A repeat of my presentation to the Orthotropics group in Calgary two weeks ago.

1. What’s an RO to do?
A replay of the March, 2014
IAFGG Annual Symposium
Calgary, Alberta
dr. barry raphael
the raphael center for integrative orthodontics
the raphael center for integrative education
www.alignmine.com
bioblocnj.com
drbarry@alignmine.com

2. IAFGG 2014

3. SOFT TISSUE DYSFUNCTION
With Chronic Open Mouth Posture
Comparison of Unsupported vs Supported Growth

4. The End

5. The Beginning

6. Everyday in my practice...

7. RO since1983 (30 years...yikes)
Bucknell University 1974
University of Pennsylvania 1978
(ThreeYears in General Practice)
Fairleigh-Dickenson University 1983
14 Instructors: 14 Techniques

8. RO since1983 (30 years...yikes)
Bucknell University 1974
University of Pennsylvania 1978
(ThreeYears in General Practice)
Fairleigh-Dickenson University 1983

9. My Dream Office, 2001

10. 1.Crooked teeth are THE PROBLEM.
2.The lower incisor must be upright.
3.Patients don’t want to cooperate.
4.Straightened teeth aren’t stable.
In the RO’s Mind

11. 1.Crooked teeth are THE PROBLEM.
2.The lower incisor must be upright.
3.Patients don’t want to cooperate.
4.Straightened teeth aren’t stable.
1.Crooked teeth are A SYMPTOM.
2. The UPPER incisor directs treatment.
3.Patients don’t want to be exploited.
4.Teeth that grow straight are stable.
A Change of Mind

12. 1.Crooked teeth are A SYMPTOM.
2. The UPPER incisor directs treatment.
3.Patients don’t want to be exploited.
4.Teeth that grow straight are stable.

13. George
Catlin
Are we developing the way
our genes program us to be?
Westin
Price
Kevin
Boyd
Peter
Gluckman
Neese and
Williams
Scott Gilbert
Clark
Spencer
Larsen
Darwinian Dentistry
Me...
James
Sim Wallace

14. Obesity
Metabolic Syndrome
Celiac
Intestinal Permeability
Type 2 Diabetes
Fatty Liver Disease
Cardiovascular Disease
Hypertension
Some Cancers
The Results of the Mismatch
Between Genes and the Environment
Chronic Non-Communicable Diseases of Civilization
Western Lifestyle Diseases
Asthma
Autism
Asperger’s
Alzheimers
ADD/ADHD
Depression
Chronic Back Pain
Osteoporosis
Caries
Malocclusion
Sleep Apnea

15. The Toothberg

17. 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

18. Airway Orthodontics
•Early Feeding and Nutrition
•Allergies,Asthma, URT infections
•Posture
•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

20. Parent’s Private-eye Sheet

21. Parent’s Private-eye Sheet
“There are many things about your child’s health that are
important to know, but that I often don’t get to see at the office.
Also, there are signs to look for that you may not have known
were connected to your child’s teeth or health. By looking for
and tracking these “signs and symptoms”, we can get a better
handle on the problem and watch for resolution.
You don’t have to spend a lot of time with this, but don’t rush
either. Watch for certain things at different times of day. Try not
to let your child know they are being watched. You want to see
the most natural behaviors.
Check off what you see. If you’re not sure, check it anyway and
we’ll talk about it. Make comments if you want.”

22. While sitting around...
While sitting around (watching TV, in the car), does
your child:
put “things” in the mouth alot (toys, sleeves, pencils,
fingernails, etc.) ______________________________
lick or suck on the lips
have the lips apart, even a little
stick or dart the tongue out of the mouth
have the tongue resting between the teeth
lean the cheek on a hand
breath with his mouth open, even a little bit
make noises when breathing
have trouble sitting still

23. While talking...
While talking, does your child:
talk very fast
talk very slowly
gasp for air
have a lisp
take speech lessons

24. During a meal
During a meal, does your child:
gasp for air while eating
stick his tongue between his teeth when swallowing
stick the tongue out to meet the drinking glass
drink a lot while eating
make noises when chewing
eat sloppily
take a breath before drinking
puff the cheeks out when drinking
make the lips purse when swallowing
make the chin “crinkle” when swallowing
bob the head when swallowing
have trouble sitting still

