An occasionally irregular blog about orthodontics

We need to talk about Myofunctional Orthodontics…

By on October 16, 2017 in Recent posts with 82 Comments
We need to talk about Myofunctional Orthodontics…

IIn this post I am going to revisit the concept of myofunctional orthodontics.  I have decided to do this because there has been increase in advertising about this type of treatment.

This is my academic opinion on this type of care. I have previously posted about this treatment.

What is myofunctional orthodontics?

The main proponent of myofunctional orthodontics is a company called Myofunctional Research. They are based in Australia and also have branches in The Netherlands and the USA.

Myofunctional Research base their treatment philosophy around the hypothesis that soft tissue dysfunction is the major cause of malocclusion and aberrant craniofacial growth.  This is nothing new, as this concept is one of the central tenets of Moss’s Functional Matrix theory.  They extrapolate this theory to put forward the concept that while orthodontic treatment effectively straightens teeth, it does not treat the soft tissue cause of the malocclusion.

Myofunctional orthodontics is different as it corrects the soft tissues and breathing when the child is young. This means that Myofunctional treatment can grow jaws, expand arches and correct skeletal discrepancies.

This treatment is very similar to orthotropics. Only a few practitioners provide this complex UK based treatment. The UK licensing authority has suspended the developer of this system (John Mew) from clinical practice.  Therefore,  there is likely to be a decline in the  popularity of this system.  As a result, I will only discuss Myofunctional Research.

What does myofunctional treatment involve?

Treatment involves a series of exercises and the use of pre-formed appliances that are similar to a loose-fitting positioner.  You do not need to take impressions before you fit an appliance. I think that the appliances are the contemporary version of a Frankel appliance, again this is not new.

They ask us to take a massive quantum leap and accept that this treatment will correct most developing orthodontic problems to provide a more natural solution than conventional orthodontic treatment.

In some ways this theory is compelling. However, it ignores the genetic component of malocclusion, which is central to conventional orthodontic treatment. The conventional theory is that there is a genetic and environmental component to the aetiology of malocclusion.  This means that conventional orthodontics recognises that there may be shortage of space for the teeth or there are skeletal discrepancies. Orthodontics direct treatment at making space and/or correcting or compensating for a skeletal discrepancy.

Does this work?

I do not know because it is difficult to find any research or even well documented case reports.  They put many pictures up on their websites and Facebook pages for comment by their admiring followers. I think that these results are similar to those obtained by standard orthodontics and functional appliances and the effects are no more than normal dental development. I have pasted some pictures in here.

Since posting I have been asked to remove the pictures because they are from a closed Facebook group  (myofunctional orthodontics). I have tried to find case reports on the Myofunctional Research website and I could not find any, I am not sure why?

Two researchers have published high quality research papers. These show that the appliances may be effective. I have posted about these before.  In one study, Emina Circic, showed that the effects of myofunctional treatment was similar to an Andreasen activator. However, the co-operation rates were very low for both treatments. For example, 70% of the Myobrace and 53% of the Andreasen treatments were not successful.  In another paper by Rita Myrlund,  the myofunctional therapy corrected mild malocclusions, but the study was small and they only reported short-term results.

How do we get trained in this treatment?

Treatment is provided by short courses for interested practitioners.  They tend to direct their  advertising at general practitioners using selected references to underpin their philosophy.  It appears that the training programmes runs over a few days and delegates can become a Myobrace Member or Certified Provider. Again, details of how they award these qualifications are not clear. The information suggests that they base this accreditation on the number of patients that the Myofunctional practitioner treats.

What do I think?

I have done my best to evaluate this treatment and I cannot help thinking that it may have potential.

It would be good to see some high quality research because it would be great if this simple treatment was effective. I have tried to engage with Myofunctional research. While they appear to encourage co-operation, when people have raised questions about the treatment the responses can be aggressive. The main spokesperson is a general dentist who is very active in writing articles that are published on websites and dental magazines.  Here is an example.  Their “followers” have called me pre-historic, out of touch, a “history man” and described as “me and my type do not understand”.  They then delete these discussions.  I cannot help thinking that they would get a long way if they became more open about their treatment and provided more information on its cost, burden of care and treatment duration. All this is missing in their information.

Is is Snake oil and quackery?

It is easy for us to dismiss this treatment because of the lack of quality evidence.   But we must be careful and we should remember the claims that people are making about self-ligation and some of the methods that are meant to accelerate tooth movement in the absence of evidence.  It is clear that someone needs to do some research. Surely, it is time for academic researchers to work with Myofunctional research and carry out a trial.  I cannot do this because I have almost finished my research career.  But someone could step up and try to work with them?

Finally, I would like to ask some questions;

  1. Why have Myofunctional Research not carried out a trial into their treatment methods?
  2. Why do dentists accept the promotion of this treatment and treat their patients in the absence of evidence on whether the treatment will work?
  3. Can patients consent to this treatment in the absence of evidence of its effectiveness?

These will be the subject of another blog, but it would be interesting to hear views about this in the comments section of this post.

(Visited 9,198 times, 28 visits today)

Tags: , , , , , ,

There Are 82 Comments

Trackback URL | Comments RSS Feed

  1. Robert Pickron says:

    Anything works to a certain extent and Myofunctional therapy does too. It lacks the ability to force cooperation and this is its biggest drawback in my opinion. You cannot treat successfully without consideration of the lips, cheeks and tongue. Without good balance in these muscles, you will get relapse. They typically over-expand and retain for life to avoid extractions. Thanks for your balanced assessment and comments.

    • Dear Dr. Pickron

      Thank you for giving your opinion that Myofunctional therapy’s (MT) ‘biggest drawback’ is that, ‘ It lacks the ability to force cooperation…’.

      Over recent decades as a teaching and practicing pediatric dentist, I have personally found that a so-called ‘inability to elicit cooperation’ from a child most often results, not so much from the inadequacy of a prescribed Tx regimen (e.g., MT, functional dentofacial orthopedics, etc.) and/or design and fabrication of a particular appliance (e.g., Myobrace, non-bonded functional appliances, etc.), but mostly stems from a provider’s general lack of training, experience and interest in the area of pediatric behavior guidance; and when the patient from whom elicitation of cooperation would be advantageous is an age-appropriately cautious, fearful, frightened and usually curious young child, a forced-march as you seem to have implied ( ‘….It lacks the ability to force cooperation…’) is seldom the correct and most compassionate approach. When I was a pedo resident at the Univ. of Iowa in the mid-1980’s our curriculum required that we’d need to spend a great deal of time with Orthodontic Dept. faculty and their post-grad trainees learning about fundamentals of cephalometric analysis and G&D (thank you Prof. Samir Bishara, R.I.P.), yet the ortho residents were not required to spend even one minute during their two years of training with our Pediatric Dentistry faculty members and trainees….go figure. I think it would be both courageous and advantageous for your own institution, The Georgia School of Orthodontics, to add a board certified pediatric dentist to your permanent faculty (a dual-boarded pedo-ortho guy, Gerald Samson is in your own backyard), and a curriculum module by which you could expose your residents to didactic and clinical experiences aimed at providing them with knowledge, experience and competence in the area of pediatric behavior guidance. I would be honored to help you with this proposed endeavor should you be curious to explore.

  2. David Matos says:

    Very good article about this subject. The main cause of struggling opinions about everything that involve orthodontic/orthopedic/myofuncyional treatments are lack in understanding the really effects, specially for those that do not spend time in studying out of “facebook university”.

  3. Dr.Michael Krennrich says:

    I can´t see the magic in this concept. I was involved in a fb discussion that soon became “religous”. I think nobody doubts that teeth erupt in a comfort zone between cheeks, lips and tongue. This zone is not always functional and not always esthetic = very often we moove teeth out of this zone and the more we move them apart, the more adaption is needed and the higher the chance of relapse. It´s imho a good idea to create a healthy environment early in the life of a patient and myofct. treatment can be a part of that. But 1.we don´t get every patient at the right age and 2. compliance is required but doesn´t always exist. So I don´t see the magic in the approach compared to what they call “historic ortho”.

  4. So I am old enough to remember John Mew talking to the British Orthodontic Society in London in the late 90s or thereabouts. I was a trainee and I remember a colleague saying something to the effect of “he’s got a nerve to turn up” and “I can’t understand why they let him in to the place”. But I wanted to hear him, because I wasn’t going to find out about him anywhere else.

    I always wondered what it was that he was proposing- I knew he existed, had been on TV talking about it, and caused raised eyebows amongst most of the people that I met who were qualified orthodontists.

    Now I know this blog is fond of Pink Floyd quotes, but there’s a Frank Zappa one to the effect of “without deviation from the norm, there is no progress”.

    If we all do things the same then we don’t really get new results, and we don’t have the chance to do things better. It may be that we’re doing the best we can, but ultimately it comes down to proof. Surely it’s possible to do a big enough study to see if myofunctional/orthotropic or any other term for non-conventional ortho treatment is effective.

    We can sit here and complain about closed minds, or quackery or whatever cliche applies to ideas we don’t embrace, but really good evidence will open minds if it’s there. It’s up to us to look for it, and deal with the facts if we do or don’t find it.

    Stephen Murray
    Swords Orthodontics

  5. I would like to point out one additional research of high quality (in my opinion) which has resulted in two published articles so far and with long term follow up publications coming up:
    http://www.angle.org/doi/pdf/10.2319/012607-37.1
    http://www.ajodo.org/article/S0889-5406(07)01023-2/abstract

    As a Prospective Cohort Controlled Study using different location cohorts but identical inclusion criteria and including the entire age samples of the populations, I believe this study is right below an RCT in the evidence hierarchy. It could even be eligible for inclusion in a Cochrane Review according to chapter 13 of the Cochrane handbook (v5.1).

