Author Topic: Story: The Heterodontist  (Read 8533 times)

Offline Charlie0186

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Story: The Heterodontist
« on: 17. March 2023, 11:52:27 AM »
The Heterodontist
an anecdotal account of a paradigm shift

The following vignette was pieced together from bits of my novel that ended up on the cutting-room floor.  It is entirely fictitious and fantastic.  Any resemblance to persons living, deceased or literary is both unintentional and coincidental.  Names and places have been changed only to protect the identities and reputations of characters in the latest draft of my novel.  In case I forgot to say so, the novel to which I refer is my first, and to date, only.  I've completed it several times as I'm still editing it.

I offer this as the first creative writing project I've thought might be worth anyone else's while reading.  I trust that you'll be kind enough to offer honest feedback.  Even if brutal, it will be received as a valued contribution to the next, and likely subsequent, revisions of the novel that I hope might even be published antehumously.

Offline Charlie0186

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Re: Story: The Heterodontist
« Reply #1 on: 17. March 2023, 11:53:25 AM »
1. Wallace Orthodontics

I turned the gleaming brass doorknob, and pushed.

"Please keep an open mind," Dad had reminded me for the umpteenth time as they'd dropped me off.  "Jimmy's one of the smartest people I've ever met."  He'd stressed variations on that theme several times too.

As much as I'd been primed to expect the unexpected, the interior still caught me by surprise.  It was exquisite in its minimalism.  Ancient amber floorboards rippled under layers of indulgent polishing.  They purred at the touch of my feet.  The heady smell of beeswax lingered in the gentle Savannah air.  Nicks and stains in the table's patina suggested hard service.  It would seat six, but I found only three wooden kitchen chairs.  Two had their backs to the opposite wall.  A third tucked under the narrow edge that wasn't buried under shipping cartons.
"Samantha Gill?" the young woman enquired.  She'd appeared in response to the tinkling of the bells above the door.  "Excuse the clutter -- package pickup is running late this morning.  Please follow me."

The second door on the left led into what might once have been the dining room.  Mismatched chairs surrounded a longer and equally venerable table.  I settled myself onto one that seemed never to have been returned to what I now realised was just the hallway.  The last orthodontist's waiting room was garish.  The far end of this table was adorned with a simple patchwork quilt, cast by the sunlight streaming through stained-glass panels in the garden door.  And with a vase of pink chrysanthemums.

"Dr Wallace will be with you shortly.  How do you take your coffee?"
She left me to my thoughts in what appeared also to be their board-cum-meeting-cum-break room.  The wainscoting mouldings held marker pens, a board eraser and even a set of darts.  With intent or not, she'd shown me to a seat opposite the framed certificates that hung from the picture rail.  I took a closer look.  Yvonne Anne Proudfoot had earned her MBA almost twenty years ago.  James Butler Wallace's DDS was only one of his many qualifications and accreditations.  They employed at least three orthodontic and two prosthodontic technicians.  A birthday calendar with still more names filled much of the smudgy whiteboard behind me.

"I'm very glad you made the time to speak with Jimmy," Dad had said on the way from the airport yesterday.
We loved visiting them for Thanksgiving, but the weekends were always too short.  I was also very glad that things had worked out this year.  For once, my preferred locum had no travel plans of her own, and Martin had no impossible deadline to meet.  Coming a week earlier would give him and the boys a few more days to spend on the water with Dad.  They deserved some time out from listening to my feeling sorry for myself.  As I needed the justification for more procrastination about the decision that weighed on me.
"I meant it when I said he comes across as something of an iconoclast ..."
"My dictionary thanks you for cracking its spine."
"... but it's not to be contrary.  He's paying a very high price for his convictions."

"I don't know how Sam manages to get a wink of sleep with that mask strapped to her face."  Mom probably hadn't realised until then that I was on Martin's heels as we'd come downstairs for breakfast this morning.  "Or that thing you keep taking out of your mouth.  I hope Jimmy can come up with something better."  I did too.  Listening to someone with alternative views seemed a good investment of an hour or two.  Especially after hearing little that didn't scare me witless in any of the five seconds I'd spent with the other orthodontist.

"What makes his approach so different," I'd asked Dad on the way over this morning.
"It's more about getting the bones in the head to grow properly than straightening teeth.  It's a sort of form-follows-function thing.  What I didn't want to say in front of Mom is that he thinks that what we let the orthodontist do to you might have mangled your jaws and facial bones."
"Are you serious?" Martin had asked.
"He is.  He showed me a paper where some British guy advances a very convincing argument against the use of headgear like the one Sammie had to wear."