25. While sleeping...
While sleeping, does your child:
have the mouth open
snore
wet the bed
toss and turn
tilt the head back
wake up frequently
have frequent nightmares
have abnormal sleep issues
grind the teeth
have trouble waking up
wake with darker circles under eyes

26. S. R. , 10-10yo M
•Missing 32,42
•Impacted 13,23
•Late mixed, 25 erupted
•Soft tissue dysfunction
•IL = 40
•Not compliant

27. S. Reardon, 10-7yo M

28. Impacted 3s, Missing 2s

29. Medical history
• Reactive Airway Disease
•“Bronchial Constriction”
•Care of Pulmonologist
• Preventil
• Dad : OSA, CPAP for 11 years, diabetes
• Grandfather: OSA untreated
• ETCO2 = 36.1 at 10 bpm (acceptable)
• Posture number - 18 (<10 ideal)
• Father refuses sleep screening

30. Treatment Options
1. Extract upper premolars.. Align.
2.Open spaces for impacted canines. Open spaces for
lower lateral implants.
What’s more important?
Ease of treatment.
Or
Breathing well at night.

31. Bolton Standards
15yo
The Maxilla is
Down and Back
The Mandible is
Retrognathic
Nasal Cartilage
Collapse
Insufficient Facial
Support
Bi-maxillary Retrusion

32. Bimaxillary Retrusion Forward Growth

33. Mouthbreathers have significantly
smaller airway space.
(measurements PAS-OccL, PAS-UP, airway volume, area and minimum axial area)
Mouth breather Nasal breather
Three-dimensional assessment of pharyngeal airway
in nasal- and mouth-breathing children
Alves, M, et.al., Int J Ped ORL 75 (2011) 1195–1199

34. 1.Crooked teeth are A SYMPTOM.
2. The UPPER incisor directs treatment.
3.Patients don’t want to be exploited.
4.Teeth that grow straight are stable.

35. B. Hockel 2012
This is the profile Biobloc
children start with:
long and retrusive
This is the profile Biobloc
children finish with:
Forward with lips
together

36. B. Hockel 2012
Here’s the “inside” look.
Notice how the upper front teeth are closer to the nose? (yellow arrows)
Notice how the lower jaw rotates around the star so the chin comes up and forward? (red arrow)
How do we make this happen?

37. From the tip of the Central...

38. ...To the Forwardmost Tip of the Nose
41mm

39. Maxillary Height
• Indicator Line (Mew)
• Distance from most anterior point on nose to upper
incisal edge
• Age + 23
• A variable number, but important to watch over time.

40. B. Hockel 2012
Here’s the “inside” look.
Notice how the upper front teeth are closer to the nose? (yellow arrows)
Notice how the lower jaw rotates around the star so the chin comes up and forward? (red arrow)
How do we make this happen?

41. Using Indicator/
Cosmetic Line
•To define a starting point
•To set treatment goals
•To track treatment progress
•To gauge the effectiveness of treatment

42. Charting the In/Cos Line
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

44. Incisor pulled away from nose.
Not “undertorqued” or “gummy smile”

45. Hypothetical ClI Ortho/MARA
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys
OJ =
7mm
Starts
Ortho
“Great
Headgear
Effect”

46. Class II Elastics
50
40
30
20
mm
y J F M A M J J A S O N
boys
Start
Non-x
Expansion
Uncrowding
Finished
Start Cl II
elastics
OK,
that’s
enough...