    Respectfully,
    Valter Rönnholm

  6. Dr. Elbe Peter, Govt. Dental College, Kottayam. says:

    Thanks for the blog Dr Kevin

    Be it self ligating brackets or myo-functional orthodontics, case selection is the key. Genetic and Environmental causes for malocclusion is perfectly right, but in practice we come across a good number of cases with abnormal breathing , posture and habits leading to malocclusion in future, giving an upper hand to environmental reasons. Right age of treatment, right amount of patient cooperation and right case selection will give good results. it is seldom possible to get all 3 choices right. However as long as it doesn’t harm, there is no problem in trying out with consent and caution.

    For the three points you raised;

    (1) When case selection and inclusion is stringent for trial in this topic, it will be difficult to get an evidence based answer in the near future. So when there is no evidence “sales man is the boss”.
    2) Absence of evidence doesn’t means that there is lack of effect. we still use functional appliance though the evidence is not strong.
    3) consent is an individual choice, information is available a mouse click away even for patients.

    The diligence of a prudent clinician cannot be overlooked in an era of e-marketing. “No Harm, lets give it a try” approach may be the driving force behind the developers.
    Thank you once again.

  7. Ralph French says:

    Thanks for the piece; great to hear comment assessing and objective!

  8. Caroline Fielden says:

    Hi Kevin, I read this post with great interest as I am a GDP considering starting Myobrace treatments on my patients. I have been on the course and read anything I can get my hands on about it. I have had a long conversation with an Anaesthetist about the effects of mouth breathing and airway development. Also I have spoken to a Speech and language therapist about how the early muscular poor function could affect development and how to train the kids to use the tongue and lips right. I am working on finding an ENT consult to chat to next. It all stacks up to be a good thing to get the kids breathing and swallowing correctly from as early as possible. My feeling about Myobrace is that with a child who is clearly using their lips and tongue wrong that training better muscle use as early as possible cannot be wrong. I am working on the belief that the genetic component is one of the factors leading to orthodontic issues but the myofunctional component must also be a fairly large factor. If we can prevent a component of the malocclusion from developing then it makes the future orthodontics simpler and more stable. It may also be the reason for many failures in post op orthodontic stability which would be nice to see less of in the future. If there is any side benefit of better posture earlier in the childs development due to better airway and jaw position the that’s an excellent additional reason to do it. I know that some of this is mimicking what functionals do but without the muscular training you are fighting against one of the causative factors for needing the appliance and surely the appliance will be less effective.

    What I strongly believe in is prevention in all areas of dentistry and this seems to be a good step in the right direction. I would love to see more research to back this up but do not feel I can rest on my laurels waiting for this to appear. It is difficult in this current climate of fear in the profession to stand against the mass opinion and I would not normally be keen to put my professional standing on the line. In this instance I am going to do it because it seems to be the right thing.

  9. Nichole Cauwels says:

    Great article. I would love to see more discussion about the “other” system called ortho-tain or now the healthy start. My understanding of both of these systems is that the benefits of early muscle training g/retraining reach far beyond straighter teeth. I think we all agree we can straighten the teeth later, after all the permanent teeth are in. Compliance is less concerning and the practioner is more in control. I believe the push for early intervention with a system like myobrace or ortho-tain is that the majority of these kids have underdeveloped jaws leading to smaller than healthy airways. This lack of airway contributes to sleep disordered breathing, reflux, allergies, mouth breathing and a host of other issues. While both companies agree that future braces may be needed for texting book smiles they also believe that the long term stability will be better if function has been addressed early. They also believe that you can never go back and regain the nuerological growth and development that was missed when the child was allowed to suffer SDB while they were waiting it out.
    I too would love to see more research. But I do believe there is a lot of evidence out there about the effects of tongue ties, bottles, pacifiers, highly processed soft diets, lack of chewing, poor tongue posture, reverse swallow, mouth breathing, SDB and it’s connection to ADHD, childhood sleep apnea, reflux both gerd and lpr. The risks associated with wait and watch maybe too great even though the teeth can better aligned later.

    • Although not an orthodontist, I would like to ask a question that is related to your question about Myofunctional Orthodontics. I am approaching it from another direction than what you are asking as I see the end result of conventional orthodontics every day. My practice is 100% airway management treating adult sleep apnea patients with oral appliances. Up until recently the orthodontic profession has never addressed the airway issue. I will just stick to the fact that the majority of my adult patients have Class I occlusions, usually a flat side facial profile and significant numbers having had serial extractions, conventional orthodontics and sleep apnea. These patients have no room for their tongue as it sits on top of their teeth at rest irrespective if their resting tongue level is normal. But they do have straight teeth. Yes, high numbers are mouth breathers with low tongue levels, reverse swallow patterns and are tongue tied to some degree. None of the patients ever had any of those issues addressed at any time of their orthodontic treatment. When I address this point to conventionally trained orthodontists they either have no knowledge about the airway and tongue level, swallowing patterns etc., state they were not trained to consider it or discount the idea.
      I can appreciate the need for research. Research from private practitioners is very hard to get and dental schools do not seem very interested in the area of the airway. Sitting in an ivory tower and complaining about the lack of studies is nonproductive particularly since virtually all research is derived from dental schools. The success that orthotropics has had is real. You can complain the studies are not there to your liking, ignore the success from the Bill Hang’s and Mike Mew’s of the world, and keep your head in the sand. This is like the doctors that initially treated thyroid issues by removing the thyroid, having the patient cured and not realize after the patient left they had created a cretin.
      From my perspective, the field of orthodontics has created and is contributing to the creation large numbers of sleep apnea patients. This is reality and I see it every day. So why not ask our professional schools to start aggressively researching the airway in an unbiased fashion instead of looking to the private sector to provide the research the schools refuse to do. By ignoring and discounting the problem, general practitioners and progressive minded orthodontists will fill the void to the detriment of the orthodontic field.

      • Kevin O'Brien says:

        Thanks for the comment. I do agree that research is needed in this area. However, we also need to remember that a large component of medical researxh is funded by drug companies. If a new drug is developed it is tested by the company in several types of study before it is released on the market. I know that there are bad and good points about this model. However, I can see no reason why the companies and individuals who are marketing this treatment are not commissioning studies into their treatments? We cannot rely on the dental schools to do this, as it is unlikely that they will attract funding from government agencies to do this type of research

        • Sep says:

          Hi prof
          I am a senior lecturer in orthodontics in Griffith university which is a few kilometres from the Myobrace company in Gold Coast Australia. If anyone is interested in conducting a RCT on this subject and they have research proposal, they can contact me on S.tabatabaee@griffith.edu.au.
          Yours Faithfully
          Sep

          • Kevin O'Brien says:

            This is great I wonder if myobrace can contact you. I will happily advise on the protocol etc.

  10. Ray Reed says:

    A small point; describing Orthodontic treatment methods as “philosophies” seems absurdly grandiose. Plain language is better.

    • Excellent points, but I am as many others are skeptical of studies provider by the company that markets the product. Dental schools have graduate students that are guided by their program directors to write their thesis and perform research. Our profession has to take the lead with those in the private sector many times opening the door to new ideas. Dental school politics and turf fights are legendary and I have had to in the past and presently am having to deal with this for the field of OAT.
      Orthodontic dept. directors need to open their eyes and take a lead with their graduate students to obtain govt. research grants. It is unfortunate when I hear that a dental school black lists certain doctors because they don’t like or agree with them. What I see every day is real and the treatment results of doctors like Dr. Hang and Mew cannot be brushed under a rug. In 1998 I was informed by one of the dental schools here in Texas I should not be treating the cases I was treating with OAT for OSA. Now look at the state of airway management and OAT in the field of dentistry.
      Your points are well taken. The field of airway centric dentistry and orthodontics is in its infancy and I am hoping organized orthodontics will be involved in its development, not left behind to have to catch up.

    • Lysle Johnston says:

      A half century ago, Robert E. Moyers said exactly the same thing. Philosophy is something for Aristotle or Plato.

  11. Dear Kevin:
    I have been a long time critic of the Miofunctional Research appliances and approach. Some of the reasons are:
    1. As you mentioned, good research and evidence is scarse or non-existent.
    2. The instructions are that the appliances should be worn 1 hour a day, and at bedtime. I question the effectivity of a 1 hour therapy in producing any perceivable effect.
    3. Most, if not all of the parents of kids I receive in my office that have used such appliances, complain that most of them wake up in the morning lying next to the appliance.
    4. Many of them are told that the appliance will likely eliminate the need for orthodontic treatment.
    5. Diagnosis is the cornerstone of any health discipline. I wonder what parameters are used to diagnosis a problem that would require the use of such appliances. Promoting expansion of the dentoalveolar process without a clear diagnosis of pathological constriction, is, in my world, wrong. Expanding for the sole purpose of making space for teeth denies the genetic etiology of malocclusion.
    6. I’ve heard doctors that prescribe this appliances say that the patient has a swallowing problem, even in the absence of a tongue thrust. Same for other conditions that I fail to see clinically…
    7. A month ago, while attending the Biennial meeting of the Angle Society, a colleague presented an interesting lecture on early treatment pro’s and con’s. On the con’s side, one aspect was “spending” too early the limited amount of cooperation a kid has now a days (surely, we had much more cooperation 37 years ago when I started my practice). I am a first hand witness of this: kids that used this appliances often say: “more stuff in my mouth??? I’ve used this for a year and haver seen no improvements…”
    8. A sad anecdote: while walking around their commercial stand at the 2015 or 2016 AAO meeting, my partner and I were approached by the person at the booth. His pitch was, give or take a few words, this: “… you have to try this system. It’s great, parents and kids love it, and you will make tons of money. We will train you and your assistants to “sell” this appliances to the patients and parents. It’s a great business…”. I said “thank you” and walked away.
    9. Final comments: it takes about 10 hours of continuos and uninterrupted force application to start to move teeth. How can a 1 hour use at daytime change anything and train muscles to behave in a different way, especially if most kids wake up without the appliance in the mouth? We
    It would be very interesting to see serious research done here.