"Hi.  I'm Yvonne."  She set down a tray with three mugs.  "Jimmy's almost done with one of our technicians.  I thought I'd come through to introduce myself in the meantime.  Barbara's always talking about how proud she is of you.  It seems kind of obvious now, but I'd somehow never thought of psychologists helping after brain injuries.  That must be so rewarding ...  Do you normally help regular people get through rough patches too?"
"Very much so, and I find that sort of work every bit as rewarding, even if it doesn't give Mom as much to talk about."

"Yvonne's quite the businesswoman," Dad had said.  "She's making sure the path to their door is wide enough for everyone who'll want Jimmy's improved mousetraps one day."

"I assume Brian's warned you that most orthodontists think we're quacks," Jimmy said almost before we'd finished shaking hands.  "And that includes many people I respect."  Dad had been referring to the scorn of his colleagues when he'd called Jimmy a modern-day Galileo, but he did resemble the portrait that came to mind.  The unruly salt-and-pepper hair, bushy beard, and wise but tired eyes could also have belonged to Gandalf.
"That only makes me more interested in your approach."
"And you're not expecting this to be a professional consultation, are you?"
"No -- just an informal discussion if you can spare a few minutes.  And then maybe a referral to someone you trust.  I saw the supposed TMJ guru back home, but what he proposes terrifies me."
"Jimmy's a born teacher," Yvonne said.  "I'll leave you to it."  She picked up her mug and the tray.  "And thank you for agreeing to look at sewing machines with me.  There's no point paying for features I'll never be able to use."

Offline TrainTrack

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Re: Story: The Heterodontist
« Reply #2 on: 17. March 2023, 14:08:06 PM »
The story has a very promising start. The amount of detail and description you put into this story is far superior to anything I have or ever will write. Additionally, the theme is unique. I have never read anything with a similar theme to this. This is my honest view. I hope you add more onto this. It truly is an amazing story.

Offline bracessd

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Re: Story: The Heterodontist
« Reply #3 on: 17. March 2023, 16:45:49 PM »
Great start

Offline kelly-Marie

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Re: Story: The Heterodontist
« Reply #4 on: 17. March 2023, 17:50:40 PM »
Hi an interesting start a little bit hard to understand in a couple of places but all in all a good beginning to Samantha's treatment as always it will be interesting to see what she gets 

Offline bsma189

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Re: Story: The Heterodontist
« Reply #5 on: 18. March 2023, 01:17:25 AM »
Excellent start! I like your writing style

Offline Charlie0186

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Re: Story: The Heterodontist
« Reply #6 on: 18. March 2023, 04:06:34 AM »
Thank you for the comments so far.

Part two (of seven) follows ...

Offline Charlie0186

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Re: Story: The Heterodontist
« Reply #7 on: 18. March 2023, 04:07:21 AM »
2. Orthodoxy

"There's a caveat before we dive in," Jimmy said.  "Please remember that some of the things we speak about won't necessarily apply to you."
"I'll bear that in mind."
"And if I don't manage to convince you that we're all dangerous lunatics, I'll arrange for you to see a colleague in St Paul.  Brian and Barb have been almost parents to us ever since we got here.  I'd rather put my sister into better hands than mine."  The flicker of a grin disappeared again.  "Brian tells me that you're no stranger to orthodontics.  I presume that would have been in middle school."
"Elementary school."
"And are you experiencing breathing problems now?  Something like sleep apnoea?"
"You're kidding!  I didn't think Mom and Dad knew about that before last night."
"So it is obstructive sleep apnoea then?"
I swallowed as much as nodded.
"Do you experience any other ailments that might relate to your airways?  Asthma, chronic sinusitis, shortness of breath -- anything like that?"
"I do get out of breath sometimes, but I'm not very fit.  Seriously though, how did you know about the apnoea?"
"Just a hunch -- based on observation, and a bit of inference."

I began to understand why Dad had begged me to meet Jimmy.  Even if his colleague was the superior clinician, I saw no reason for him to doubt his own abilities.  He'd seen my tech-neck posture, and that my mandible tended to drift a little down and forward.  I left my lips apart, with my flaccid tongue lying in the hollow behind my lower teeth.  Each might hint at airway constriction.  Four flags warranted his question.  And my confirmation had suggested to him that TMD pain might not be the only reason for disrupted sleep.
The combination of obstructive sleep apnoea and TMD was not unusual, he informed me.  Airway restriction was part of a syndrome called craniofacial dystrophy.  "That's why we should always try to keep the big picture in mind.  Addressing malocclusion in isolation seldom produces stable results.  It can sometimes even cause further problems.  So when did the orthodontist start your treatment?"
"Hold on a moment, please.  Dad said you thought that braces might have contributed to my problems?"
"We'd both do well to remember my caveat.  How old were you?"