47. Hypothetical Mouthbreather
(Dr. Mew’s Hamster Boy)
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys
Boy
gets
hamster
MFT

48. Hypothetical BBO, 7yoM
50
40
30
20
5 6 7 8 9 10 11 12 13 14 15
girls
boys
Initial
Start
BB1
BB3
Night

49. •L.R. 11-9yF
•Missing all 5s,6s,8s and upper 4s
•Had ortho to close diastema…
•InL = 39
•GP objects to deX, plan equil

50. L.R.Tx Plan
1.Preparation: Hang Expanser
2.deX
3.Training: BB3 to advance mandible
4.Myofunctional Therapy
5.Orthopostural Training
6.Myobrace to hold
7. Reevaluate for dental detailing

51. L.R. : Spotty progress
50
40
30
20
mm
y 3/13 4 5 6 7 8 9 10 11 12
1/
14
2 3
Expanser
Parents
dragging.
30 turns.
Start Adv.
Rx deX.
GP
objects
After
delays,
Equil e’s,
BB3

52. •L.R. 12-3 yF (6mo in tx)
•InL = 37 (+2)
• e’s equilibrated
• OJ =10
•Appliance OJ = 5
• Still accommodating to BB3

53. Is there a calculus for the Indicator Line?

54. Treatment Goals
Based on Indicator Line

55. Incisor Goals
Type 1 Treatment:
Place U1 in ideal position
Biobloc Orthotropics, Orthognathic Surgery, Distraction Osteogenesis

56. Type 1: Ideal In/Cos line
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

57. Y.Z., 9yo M
•Lost upper d-space
•InL = 36(+4)
•OJ = 9mm
•Lip entrapment
•Lip Incompetence

58. Y. Z., 9yo M

59. Y. Z., 9yo M
9mm OJ

60. Y. Z., 9yo M

61. Treatment Options
1. Type 1: Reduce InL, open lost space, BB3 to advance
mandible.
2. Type 2: Open lost space.Align.
3.Type 4: Extract four premolars.

62. Y.Z. 9yoM
50
40
30
20
m
m
y
M A M J J A S O N D J F M A
boys
Hang
Expanser
Upper and
Lower
Brackets Hang
Retainer
BB3

64. Incisor Goals
Type 2 Treatment:
Develop arch just enough to uncrowd
Biobloc, Myofunctional Ortho, Myofunctional Therapy, Crozat,ALF, Expansion Orthodontics

65. Type 2: Uncrowding
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

66. •Lip incompetence
•Lip entrapment
•Hypermentalis
•Mouthbreathing
Type 2: Uncrowding

67. 12 month progress

68. 12 month progress

69. 12 month progress

70. After Treatment
Bent-wire
6 months
Myobrace
12 months
Hey,
Raphael...What
about that
profile?

71. Z.P., 9-5yoM
i

73. After Expansion Phase

74. Incomplete profile improvement...
better breathing, head posture and sleep.

75. Incisor Goals
Type 3 Treatment:
Maintain UI
Functional Orthodontics, Expansion Orthodontics, Distalization Ortho
or No Treatment

76. Type 3: Maintain
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

77. Bimax
retrusion

78. Successful
dental result

79. Profile Unimproved

80. Incisor Goals
Type 4 Treatment:
Retract/Extrude UI
Extraction Orthodontics, Retraction Ortho, Distalization Ortho

81. Type 4 : Retraction
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

82. Bimax
retrusion

83. Successful
dental result

84. Failed Profile Result

85. Changes of pharyngeal airway size and hyoid bone
position following orthodontic treatment of
Class I bimaxillary protrusion
Qingzhu Wanga; Peizeng Jiab; Nina K. Andersonc; Lin Wangd; Jiuxiang Line
Angle Orthodontist, Vol 00, No 0, 0000 (pre-publication 2012)
“the dimension of the velopharynx, glossopharynx, and
hypopharynx were decreased after maximal retraction of
anterior teeth with extraction of four premolars…”
“Any factors that can influence the posture and position of
tongue and soft palate may displace them backward and
encroach upon {the pharynx}.”
“the more the incisors were retracted, the more the
pharyngeal airway was reduced.”

86. 1.Crooked teeth are A SYMPTOM.
2. The UPPER incisor directs treatment.
3.Patients don’t want to be exploited.
4.Teeth that grow straight are stable.

