Equilibrium Theory Revisited: Factors

Influencing Position of the Teeth

WiLLIAu R. PROFFIT D.D.S., Ph.D.

It has been fif teen years now since possible to produce a stable ideal oc-
Weinstein et al. in their paper entitled clusion without extraction of teeth be-
“On an Equilibrium Theory of Tooth cause the environment could be modi-
Position” attempted to put the equilib- fied by orthodontic treatment. It is well-
rium theory of tooth position on a known now that extraction of teeth is
sounder scientific base.' This paper is required in some cases, but the per-
presented with the same objective. It centage of extraction cases varies great-
represents an attempt to review the con- ly among orthodontists. That percent-
siderable amount which has been age reflects more than anything else a
learned during the past fifteen years, judgment as to the importance of modi-
and to place equilibrium into perspec- fiability of the equilibrium of environ-
tive for practicing orthodontists. mental forces around the dentition.
The views of the dental equilibrium There can be no doubt that there is
which have prevailed at different points an equilibrium. By definition, an equi-
in time have made a great deal of dif- librium exists when a body at rest is
ference in the day-to-day practice of subjected to forces in various directions,
orthodontics. Malocclusion of the teeth but is not accelerated. This requires
and the broader spectrum of dento- that the opposing forces be balanced so
facial deformity is due, of course, to an that their resultant is zero. Such a de-
interplay between innate genetic fac- scription applies to the teeth, which
tors and external environmental factors. are subjected to a variety of forces in
The environment of the teeth and al- multiple directions, yet remain stable
veolar bone includes conflicting forces (most of the time) in their positions in
and pressures, primarily from muscular the dental arch. During mastication,
function, which in part determine tooth not only do the teeth move slightly, but
position. The more important these the alveolar bone and the basal bone of
forces on the teeth are conceived to be, maxilla and mandible bend and flex.
the more one takes an environmentalist These changes occur in a matter of
view as far as the cause of malocclusion seconds, and the teeth and jaws are re-
is concerned. The more one believes in stored to their original positions as
inherited causes for malocclusion, the quickly as they were displaced. Wheth-
less attention he is likely to pay to the er the time span of observation is in
environment of the dentition. These minutes, hours or days, the teeth are
different viewpoints go to the heart of stable despite the considerable forces
the major diagnostic decis‘on which is exerted against them. Natural denti-
required in orthodontic practice, tions are stable over a time span of
whether or not to extract some perma- years after growth is completed. Ortho-
nent teeth to properly align the others. dontic appliances produce changes in a
Edward Angle believed that the envi- time span measured best in days. These
ronment of the dentition was a major orthodontic movements are clearly dif-
cause of malocclusion, and that it was ferent from the natural situation and
are eloquent testimony that the appli-
Presented at the 1977 biennial meet- ance alters an equilibrium situation.
ing of the Angle Society, October, 1977.
From the Department of Orthodontics, Anyle felt that relapse after ortho-
Univ. of North Carolina. dontic treatment was due to forces on

175
 76 Profht July 1978

the teeth resulting from an improper

environment. It is difficult even today
to disagree with that view. As the
French molecular biologist Jacob quotes 50 20
an earlier physicist, however, there is (is) (10)
always a desire in science to “explain
the complicated visible by some simple
invisible.” z Tongue pressure, lip pres-
sure, pressure from erupting third mo-
lars—all make nice “simple invisible” Swallow
causes for orthodontic relapse. Unfor- (Rest)
tunately, the simple explanations have Fig. l Diagrammatic representation of
a way of being wrong at worst and mis- tongue and lip pressures during swallow-
ing and at rest. In both instances tongue
leading at best. Harold Frost proposes pressure ie greater than lip pressure
an interesting test: “When one truly with the usual ratio of tongue to lip
understands how a given system works, pressure shown here.
it can be treated or intentionally ma-
nipulated with predictable success 98
times out of 100. If this cannot be sucking, etc. ) , orthodontic appli-
done, then in spite of elaborate con- ances
ceptualizations and verbalizations of the 3. Forces from dental occlusion
mechanism, (the system) is not ade- 4. Forces from the periodontal mem-
quately understood.” 3 By that standard brane.
we are improving but still well short of Intrinsic Forces: Tongue Versus Li ps
understanding the dental equilibrium Since the teeth are positioned be-
system. tween the lips and cheeks on one side
In this presentation I plan first to and the tongue on the other, the oppos-
consider the primary factors in the den- ing forces or pressures from these or-
tal equilibrium, that is, the factors gans should be major determinants of
which directly create the equilibrium; the éientai equiiii›rium. in tact, many
second, to examine significant influ- observers have concluded that the equi-
ences on the primary factors, and con- librium is defined solely by opposing
sider their modifiability; and finally, to tongue and lip pressures. Diagrams can
summarize briefly by reviewing the be found in current texts showing the
probable importance of all these envi- incisor teeth positioned between the
ronmental factors as compared with in- tongue and lips with arrows indicating
herited or innate characteristics in the precisely balanced opposing forces. Re-
et'ology of malocclusion. sults from studies with modern elec-
tronic instrumentation indicate that this
PRi MARY FxGTORS IN Eq ILIBRIU M simplistic view of the equilibrium situa-
Four major primary factors in the tion is incorrect (Fig. 1 ) .
dental equilibrium can be identified at Even a superficial consideration of
present. There may be others, but it is the dental equilibrium requires that a
likely that any other possibilities are distinction be made between the
special cases of these four. The four amount of force generated against a
primary factors are: tooth and the duration of force appli-
cation. The first satisfactory electronic
1. Intrinsic forces by tongue and
instrumentation for studying tongue
lips
and lip pressures became available at
2. Extrinsic forces: habits (thumb-
Vol. 48, No. 3 Equilibrium 177