"It was in seventy-two, almost exactly a month after my eleventh birthday."  I felt vindicated by his question, and triumphant at being able to give a detailed history.  The hours I'd spent on the phone with Mom and poring through photo albums had been wasted on the other orthodontist.  "The dentist I'd been seeing wanted to start earlier, but we were about to move to Denver."
"How long did your treatment last?"
"Almost twenty-two months, with retainers for about a year after that."
"And when did you first become aware of TMJ and apnoea problems?"
"I've sort of heard clicking when I yawn for as long as I can remember.  Mostly on the left side.  Various dentists asked about it at different times, but nobody seemed very worried."
"So when did it start bothering you?"
"A little over a year ago.  The pain came and went, but I could manage it with Tylenol at first.  When it got worse, my doctor thought it might be because I was clenching my teeth at night, so I ended up at a sleep clinic.  That's when they picked up the apnoea.  Before that, I had no idea.  I'd always thought everyone was exaggerating about my snoring."
"When was that?"
"Mid-September, this year."
"And did they refer you to the orthodontist?"
"Not immediately.  The dentist at the clinic made a splint for me, but it didn't work as well as he hoped.  That was my fault.  He wanted me to wear it twenty-four-seven, but that's impractical.  It's so bulky that I can't speak clearly, no matter what I try.  I'm starting to understand what some of my patients go through.  I did try to wear it whenever I didn't have to speak with anyone, but he pretty much gave up on splint therapy and referred me to the orthodontist."
"Did the splint help at all?"
"That's what makes me unsure whether to go with what they're proposing now.  It does help when I can wear it consistently for a day or two.  The orthodontist said it's a waste of time, but his proposal feels like jumping out of the frying pan into the fire."
"Before we get into that, did anyone recommend anything else?"
"I take prescription anti-inflammatories and painkillers when I need to."
"Exercises, or stress management techniques?"
"Only that I should try to remember to relax my jaw muscles."
"So what did the orthodontist propose?"
"Jaw surgery.  They want to bring my lower jaw forward and make the upper one line up with it properly.  Joint replacements at some point, and braces, of course.  I'd almost let him talk me into it until I read the consent form.  It said there was a chance of nerve damage that could cause me to lose sensation permanently.  If I could end up with a mouthful of marbles anyway, I might as well wear the splint."
"To be fair, that would almost certainly have been referring to superficial numbness in a little patch of skin somewhere.  Anything that could impair speech would be extremely unusual.  I had excellent results with orthognathic surgery, but I only ever referred my patients to one surgeon.  That's why I'd like you to see Peter.  He'll know who's on top of their game."
"Do you think he could use braces like those ones on me?"  I indicated a model displayed on the dresser.  The clear brackets and white wires were practically invisible.  "I was so freaked out that I didn't even think to ask.  I know I'm being silly, but ..."
"He may prefer not to use fixed appliances at all if he thinks there's a viable alternative to surgery.  He's convinced that continuous pressure causes unnecessary damage to the roots of teeth."  He began to page back in the hard-cover notebook he'd brought with him, then stopped.  "Please excuse me for a moment ..."
He returned from the workshop with an appliance on a mould.  "We've made several of these for him."  It looked like an overcomplicated version of my old retainer.  "It is quite disruptive to speech, but the whole point is to apply intermittent forces, so it's generally worn only at night."
"What are the chances that it could work for me?"
"Let's just say that I'd trust his judgement.  You should too, whatever he recommends."
"That's comforting to hear.  I appreciate your making time for me."  I leaned forward and gripped the armrests of the chair.  I had the answers I needed, clarity about my next move, and even a sense of the feedback I wanted to give Mom and Dad.  "How do I make contact with your colleague?"
"I didn't mean to suggest that our conversation's over.  Unless you're in a rush?  I thought it would be better to answer your questions about the current proposal before I start talking about the kind of thinking that may allow him to suggest alternatives."
"Are you sure you can spare the time?"
"I'm enjoying your company, and I love the challenge of unanticipated questions."  I settled back.  "Any paradigm tends to prevent critical thought.  That's dangerous, so you're doing me the favour by listening to me.  Can I make us some fresh coffee?"