  12. Fenris Ulfr says:

    So, where’s the proof that the field of orthodontics creates all these horrific sleep apnea cases? There must be some, right? Or are we “too busy” filling out membership applications to the Flat Earth Society to provide evidence to support our incredibly unsubstantiated claims? Why has Hang or Mew not supplied this data? Could it be because there is none? Methinks the myofolks doth protest too much. Time to present data.

  13. Yagnesh Mantha says:

    Sir most myofunctional appliance fail because of lack of proper diagnosis. Dignosis of the etiology is very much important in treating cases . If a family has a predisposed condition for class III giving an appliance actually stops nothing. General dentistry prescribing myofunctional appliance without sound knowledge on etiology would end up in relapse of the treatment . This has a great effect on entire orthodontics .

    • Have always loved this rude, unidentifiable person, sorry cannot use the term professional due to your tone and attitude, throwing stones. You have a right to your opinion, I respect that. I do not respect and there really is no place on any forum for rudeness and being unprofessional. I am happy to exchange ideas with anybody, but not from individuals that refuse to identify themselves so they can remain anonymous and provide insults. Kevin, we may not see eye to eye on some subjects, but I would hope you would elevate this platform to keep out individuals like this.

  14. Mark Hodge says:

    It is interesting to note that Loma Linda University School of Dentistry has incorporated Myobrace training into their orthodontic residency program. They sent faculty members to attend Myobrace training and with that first hand information, it past their academic scrutiny and became part of their clinical education.

  15. Lysle Johnston says:

    In your concluding comments, you note,”It is clear that someone needs to do some research. Surely, it is time for academic researchers to work with Myofunctional research and carry out a trial.” Academic researchers? Surely you know that academicians have better things to do than play “whack-a-mole” with the latest gimmick introduced, not because of its theoretical basis and its supporting data, but rather because of its salability. Further, given your rigorous criteria for proper research, an RCT would certainly be casting pearls before swine. Moreover, the great intellectual unwashed would embrace the study only if it were to support their “bottom line.” Failing that (as would almost certainly be the case), the offending study would be dismissed as having been done wrongly by folks who lack “the skills to pay the bills.” Why else, other than “bad hands,” would anyone go into academia? As a last resort, there is always the threat of a lawsuit to keep the doubters at bay. Moyers was my professor, so I am familiar with exercises designed to get children to chew, breathe, and swallow correctly. These ideas have been out of circulation for about 40 years (thanks, if memory serves, to a paper by Proffit and Mason). In any event, it’s not your job or my job to test ideas that seem bereft of reason; rather it is the job of the person who has inflicted these ideas on our profession and our specialty. Don’ hold your breath: 21st Century orthodontics is fast becoming the uncritical selling the unlikely to the unknowing. World without end.

    • Hmmm… the premise of any management of any disease is to eliminate a cause, and reverse a pathological effect. The fundamental premise of treating malocclusion, is to state that malocclusion is the disease.
      If that premise is correct (malocclusion isa disease), then there must be a cause (genetics, swallowing, soft tissue abnormality)… and that then leads to a debate as to what treatment is fundamentally effective at treating that disease in order to acquire “normality”… in this case a Class I Occllusion free of dental crowding…
      But in all of this conversation, and in all the bitterness and argument of who is right, or with what profession owns what, or which institution is responsible to provide proof, or not…
      has anyone ever questioned the original premise which underlies it all…
      is the original premise that is the foundation of all this debate correct?
      Was Angle right in describing malocclusion as a disease?

      • Michael Ewing says:

        The angle classification is a nice hypothesis that couldn´t be proven up to date. I think its a good reference point but definitely not a disease. It was questioned a couple of times. The last time within a Health Technology Assessment in Germany.

        1. Moorrees CFA, Burstone CJ, Christiansen RL, Hixon EH,
        Weinstein S. Research related to malocclusion; a ‘‘state-ofthe-
        art’’ workshop conducted by the Oral-Facial Growth and
        Development Program, The National Institute of Dental Research.
        Am J Orthod. 1971;59:1–17.

        2. Isaacson RJ, Christiansen RL, Evans CA, Riedel RA. Research
        on variation in dental occlusion; a ‘‘state-of-the-art’’
        workshop conducted by the Craniofacial Anomalies Program,
        the National Institute of Dental Research. Am J Orthod. 1975;
        68:241–255.

        3. Morris AL, Ackerman JL, Flesch R, et al. The National Research
        Council Report of the Committee on Seriously Handicapping Orthodontic Conditions. Washington, DC: National
        Academy of Science Printing and Publishing Office; 1976.

        4. Wilhelm Frank,Karin Pfaller, Brigitte Konta
        GMS Health Technology Assessment
        Oral health with fixed appliances orthodontics.
        GMS Health Technol Assess 2008;4:Doc02

        5. Hartmut Bettin · Alexander Spassov · Micha H. Werner
        Asymmetries of the public and providers views of the orthodontic treatment need Orthodontic practice and orthodontic standards as an area of conflicts between patients, physicians and society.
        Ethik Med DOI 10.1007/s00481-014-0293-9

  16. Fenris Ulfr says:

    When one attempts to level broadsides against an entire profession, accusing the purveyors of some serious iatrogenic damage, and yet takes umbrage at being asked to provide some evidence, one has to wonder if this “outrage” is really justifiable? One cannot have it both ways. Cast diatribes, and then feign affront? This constant, and completely unjustified haranguing of the orthodontic profession by folks that know little of it has gone on for too long. Please address the lack of evidence instead of indulging in these wearisome red herrings and appeals to emotion. Should be easy enough given the audacity with which one claims that “orthodontists have created sleep apnea patients”. Surely for someone that claims to have been doing something for years, there should be more than enough data to publish? As for Dr. Mew, apparently he is no longer allowed to practice. This is a scientific profession, and not the drama club. As Dr. Johnston noted, it is not incumbent on academics to prove claims made by peddlers of serpentine unguents. Until then, four on the floor it is.

  17. Fenris Ulfr says:

    Not to derail the thread, but here is a frequently cited study in support of MFT for open bites. Smithpeter et al. Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. Am J Orthod Dentofacial Orthop. 2010 May;137(5):605-14. This study while interesting, has several critical flaws in study design, sample selection, methods and conclusions. Below are a few –
    1. There was no data presented on the similarity or homogeneity of pre-treatment skeletal or dental characteristics between the experimental and control groups including cephalometric measurements etc. How similar were the two groups? We don’t know.
    2. The lack of random allocation to experimental or control group and lack of blinding leads to a significant amount of selection bias.
    3. Out of the 27 subjects in the experimental group, 23 had no previous orthodontic treatment whereas all 49 patients in the control group had relapse following orthodontic treatment. This is therefore a comparison between 4 patients who had post-Ortho relapse vs. 49 in the control group. Not exactly an apples to apples comparison, and a totally inadequate sample size to reach the conclusions of the study.
    4. Did the subjects in the control group have AOBs before orthodontic treatment or only after? IOW was the AOB iatrogenic? We don’t know.
    5. As an additional example of cognitive and observer bias, the control group was referred to MFT AFTER relapse of orthodontic Tx, whereas the experimental group was referred to MFT BEFORE or DURING orthodontic treatment. This leads to a couple of confounders. (A) There is no reason to believe that a similar degree of relapse would have occurred in the experimental group relative to the control group (especially since there was no attempt to match the groups at baseline. (B) It is impossible to delineate the supposed effects of MFT from the effects of orthodontic treatment alone.
    6. Also, this exposes an a priori underlying and unfounded bias (ironically one that this study purported to address) that MFT would “prevent” AOB relapse.
    7. No mention of the nature of orthodontic treatment provided or mechanics used. Certain types of tooth movement (incisor extrusion with vertical elastics) is more prone to relapse. In this particular study, the degree of frequency of vertical elastic usage is unknown.
    If this is the quality of the science, is it a wonder that there is a lack of traction in proposing MFT? If the proponents of MFT expect to be taken seriously, they need to tone down the rhetoric, stick to the facts, present research/cases with complete records and abstain from pontificating about other aspects of orthodontic treatment that they have no clue about. So paradoxical….every time there is an unfounded criticism of extractions, it just completely de-legitimizes the rest of the argument as being illogical also.

