clinical | EXCELLENCE

The key to facial beauty and

optimal patient health - Part 1
By John Flutter, BDS

ll evidence supports the concept that forward Research shows that much of the orthodontic

A growth of the face produces the most attrac-

tive faces. The driving force behind forward
growth of the face is the tongue. Gram for gram, the
treatment used to correct the position of the
teeth will further lengthen the face. It is also known
that lengthening the face will produce a less
tongue is the strongest muscle in the body. It has attractive face.
been calculated that it can produce 500 grams of
force against the anterior teeth.1 Expanding the upper jaw
This force needs to be directed up and forward There is considerable research and clinical experi-
“the reason into the anterior part of the upper jaw in order to: ence to show that when the jaws have been
1. Create the correct shape and size of the upper expanded, they usually return to the original shape
the upper jaw jaw with room for all the adult teeth; and and size after a few years. However, this does not
size remained 2. Drive the forward or horizontal growth of the face. always happen. I attended Dr Skip Truitt’s series of
stable and the It has been estimated that 75% of young Aus- lectures about 25 years ago. Using the techniques
occlusion tralians have crooked teeth. It begs the question, and the appliances he taught, I started to expand the
improved, was why is this so and what can we do about it? In addi- jaws to provide room for the teeth. I am showing
tion to crowded teeth, the predominant direction of you the first case I treated by expanding the jaws
due to the growth is vertical or downwards. The muscle forces (Figures 1-5).
fact that after of the lips and tongue push the teeth into the correct I expanded the upper and lower jaws with an
expanding the or incorrect position. upper Schwarz Plate and a lower Jackson Appli-
upper jaw the We require five patterns to optimise healthy ance. Today I would use neither of these appliances.
tongue learned to growth of the jaws and face: I corrected a bilateral cross bite in about 18 months.
1. Lips together at rest; Many years later and with no further treatment, I
rest and function 2. Teeth in or near contact; saw the patient again. I recorded that not only had
in the palate...” 3. Tongue resting in the roof of the mouth; the jaws maintained the expanded size but the
4. Breathing through the nose; and occlusion had improved (Figures 6-7).
5. No muscle movement around the mouth on the In the early days, this was not a common out-
subconscious swallow. come. In most cases where I expanded the jaws,

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Figure 1-4. Before and after 18 months of arch expansion starting at age 7. When the upper arch expands, the width of the nasal
passages increases.
Figure 5. Before
treatment and after
18 months into
treatment. During
jaw expansion, the
maxillae moves
forward within the
cranium. This is
best done before age
eight and a half.

Figures 6 (above) and 7 (right). Several years post-treatment, the jaw expansion had
been maintained and occlusion had even improved.

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Figure 8. Before treatment.

they would return to where I started within

just a few years. When the upper arch is
expanded it moves forward within the cra-
nium. This is particularly true when the
child is less than eight and a half years old.
I often use a forward pull face mask to
bring the upper jaw further forward. I ask
myself, “why in this first case does the
improved jaw size remain stable?” It was
not any special skill that I had, nor was it
the particular appliances I used.
I now realise that the reason the upper
jaw size remained stable and the occlusion
improved, was due to the fact that after
expanding the upper jaw the tongue
learned to rest and function in the palate.
We have a paradox! When we see a Figure 9. Biobloc stage 1 worn for six months.
narrow upper jaw there is not enough
room for the tongue to rest and function
there. Once we have expanded the upper
arch, unless the tongue learns to rest and
function there, the jaw size will return
towards its original size.
The upper arch form remains stable into
adult life when the tongue supports the
new jaw size. First, we need a good jaw
size for correct muscle function. Second,
we need good muscle function to maintain
the jaw size. This is the paradox!
I suspect this patient was doing a lot of
mouth breathing before arch expansion.
By expanding the upper jaw, the width of
the nasal passages would also have
increased, therefore making it easier to
establish nasal breathing.
In the 25 years since I treated this case,
I have learnt a lot of things. I now know
that we cannot assume that once the arch
is developed that the tongue will learn to
rest in the palate, nor that nasal breathing Figure 10. Face mask worn 12 hours a day. Cross bite corrected.