Offline Braceface2015

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Re: Story: The Heterodontist
« Reply #8 on: 18. March 2023, 06:02:39 AM »
Speaking from a technical angle, you should work on your formatting a bit.

If you take a look at what I have done with the spacing of Kelly Marie's stories, you will see what I mean. Kelly Marie is a good writer, and I am willing to help with proofreading her stories.

I also suggest using a good spell checker. I recommend I use three spell checkers when I write my stories before I post them.

You have the start of an interesting story and It will make an interesting addition to TheArchive.

Offline mr_90proof

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Re: Story: The Heterodontist
« Reply #9 on: 18. March 2023, 06:26:03 AM »
Ugh, this shit again.

Offline Charlie0186

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Re: Story: The Heterodontist
« Reply #10 on: 18. March 2023, 20:08:12 PM »
3. Dissonance

We returned from the kitchen with extra mugs for Yvonne, her assistant and the USPS guy.  Jimmy began asking about my original orthodontic treatment and my current problems.  As I answered, he sketched and jotted in his notebook.  He'd carried it with him even into the kitchen.  He inflated a green balloon he'd pulled from a dresser drawer.  Pinching it closed, he drew a rough face onto it with a marker.

"Drawings are static and two-dimensional.  This helps me visualise growth."  He paused to blow a little more air into the balloon to make his point.  He tied it off and put it down in front of me.

"Let's set aside your current quandary for a minute.  There's a fundamental question we need to consider first.  Our young lady presents at about eleven years of age.  She has excessive overjet and overcrowding.  Her orthodontist says her mouth is too small for all her teeth, so he proposes extracting some to make space.  He'll reposition the rest until he's achieved good functional and cosmetic results.  That sounds reasonable, doesn't it?"

"I suppose so."

He reached into the drawer again and pulled out a roll of little adhesive labels.  He began sticking them onto the mouth he'd drawn on the balloon.  "Here's that young lady aged thirteen or so, on the day they remove her braces.  Imagine that these stickers represent her adult teeth.  Her skull would have kept growing through adolescence, but teeth are already fully-grown when they erupt.  Are you with me?"  I nodded.  "So what would you expect to see happening to them if I blew more air into the balloon?"

"They'd move apart, wouldn't they?"

"So why are her teeth a little overcrowded again?"

"The dentist said it was because she didn't wear her retainers long enough."

"You said she wore them for about a year, didn't you?"

"Yes.  He had to cut off the bands for my lower one before we moved to Fort Walton.  He took away my top one at the same time."

"Was she good about wearing her Hawley -- the upper one?"

"Mom made sure about that.  That's kind of what worries me about the treatment they propose now.  If it doesn't work out, someone's bound to tell me it was my fault, the way I should have worn the retainers that they threw away."
Jimmy didn't smile.  Comedy never had been my strong suit.

"Your instincts may well be right.  There's a dirty little secret hiding in our stats.  We make a hoopla about how adults now comprise about a quarter of all patients.  What we don't say quite as loudly is that about half of them are there to address issues that were supposed to have been sorted out in earlier rounds of treatment."

"I was kind of joking."

"I realise that, but it raises something important.  Six months of retention used to be a standard recommendation.  It's now more often night-time wear for life, so it's not unreasonable for you to ask why you weren't even given the option.  Knowing a little more now, I argue that having to tell a patient to wear retainers forever is effectively an admission that I couldn't resolve the underlying problem.  That's really why you're leery, isn't it?"
He looked me in the eyes until no trace of a smirk remained on my face.

"That's why I'd like you to see Peter.  He's one of a handful of people making a serious effort to deal with the fundamentals.  We need to consider the craniofacial complex as a whole if we're going to answer two questions.  First is how and why malocclusions develop.  Second is how to manage them in a way that doesn't make relapse inevitable.  But I'm getting ahead of myself."

He picked up his mug and studied the dregs.  "Oh yes ..."  He set it down again.  "Don't you find it remarkable that she didn't develop gaps between her teeth as her face and jaws continued to grow?  Especially since a quarter of her teeth had been extracted?"

"It was only four.  The ones you mentioned, on each side, on the top and bottom."

"Four extractions then."  He paged back until he found the sketch showing the gaps where my teeth had been pulled.  "Let's consider what her orthodontist might have been trying to do."  He added a facebow and elastic bands, and a neck strap until I corrected him.  "Starting treatment in early adolescence is conventionally about taking advantage of growth spurts.  The idea is to intercept and control growth patterns that were considered undesirable.  That would most likely have included the relative prominence of her upper teeth in our young lady's case.  The headgear would have been to restrict the growth of her maxilla while the mandible caught up."  He drew a faint outline of a larger lower jaw.  "Wearing headgear ten or twelve hours a day would anchor her molars, preventing them from drifting forward into the extraction gaps.  He'd pull her upper front teeth into the gaps with these intermaxillary elastics.  Does that all still sound sensible?"