the height of orthodontists' enthusiasm to resist short-acting forces such as

for tongue thrusting as an etiological those generated during chewing, speak-
factor for malocclusion. That wave of ing and swallowing where the duration
enthusiasm was triggered by Walter of force application is typically one sec-
Straub in the 1950’s after he had de- ond or less. Would a balance be ob-
cided from clinical observation that in- served if all short-duration forces, not
correct swallowing was a major cause just forces from mastication, were dis-
of anterior open bite and incisor pro- regarded? Then only resting pressures
trusion.* It seemed logical that patients of tongue and lips would be considered
who swallowed incorrectly should have as factors in the equilibrium. This was
protruding incisors or open bite be- and is a most reasonable suggestion, yet
cause of different tongue and lip pres- resting pressures do not balance.’ Bra-
sures. When pressures were studied, der cleverly suggested that the geomet-
however, it quickly became apparent ric radius of curvature might supply
that tongue and lip pressures during the missing link, and that if resting
swallowing varied greatly among indi- pressure plus radius of curvature were
viduals and did not correlate well at all taken into account, a constant relation-
with the position of the teeth. F urther- ship would be seen.' This, too, has not
more, tongue and lip pressures during proved to be the case for individual
swallowing never balanced. The early patients. 7 The result of all these investi-
investigators quickly noted that tongue gations is overwhelming evidence that
pressures during swallowing always are the equilibrium defining tooth position
several times higher than the lip or is not determined solely by the opposing
cheek pressures which should balance forces of tongue and lips. Other factors
them. The logical next step is to think must be taken into account.
immediately of time as a variable, and
to see if longer duration of lip pressures Extrinsic Forces: External Presswe
supplies the presumed balance. Again, Habits and Orthodontic Appliances
the answer is no. When time-pressure Insight into the importance of force
integrals are compared ( the areas un- duration in moving teeth can be gained
der pressure curves) , tongue and l'ps from considering the effect of exter-
come closer to balance, but tongue pres- nally applied forces. All clinical ortho-
sure is still considerably greater than lip dontics is based on moving teeth by
pressure. There is no balance of pres- deliberately altering the force equilib-
sures for swallowing.' rium on the dentition. Teeth can be
Reasoning that other activities con- moved effectively by a force of only a
tributed to the over-all balance, Lear few grams provided that the force is
and 'Moorrees attempted to sum up maintained continuously. Too much
opposing tongue and lip forces over a force i3 destructive, but a relatively
four-hour period and project them to wide range of orthodontic forces can be
twenty-four hours using a log of the effective if the duration is long enough.
subjects’ activities.’ This twenty-four The duration of force is a more critical
hour summary of tongue and lip pres- variable in orthodontic treatment than
sures brought the figures closer to equi- force magnitude. The same is true
librium, but a considerable imbalance for external pressure habits, such as
of total tongue and lip pressures still was thumbsucking. The greater the dura-
observed in subjects with a stable den- tion of the habit, the greater its impact
tition. on the teeth is likely to be. For both
orthodontic appliances and habits, du-
The dental apparatus is well-adapted rations must be measured in hours per
178 Proffit July 1978

day to produce significant changes in

tooth position. command
swallow
Extrinsic forces can be quite effec-
tive when their duration approaches
fifty percent of the time, and some im-
pact apparently can be produced by
durations of only a few hours. Below E
280
that, no effects are observed. By anaI-
ogy, resting pressures of tongue and
lips have durations which are entirely
consistent with importance in equilib-
rium ; but short-acting pressures during 0 22 5 ^5 67 5 90

