Muscle Wins ! Treatment in Clinical Orthodontics

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Preface
Many interesting phenomena have come into sight through long-term follow-up of many treated cases over a period of 40 years. The occlusion changes with posttreatment growth, jaw movement, muscle status (tongue, perioral, masticatory and cervical muscles) and respiratory pattern. In other words, the teeth will move posttreatment, causing changes in torque, occlusal plane, etc. When function is restored at an early stage of orthodontic treatment, the teeth can be properly positioned to favorably affect subsequent growth and development and allow the formation of a functionally and esthetically balanced maxillofacial skeleton. The form of occlusion established at the end of active treatment will not remain the same, particularly in patients with long-term occlusal stability. Instead, the teeth will find
their own places for stability by accommodating to changes due to growth and jaw movement until a functional occlusion is established with proper anterior guidance, posterior guidance and condylar guidance.

What concerns us as orthodontists most seems to be patient compliance, treatment time and posttreatment stability. I wonder if you have seen occlusal instability develop only a couple of years posttreatment, even after an extended treatment time of 3 to 5 years. Can this be classified as a genetically caused relapse or a relapse caused by posttreatment growth and development? Have you experienced postorthodontic occlusal instability in nongrowing adult patients as well?

What has been overlooked in our orthodontic treatment? We may have failed to recognize the merit of the function inherent in the human body because of our overdependence on mechanotherapy. My clinical experience suggests that failure to respect basic physiologic functions such as respiration and perioral muscle function when performing occlusal treatment would give rise to not only the problem of relapse but also adverse effects on posttreatment growth and jaw function.

I have learned through a number of cases treated over the years that it is diffìcult to solve orthodontic problems with mechanotherapy alone. In light of adverse effects with extended use of retainers, the most effective and physiologic approach to retention would be to gain adequate tongue space for nasal respiration at an early stage of treatment and restore muscle function by creating a balance between the tongue, perioral and masticatory muscles. Not only would this maximize the effect of mechanotherapy, but this would serve as the best possible retainer given by nature.

I find the most important source of knowledge and skills to be my patients. The case presentation section of this book contains the very first case (Case 9) I treated in my orthodontic career and the first case (Case 1) treated based on the hints learned from the very first case. It would be no exaggeration to say that the roots of my orthodontic treatment can be traced to these two cases. Case 1 still visits me for an occlusal checkup more than 38 years after treatment. The changes observed in this case throughout this period has taught me the lessons mentioned above and convinced me of the utmost importance of carefull observation of occlusal changes in each patient we treat, not only for the enhancement of our orthodontic knowledge but also for the establishment of doctor-patient rapport.

I believe that early resolution of patient's chief complaints and use of minimally invasive treatment modalities (avoidance of orthognathic surgery and extraction if at all possible) are keys to patient compliance. What I have put into practice over the years by trial and error is to achieve these objectives that comprise this treatment based on the “Muscle Wins" philosophy. “Muscle Wins" is the name given by Dr.
Graber when I showed him a severe skeletal Class III open-bite case treated by nonsurgical and non-extraction approach whose occlusion remained stable for more than 16 years (Case 17). The "Muscle Wins" treatment would not work without patient compliance, and I am so grateful to the many patients fo 1' their contributions to treatment success.

I hope to demonstrate through this book the need to probe the causes of functional abnormalities and treat the problems each patient presents by focusing on functional recovery while making an effective use of mechanotherapy. Nothing could give me more pleasure than to see this book be of some clinical use and help clinicians provide patients suffering from malocclusion and TMD with dreams, hopes of treatment success and a happier life.

Finally, I want to express my deepest appreciation to Prof. Gakllji Ito and Mr. Takao Nakazawa of Ormco Japan for their advise to Prof. Yoshinobu Ide for checking the conceptllal drawings and proofreading the manuscript from an anatomist's standpoint, tωo Ms. Akane Tobiishi of Ishiyaku Publishers, Inc. and Ms. Tokiko Saito of E&P for their editing work, and to my clinical staffs (Shiho Arai, Junko Noda, Sumie Sllzuki, Michiyo Sasaki, Kuniko Takada, Kikue Ohno, Yukie Sakamoto and Harumi Shinada) for organizing and managing the patient records.
2007/02/02
Etsuko Kondo