"Yes, but I had to wear headgear way more than twelve hours a day.  And I remember him welding little stoppers onto the ends of the facebow to make a bit more space when it came close to touching my front brackets.  So he must have been pulling my molars back, not so?"

"That would seem to make subsequent crowding problems even more surprising, wouldn't it?"

"I guess."

"And did they tell her that they had to extract her wisdom teeth too?  Maybe because there wasn't enough space for them."

"That was in my senior year.  The dentist said they were pushing the other teeth out of alignment.  He said that I should get braces again after he'd pulled them, but Mom and Dad were saving for us to go to college, and I didn't want to go through all that again."

"Do you happen to remember if the x-rays looked something like this?"  He added upper wisdom teeth to his drawing.  They lay at an angle, pushing forward against the roots of the molars that had already emerged.

"Hell no!  Sorry.  Are you saying that the headgear moved my molars to where the wisdom teeth were supposed to come in?"

"Not necessarily.  They removed her lower wisdom teeth too, didn't they?"

"Yes ...  Why?"

"And she didn't have a lip bumper or any sort of headgear to anchor her lower molars?"

"What's a lip bumper?"

"It's a removable arch that fits between the front teeth and the lips -- a little like a facebow without the whiskers."

"No, thank goodness.  One facebow was more than enough.  My husband had to wear two for a while when we first met.  They made me think of a duck's bill when he spoke."  We'd shared a corner of the college library for weeks before I'd even been able to bring myself to return his smile.  "He hated having to wear them," although they did make him kind of adorable.  Despite his trying his best to be supportive the past few weeks, I'd been harbouring serious doubts about how Martin would really feel about me wearing braces.  Even those ceramic ones.  I prayed for the kind I'd be able to take out.

"Indeed.  I assume the elastics stretched from her upper canines to the lower molars like this, didn't they?"

"It was from little gold hooks on either side of my front teeth."

He modified his drawing.  "Without anything anchoring her lower molars, those elastics would have tended to pull them forward.  Any movement would have created more space for these third molars to erupt into, not less.  Even so, they considered it necessary to remove them too.  That's why it's important for us to remember my caveat and not rush to premature conclusions."

"So why wasn't there enough space for those teeth to come in?"

"Good question -- stick a pin into that for now.  Did she have any other teeth extracted for any reason?"


"So then we agree on my initial postulate.  Our young lady had four first bicuspids and four third molars extracted.  By my count, four plus four is eight.  Fully a quarter of the thirty-two adult teeth that her jaws should be able to accommodate."

"... I suppose so.  That's hard to believe, though."

"It is, indeed.  Which makes this an even more fascinating conundrum.  Why are her teeth overcrowded again now, after all those extractions?"

"My wisdom teeth pushing on my molars?  That's what the dentist said."

"Did the extractions stop the misalignment from progressing?"

"No, they're definitely more crooked now."

"So then we'd have to conclude that something else must be going on, wouldn't we?"

"Like what?"

"You have the advantage of coming at this without years of indoctrination.  Try to think in three dimensions."

He made an arch with his thumb and forefinger and held it against the stickers.  "Imagine I've fitted braces onto our patient's teeth."  His hand slightly indented the balloon.  "Here's a growth spurt while she was wearing them ..."  He mimed blowing more air into it.  "What have we been ignoring so far?"
He watched me while repeating the performance.  I wasn't sure how much insight he expected to see.  The tiny glimmer seemed unreasonable.

"Are you saying that the braces prevented my jaws from growing?"

"It's safe to assume that consistent retainer wear would have maintained the size and shape of her dental arches as they were on the day her braces were removed.  That's precisely what they're intended to do."  He pushed his thumb and forefinger into the balloon again.  "The original assumption was that her teeth were crowded because her facial bones were underdeveloped, but her arches apparently still can't accommodate her teeth, even after all that extraction and retraction.  You agreed a few moments ago that the treatment proposal sounded reasonable.  Do you still think so?"

Offline Sparky

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Re: Story: The Heterodontist
« Reply #11 on: 18. March 2023, 23:02:54 PM »
First of all, I don't care what others say, your spending a bit of time formatting that last chapter did make it a lot easier and more pleasant to read, so thank you!