trarsducer angvlat ion --degrees

speaking and swallowing should be dis-
Fig. 2 Comparison of tongue pressures
counted because the total duration of during swallowing in patients with an-
thèse pressures is a few minutes per day. terior open bite (solid bars) and pa-
tients with normal occlusion (dotted
To this point the discussion has re- bars) . A variable angle pressure trans-
lated largely to tooth position in the ducer was mounted so that pressures
anterior-posterior and transverse planes could be recorded perpendicular to the
long axis of the maxillary central inci-
of space. What about the vertical plane sor (90°), parallel to the long axis (0° ) ,
of space? Vertical tooth position cer- and at intermediate angles. Note that
tainly can be influenced by environ- the normal subjects had considerably
more vertically directed tongue pressure
mental factors. In fact, the clinical than the open bite subjects, all of whom
problems which are usually cited as re- created an anterior seal by placing the
tongue between the anterior teeth
la ted to environment have a strong against the lower lip (from Wallen' ) .
vertical component. Tongue, lips and
extrinsic forces are possible influences venting eruption. If the pressures were
on vertical positions of the teeth. Other the same in open bite or normal occlu-
factors which come to mind immedi- sion, one could say that the teeth were
ately are forces of occlusion and forces being impeded by this pressure and
of eruption. This will be discussed be- field at a higher ievei. zut tne Ôata
low. show, not higher or equal pressures,
There is char evidence that sucking but consistently lower pressures. It ap-
habits in children are strongly corre- pears that the relatively high position
lated with anterior open bite.' Despite of the incisors keeps the tongue from
the common belief among orthodontists contacting them quite so much during
that the tongue activity in swallowinq• is swallowing. This does not support the
an important cause of open bite, little idea that tongue placement during swal-
experimental work has been done on lowing causes open bite. Certainly for-
tongue and lip pressures as cÎetermi- tard tongue position du ring swallowing,
nants of vertical position of teeth. Stud- which usually is called tongue thrust, is
ies by Wallen" indicate that vertically associated with open bite, but it seems
directed pressures du ring swallowing more likely to be effect than cause.
actually are less in patients with ante- There are many possible causes of open
rior open bite than in patients with bite. As we will discuss below, jaw pos-
normal vertical relationships (Fig. 2) . ture, occlusal forces, and eruption
If the tongue pressures were grcater in forces from the periodontal membrane
the open bite patients than in the nor- must be cons'dered. Resting tongue and
mal occlusion patients, it would be easy lip pressures might logically affect the
to understand how the tongue was pre- vertical position of teeth, just as they
Vol. 48, No. 3 Equilibrium 179

affect positioning in other planes of occlusal contact has been hampered,

space. There is no reason to attach spe- even in the era of modern electronic
cial importance to tongue pressures instrumentation, by the thickness of the
during swallowing except that an un- force measuring devices. If the pressure
usual tongue position in swallowing measuring devices used for evaluating
may also indicate an altered resting tongue and lip pressures can be kept
posture. under two millimeters or so in thick-
Forc es from Dental Occlusion ness, errors in evaluating lip forces are
The attachment apparatus of all minimal.'2 The potential for error in
teeth is an effective hydrodynamic measuring tongue pressures is less easy
damping system, like an automobile to identify, but appears to be about the
shock absorber, and is well-designed to same as for lips. Because occlusal forces
withstand occlusal forces. If teeth did are much heavier, instruments to evalu-
reposition themselves in response to oc- ate them have had to be several milli-
clusal forces, it would not be necessary meters thick. Placing an object this
for dentists to be so careful svith occlu- large between the teeth does introduce
sal relationships. The teeth would make significant changes. Until recently, the
minor corrections for themselves. This only way around this was to use sub-
does happen just after the completion jects who had at least one missing
of orthodontic treatment, when the tooth, so that the force measuring in-
teeth are hypermobile and the attach- strument could be placed in the space
ment apparatus is reorganizing. O ther- like a bridge pontic.' 3 As a result, little
wise, it is common experience that teeth information is availab!e as to how oc-
remain in positions of traumatic occlu- clusal forces vary according to type of
sion rather than moving away from the malocclusion, vertical dimension of the
offending occlusal contacts. face, and other important orthodontic
variables. It has not been possible to
Despite the mechanism to dissipate study subjects with an intact natural
short-duration occlusal forces so that dentition.
teeth do not permanently intrude or
move buccally or lingually because of During the past year we have been
occlusal forces, occlusal forces can be able to fabricate a new type of occlusal
important in equilibrium related to ver- force transducer in our laboratories at
tical tooth position. The vertical posi- North Carolina.'• The active element
tion of the teeth is determined by a bal- is a piezoelectric film (polyvinylidine
ance between the forces which oppose fluoride) which has the property that
eruption and those which promote it. its electrical characteristics are altered
Occlusal forces have an influence re- as the internal structure is distorted by
lated to this. force application. The foil is only 0.1
mm in thickness, less than the thinnest
From numerous studies of occlusal articulating papers. Although protec-
forces it is known that a maximum tive coatings must be added to make a
force of one hundred kilograms or satisfactory occlusal force measuring
more, sustained for only a fraction of a device, the total thickness can be held
second, can be exerted against a single under 0.5 mm. Only preliminary data
tooth during occlusion. Forces exerted for a few subjects are available as yet,
against artificial teeth, particularly if but it is clear that a very thin occlusal
complete dentures are worn, are only a force transducer can be manufactured
fraction of forces against the natural satisfactorily. We anticipate interesting
dentition.'' Evaluation of the force of data on occlusal contact characteristics
180 Proffit July 1978