目錄

Prologue .. . . .. . . . .. . ....... . . . .................. .... ..... . .... . ............... . .... . .. ............. v
Foreword .. . . .. . .. ...... ... .... . . .. .... . . . . ....... . .... . ... .. .. . .... .. . .. ........... .. . ....vii
Preface ..................................................................................................................... xii
，恥~川s … -Wh are muscle function and nasal res iration im ortant? 一.
I.Muscle Wins concept
 -Why are muscle function and nasal respiration important?............................1
u Close relationship between muscle function and occlusion . .. . . . . . . . . . . . . 2
1. Tongue and occlusion…….. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  2
Tongue behavior and tongue space
• A case illustrating imbalance between tongue and lip pressures .. . ....... . .. . 2
Anatomic drawing: Tongue muscles . . .... . .. . ....... ... . .. . . .... .. ……... ..…. 3
2. Masticatory muscles and occlusion . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. 4
1) General actions of the masticatory muscles . . . . . . . . . . . . . . . . . . . . . . .. .. 4
2) Relationship between masticatory muscle activity, posterior occlusal
vertical dimension and mandibular morphology .......................................... 4
Anatomic drawing: Chewing muscles ... .. ......... .......... .... . ..... ..... ..... ..... ... 5
3. Neck muscles and occlusion ................. . .... . .. ........ .. ................................. 6
1) General actions of the anterior neck muscles . . . . . . . . . . . . . . . . . . . . . . .. 6
• A case with strained infrahyoid muscles . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6
2) Lateral neck muscles: Actions of the sternocleidomastoid muscle ... ..... ... 6
• Anatomic drawing: Perioral mimic muscles and neck muscles .. .. ...... . .. . .7 vNasal respiration is the key to occlusal improvement and
post-treatment stability …………………………………………. ….. . . . . . . .. 8
• Effects of establishing nasal respiration as observed on intraoral
photographs and CT images . . . . . . . . . . . . ……………. . . . . . . . . . . . . . .. 8
11. Clinical ke s to Muscle Wins
II.Clinical key to Muscle Wins
  -Treatment combining restoration of muscle function and appliance therap..1
uKey points for patient examnination-what to examine………………………….12
• Frontal view of the face / • Profile view of the face /
•Intraoral photographs (frontal , lateral , occlusal) ....................................... 12
• Orthopantomogram /•PA and lateral cephalograms /
•TMJ radiographs /•EMG /• MKG ............................................................... 13
• 3D and CT images ..................................... : .... .... ................. . . . . . ........ 14
• Palpation / •Functional tests . . . . . . . . . ……… . . . . . . . . . . . . . . . . . . . . . 15
• Important measurements for cephalometric analysis . . . . ……………. . . . 16

vKey points for diagnosis and treatment………………………………………..18
1.lmporance of relationship between masticatory muscle activity and posterior occlusal vertical dimension…………………………………………………..18
1) Deep-bite cases…………………………………………………………….18
2) Open-bite cases…………………………………………………………….19
3) Cases with asymmetric neck muscles……………………………………...20
4) Cases with strained hyoid muscles…………………………………………21
2. Data from a statistical analysis of cephalometric measurements in patients with long-term occlusal stability……………………………………………...22
- A treatment plan considering post-treatment growth and development………24
3. The ideal occlusal relationship to be established at the end of active treatment based on the statistical data……………………………………….26

wCharacteristic “Muscle Wins" treatment………………………………………26
1. Improvement of tongue behavior and perioral environment
- Lingual and labial frenectomies -…………………………………………...26
2. Establishment of nasal respiration - Arch form correction………………...26
1) Tongue-lift training………………………………………………………….26
2) Use of slightly expanded arch wires…………………………………………26
3) Use of a removable expansion plate…………………………………………26
4) Use of a slightly expanded lingual arch……………………………………..26
3. Correction of the posterior occlusal vertical dimension……………………28
• How to place elastics•………………………………………………………...30
4. Normalization of masticatory muscle activity – MFT………………………32
1) Tongue training (Iift to the palate, tapping)…………………………………32
2) Lip training…………………………………………………………………..32
3) Training for nasal respiration………………………………………………..33
4) Open/close and clenching exercises…………………………………………33
5) Massage……………………………………………………………………...33
5. Others…………………………………………………………………………..33
1) Timing and sequence of appliance removal…………………………………33
2) Duration of retainer use……………………………………………………...33

xCriteria for extraction - When to decide and on what basis…………………..34
1. Timing for extraction/nonextraction decision - After aligning teeth…………...34
2. Points to consider in making an extraction/nonextraction decision…………….34
1) Possibility of arch expansion………………………………………………...34
2) Position of four second molars relative to the PM line………………………35
3) Posterior occlusal vertical dimension and lower incisor inclination………..36
4) Lip profile (nasolabial angle and E line)……………………………………37

III.Muscle Wins cases-Treatment without orthognathic surgery or headgear-'39
Angle Class 11 cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
• Division 1 deep bite
* Case 1 Keys to long-term occlusal stability learned through 40 years of follow-up
-The first Class 11 , Oivision 1 deep-bite case treated by the author-
Late mixed dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ……… 42
Case 2 A deep-bite case treated by increasing the posterior occlusal vertical
dimension rather than intruding the incisors: Late mixed dentition . . . . .. 62
Case 3 A case with ANB of 9.50 whose occlusion has remained stable for over
13 years: Late mixed dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
* Case 4 A case with occlusal stability maintained for 26 years without using a
positioner: Before completion of permanent dentition ………………….74

• Division 1 open bite
Case 5 An open-bite case with ectopic eruption and ANB of 8.0º
Early mixed dentition ..... . . . . . . . . . . . . . . . . . . . . . . . . ……………… 80
Case 6 An open-bite case showing posttreatment occlusal stability with tongue
-lift exercise: Early mixed dentition . . . . . …………………………… .. 84 .