So, the story so far... definitely NOT the normal "I went to the ortho, who filled my mouth with metal" stories. But something to make you think! I'd be interested in the background that led you to write such a story...

Offline mr_90proof

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Re: Story: The Heterodontist
« Reply #12 on: 19. March 2023, 02:33:29 AM »
There is a reason that the same three or four people have contributed stories for years.   And new writers show up for a few months, contribute good content, catch shit, and then leave.

Offline Charlie0186

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Re: Story: The Heterodontist
« Reply #13 on: 19. March 2023, 04:53:18 AM »
4. Schism

"I argue that it's a bit like the ancient Chinese practice of foot-binding," Jimmy continued.  "The price for a debutante's beautiful smile could end up being a lifetime of pain and debilitation.  You're not the only one with sleeping problems.  What keeps me awake at night is wondering how many of them were my patients as children.  And how often I might have made things worse.  And why I treated them the way I did despite having all the information I needed to make better decisions.  I remember reading an excellent paper in the early eighties that raised the alarm, but I ignored it because I wasn't ready to listen.  Nobody was.  That's the problem with a paradigm.  Most subsequent studies have concluded that standard techniques are safe and effective.  Reading them more carefully now, the obvious shortcoming is that very few consider long-term effects.  The magnitude of the problem is becoming apparent only now that large numbers of patients are maturing."

"It must have made you a much better orthodontist, though?"

"I wish I knew.  All I'm aiming for right now is to be more open-minded.  I used to be such a big freaking Philly deal that I never had time to work through the literature, or any inclination to learn from anyone else."  He toyed with the appliance he'd brought, and paged back to look at one of his sketches for a moment before setting it aside.  "But we've still not answered that fundamental question about our young patient.  I'd like to try to do that and apply what we learn to the possible consequences later in her life.  There's one more learning point I want to wring out of our little balloon."

He picked it up.  "We're still looking for a reason why her teeth didn't move apart with growth once they were no longer held in place by an orthodontic appliance."  He squeezed and released the balloon a few times.  "If the air pressure inside the balloon represents the tendency to grow, what opposes that?  What does the elasticity of the latex represent?"

"After teeth and bone, there's only the soft tissues.  Skin, fat, muscle ... and connective tissue I guess.  Is it muscle?"

"They're likely all involved to some extent, but let's go with that.  That's the myo- part of why we say we take a myofunctional approach.  It's easy to forget how many muscles there are in and around the mouth.  Please put your hands on the balloon where the cheeks would be ... right there."  I did as he asked.

"Imagine our young lady at age eleven, before she wore any braces.  Let's say for the sake of argument that her nasal airways weren't as wide open as they ought to be, for whatever reason.  Humans are remarkably adaptable, so she very likely learned to breathe through her mouth to supplement the airflow.  The way you still do."  My mouth snapped shut.  "So her lips would often be applying less force to her dental arches than her cheeks.  It's not the whole story, and I'll come to the rest later.  But if I hold the cranial vault like this to isolate the facial bones," he placed his hands behind and on top of the skull so that only the front remained free; "and you simulate the relatively greater force of those cheek muscles by squeezing the balloon -- what happens to the face?"

I squeezed.

"Do you see the maxilla projecting forward over the mandible?  And that it may have more to do with angles than their relative sizes?"

I squeezed and released the pressure a few times.

"You see the paradox, don't you?  We were trying to restrict the growth of the maxilla that we thought was already too small for all her adult teeth."

I felt as though I was drowning in a calculus class.  I said "OK ..." without any clear understanding of the implications.

"Good.  You're a very quick study.  So then ..."

"No, please.  Let's go over that again.  You're saying that an overbite might be a kind of illusion, not because of a big upper jaw or a small lower one?"

"Overjet, but yes.  Those prominent upper front teeth might not result from the relative sizes of the jaws.  We agreed earlier that our patient's orthodontist very likely believed that her upper jaw was too small.  Despite that, the headgear and elastics suggest that he was trying to slow its growth, or even pull the whole arch back a bit.  That seems ludicrous looking at it from your and my current perspective this morning.  But I would most likely also have missed the obvious and treated her in exactly the same way."

"I think I'm with you."