of various types of patients in the near moves a tooth through bone and con-
future. Is a reduction in biting force, tinues to move it after it has broken into
which allows more eruption of posterior the oral cavity. The eruptive force re-
teeth, one factor in producing an open mains active after a tooth has come into
bite? No one knows, but now it is pos- occlusion and function has been estab-
sible to test such an hypothesis. lished. Eruption continues along with
In patients who have lost their nat- vertical growth of the face. A maxillary
ural teeth, the resting position of the first molar typically erupts for a centi-
mandible is determined independently meter or more between age six when it
of the vertical level of replacement first comes into occlusion and the time
teeth. It is critically important for the in the late teens when vertical jaw
prosthodontist to accurately evaluate yrowth ends. If its antagonist is ex-
and determine a rest position compati- tracted, any tooth may erupt again
ble with placement of denture teeth. years after its vertical position appar-
Although there may be several com- ently was stable, indicating that the
patible positions for any patient, there eruptive mechanism remains intact and
is a limit of jaw opening which will be capable of generating forces which can
tolerated. For a long time this prostho- move a tooth.
dontic concept was applied uncritically
to the natural dentition. It is now Although many theories to account
known that changing the vertical level for tooth eruption have been proposed,
of the natural teeth can cause an alter- they can be divided into three major
ation in rest position of the mandible. S*° *1°S ' l ) theories based on cell
If the molar teeth are extruded by or- pro- liferation at the root apex; 2)
thodontic forces, the mandible will ro- theories based on blood pressure-blood
tate downward and backward as the flow dif- ferentials in the periodontal
membrane ;
occlusal contact and rest positions
change. Once a natural tooth has or 3) theories based on metabolic
changes in the periodontal membrane,
erupted or been extruded, the muscu-
a ure a>ap.s .o :.s pos:.:on. :m:!ar!y, usually involx ing collagen polymeriza-
tioi.' Experimental manipulation of
if the maxillary posterior teeth are in-
ñ ifisfi Vat i‘lit tjié s th o 1 i i in ii iccc in a ii oc ii*
truded surgically, the mandible will ro-
tate closed, and a new rest position as the small forces and slow rates of tooth
well as occlusal position is observed. eruption. The weight of present evi-
These chanp•es may be mediated by dence indicates that eruptive forces are
proprioceptors in the periodontal mem- gcnei ated in the periodontal membrane
brane, although there is no direct evi- rather than at the root apex, but exact-
dence as to the mechanism. How man- ly how remains unclear.
dibular positioning during growth influ- In our laboratory at UNC we have
ences eruption and the final vertical also made progress in the past year to-
position of the teeth remains entirely ward developing electronic instruments
unknown. Occlusal forces during which will .iflow changes in eruptive
growth probably play a significant role. force and rate to be studied in short-
term experiments“ so that the effect on
Forces From the Periodontal
er• 1» tion of altering potentially impor-
Mem branc: Ertt§Iiott Forces
tant variables can be observed directly
Despite intensive continuing investi- and immediately. For exa r •, the ef-
gations, the cause of eruption of the fect of elevating the blood pressure on
teeth remains unknown. In some way eruption force could be stud red. The
an eruption force is generated which continuously ergi r tin incisors of ro-
dents are chosen for such investigations
Vol. 48, No. 3 181