  18. Of course myofunctional therapists can show some treatment effects. We already know that when we change tongues or lips that we can affect dental change. That is the half nugget of truth that “fuels the religion” that seems to be associated with this treatment philosophy. It is an easy sell to dentists because they can see the “abnormal swallowing pattern” (actually adaptive swallowing pattern would be a better term) but what they can’t recognize is the underlying skeletal malocclusion that is the true cause of this adaptive pattern. We should not be to harsh in our criticism, This is an understandable effect of how humans process information. Our brains are wired to make instant cause and effect judgments about everything we see (Read “Thinking Fast and Slow” by Daniel Kahneman for more on this). It is hard to argue against this basic human instinct to believe our own conclusions from what we “see with our own two eyes”. To fight this, we as orthodontists must counter these types of misguided cause and effect arguments with counter evidence rather than ridicule. For example, for those of you fighting the “extractions cause sleep apnea” craze that seems to be sweeping general dentistry, I offer you the following: https://www.youtube.com/watch?v=1iDFtPj6AHA This is a video of a Dynamic MRI of someone during an episode of sleep apnea. The tongue is nowhere near the teeth while the airway is blocked! The image of the tongue being “trapped” by the teeth and “forced” to the back of the throat create a great visual story in peoples minds, but they are completely wrong. I would encourage every orthodontist to have a copy of this video to gently educate our general dental peers that the sleep apnea/orthodontic connection is not at all what is currently being preached by many guru’s. We all need to follow the example that Kevin has set with this Blog. Fight bad information with good science and take the high road as we attempt to correct the misinformation that has plagued our specialty since Edward Angle began claiming that God intended man to have non extraction treatment only….

  19. Myofunctional appliances and therapy have been around for a long time and Alfred Rogers (1873-1959) introduced the concept of myofunctional therapy back in 1918. It was debated in the orthodontic literature back in the 1930s, again the 1960’s and now again but this time more heavily promoted to the general dentist in many parts of the world. The dental profession seems destined to repeat the history it has forgotten (can’t remember who said that?? – apart from Churchill, Santayana, oh yeah and Edmund Burke back in the 1700’s!!). The appliances have been around much longer than SL brackets or appliances claiming to accelerate dental movement but with very little research or mostly of poor quality. Research in most cases then comes from outside the companies so the question begs… do the manufacturers really want to know the answers?
    The article by Keski-Nisula http://www.angle.org/doi/pdf/10.2319/012607-37.1 was raised and is oft quoted by the myofunctional camp as it reported a statistically significant effect – sounds good? But let’s look simply at overjet and the correction achieved was 1.1mm with 3.3 years of treatment – the reader then has to decide is this ‘clinically’ significant and cost or time effective? Even when compared with a ‘non-matched’ control the difference was only 2.4mm and we know from excellent clinical trials that we can effectively treat overjets of >7mm at a later age. Other studies have also found similar 2mm changes in overjet and a study by Janson http://www.ajodo.org/article/S0889-5406(06)01328-X/abstract found a 2mm correction in overjet (with 3.6 years of treatment) which dropped back to 1.5mm over time and the changes in overbite and lower crowding relapsed back to almost where they started. The claim is made that this very early treatment is more stable but this paper does not support that. Now there are a number of flaws with these papers which exclude ~30% of data so this biases the 2mm result to a ‘best-case’ scenario. Until more quality research is performed, this current evidence suggests myofunctional appliances can achieve a minor overjet reduction of ~1-2mm while any lower crowding and overbite change is not stable.

  20. Dr. V John says:

    Hi Dr. Kevin,
    First off, great discussion on a topic I still am a bit wary about. Two years back, while consulting in a particular private clinic(for a few months), I was informed of this system and how the Gen. Dentist there wanted to start using this. I was intrigued, no doubt, because as far I could see, the philosophy behind it was pretty much parallel to Moss’ functional hypothesis. And many appliances were already there in the field from as early as the 1800’s working on those very principles! But what baffled me was that this particular system boasts treatment effectiveness in adults as well!! Of that I have grave misgivings. Furthermore, to my dismay, the doctor displayed adults presenting severe malocclusions being convinced to go for this system! I must say, I’m concerned.
    In children, I acquiesce to it’s effectiveness (provided that a genetic component doesn’t exist). But an adult? Granted, there may be occasions where a tongue crib or a lip bumper may have worked. But I am unconvinced…
    Am I missing something? If so, I would appreciate a clarification.
    Thank you

  21. Rob Lawrence says:

    This is a great topic and I am really interested in learning more about a 100% airway practice. Could you elaborate on how patients end up in your office? Are they referred to you by medical doctors after they have denied CPAP or surgery? I was under the impression that oral appliances were only appropriate, medically and legally, after a patient denies the gold standard for treatment being CPAP and after a medical doctor has diagnosed them. Do you ensure your patients do multiple sleep studies after an oral appliance has been placed to make sure the apnea is appropriately treated? Serial extraction is different than 4 bicuspid extraction in that serial extraction starts with extraction of primary teeth in preparation for adult teeth. Perhaps you are on to something here…. that serial extraction could be limiting growth and reducing arch length and arch width more since it is done in the mixed dentition during times of remarkable growth. Arch length should not change with extractions, but maybe it does when serial extractions are introduced? I know many orthodontist only consider true serial extractions if the patient is perfect class I and their arch length and arch width cannot be modified and cannot accommodate their teeth without being impacted or severely ectopic. On the other hand, thinking about it more, what if small jaws is associated with sleep apea. Most patients who had to have serial extractions have a significant tooth size jaw size descrepancy… There is not enough room in the arch length or width to accommodate their teeth so they have extractions. What if the jaw size is related to the apnea and not their extraction procedure? What if changes in the sinus’ post extractions are associated with apea? In that case should a sinus procedure accompany serial extractions? Perhaps, someday, if someone cannot be treated without extractions, then sleep apnea should be in the informed consent as a potential risk of orthodontic treatment. So much is unknown about it. But, we do know that sometimes extractions of adult teeth are required if the patient desires a class I occlusion with esthetics.

  22. Fenris Ulfr says:

    Expansion and extraction are not mutually exclusive or substitutes for each other. Non-extraction/extraction is strictly a modality and not a treatment goal. Several of these conflated side-effects are not inevitable, and are a function of poor diagnosis or improper mechanics as opposed to erroneously ascribing it to a treatment modality. Nothing that has been stated/presented/implied by the various detractors re: extractions and OSA/Esthetics/TMD etc. is the slightest bit convincing or likely to change the minds of practitioners. What appears abundantly clear, is that these statements are bereft of an understanding of orthodontic boundary conditions, bone biology, facial balance, TMJ and periodontal health, and the correlation & causation fallacy.

  23. Gabor Hermann says:

    Dear Dr O’Brian, Dear Colleagues,
    Please forget MRC, forget appliances and forget this evergreen fight of orthodontists vs general dentists for a minute. I am sure that this post is a very important one and arises some very fundamental questions. We as orthodontists are claiming that we are doctors. We all want to hope that this specialty is based on evidence based science. So lets talk about these issues in the light of evidence based medicine.
    In this post there are two terms being used. Conventional orthodontics versus myofunctional orthodontics. “WE” as conventional orthodontists criticize myofunctional orthodontists since “THEY” claim that what they do works but they cannot prove it. This behavior could be correct, if WE would really hold the absolute truth. There is a comment saying that this debate comes and goes over the history of the specialty. So I call everyone who can make this situation clear to answer some questions:
    1. Where is the evidence proving that the fundamental concept of genetically based ethiology of so called malocclusion is still valid? I just see a growing number of publications out there proving the environment has way too much effect on swithing on and swithing off genes and can modify, supress of the expression of the genetic information, moreover food and environment can even modify the genom. So please show the evidence that genes are the most or only responsible for what we see in the mouth and on the face. If there is nothing like this please stop criticizing other concepts and stay silent. At the moment what we can read in textbooks is a multifactorial origin of the malocclusion accepting that orofacial myofunctional balance is one of the factors. This means that we are aware of this relationship for decades, just we neglect dealing with this since motivation is difficult
    2. I really like when people start criticizing a technique that casues instable result. Please show us the evidence that conventional orthodontics, or any technique of this branch can provide short, mid and long term stability. If there is no such evidence please remain silent and try to achieve better results
    3. Malocclusion and malformation. We like using this term. Apart from the fact that this is a nice tool to frighten patients, please show us the evidence that malocclusion is really a disease. What is the evidence based value of norm occlusion? Why do we have to treat ClassII or anything that is not ClassI? I just see publications that closes out all the connections between occlusion and TMD, periodontal diseases and decays. So, please provide evidence that malocclusion is bad and normocclusion is good.
    4. Diagnosis. One comment criticizes functional guys, that their treatment is being based on inappropriate diagnosis. Please show us the evidence that there is an evidence based diagnostic procedure. If there is nothing like evidence based diagnostics than we are in a big trouble. Each and every medical intervention must be based on an appropriate diagnosis. If there is no evidence based diagnostics, how can we talk about evidence based orthodontics?
    The real value of evidence based orthodontics is its applicability in the everyday practice. If we don’t have the evidence of the fundamental questions than evidence based orthodontics is nothing more than a bubble or/and just an opportunity to stigmatize others without any right

  24. Dear Prof. O’Brien

    It is always a good thing within the context of scientifically-supported reality (a.k.a., ‘reality’) to call into question any novel hypotheses, such as myofunctional orthodontics and orthotropics, etc., that seemingly refute/contradict an hypothesis that is believed to be overwhelmingly supportive of current ‘conventional practice’, which in your own words posits, ‘…the genetic component of malocclusion (, which) is central to conventional orthodontic treatment….’). And while you carefully go on to state, ‘The conventional theory is that there is a genetic and environmental component to the aetiology of malocclusion’, you do seem imply, or possibly I erroneously inferred(?), in your previous sentence that the dominating moiety of this ‘nature vs. nurture’ etiological dyad, is the ‘genetic component’. But, according to orthodontic peer-reviewed literature from the mid-19th thru early 20th-Centuries, there is really nothing new here. For example, in the series of articles each entitled ‘Basic Principles of Orthodontia’ (Dental Cosmos 65(7):719-32, 1923), author A.L. Johnson states, ‘ The question of heredity has been a bone of contention since the first days of modern orthodontia, and writers are so dogmatic in their assertions in regard to it that they would put an end to all argument.’ And Dr. Johnson goes on to state, ‘Dogmatism in science is a contradiction of the spirit of science.’ And there are numerous articles published in Cosmos, American Orthodontist and other journals from the two centuries previous to this, that give strong support to recent speculations that myofunctional forces can not only be causative of orthodontic problems in early childhood, but also that their redirection/re-education can be key to prevention and reversal of malocclusion (references upon request). The University of Michigan Library gives open online access (https://quod.lib.umich.edu/d/dencos/ ) to these precious documents should anyone be interested in also researching how little things have changed in the orthodontic profession since beyond 150 years ago.

