dysfunction. So, what grows a face? It’s the interaction between forma dn fucntion again. So the functions of the face including breathing, swallowing, chewing, vision that grows a face.

(8)Illustrated here, is a neonatal skull enlarged to the same size as a fully grown one. The child face is not merely a miniature of the adult. Rather, progressive facial enlargement is a “differential” developmental process in which each of the many component parts mature earlier or later than the others, to different extent in different rates. Here are some examples, the baby’s face grows out form under the brain. Structures must grow proportionally more and for a longer period of time the further they are from the neurocranium. Therefore, growth of the mandible begins later and continues longer than midfacial or orbital development. We also see here that the infant and young child are characterized by a wide-appearing face which is because of the broad basicranium template, but the face otherwise is vertically short. This is because the nasal and oral regions are yet diminutive, matching the smallish body and pulmonary parts and with masticatory development in transition. We see that the face growth predominates in the vertical and horizontal. We see that the orbits do not change dramatically in size but the mandible does. Most of development occurs in the nasomaxillary complex and the mandible. The nasomaxillary complex includes the nasal, maxillary, palatines, ptyergoid plates, and zygoma.

Dynamics that Develop the Face

• Brain Growth

• Swallow

• Breathing

• Chewing

• Vision

(10)now lets talk about dynamic of growth. The functions are what mostly grow a face (hearing, vision, smell). The functions come in this order.. breathing, swallow and chewing

(13) One very influencial cranial growth that affects the face is the growth of the anterior cranial fossa. The nasomaxillary complex is suspended from the anterior cranial fossa, and the width of the facial airway, the configuration of the palate and maxillary arch, and the placement of all these parts are influenced by the length and width of the anterior cranial fossa.

Swallowing

(23)sucking and swallow begin in utero but interestingly the swallow that developed in utero is different than the swallow of a older child and adult and this transition (as we heard from Joy) is vitally important to growth and development not only of the face but of the cervical, thoracic lumbar and pelvic region. Let’s look more closely are an infants swallow.

Infantile Swallow

(24)The infantile swallow is characterized by the tongue held between the gum pads while swallow is completed. The mandible is stabilized by the facial mm (Seventh cranial nerve) and the interposed tongue. The swallow is initiated by sensory contact of the tongue with the lips.

Mature Swallow

(26)The characteristic features of the mature swallow are; (1) the teeth are together with swallow; (2) the mandible is stabilized by the contractions of the fifth cranial nerve muscles; (3) the tongue tip is held against the palate above and behind the incisors; and (4) minimal contractions of the lips are seen during the swallow. (Handbook of Facial Growth p.379) Stabilization by the first molars. So we have an understanding of the importance of the tongue movement, this will help create a wide palate. Also, a functional bite will stimulate growth and functional contractions of the mm of mastication.

(29) Here we see the soft palate and again note the proximity of the soft palate to not only the SBS but the sella turcica which is also dependent on movement for the excretion of it’s hormones. Swallow creates the augmentation of the motion in the cranium. When the tongue doesn’t contact the palate functionally we do not get the most efficient draining of the sinuses and the middle ear. We will talk about more about this later. The function of swallow is a basic driving force for the growth and development of the middle face.

(21)pg 104, Again this is the connection between the occiput and the sphenoid the SBS which is dependent on compression-decompression forces to stimulate growth. It is a cartilaginous structure. Feel with hands around mastoid process and on vertex. Bite and feel pressure expand on the vertex after biting down. Then feel swallow and feel pressure on the vertex when swallow. Now that we have a clear understanding that the cranial base gives the perimeter for facial growth let’s talk about the functions or dynamic that play another vital role in facial development.

Breathing

(30)So we understand that swallowing is a primary function that develops the middle face and maxillary arch. Let’s look at another function that also helps to develop the middle face. Breathing. It has been said by many sages that proper breathing is the most fundamental contribution to health. Not only is it vital to life itself but it plays a very important role in facial development.

Breathing

Breathing as we saw with the embryological development of the diaphragm and watched the function of breathing begin we see that a structure was domed then flattened. There is a pressure change form on closed area to another. The lower the thoracic pressure is the greater the amount of air comes into the lungs. Breathing is thee creation of empty space in the chest. It is also this pressure gradient created throughout the body that is the driving force for venous and lymphatic return. Experience tongue down which open the TMJ a little. Put hand on chest. Now take a deep breath. Notice thoracic diaphragm excursion, notice post pharyngeal space and pelvic diaphragm. Now tongue is up and take a deep breath. Any restriction to these structures that create a piston like action will affect airway and thus facial development.