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Figure 11. After six months of expansion, an i-3™ Appliance was fitted and worn for one year.

will automatically start. This rarely hap- Once I had developed the upper References
pens, which is why relapse is so common jaw, creating room for the tongue to rest 1. Ramirez-Yañez GO, Farrell C. - Soft
after expanding the upper jaw. in the roof of the mouth, I started to Tissue Dysfunction: A missing clue when
Figures 8-11 show a case I started in correct the myofunctional patterns. I treating malocclusions. Int J Jaw Func
September 2007. I noted anterior and pos- fitted a TRAINER supplied by Myofunc- Orthop (in press) 2005b.
terior cross bites. This was not as a result tional Research Co. (MRC) called the 2. Ramirez-Yañez, German O. DDS. -
of a large, prognathic mandible, rather it i-3.2 This was worn for one hour a day Early Treatment of a Class II, Division 2
was an underdeveloped retrognathic upper while keeping their lips together plus Malocclusion with the Trainer for Kids
dental arch. The tongue never rested or overnight while sleeping for a period (T4K): A Case Report J Clin Pediatr Dent
functioned in the palate and the girl was of one year. 32(4): 325–330, 2008.
an habitual mouth breather. In addition, the patient also completed
I expanded the upper dental arch with a my “Postural Correction and Breathing About the author
Stage 1 Biobloc™ appliance. This is an Retraining Programme”. The programme Dr John Flutter graduated in London and
appliance worn 24 hours a day, removed is designed to support children while worked in general practice there before
only to clean the teeth and turn the screw. they improve muscle patterns, jaw posture moving to Australia. He is Board Eligible
The screw is turned one eighth of a turn and nasal breathing. More details with the International Association for
every day, expanding the arch by poten- about this programme will feature in a Orthodontics (IAO) Hawaii and
tially seven eighths of a millimeter a coming issue or visit my website at is a former federal president of The
week. This is semi-rapid expansion that www.orthodonticearlytreatment.com. Australian Association of Orofacial
opens up the midline suture but not snap- On my website you will find an Orthopaedics (AAOO). He has lectured to
ping it. Turning the screw at this rate will article that was published in the Journal dentists and orthodontists on myofunctional
lead to less buccal tipping of the teeth and of the International Association therapy in over 60 countries in the world in
more development at the suture. In order for Orthodontics. association with the Myofunctional
to turn at this rate, well-constructed I have spent the last 15 years working Research Company and has produced a
Crozat cribs are needed to hold the appli- on helping children to breathe through the DVD entitled : “Myofunctional Effects on
ance secure on the teeth. While I expanded nose. Unless the child learns to breathe Facial Growth and The Dentition”. Dr
the upper arch, the girl wore a forward through the nose, the tongue cannot rest in Flutter works in private practice in the Bris-
pull face-mask 12 hours a day, mostly the palate and support the new jaw shape bane suburb of Fortitude Valley limited to
overnight while sleeping. and size. orthodontics and dentofacial orthopaedics.

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The key to facial beauty and

optimal patient health - Part 2

By John Flutter, BDS

“The function
of the Trainer
is not to move Resting Position Correct Breathing Pattern
the teeth and
Figure 1. The resting position (left) and correct breathing pattern (right).
jaws, but to
re-train the
ifteen years ago, I looked at many alternatives 3. Tongue resting in the roof of the mouth (tongue
muscles of the
lips and tongue
to correct bad
F to help children improve the muscle
patterns of the lips and tongue in order to
optimise health and achieve better facial growth.
tip on the SPOT);
4. Breathing through the nose; and
5. No muscle movement around the mouth on the
oral habits...” Using the five key patterns, as described in subconscious swallow.
Part 1 of The Key to Facial Beauty and About 12 years ago, I started treating patients
Optimal Patient Health,1 I tried many different using appliances designed and manufactured by
techniques which required a great deal of co-opera- Myofunctional Research Co. (MRC) in Queensland.
tion from the child and parent. On the rare These prefabricated appliances called “Trainers” are
occasion when they did the exercises, I saw worn in the mouth and are designed to improve
substantial benefits. muscle patterns (Figure 2). The function of the
The five patterns to optimise healthy growth of Trainer is not to move the teeth and jaws, but to re-
the jaws and face (Figure 1) are: train the muscles of the lips and tongue to correct bad
1. Lips together at rest; oral habits. It is therefore the new muscle patterns
2. Teeth slightly apart; that make the changes, just like in normal growth.