  25. Hello Kevin and colleagues.
    I’m an orthodontist in the US and use the Myobrace System as a core service in my practice. I also get paid to lecture and teach for them (but not enough that I do it for the money, that’s for sure). I also use Orthotropics and the ALF and the DNA and fixed appliances with TADS, etc. I’ve posted here before, often favoring the myofunctional concept. To be succinct, while I believe there are both genetic and environmental etiologies of malocclusion, my practical approach is to deal with the etiologies I can do something about. If behaviors are responsible for the physiological outcome of collapsed jaws and crooked teeth, and I can change those behaviors (especially) before that collapse occurs, then I have a professional responsibility to do everything I can to help the child change those behaviors in order to change the outcome.

    Behaviors? Mouthbreathing. Open mouth posture. Poor sleep. Poor nasal hygiene and nasal obstruction. Sensitivities to non-nutritious food. Overuse of baby bottles and pacifiers. Digit habits. Need I go on? Can’t we all agree that all these behaviors are destructive? We may not agree on how pervasive they are yet, but look at the literature on all chronic diseases of lifestyle and you will see that they, along with malocclusion and sleep-disordered breathing, are on the increase. The WHO now says CHD’s are the largest source of death in the world.http://www.who.int/publications/10-year-review/ncd/en/ And if you look carefully, you will see them in every child that has malocclusion to one degree or another.

    Outcomes? A narrow palate is not genetic. It is a distortion of a genetic trait (ie: a wide palate with room for 16 teeth). A collapse palate is the result of a poor functional matrix (ie: open mouth posture with the tongue not able to support the developing maxilla (yes, the heart of Mew’s Tropic Premise). Humankind did not have narrow palates until we started eating sugary, processed foods. The anthropologists will tell you that. When you look at the contours of the palate in children with crowded upper teeth, you will see prominent, bunched up gingiva and rugae, narrow cross-arch dimensions, and often a high vault. You don’t see palates like that in pre-industrial revolution skulls (with some notable but rare exceptions).

    Change behaviors? The Myobrace System, myofunctional therapy, and other repatterning protocols are useful for teaching four simple behaviors. You tell me if you need evidence to know these are helpful, healthy behaviors: 1) Nasal breathing as the default mode, 2) a good, competent lip seal, 3) tongue on the palate at rest (this is key. Ask Profitt). and 4) Being able to swallow using just the tongue and NOT the facial muscles.

    Now, how controversial can that be? Can anyone say it’s best NOT to do those things?

    And that is ALL that Myobrace is. It’s an exercise accessory used to teach those four things.

    Saying that Myobrace “doesn’t work” is like saying a jump rope doesn’t work when someone fails to lose weight with it, or like saying books don’t work because someone gets a poor grade on a test. The Myobrace does not do the work. The Patient does the work with the Myobrace. Period. It is NOT an orthodontic appliance.

    What’s more, it cannot do everything. The child has to LEARN about those four things, practice them, and make them their own new habits. What, a second grader can’t learn to breathe through her nose? She can learn to dance, to play piano, to do a walkover handspring, math and science, but we can’t teach her how to breathe through her nose? If you can’t teach children healthy habits it’s only because you don’t WANT to teach them healthy habits. (And I understand this as orthodontists are generally burnt out from asking for cooperation from kids for things they don’t want to do. I get it. But we’ve boxed ourselves into a corner.)

    Plus, Myobrace is just a starting point. I still have to use other techniques to bring a child’s face to it’s RIGHTFUL genetic potential, ie: the best that their genetics will allow them to be.

    I could say more, but I’ll wait for you to challenge me.

    • John McDonald says:

      He is my summary of the rather verbose support for the Myobrace in these comments: Quasi facts and Quasi conditions (a narrow maxilla is a distortion of a genetic trait, really!?!) deserve a Quasi therapeutic approach with a Quasi appliance well managed by a Quasidontist to provide Quasi outcomes that, unfortunately just can’t be measured as of yet. Someone needs to invent a Quasi-o-meter to get a handle on this stuff…..

      • Gabor Hermann says:

        This meter is called Quasi Evidence Based Orthodontics. This specialty (and Western Medicine in general) is hungry for something that we should call: Best Evidence.
        But the unconvenient truth is that this doesn’t exist. How are we able to distinguish the Quasi from Real without having evidence based treatment objective (e.g a 2.0 definition of the specialty) and evidence based diagnostics?
        By using the term of one recent blogpost this is the real perfect storm that can affect the specialty. The orthodontist vs dentist competition is just a consenquence but not a cause. If we could define what orthodontics really about we wouldn’t be in this trouble.

    • Rodrigo Viecilli says:

      Ruling out a genetic component to problems such as a narrow arch may be premature. If we study craniofacial anomalies and the effect of certain genes associated with them we will see that these individuals are much more likely to present orthodontic problems such as a narrow palate that you refer to. Although there is not a gene that directly relates the problem in question, there are mutations that determine collagen abnormalities, fibroblast growth factors, etc… that affect these orthodontic “entities”. Polymorphisms of these genes and others we still don’t know about can lead to higher likelihood of these entities appearing. Nature or nurture is still a fuzzy topic in development.

      • Gabor Hermann says:

        No one wants to rule out genes. The only question is wheter genes predispose or determine. The most recent publications on genetics suggest that gene expression became equally important than gene itself. In addition these publications also suggest that environment will significantly influence gene expression. In other words we have to rethink the agenda completely accordingly. We simply cannot neglict environment (orofacial myo, and orther function, like mouth breathing) any more. We are doctors and we are responsible for what we say. If we say that the ethiology of maloccusion is multifactorial in which environment plays a significant role (this has been written in textbook for decades) simply we are breaching medical ethics if we don’t address a factor on which we have a potential to influence.

  26. Fenris Ulfr says:

    In addition, when these Quasi claims are debunked by science, the quasidontists don’t eschew their claims…they castigate the science! Putting very poor research and well done clinical studies on the same pedestal, and exalting anecdote over fact are other symptoms of this curious affectation.

  27. Before responding to your blog, Dr. O’Brien, I would like to introduce my credentials. I am Dr. German Ramirez-Yanez, I am certified Pediatric Dentist with a Diploma in Orthodontics. Also, I have a Master in Oral Biology, a Master in Craniofacial Pain and Sleep Apnea and a PhD in Oral Biology. I am the scientific adviser and researcher for MyoResearch, Co. and I have my private practice in Ontario, Canada.

    I feel sad that a colleague try to discredit a System misguiding your readers by saying that there is no scientific evidence or research with the Myobrace system. I invite you to read the following publications in peer-review journals:

    1. The effects of early preorthodontic trainer treatment on Class II, division 1 patients.
    Usumez S, Uysal T, Sari Z, Basciftci FA, Karaman AI, Guray E.
    Angle Orthod. 2004 Oct;74(5):605-9.
    2. The effects of myofunctional appliance treatment on the perioral and masticatory muscles in Class II, Division 1 patients.
    Yagci A, Uysal T, Kara S, Okkesim S.
    World J Orthod. 2010 Summer;11(2):117-22.
    3. Influence of pre-orthodontic trainer treatment on the perioral and masticatory muscles in patients with Class II division 1 malocclusion.
    Uysal T, Yagci A, Kara S, Okkesim S.
    Eur J Orthod. 2012 Feb;34(1):96-101
    4. Dimensional changes in dental arches after treatment with a prefabricated functional appliance.
    Ramirez-Yañez G, Sidlauskas A, Junior E, Fluter J.
    J Clin Pediatr Dent. 2007 Summer;31(4):279-83
    5. Early treatment of a Class II, division 2 malocclusion with the Trainer for Kids (T4K): a case report.
    Ramirez-Yañez GO, Faria P.
    J Clin Pediatr Dent. 2008 Summer;32(4):325-9.
    6. Electromyographic muscular activity improvement in Class II patients treated with the pre-orthodontic trainer.
    Satygo EA, Silin AV, Ramirez-Yañez GO.
    J Clin Pediatr Dent. 2014 Summer;38(4):380-4.

    After you read those scientific articles, I hope you may clarify that the Myobrace System has scientific evidence to state that:
    1. The System improves mandibular posture (Usumez, 2004)
    2. The System stimulates transverse development of the dental arches (Ramirez-Yanez, 2007)
    3. The System improves dental position as a result of correcting oral dysfunctions (Ramirez-Yanez, 2008)
    4. The System changes the masticatory and facial muscles activities (Yagci, 2010; Uysal, 2012; Satygo, 2014)

    As a experienced researcher, you should carefully review the literature before saying that there is no scientific evidence and, that MyoResearch Co is not promoting research on their System because they did not invite you to do research with them, as it can be read within lines in your blog. As you may see there is scientific evidence for the Myobrace System and not just random clinical cases on a web site as you said in your blog

    I also would like to inform you that currently we have got ethical approval for other three research projects evaluating the efficacy of the Myobrace System with Sleep and Breathing Disorders children. This research is going to be developed in two hospitals in USA and a University in Italy.