87. Backed into a corner...
•
Moving teeth faster, more efficiently…
...in the wrong direction

88. Now that we’ve made
smoking unacceptable,
could we not do the same with...
• Sugar?
• Processed food?
• Cheap milk and meat?
• Fast food?
• Pill popping for symptomatic relief?
• Looking for the cure instead of the cause?
• Surgery as a quick fix?
•Thinking braces are a status symbol?
Each industry thrives on the status quo.
Consumers must drive the change.

89. N.P. 10yM

90. N.P.

93. Sister’s non-x ortho
She’s happy….but I’m not, so...

94. I make my pitch for BBO

95. The dilemma of progress.
(I forgot the progress pictures….)
Dad sells prosthetic parts to orthopedic surgeons.
I selling the case against my previous work they loved...
It takes me 3 hours to sell the case.
They fret until the BB3 goes in...

96. 1.Crooked teeth are A SYMPTOM.
2. The UPPER incisor directs treatment.
3.Patients don’t want to be exploited.
4.Teeth that grow straight are stable.

97. Connecting the dots...
• Adult SDB and OSA
• Narrow jaws and faces
• Soft tissue dysfunction
• Early parafunctional habits, ie. open mouth posture
• Environmental stressors
• CPAP, MARA,UPPP, Surg
Where’s the best
place to start
treatment? here?
orhere?

98. 1. Prevention
2. Undo the damage already done
3. Establish good habits
When to start?
When damage from poor breathing is noticed and
when bad habits are discovered.
The strategies of
Airway Orthodontics

99. Prevention
• Remove ankyloglossia
• Promote breastfeeding
• Harden the diet
• Develop masticatory strength
• Discourage oral habits
• Promote whole-foods, low sugar diet
• Reduce oropharyngeal obstruction
• Promote nasal breathing

100. Breathing retraining
• Nasal rinsing
• Nasal clearing
• Decongesting

101. The goals of
Airway Orthodontics
1. Breathing through the nose
2. Lips together at rest
3. Correct tongue position
4. No facial muscles moving on swallowing
5. Optimal forward facial development
6. Class I occlusion
7. Straight teeth
8. Better stability long term

102. Myofunctional Trainers
Professors R. Soulet
and A. Besombes
Dr. Earl Bergeson
Dr. Chris Farrell
The Multi – Family System

103. Orofacial Myofunctional
Therapy
Oral Myology
Myofunctional Therapy
Tongue Thrust Therapy

104. B. Hockel 2012
Back
Undoing Bimaxillary Dysplasia
1. Maxillary deconstriction
2. Maxillary advancement
3. Maxillary impaction
4. Mandibular advancement

105. 1. Maxillary Expansion
Treatment for Bimaxillary Dysplasia
ALF
Crozat
Bent Wire
Hyrax
Haas
Niti Exp BioBloc
Schwartz

106. The Farrell BENT WIRE System™

107. Recommended Age Group:
5-12 yrs
Arch Development in
conjunction with the
TRAINER System™

108. Dr. John Mew

109. Establish Good Habits
1. Breathing through the nose
2. Lips together at rest
3. Correct tongue position
4. No facial muscles moving on swallowing
5. Stand and sit in balance
6. Breath gently using the diaphragm
7. Eat to nourish
8. Sleep to rest

110. Ortho-Postural Training
Workshops
Breathing
Nutrition
Posture
Sleep

112. COPYRIGHT
Roger L Price
October 2012

113. Posture Number
Forward head posture
can be a compensation
for a deficient airway

114. Sleep Screening and Hygiene
SQI = 10 SQI = .98

115. Integrative Healthcare
Function Professional
Nasal clearing ENT, Pulm, MFT, Breathing
Muscle balance and tone MFT, Myofunctional Ortho
Undoing damage GP, Pedo, Ortho, OMFS
Breathing dynamics OPT, MFT, Breath Physiologist
Posture DC, OPT, PT, Osteopath
Cranial balance Osteopath
Nutrition RDH, Nutritionist, Dietitian
Sleep ENT, Sleep Med, Dent
Neurocognitive development Ped’n, SLP, Psych, Sp.Ed.
The Interdisciplinary Center

116. 1.Crooked teeth are A SYMPTOM.
2. The UPPER incisor directs treatment.
3.Patients don’t want to be exploited.
4.Teeth that grow straight are stable.