•Division 2 deep bite
Case 7 A case whose TMO symptoms were eliminated with correction of incisor
inclinations and bite opening : Late mixed dentition ..................... . . .. . 88
Case 8 A case of occlusal improvement obtained with an increase in posterior
occlusal vertical dimension: Permanent dentition .................... ... ......... 94

Angle Class III cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
•Deep bite
Case 9 A case demonstrating the effect of masticatory muscle activity on
posterior occlusal vertical dimension: Early mixed dentition . .. ..... ..... 98
Case 10 A nonextraction case with four replanted lower incisors:
Early mixed dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  112
Case 11 An early mixed dentition case with an impacted canine and anterior
crossbite: Early mixed dentition .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . 118
Case 12 An early mixed dentition case with ANB of -6.0º
Early mixed dentition ………………………………………………..122
Case 13 A case with ANB of -5ºand anterior crossbite corrected 3 months into
appliance therapy: Late mixed dentition ............................................ 124
* Case 14 A case with ANB of _10º showing 22 years of posttreatment occlusal
stability: Permanent dentition ............................................................ 128
Case 15 A case with the upper right central impacted upside down and ANB of
-10º: Permanent dentition . . . . . . . . . . . . . . . ……………………. . . 134 .
•Open bite
Case 16 A case with tongue thrust treated using a habit breaker:
Early mixed dentition .. . .. .. . .. .. . .. . . .. .. . .. .. . .. .. . .. .. . .. .. . ..  136
* Case 17 A case demonstrating that recovery of muscular and respiratory functios
is the key to shorter treatment time and posttreatment occlusal stability:
Permanent dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Case 18 A severely crowded case demonstrating high adaptability of the alveolar
process: Permanent dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .160
* Case 19 A full Class 111 case maintaining occlusal stability for over 21 years without retainers: Permanent dentition .. . . . . . . . . . . . . . . . . . . . .  . . 166
* Case 20 An adult open-bite case with a full Class 111 malocclusion corrected in
7 months - A case presented in the first WJO World Board Case Report
-Permanent dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Case 21 An adult case with a non-vital lower second molar replaced by
a horizontally impacted third molar: Adult . . .. . . . . .. . …….. ........ . 190

Angle Class I cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ….. 195
•Deep bite
* Case 22 A case with long 曰term occlusal stability for over 20 years following
7 months of active treatment: Before completion of permanent dentition 196
Case 23 A case with relapse of lower anterior crowding due to lip-biting habit:
Permanent dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

•Open bite
Case 24 A case demonstrating markedly enhanced treatment effect and
posttreatment occlusal stability with tongue-lift training :Early mixed dentition . …………………………………………………. . . . . . . . . . 202
Case 25 A case whose open bite was corrected with early functional recovery:
Early mixed dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

•Crowding
Case 26 A nonextraction case treated with arch expansion leading to occlusal stability: Permanent dentition . . . . . . . . . . . . . . . . . . ………. . . . . . . . .208
Case 27 A case whose treatment effect was enhanced by establishment of nasal
respiration with increased tongue space: Permanent dentition . .. . . . . .. 210

Cases with asymmetric posterior occlusal vertical dimension
(asymmetric neck muscles) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ….  213
Case 28 A case suggesting the important role of the cervical muscles in morphologic development of the ramus and condyle:Early mixed dentition . . . . . . . .214

•Open bite
Case 29 A case showing normal TMJ development following plastic surgery
of the sternocleidomastoid muscle: Early mixed dentition . . . . . . . . . . . 224

•Deep bite
Case 30 A Class 111 deep-bite case with ANB of _80 and mandibular deviation
Late mixed dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Case 31 A Class 111 case with residual mo 巾hologic abnormalities of the ramus and condyle due to inadequate correction of neck muscle imbalance:
Before completion of permanent dentition . . . . . . . . . . . . . . . . . . . . . . …242
Case 32 A Class 111 case with lateral deviation and asymmetric occlusal vertical
dimension aggravated by unilateral chewing: Permanent dentition . ..........248
Case 33 An adult deep-bite case successfully treated with nonextraction because
of dentoalveolar adaptation: Adult ... . ... . . .. . .. ... . ........ .. . . ........ . ….. 254
*30 and CT images are available
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Index………………………………………………………………………………..270