    I hope you will publish my response in your blog and acknowledge that you did not review the literature properly before writing your blog.

    Sincerely

    Dr. German Ramirez-Yanez, DDS, Pedo Cert, Ortho Dip, MDSc, MSc, PhD, FRCDC

    • Kevin O'Brien says:

      Thanks for your comment. I can assure you that I did review the literature on myobrace and I looked at the papers that you have listed. I have looked at them again and papers 1-4 are low quality retrospective studies with convenience controls, paper 5 is a case report and paper 6 is a case control study. These are all recognised as being of a low level of evidence and subject to bias. None of these are trials which would provide us with high level information. As a scientific advisor I am sure that you are familiar with trials and it is great to see that you are carrying out research. Can you let us know if these are trials?

      • Dr. German Ramirez-Yanez says:

        This studies are trials performed at Universities with ethical approval. Furthermore, they include a number of subjects that were above the minimal numbers to produce statistical significant data, after performing a power statistical analysis. Furthermore, EMG studies, particularly the one by Satygo, 2014, included control groups comparing the results of treated patients with non-treated patients and patients without malocclusion, a difficult task in clinical research.

        So I do not understand why you say they are low evidence when they were complying with all the parameters to be accepted in peer-review journals. Those studies fulfill the requirements to become scientific evidence. Now I can ask you: Do yo have any study with the Myobrace showing opposite results to reject our published data?

        It is your word against published data. Sorry, but you have no scientific evidence to support your words, AND we have published scientific data to prove the Myobrace system works and may produce results. I may agree when you said it may no produce results because compliance, due to the dental professionals not being trained to motivate the young patients. But, it does not mean that the Myobrace does not work, as you said.

        • Kevin O'Brien says:

          Thanks for your comments. I would expect the scientific advisor to a commercial organisation would have a greater understanding of levels of evidence and interpretation of types of study design. As I explained before these are not trials and are not high levels of scientific research. If you want to find out more about this you could read more of my blog posts. Alternatively, you could read the excellent book by Trisha Greenhalgh called “how to read a paper”. This is an excellent guide to interpretation of research.

    • John McDonald says:

      Dr Ramirez-Yanez, thank you for joining the discussion. As the “scientific adviser and researcher” for Myoresearch Company you now have the tools and the responsibility to step up and “advise” Myobrace that they need to provide some acceptable proof for their claims. It is what we here in the U.S. would call “Gut Check Time” meaning time to prove who and what (you and Myobrace) are deep down inside.

      Kevin has already reviewed your research (presumably your best stuff) and essentially said it meets the standard of an infomercial and should not not be taken seriously by clinicians who care about providing the best possible treatment to their patients.

      This blog post has been visited over 7000 times mostly (I am guessing) by clinicians who share the desire to provide proven, effective methods to treat the patients who trust them. Kevin has offered to help you create a study that would be more than infomercial worthy, A faculty member at Griffith University has offered to organize some research. What are you going to do with that information? Thousands of interested, committed orthodontists are watching your next move.

      In the “Gut Check” world there are really 2 possibilities moving forward:
      1) Myobrace will step up and support or fund a study using appropriate research design, prove itself a legitimate, effective treatment that responsible, evidence based clinicians can recommend to their patients.
      OR….
      2) Myobrace will ignore these offers and prove to this very large world wide audience that Myobrace is no more than a hype driven company selling “Snake Oil” to gullible clinicians and others who know better but still choose hype over science.

      So, Gut Check time: What kind of company will Myobrace prove itself to be? Rest assured that thousands and thousands of us are out here watching and waiting to find out.

      • Dr. German Ramirez-Yanez says:

        John, as I mentioned previously, MyoResearch is currently supporting research in 2 hospitals in the USA and 1 in Italy which have got ethical approval. Now I ask you:
        Does anybody has done a research demonstrating the scientific reported data is not valid?
        Does not published data in 6 papers published in peer review journals demonstrate the efficacy of the Myobrace?
        Does because one person does not want to acknowledge the scientific reported data published make that a strong argument to invalidate what peer reviewers (experts in the field) have accepted?
        I have to say: There is no worse blind person than that who does not want a see and, not worse deaf than that who does not want a hear. It is hard to discuss with blind and deaf colleagues !!!
        I would accept your suggestions when you show me evidence against the results we have reported and those we are going to publish in the future. So far is one person’s word against 6 papers published in peer review journals.
        By the way, I already sent another response to the last comment from Dr. O’Brien and, I do not see it published yet.

        • Kevin O'Brien says:

          I have accepted all your comments. Just follow the thread. Please remember that I am in a different time zone to you. So it is now night here and I will not post anything until it is morning in the UK.

  28. Fenris Ulfr says:

    I second what Drs’ OBrien and McDonald state – as practitioners, we would be more than willing to endorse this therapy whole-heartedly provided there is good quality data to support it. This is a golden opportunity to silence the critics and push forward this form of treatment.

    • Dr. German Ramirez-Yanez says:

      Again I have to say, it is very difficult to discuss with somebody who does not want to listen. I would like to have an answer for the questions I have asked:
      Do you have any scientific evidence to deny or reject the results we have reported in the scientific literature?
      And I ask again:
      Does not published data in 6 papers published in peer review journals demonstrate the efficacy of the Myobrace?
      Does because one person does not want to acknowledge the scientific reported data published, does it make a strong argument to invalidate what peer reviewers (experts in the field) have accepted?
      I have seen in this blog just personal ideas and negative criticism without science supporting those comments. However I have to thank you, Dr. O´Brien, for letting me present the scientific evidence we have produced so far with the Myobrace System and comment on how MyoResearch Co. is supporting further research that will become available in the near future adding more evidence on the efficacy of the System.
      Finally I want to advice the readers of this forum to individually judge by reading all the scientific papers I have presented here and, by looking at all the positive clinical results thousand of dentist around the world are getting with the Myobrace System. Many of those clinical cases are presented in my second book “Guiding Craniofacial Growth and Development with the Myobrace System”.

      • Kevin O'Brien says:

        Thanks for your comments. I really do want to listen to the evidence on this treatment method.

        You ask me to provide evidence on my opinion on the studies that you quoted. As I said at the start of my post this was my academic opinion on myobrace and its research. I have simply interpreted the papers using standard scientific appraisal techniques. I am really surprised that you do not appear to have come across this approach before, beating in mind your role for myobrace. Your book may be interesting but clinical books are certainly not considered to provide high levels of evidence. I look forward to seeing your new trials published.

  29. Fenris Ulfr says:

    Not to belabor the point, but it might be worth evaluating some of the constructive comments made by Kevin. Taking the Usumez article for example –
    1.The Usumez article was a retrospective study that included 40 subjects (20 in the Myo and 20 in the control group).
    2. The design of the paper precludes random allocation to each intervention.
    3. Except for ANB, overjet, age, (on average, the control group was slightly older) and gender it is not clear if the treatment and control groups were adequately matched, and there doesn’t seem to be any tabulated data on if the pre-treatment differences between the groups approached statistical significance.
    4. No mention of concealment/blinding during measurement. The mean changes in SNB (1.31±1.35) and ANB (-1.19 ± 1.18) were rather small with standard deviations approaching the mean. This represents a significant degree of variability within a small sample size.
    5. The authors have not provided linear or angular error values for any of the measurements, so some of the change could easily be measurement error. It is also unclear if the small change in mand. position was attributable to a “Sunday bite”, as is frequently observed after treatment with functional appliances.
    6. Thus, this is a small study with a limited sample size, significant risk of bias, no information on measurement error, and showing small differences with large variability. Not a very compelling paper and a rather low level of evidence.

  30. Fenris Ulfr says:

    1. The Ramirez-Yanez paper (Dimensional changes) was a retrospective study that evaluated pre- and posttreatment casts of 60 patients treated with T4K over 1.3 ± 0.5 years.
    2. The study involved preadolescent children 3 different countries, Australia (10 patients), Brazil (26 patients) and Lithuania (24 patients). Sample homogeneity is a concern, given the potential inter-ethnic variability between these subjects. What was the rationale for treatment at this age?
    3. All patients had Class II, Division 1 malocclusions with crowded teeth. How was this established, and what was the cutoff? ANB, molar relationship? The control group composed of 32 girls and 28 boys was built from data published by Moorees.
    4. This is a historic control, and as elucidated by Kevin in one of his earlier posts (and excerpted below), the use of historical controls can be problematic.
    5. For clinical questions, studies should include concurrent untreated controls. When untreated controls are not available, or possible, a control group receiving standard therapy should be used (treatment as usual). Studies with retrospective designs and historical control groups should be viewed with caution.
    6. In addition, it appears like the treatment group on average had much larger pre-treatment transverse dimensions relative to the control group. For example the pre-Tx IM width in the treatment group was 47.5 mm vs. 33.7 in the control group!! With this degree of variability in pre-treatment characteristics, these controls are not appropriately representative of the treatment group.
    7. Inter-canine, inter-premolar, inter-molar (IM) distance and height of anterior arch (AAH) were measured. No mention of concealment/blinding during measurement acquisition.
    8. The clinical significance of treatment was determined by subtracting natural growth from the treatment change, then, the difference compared with twice the method error. A difference higher than the value of twice the method error was considered a clinically significant effect produced by the functional appliance. Using growth estimates from dissimilar and historic controls is not very scientifically valid.
    9. The authors reported a clinically significant increases of transverse dimensions; however, the net treatment effects were very small with large deviations and method errors.
    10. This is another example of a poorly designed study, at significant risk of bias, utilizing questionable methodology and reporting very small differences as being clinically significant. This is a very low level of evidence.