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Figure 2. The T4K (Trainer for Kids) from Figure 3. The Breathing Well Programme: Nasal Breathing is essential for good
Myofunctional Research Co. cranial development.“The single most important thing that you can do to improve
a child’s health is to establish nasal breathing.

Figure 4. The dental and facial pattern after one year with the i-3™.

Figure 5. Profile
change after arch
expansion and then
after myofunctional
training.

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Figures 6 and 7. Facial and profile changes showing forward growth of the maxillae after one year using only an MRC Trainer™.

At the “Orthodontic Early Treatment Centre”, I have developed result, with this knowledge and confidence, I am able to
a programme to support children while they improve muscle pat- diagnose growth irregularities in young children and treat patients
terns, jaw posture and nasal breathing (Figure 3). at a far higher level.
From 2001-2004, I co-operated in a research project using
MRC’s appliances with the University of Belfast. The results References
were used in a study that was published in The Journal of Pedi- 1. Dr. John Flutter BDS (London). The Key to Facial Beauty and Optimal Patient
Health - Part 1, Australasian Dental Practice (2009).
atric Dentistry (Volume 31, Number 4/2007) on Dimensional 2. Ramirez-Yañez G, Sidlauskas A, Junior E, Flutter J. Dimensional Changes in
changes in dental arches after treatment with a prefabricated Dental Arches After Treatment with a Prefabricated Functional Appliance, The
functional appliance.2 Journal of Pediatric Dentistry Volume 31, Number 4/2007.
Shown here to demonstrate that it is possible to help the max- 3. Ramirez-Yañez GO, Farrell C. - Soft Tissue Dysfunction: A missing clue when
treating malocclusions. Int J Jaw Func Orthop (in press) 2005b.
illae grow forwards without using a plate in the mixed dentition is
4. Ramirez-Yañez, German O. DDS. Early Treatment of a Class II, Division 2 Mal-
one of the children from the study. The tongue, once trained to occlusion with the Trainer for Kids (T4K): A Case Report J Clin Pediatr Dent 32(4):
function in the palate, can redirect growth upwards and forwards. 325–330, 2008.
The children in the study were instructed to wear a TRAINER™
(MRC’s i-3™ or T4K® appliance) for one hour a day while About the author
keeping their lips together plus overnight while sleeping for a Dr John Flutter graduated in London and worked in general
period of one year. You can see from the photographs the maxillae practice there before moving to Australia. He is Board Eligible
and mandible moved forward within the cranium bringing the with the International Association for Orthodontics (IAO) Hawaii
orbit forward with it (Figures 4-7). and is a former federal president of The Australian Association of
Over the past 20 years, I have come to understand and Orofacial Orthopaedics (AAOO). He has lectured to dentists and
recognise the health issues related to poorly directed growth orthodontists on myofunctional therapy in over 60 countries in
and development. I also realise the importance of facial the world in association with the Myofunctional Research Com-
structure for more aesthetic results and can recognise the pany and has produced a DVD entitled : “Myofunctional Effects
deficiencies in facial form when developing a correct diagnosis. on Facial Growth and The Dentition”. Dr Flutter works in pri-
I understand the importance of horizontal growth in younger vate practice in the Brisbane suburb of Fortitude Valley limited to
patients and have the knowledge to treat accordingly. As a orthodontics and dentofacial orthopaedics.

168 Australasian Dental Practice September/October 2009