He released the balloon and referred to a sketch, pointing to the cheekbones.  "We're so fixated on profile views that we often don't consider that the real problem might lie in the transverse plane.  It could be that the facial structures didn't broaden as they should.  A narrow face could lead to reduced nasal airway volumes.  We've seen how that, in turn, could lead to prominent front teeth."  He squeezed the balloon, not that I needed the reminder.  "Trying to improve the profile with extractions and retraction misses the root cause and might actually make it worse."  He referred back to his sketch with the facebow.  "Small dental arches mean less space for the tongue in the mouth, forcing more of it back and down into the throat.  And restricting the growth of maxillary structures might also prevent normal growth of the pharyngeal cavity, or even reduce its volume."  He added a few heavy lines to his sketch.  So heavy that he almost ripped the throat.  "Are you still with me?"

The dawn sky reddened as I nodded in reluctant understanding.

"Might one reasonably conclude that constricting the pharynx could cause even more breathing difficulty?  Even obstructive sleep apnoea?"  I found myself quite unable to draw breath.

"So what's the solution?"

"It should have been to make better use of the structure that nature provided to maintain wide arches.  Your natural retainer, if you will.  That's what Peter's myofunctional therapist is likely to focus on."

"The bones of the palate?"

"Not quite.  What structure protects them from the forces that compromised the maxilla and nasal airways in the first place?"

"I wish I'd paid more attention in my anatomy classes.  Those little bones in the nose?"

"Remember that she's a myofunctional therapist.  The cavity within your upper arch is almost exactly the same size and shape as what?"

"The tongue?"

"Exactly.  It's a lump of very powerful muscle.  If the tongue is where it's supposed to be in the mouth, it works much like the plate part of a retainer.  The tongue's the key to developing and maintaining wide dental arches."

I tried to keep up as he spoke about environment rather than genetics.  The work of a dentist who'd studied primitive populations.  How much chewing was required by ancestral and modern diets.  Of the relationships between posture, head carriage, narrow arches and facial development.  How the structures of the head and neck worked as a dynamic system, and how any perturbation was likely to cascade into secondary problems.  Colleagues who were trying to assemble a body of relevant knowledge, and their insights into poorly-developed faces, restricted airways, crooked teeth and even poor articulation of the temporomandibular joints.

I felt overwhelmed, but I did catch that last part.  "Just go over that again please."

"It's a remarkable joint."  He used several more pages in his notebook to illustrate the range of motion and the complexity of the structures that enabled this.

"What are the options for treatment?"

"Apart from what your orthodontist proposed, remodelling facial bones with functional appliances like this one may be a viable alternative.  Peter thinks he may even be able to stimulate some growth, although most people argue that that's feasible only until the end of adolescence.  There's remarkably little solid empirical evidence either way in adults, but I know him well enough to believe he'll want to try that first if he thinks it's possible.  I'll have Mandy dig out his contact details for you."

"Thank you.  You said there were some exercises ..."

He stressed the importance of lifting heavy things, good overall posture, adequate chewing, especially on firm foods, concentrating on breathing through the nose, and keeping the tongue up against the full length of the hard palate even though my narrow arch might make this difficult.  "Google 'good oral posture exercises.'  Or 'Mewing.'  You'll find it interesting."

Offline Charlie0186

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Re: Story: The Heterodontist
« Reply #14 on: 19. March 2023, 10:26:58 AM »
5. Receptiveness

"But how am I supposed to keep my tongue up there on my palate if I'm wearing my splint?"

"I thought you said you'd given up on that?"

"No, I still wear it whenever I can."  I opened its case to show him.  Sorry -- I should have rinsed it.

"No matter, and to answer your question, you probably can't.  All this acrylic on the lingual surface just makes an already narrow arch an even tighter fit for your tongue."  He'd indicated what he meant by pointing with his pen.  "And its rigidity prevents what we're trying to achieve with tongue posture anyway."

"Should I stop using it and rather concentrate on my tongue?"

He disappeared into thought for a moment.  "How likely are you to see Peter when you get home -- honestly?"

"One hundred per cent.  What you've said makes good sense."

"And you're sure that wearing it helps?"

"Yes.  I only took it out when Yvonne brought coffee."  I popped it back into my mouth.

"And the only reason you don't is the speech issue?"

"Yes."  That single syllable confirmed my problem.  "That and having to take it out to eat or drink anything that could stain it."

"Nothing else?  It's not causing any discomfort -- anything like that."

"No.  It's just that I can't speak clearly with it.  It's fine otherwise.  I'd wear it all the time apart from that if I could be sure I wouldn't need surgery."

He placed his fingertips on my joints.  "Please open for me ... close ... again."

"And you're certain it's the splint, not painkillers that you're taking at the same time, for example."

"As certain as I can be."

He paused again.

"How would you feel about being a guinea pig?"

"For what?"