  31. Chung Wai Chung says:

    There even has not a proof that a post orthodontic occlusion is better than a ” malocculsion”, not to mention all the relapses, decays, mobile teeth and resorbed roots. There actually exist a problem of patients’ cooperation for myofunctional therapy like all other removable appliances. Nonetheless, they do give very satisfying results if implemented at the right time with good compliance as I have seen.

  32. You are polarizing over an appliance. It’s not about the appliance.

    The question is what are you doing to address dysfunction? How are you helping a child to learn to breathe through their nose? How do you establish lip competence? How do you get the tongue to rest on the palate where it supports maxillary growth and oral stability?

    You do not have to use the Myobrace System to achieve these goals if you have another way to do it. There are other approaches. But if you are criticizing the approach because you have no other way to achieve these important physiologic goals and don’t want to have to deal with them, then your hiding behind “the lack of evidence” may protect your ego but it does no good for your patients.

    As orthodontists we have a responsibility to mitigate the factors that lead to deficient growth and development. The ADA had now come out with a policy statement saying such. You need to be prepared to serve the public in this way.

  33. Idil A. BURT says:

    Hi,
    We would love to start a multi-center research Project about Myofunctional appliances.
    I am supervisor for a couple of undergarduate as well as MSc. students who are already started some pilot studies in this field.
    Please be with us in this study.
    Idil Burt
    Karolinska Institute
    Department of Orthodontics
    Stockholm
    Sweden

    • Dr. German Ramirez-Yanez says:

      Idil
      I would be glad to work with you in developing a research project together. Please contact me at german@myoresearch.com and let´s start talking

      • Kevin O'Brien says:

        Dr Ramirez-Ganez, thanks for the offer of co-operation. Have you ever carried out a prospective randomised controlled trial. If you are going to use this method of research, I would happily provide some advice on design, outcomes and ethics etc. Just let me know?

        • Dr. German Ramirez-Yanez says:

          Actuallly my offer was for Dr. Idil
          I would be glad to collaborate with you as soon as I can read one of the Randomizaded Clinical Trials you have published. I have to say I search your name as Author in Pubmed and I could not get one paper published by you quoted in Pubmed.
          Can you please send me the references for your Randomized Clinical Trials published so, I can read your publications and evaluate your research experience? I would appreciate that

          • Kevin O'Brien says:

            Thanks for the comments.
            Just cut and paste this into Pubmed “O’Brien K & Orthodontic”
            You can also look me up in Research Gate and Google Scholar.

            I have to say that your last few comments are great examples of the way that Myobrace dismisses discussion and any criticism. This appears to be in contrast to Rohan Wijey who is being very constructive on the myobrace facebook pages. Are you really the scientific advisor?

  34. Idil A. BURT says:

    Hi,
    We would love to start a multi-center research Project about Myofunctional appliances.
    I am supervisor for a couple of undergarduate as well as MSc. students who are already started some pilot studies in this field.
    Please be with us in this study.
    Idil Burt
    Karolinska Institute
    Department of Orthodontics
    Stockholm
    Sweden

  35. Fenris Ulfr says:

    What is the etiology of the lip incompetence etc? Of does it even matter when one uses these magical therapies of questionable validity ? For lip incompetence in conjunction with bimax. protrusion I recommend extraction and retraction +/- a genioplasty. How would a proponent of said therapy address it, and how does he/she quantify the change and the role their intervention played? In the absence of such proof, how is one to know if we are deluding ourselves and our patients…This is why discerning professionals ask questions re: the quality of evidence. When the evidence doesn’t support our claims, do we don this lack of validity as a proud escutcheon of how we are ” serving the public”? How is the public better served by this? As orthodontists we have the responsibility of endorsing evidence-based protocols in our patient care, as well as protecting patients from unproven therapies peddled by uncritical purveyors. Anything less is doing our patients and profession a disservice. These platitudes have run their course as the de facto retort when the content is lacking in veracity.

    • Dr. German Ramirez-Yanez says:

      I am very glad you as an orthodontist only endorse evidence-based protocols in your patients. So, I suppose you have randomized clinical trials to support Angle Class I Molar relationship have to be given at the end of the orthodontic treatment to create stability. I would like you sharing with us those randomized clinical trials.
      Furthermore, why only 10% of the cases treated with fixed orthodontics and premolar extractions are stable after 10 years postretention (Little RM, Am J Orthod Dentofac Orthoped, 1988). Do you have a randomized control trial to support your protocol ????

      • Kevin O'Brien says:

        Thanks for the comments. I really think that it would be a good idea for you to read up on evidence based care. You can do this by buying some excellent books and I have also posted about this several times in my blog.

        You will see that I have suggested that we need to be careful when we make claims about treatment in the absence of high level evidence. This is part of consent. If I look at your examples, I inform my patients that I will try and obtain an ideal occlusion because this wowuld lead o ideal aesthetics, but it is not essential. I also inform my patients that they will need long term retention. When I consider myofunctional ortho, do you let them know that there is only weak evidence that the intervention is going to be effective?

        • Dr. German Ramirez-Yanez says:

          Very interesting answer from you Dr. O`Brien. When I mentioned my book before, your answer was “clinical books are certainly not considered to provide high levels of evidence” without even having a look what evidence I present in my book.
          Now you refer me to some excellent “Books” for me to find the evidence of the treatment you and those colleagues against myofunctional orthodontics are proposing here. However, you do not quote even a couple of well designed Randomized Clinical Trials to support that treating malocclusions with extractions, as proposed by one of the orthodontist here, has good and evidence based scientific evidence.
          I also see that you inform your patients that they will need long term retention. Traditional orthodontists claim that Class I molar relationship is one of the keys to provide stability to the treatment. So, why do you need “long term retention” if you are giving a treatment that warrants stability? Can you please quote here a Randomized Clinical Trials which give us scientific evidence on that statement of stability of the treatment associated with a Class I molar relationship?

    • Gabor Hermann says:

      I am really jelous Dr Ulfr. In your World everything is so black and white. Conventional orthodontics is good and anything that is not conventional is putting poor patients to danger. This is really nice to see how people are convinced that their truth is the absolute truth.
      Let me ask you some questions:
      Is bimaxillary protrusion a disease?
      Where is the high level of evidence that bimaxillary protrusion is a danger to the oral and general health and patient will have more benefit from a 2 year long orthodontic treatment assisted by extraction and genioplasty surgery over the risk of when patient will remain untreated?
      In other words where is the evidence that the risks associated by the lack of treatment is higher than the risks associated by the treatment?
      Where is the evidence that when lip incompetence has a “short upper lip” factor that it is only genetic and cannot be altered by myofunctional exercises?
      Orthodontic treatment is not equal to moving teeth. Evidence based orthodontics starts with evidence based treatment objective and evidence based diagnosis. Is your treatment concept evidence based? I am afraid not.
      When you start stigmatizing others by calling them “magic” and “non-evidence based” you have to be sure that your treatment concept is very well protected by high level of evidence, otherwise I have to say this is stigmatizing behaviour is nothing more than just unethical.

  36. Victoria Quade says:

    Thanks for your article. I’m currently wearing a Myobrace trainer, on the recommendation of a dentist who I went to for treatment (I have very deep pockets – part heredity, part life-style so I am prone to gum disease). After I expressed concern about the step between my front four lower teeth and my right molar teeth she suggested this could be the result of a combination of factors from tongue position to infantile swallowing and clenching my teeth at night. She then suggested I could help myself by using a trainer – first dentist to ever do so. I do not know what the long term effects will be but I am hopeful. Although, as your article points out it is difficult to find evidence based research. My dentist was very honest that at my age (50+) improvement would be limited and would take years. In just over three months I can see no improvement in my teeth but I have have reduced the appearance of a receding chin and become more aware of my jaw position/muscles, my tongue position and mouth breathing. I am willing to persevere on this alone but it would be nice to have some evidence (as opposed to commercially motivated) based confirmation that I am not wasting my time or doing harm.

  37. Fenris Ulfr says:

    Jealousy is not normally observed among those who endorse the pyramid of denial…so this is new and exciting! But not entirely unexpected when you consider the constant uncertainty that surround those who don’t let facts get in the way of their “theories “. As most sane practitioners understand, bimax. protrusion is not a disease. Neither is crowding, overjet or a deep bite. Doesn’t mean there is no benefit to resolving it. No treatment is always an option. Sometimes the truth can be hard to bear…for such sensitive souls, perhaps a different sort of blog might be more appropriate. One where fantasy and reality are the same.

  38. Fenris Ulfr says:

    I am unaware of any claims made by anyone that a Class I molar relationship leads to increased stability…perhaps you might enlighten us with where this was stated/reported? Also, what does the Little study have to do with myo-functional therapy? So, in summary, it appears we can conclude the following from this discussion –
    1. “Conventional” orthodontics creates obstructive sleep apnea
    2. The plural of anecdote is Data
    3. Correlation = Causation
    4. Questioning unsupported claims is stigmatizing and unethical
    5. Orthodontic treatment is not equal to moving teeth

    Quite fascinating.