(18) ice arch

Mastication

(46) Chewing is the not a function that come into play until the development of teeth. It is the main function that stimulates the vertical growth of the mandible and the face.

(47) mandible comparison. The mandibular ramus lengthens giving vertical height which also brings mandible forward and widens arch which increases oral volume. Can also image that between the two rami houses the oral pharyngeal space and we can see that as we get widening and lengthening of the mandible we are also increasing the oral volume and the pharyngeal volume for increase food bolus and airway increase to adapt to increasing body mass.

Mandibular Changes

(48)Here we see the change in the angle of the mandible as we grow. (Masticatory musculature is proportionately sized and shaped to progressively match increasing function and to interplay developmentally with the ramus.) Studies have shown that a molar contact stimulate mandibular growth as well as a hard food diet. Increasing the angle gives vertical height and contributes to more oral volume. Soft diet decreases ht of mandible, decreases angle and creates more porous, softer bone, there is also less water in the cartilage. Soft diet has also been associated by malocculsions. The less stimulation and use of the joint the increase in bone turn over...leads to question of management of mandibular fractures. Function is intimately related with mandibular growth (incisor contact stimulates growth). Research also showed that mastication has to be balanced bilaterally. When a change in the bite on one side occurs it caused a elongation of the mandible on the other side.

Etiology• Trauma

• Breathing dysfunction

• Non-functional Orthodontic treatment

• Myofunctional dysfunctions

• Dysfunctional occlusions

• Nutritional Deficiencies

• Sleep positions

(2)Any influence which affects growth and development could also create facial dysfunction. Others not mentioned here are neurodevelopmental issues, nutritional deficiencies

Epidural Births

(3)Birth trauma is very common and easily overlooked. This is very important for the dentist to know and to know what questions to ask about birth to assess who needs a referral to the osteopath. Any epidural/pitocin birth is considered to be a traumatic birth. When there is extraneous forces that is pushing on the babies head without the mothers natural feedback system in place because of the eipdural....there is a disconnect. All babies would benefit from treatment after birth. I think this is one reason why we are seeing more facial dysfunction and occlusion issues in younger children.

First Breath

(16)First breath is so important. It is the ignition that turns on the engine and coordinates the diaphragms. It lights the spark that is the potency. See diaphragmatic somtic dysfunction that is associated with facial dysfunctions. If the diaphragm doesn’t ascend and descend in an unimpeded motion there can be restrictions thru the central tendon of the diaphragm to the sternum to the infra hyoid mm and to mandible.

Mouth Breathing

(19) The buccinator mm overactive because it lacks the normal counter pressure of the tongue’s lateral pressure during swallow. The buccinator mm is a thin flat mm that aids in mastication by pressing the checks against the teeth during chewing. This pushes the food against the occlusal surface of the teeth. It is used when sucking by forcing the cheeks against the molars. To feel place fingers under zygomatic arch and suck cheeks in. Also the orbicularis mm is a sphinter around the mouth. It’s fibers are continuous with the buccinator mm. It closes the mouth, purses the lips (whistling and sucking) and plays a role in speech and chewing. It works with the buccinator to hold food on the teeth for chewing.

Cross Bite

• Under developed maxilla resulting in a cross bite.

(20)Because of lack of stimulation to palate, it is underdeveloped. This may create a cross bite where the upper maxila fits inside the lower jaw.

Nursing

(4)Nursing. Important to ask how was nursing. It gives us the first clue of the organization of the oral region and how traumatic birth was. Of course, nursing issues could also be positional for mother or milk supply issues. That is to say there are many causes for difficulty nursing and a consultation with a Leletch League could be helpful. It is very important to start this first suck and swallow experience with a well organized and functional swallow. We also remember that this is one the main ways newborns release and work thru cranial and facial trauma from birth. The other ways include crying and yawning which are both natural release to the pharyngeal area which attaches to base of the occiput.

Birth Trauma

(5)We talk about condylar compression affecting the 9,10, 11 and 12 cranial nerves. As we know this affects the coordination of swallow thru the hypoglossal nerve affecting the coordination of the tongue for suck and swallow and the glossopharyngeal nerve affecting swallow. Another lesion to be aware of is an extension lesion at C-1. We see this often. This lesion tend to tilt head backwards which decreases airway. This also tend to bring the mandible back along with the tongue because the tongue follows the mandible. From this compressed position the reflex towards health is for the tongue to push forward and downwards on the mandible in attempt to open airway and increase oral volume. This tends to create a division 2 class1 obtuse angle cases.. They can be difficult to treat and we can see congestion adenoidal and tonsil congestion. Help to widen maxilla with upper ALF.