"As it happens, I'm working on an occlusal splint that's compatible with good tongue posture.  I'd like to think that Peter might agree that you're an ideal candidate.  Would you be happy to see how you get on with it until he decides on something else?"

"If you think it could help.  I value your judgement."

"I'd be most obliged if you'd give me honest criticism about what you do and don't like about it.  He'll provide all the technical information I need."

"That's very generous.  I'll give you whatever feedback you need."

"You're flying out the Monday after Thanksgiving, aren't you?"

"We are."

"Could you come in on Saturday morning before you go shopping with Yvonne?  It won't take long to fit."


"Please excuse me for a moment.  I'll have Mandy prepare a copy of the informed consent forms for you.  Yvonne's very fussy about making sure that we protect the design and record your understanding that it's not quite ready for prime time.  I'll explain everything in detail while I examine you."

He continued as he stood up.  "I hope you'll find it much easier to wear.  You won't even have to remove it to eat if you cut your food into small pieces and avoid the usual contraband.  If it does break, I'd like to know about the circumstances.  Otherwise, all I want from you is to wear it all the time except to clean your teeth until Peter says otherwise.  I'll make sure it's not going to do anything that might cause any further damage.  I'd appreciate your reading through the paperwork tonight and telling me early tomorrow if you decide not to participate.  Does that sound fair?"

He returned a few moments later.

"I presume the orthodontist and surgeon must have done x-ray imaging?"  I nodded.  "And that would have been in the past month or two?"

"Just over a month ago."

"I don't want to expose you to more x-rays than necessary.  Peter has much better equipment than mine at the moment, and he'll do all the imaging I'd have done anyway.  If your Michigan splint isn't causing any harm, there's no reason for mine to do so, but stop wearing either of them if you feel any discomfort at all.  Please come through with me."

We went through to his consulting room.  It was as utilitarian as I'd come to expect.  I reclined on the chair while he gave my jaws and splint a thorough examination, observing as much with his fingertips as with his eyes and the various instruments he used.  As he worked, he did what dentists do.  He chattered his way through a one-sided conversation, stopping only when he hunted for a replacement battery for an electronic stethoscope, and then while he listened to my joints.  He explained that my current splint was creating a smooth surface between the molars, preventing them from engaging when I clenched my jaws.  This removed some of the stress on the temporomandibular joint.  His splint would do the same, but with less disruption to normal function.  Instead of acrylic bite plates, he would use precisely moulded metal pads between the teeth to smooth and very slightly raise the occlusal surfaces.  It would help resolve my overcrowding by training my tongue and by stimulating the bone in my jaws as I chewed, and it would also have lightly-sprung pistons between the top and bottom components to guide my lower jaw and gently nudge it forward to help open my airways when I was asleep.  All the forces applied by the appliance itself would be very light initially, but there was plenty of scope for Peter to adjust whatever he considered necessary.

"If you're still happy to continue, I'll take some impressions of your teeth and bite."

"I wish I lived close enough for you to treat me," I said while he loaded goo into the lower tray for the second set of impressions.  "I don't care what any other orthodontists might say, I'd be happy knowing that I inspire half as much confidence in my patients as you do."

"That's very kind of you to say so.  Open please."

"Oh ..." he said as he clamped his index finger under my chin.  "Something I forgot to say earlier.  It's important to train yourself to breathe through your nose.  Buy a roll of surgical tape to keep your mouth closed while you sleep for a few weeks."

He returned to the issue at hand after I'd had the opportunity to rinse.  "Your appliance will look very much like Yvonne's."

I saw her smile in my mind's eye.  They kind of suited her, but ...  But I'd more than likely soon have been wearing braces anyway.  I might still, depending on what Peter said.  It was all too fast, but Jimmy had been more than generous with both his time and wisdom, and his appliance might just help.  But, but ... but nothing!

"Yes, thank you.  But I thought you said it would be a removable appliance.  Isn't she wearing regular braces?"

"No, we finished her active treatment several years ago.  That was before all this, so she wears my prototypes instead of retainers.  The design's based partly on her insights."

Yvonne came through with the trial documentation.  "The confidentiality clause doesn't apply to Peter, so I've added explicit authorisation to show it to him."  She also had a printout of Peter's contact details.  I took my glasses out of my handbag to study her mouth as much as the paperwork.

"I don't know how to thank you.  Both of you, for all your kindness.  I really do appreciate your letting me participate in the trial."

"Please just let us know how it goes with Peter."

"And I'm looking forward to getting to know you a little better after the fitting," said Yvonne with her bejewelled smile.

My many uncertainties had reduced to one -- Martin's reaction.