  39. John McDonald says:

    Dr Ramirez-Yanez, why do you deflect every time the question of the quality of your evidence come up? This discussion is about myobrace products and their unsupported claims, not whether a class 1 occlusion is evidence based.
    The point that is being made in this forum is that it is not enough to get studies done that are ethical. It is not enough to get studies published in peer reviewed journals. The point is that those studies must be designed and conducted in such a way that they actually produce valid results. Your studies do not meet the current standard to be considered valid. End of story.

    Your responses do not address this point. Your responses sound like a con man who’s con has been discovered. Please stop deflecting, just agree to do a study that proves the product does what it says it does. The more you deflect and argue this simple point, the more I think you are just trying to con me.

    • Dr. German Ramirez-Yanez says:

      I would accept criticism from colleagues who are able to present scientific evidence on the protocols they use and defend. Therefore, the criticism against myofunctional orthodontics presented here and to the studies we have published has to be considered biased. I would invite you to consider three quotes from Prof. Ackerman in the American Journal of Orthodontics (2015)

      – In the last 100 years, no one has been able to produce scientific evidence to corroborate Bonwill and Angle’s original hypothesis
      – Ideal occlusion has served as a highly useful arbitrary standard for judging the skills of orthodontists
      – it is fair to say that orthodontics has been more technologically driven than biologically or scientifically based

      In that context, we are trying to develop studies, and will continue in that way, to innovate and develop systems biologically driven.
      I would be glad to collaborate developing research as proposed here with the Myobrace System. But, to develop that research, we need you coming with an open mind to accept what others want to propose and, accept new concepts based on the biology of the mouth and the human body. If any of you wants to meet with me and discuss the biological, anatomical and physiological concepts behind the modus operandi of the Myobrace System with an open mind, I would be glad to team with you and develop research together.

      Our goal is to treat the cause of the problem. Not, just giving an arbitrary standard ideal occlusion, as Prof. Ackerman said has happened over the last 100 years.

      • Kevin O'Brien says:

        I actually have an open mind about myofunctional treatment. I stated this in my blog post. The general theme of the post was that we need to do some research and this should be trials.

        As I have said several times I have experience of running studies and I would happily act as an advisor. The big question you need to able to consider is whether you would be willing to randomise children to receive myobrace treatment or no treatment. If you can do this then you can carry out the trial.

      • John McDonald says:

        Dr Ramirez-Yanez, please accept my apologies if you interpreted my question as a personal criticism. This is not about you. I am sure you are a nice guy and your kids love you etc, etc. What I am doing is asking you a question: Can you prove the product you support actually does what it says? You offered some proof, but it does not meet the current accepted standard in our field. Can you adjust your trials to make them meet the current standard that are accepted across medicine and dentistry? That is all that this discussion is about. Why do you keep trying to make it about something else?

        • Dr. German Ramirez-Yanez says:

          Dr. McDonald
          Thanks for your apologies and it is good to see this is not personal. Apologies accepted.
          I will be glad to develop a randomized clinical trial with you and Dr. O’Brien, who is also open to listen and understand the biological concepts behind the Myobrace System. Let’s start communicating by e-mail, so we can plan how to work together in a positive and constructive way. I placed my e-mail before,
          but here it is again (german@myoresearch.com)
          I look forward to hear from you and Dr. O’Brien on this regard soon

          • Kevin O'Brien says:

            Thanks, but before we start communicating about this can you let me know if you are willing to randomise children to myofunctional treatment or untreated control groups.

  40. Fenris Ulfr says:

    This is simply yet another futile attempt at deflection . Please stay on point. This discussion has to do with MFT, and not these other silly obfuscations you seem to revel in (Class I molars, retention, bimax. protrusion etc.). Bringing in unrelated quotes from Ackerman does nothing but detract from your point. If this is the level of scientific discourse one can expect from MFT proponents, it is no wonder that this field has met with some disdain. What is your response to the design and methodological flaws that seem rife in the research that you presented in support of MFT? If you are unable to comprehend or acknowledge these deficiencies (as several posters have repeatedly pointed out), that is indicative of significant cognitive (and/or other) bias. Given that level of disparity between the two views, it is very unlikely that this would ever be accepted by the scientific community.

  41. Gabor Hermann says:

    There is a debating technique that tries to minimize the opponent by altering the opponent points
    Now we know that you use this technique Dr Ulfr. This is fine
    For example I have never said that questioning is unethetic. Questioning, criticism and self criticism ( I hope you know what it means) are the ones that moves the specialty forwards
    However criticisn in the name of evidence based orthodontics the way that pretends that your concept is better supporterted by evidences (when it is not) is unethical
    Moving teeth is certainly not equal to orthodontics. You can laugh at this but unfortunately we have to stress this trivial fact. The reason is that some forget the real essence of orthodontics. If we have some traits of evidences in treatment this is not equal to evidence based orthodontics
    There are thousands or sensitive orthodontic souls out there holding the breath back waiting for the announcement of your hard truth because they were told that they can now practice evidence based orthodontics and they don’t know how to perfom this
    And the fact is that practicing evidence based orthodontics is impossible
    Orthodontics as any medical intervention starts with the questions
    What shall I do with my patient?
    How can I treatment plan this case?
    What is the objective of orthodontics?
    So making statements like “now you can practice evidence based orthodontics if you want” or “I have been practicing evidence based orthodontics in my department” or “my approach is better supported by evidence based orthodontics ” are unethical because these are simply not true
    Yes, bimaxillary protrusion is not a disease, nor deep bite nor malocclusion.
    However here is the simple question
    How evidence based is the definition of the orthodontic specialty that defines the specialty the treats malocclusionss and facial malformations? Why do we treat our patients with these conditions that
    are not diseases?
    “There are some benefits…”
    This doesn’t sound scientific.
    I accept that this blog is not dedicated to the big question “how evidence based is evidence based orthodontics” however we have to be aware of the fact that at the moment neither orthodontic concept is more evidence based over another
    So, criticisn in the name of evidence based orthodontics the way that pretends that your concept is better supporterted by evidences (when it is not) is unethical

  42. Fenris Ulfr says:

    Dr. Hermann – I’m simply unable to understand the crux of any your posts, or what it has to do with MFT. Are you suggesting that we accept the low quality evidence proffered, and enthusiastically endorse this therapy? This is not a difficult concept to grasp. If you make a claim, it is incumbent on you to prove it and not on the rest of the world to disprove it. All these other facile and specious pontifications about ethics, treatment planning etc. are simply irrelevant to the argument and yet another example of how not to prove your point

    • Gabor Hermann says:

      Thank you Dr Ulfr to bringing this sentece to this conversation.
      “If you make a claim, it is incumbent on you to prove it and not on the rest of the world to disprove it”
      THIS is the ultimate link between ethics and MFT.
      Let me start with a question. What percentage of your daily orthodontic practice is supported by high level of evidence? 1%, 5%, or eventually 10%? Is you wire sequence supported by by high level of evidence? How about the slot selection, intermaxillary elastics, recall intervalls? Literature either doesn’t exist, or finishes articles with this statement. “further research is needed” And no one (at least very few) is questionning this, you and everybody is feeling perfectly comfortable with applying them. However, when it comes to something that you don’t like this sentence is pulled out like a rabbit from the hat. “Oh boy you know how it works. I know that bearing the truth is hard, but…”
      “If you make a claim, it is incumbent on you to prove it and not on the rest of the world to disprove. Until this we are not able to use it, because this is not supported be high level of evidence. You know we are so trick and we are practicing evidence based orthodontics”
      However, there is a little problem.
      There is a tag behind our names. This DDS, DMD tag is something that can be beneficial at the seating in the golf club reception but also gives us some responsibility. Let’s suppose that you are aware of something relating to your patient’s health and treatment. This information might affect the treatment, ultimately your patient health by causing side effects, longer and more intensive treatment, or instability. You are responsible for this information.
      What do we know about the ethiology of malocclusions? This is multifactorial. Do we have to prove it? Well this is a good question, however at least this is part of the curriculum and fundamental teaching of this profession. Among the many factors orofacial myofunctional balance is listed. So we can’t say we don’t know about this relationship. This is written in textbooks for decades. AAO has a statement considering the use of CBCT. “You don’t have to be qualified for reading the CBCT image, but you are responsible for the information and you have to send the patient to a qualified specialist”. Our situation is exactly the same. The ethiology of maluccusion is multifactorial, including orofacialy myofunctional balance. We are perfectly responsible for this information. You say, that MFT has low level of evidence. This means that there is SOME evidence supporting that MFT helps in factors that are playing role in the development of the malocclusion. This level of evidence is exactly the same (or even higher) than many of the techniques that you and me are using in the everyday practice. We are doctors. This means the using this sentence regarding MFT is not only cynic and unethical, but neglects the fundamental teachings of this profession and medicine.

  43. Fenris Ulfr says:

    Dr. Hermann – The existence of unicorns also has a low level of evidence. Obviously this means that there is SOME evidence supporting the role of unicorn flatulence in climate change? Do you see what I did here? It is now abundantly clear that proponents of this therapy cannot answer any question without conflation, diversion or meandering into metaphysical drivel. Who made any claims about IM elastics, slot sizes etc.? And ethics? Wow. These sort of absurd logical fallacies are another reason why there is a complete lack of credibility with your perspective. Yet another nail in MFT’s coffin.

Post a Comment

Your email address will not be published. Required fields are marked *

Top

Pin It on Pinterest