Chin Trauma

(8)fall on chin create TMD, Talk about treatment of fracture, any fall on head could affect the dynamic motion of the soft tissues. Compression into the condyle can cause growth lesion. These are not that uncommon

Whiplash

(9)it is not uncommon for people to have jaw pain after a whip lash injury. Remember that the mandible is also suspended from the sphenoid by the sphenoid mandibular ligament and from the temporal by the hyoidmandibular lig.

Hyoid Strain

(10) Talk about chin trauma and affect on hyoid region. Why hyoid needs to be supple with full range of motion. Hyoid dysfunctional swallow is head forward and then up just like how hyoid needs to move to pass bolus. Head back during swallow is ass with weak posterior pharynx muscles.

Myofunctional Dysfunctions

(26)Myofunctional Dysfunctions

Finger Sucking

(27)thumb sucking is common. Infantile anterior swallow as well as bringing premaxilla forward. Yes, can be an attempt to treat cranialfacial birth trauma. Case of one time treatment and child stopped sucking. Can also become a habit and lead to TMJ, assymetrical growth of thecondyle. Send to myofunctional therapist.

Anterior Tongue

(44) tongue in ant tongue thrust

Open Bite

(43) anterior tongue thrust. common occlusion for relapse after traditional ortho secondary to being primarily a myofunctional dysfunctional habit. The first molars are hyperextruded and the premaxilla is in external rotation or internal rotation? It is flared open.

Stimulation of Mandibular Growth

(51) Muscles of Mastication are the temporalis and masseter and med. pterygoid and lateral pterygoids. They all close the mandible except the lateral pterygoid. Mandibular cartilage on the condyles plays two functions one endochondral growth area and support for joint function. The cartilage is composed of fibrocartilage which plays function in weight bearing and a hyaline cartilage which mainly participates in endochondral ossification and mandibular growth. Research has shown that these cartilages respond to mechanical forces which stimulate growth. The condylar cartilage is one the most imp growing site in the mandible (the ramus being the other), it is responsible for the final length which gives us our vertical ht. The mandibular condylar cartilage originates from bone membrane during embrogenesis as opposed to typical epiphysiary cartilage which comes from the chondro-skeleton. It is considered a secondary cartilage which gives a greater adapability to the joint in terms of stimulating not only the direction of growth but also the amount. With primary cartilage of the long bone the stimulation to growth is limited to direction and not amount. Bone growth can continue until at least the end of the 3rd decade...more research needed.

(53)Lateral pterygoid mm with the infrahyoid and suprahyoid mm open the mandible. Another important point for growth and development is the health of the TMJ disc. The disc is avascular and what diffuses nutrition to this structure is compression and decompression, which is the function of the joint. So we see again that function supports the development of the structure. The lateral pterygoid attaches directly onto the disc. It’s important that this muscle is soft and pliable.

Nonfunctional Orthodontic

(23)Talk about why changing the position of the teeth has can have such a dramatic affect on functioning of breathing, swallow, chewing.

Braces

(24)When a tranditional orthodontic assess a patient for ortho treatment. A structural exam of the whole body is not part of the traditional learned process. Therefore if there is any rotaion at the base of the head at the level of the OA, any head tilting is not incorporated into the treatment plan. Dentin is the hardest substance in the body, harder than bone. Main point they decrease oral volume.

Palate Expander

(25)Palate expanders do not symetrically widen the maxilla, rapid expansion causes asymertical growth of the septum, affect the most powerful orthodonics appliance from doing it’s work--the tongue. Also with retainer that cover the palate inhibit tongue affect on the palate. Remember the importance of what swallow does--causing pressure changes on the base and augmentation of the CSF

Birth History

• tell me about your child’s birth

• epidural and/or pitocin

• forceps or vacuum extraction

• how much molding and describe where

• any trouble nursing

• colicky baby

Trauma History

• concussions

• fractures

• whiplash injuries

• stitches

picture of 6-7 year old

(63) The children are the inspiration. We need to learn more about facial dysfunction to help these children grow into their greatest potential. They are the being of our future.