117. Now that I know...
My personal mission:
To create, from what I’ve
learned from the best,
a model for others to follow….
...especially the orthodontists.

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

119. Oral Myology
Oral Myology Basic Course
Joy Moeller
NYC 2011
LA 2012
Oral Myology: Levels 2, 3
Kim Benkert
Clifton 2012
Habit Cessation
Shari Green
Clifton, 2013

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

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

122. ALF and Cranial
Jim Bronson
2013 Tasha Turzo
Cranial Academy
2014

123. Bucket List
•ALF and Crozat (Bronson’s course)
•More on Biobloc (Hang’s Advanced, London School)
• More Cranial (The Farm)
•Chirodontics (Bob Walker)
•Airway Dentistry with Marc Cruz, Jeff Rouse
• Sleep Dentistry
• Less-than-Six with Kevin Boyd
• Intra-mandibular Distraction Osteogenesis (IMDO)
Off My List
Anything that moves the teeth faster in the wrong direction...

124. What’s an RO to do?
To create, from what I’ve
learned from the best,
a model for others to follow….
...especially orthodontists.

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

126. Mt. Sinai School of Medicine
Pedodontic Residency
Guest Speakers
Jim Bronson
Mike Mew
Kevin Boyd
Sandra Kahn
Jennifer Tow
Roger Price
Paula Fabbie
Damien O’Brien
First clinical program in myofunctional orthodontics

127. Airway and Facial Development
Collaborative Webcast
Mark Cruz

128. AAPMD Symposium
www.aapmd.org
Annual Meeting
April 25-26, 2014
Westin Chicago North Shore

129. the raphael center for integrative orthodontics
www.alignmine.com
www.bioblocnj.com
www.myobracenj.com

130. Integrative vs Conventional

131. Integrative vs Conventional

132. “With improvements in
expansion orthodontics,
advances in myofunctional
orthodontics, and the growing
recognition about sleep
disordered breathing among
children and adults, it is time for
orthodontics to expand its
horizons. There is now so
much more we can offer.”
The Raphael name has been associated with high
quality orthodontics in New Jersey for over 60 years.
Dr. Barry Raphael has been a university trained
orthodontic specialist and a member of the
American Association of Orthodontists for 30 years.
He has a wide range of techniques and services to
offer. He has studied oral myology, applied
kinesiology, Buteyko breathing, Biobloc Orthotropics
and Myobrace as part of his integrative training. He
can offer Damon, Invisalign, Insignia and Incognito
appliances designs as some of his many
conventional orthodontic services, too.
Dr. Raphael teaches his techniques at
post-graduate residencies, study clubs, dental
societies, and for the Myofunctional Research Co.
He is available for presentations to any group
interested in learning more about the benefits of
integrative orthodontics.
www.alignmine.com
Learn about the choices you have in orthodontics
dr barry raphael
Why it's
too Early...
never
1425broadstreet
clifton,nj07013
973-778-4222
fax973-778-9625
njspec#3684
1425 broad street, clifton, nj 07013
973-778-4222
www.alignmine.com
the
raphael center
for
integrative
orthodontics
theraphaelcenterfor
integrativeorthodontics
Learn about an important
choice you need to make
before starting braces.

134. the raphael center for integrative education

135. the raphael center for integrative education
Ongoing Intro to Airway Orthodontics
April Biobloc Study Group
April Training Ortho-Postural Therapists w Roger Price
June MRC Myobrace Basic Series
August Airway Dentistry with Mark Cruz and company
October Advanced MFT with Sandy Coulson
October Less than Six with Kevin Boyd
(who else wants to play?)
Mission: to create a space for spreading the word about
Airway and Orthotropic principles and practice.

136. Orthodontics in the
21st Century
Esthetic
Orthodontics
Airway
Orthodontics
Genetic
Tooth-Focused
Dental: Perfection
Esthetics Primary
Treating Symptoms
Airway Ignorant
Adaptation
Muscle-Focused
Medical: Better
Esthetics Secondary
Treating Causes
Airway Conscious

137. The End
And
The Beginning