Fig. 4 Eruption force of a guinea pig

incisor. After 50 minutes of continued
eruption against the transducer, which
exerts an increasing force as it is de-
Fig. 3 Strain gauge pressure trans- flected, eruption stopped and the tooth
ducer placed against the erupting incisor settled slightly back into its socket. In
of a guinea pig to measure the force of this instance the eruption force was 3.0-
eruption. 3.5 grams.

because they erupt much more rapidly eruption rate can be calculated pre-
than other teeth. If satisfactory instru- cisely. By moving the transducer sup-
mentation for studying rodent incisors port in parallel with the erupting tooth,
can be developed, however, it should the effect of constant forces opposing
be possible to improve it to study more eruJation can be studied. This instru-
slowly erupting teeth in dogs and pri- mentation also is new and only prelim-
mates and, ultimately, in humans. Our inary data are available now. We be-
approach has been to adapt the strain lieve that with it a whole new series of
gauge technology with which we have experiments can be set up which will
become familiar in studying tongue and allow physiologic rather than histologic
lip pressures to produce a very sensitive investigation of some of the parameters
and highly stable transducer which can relating to eruption.
be placed against the tip of an erupting Although no investigator has pro-
incisor (Fig. 3) . Both the transducer duced quantities of data for eruption
and the animal must be positioned very force under varying conditions, erup-
precisely, since the eruption rate is in tion forces have been measured in sev-
microns per hour. As the tooth erupts eral different ways by varying research-
against the transducer, a force opposing ers.'' ’ The eruption force always is
eruption is generated which increases as evaluated as between two and ten
the transducer lever arm deflects.
grams. Smedley," working in Bond’s
Eventual ly, the force opposing eruption
laboratory at Temple University, found
equals the force promoting it. and
that the eruptive force of a human sec-
eruption ceases. Eruption rate as a
ond premolar in the prefunction phase
function of the increasing load can he
ss’as about five grams ( technical difFi-
read directly from a graph (Fig. 4) . By
cultic › were so great that he was able
positioning the pressure transducer a
to obtain data on only a single patient) .
precise distance away from the erupt-
Nothing is known about the duration of
ing incisor and observing the time be-
this force, but it seems reasonable that
tween positionings and initial contact
the duration is quite long even if the
with the transducer, an unimpeded
force is not constant.
182 Proffit July 1978

TABLE I sures are sustained for a matter of

EQU I LIBRIU M COM PONE hours each day. Some things which
NTS
traditionally have been considered im-
Of the primary factors which might be
involved in the dental equilibrium it ap- portant, particularly tongue pressures
pears that re8ti' p pressure of tongue during swallowing, seem upon further
and lips, and eruption forces have the investigation to have little importance,
proper force and time characteristics to
relate to tooth position. probably because the duration of the
fiom potteti I Intenzit g Duration pressure is not nearly long enough to
Forces of
Occlusion Very High Very Short be effective.
Lip or Tongue
Pressure SECONDARY FACTOR S I N E9U ILI BRI U M
—Swallow High Short If pressures produced by the resting
—Speech Low Short posture of the head, jaws, tongue and
—Rest Low Long lips are important in the dental equi-
Forces of
Eruption Very Low Long librium, and if the same is true of
forces produced by metabolic activity
Forces from the periodontal mem- in the periodontium, is it possible to
brane quite possibly could play an im- identify significant secondary factors
portant part in stabilizing teeth after which influence the way these primary
their final vertical positions have been factors are brought into play? There is
attained. This is probably the source of considerable information about influ-
the forces which maintain teeth in ences on resting posture in the stoma-
stable positions despite an imbalance tognathic system. Although less is
between resting tongue and lip pres- known, some information can be col-
sures. One line of evidence sug•gesting lected about the periodontium as a gen-
this is the migration of teeth which of- erator of tooth-stabilizing forces.
ten is observed as periodontal break- In fluen ces on Postural Relationships
down occurs. For example, many pa- in the Stomat ognath ic System
tients report that the maxillary incisor
The postural position of the head is
teeth have begun to migrate forward
ti:c r<•!ati<ns*.ip ii:c i:can *.as .i':I*. :i:<•
at age 40 or 50. Periodontal breakdown
neck and the rest of the body, not n'hen
around the incisors invariably is ob-
the musculature is at rest, but v›'hen no
served, but usually the tooth movement
purposeful attention is being paid to
is blamed on the tongue. In this in-
head position. The relationship is es-
stance the destabilizing factor probably
tablished at a subconscious level. The
has been loss of stabilizing forces from
same is true for the postural position
the periodontal membrane, so that un-
of the mandible, the tongue, and asso-
balanced tongue-lip forces cannot be
ciated structures. In all three instances
counteracted any longer.
there is a variety of positions in which
In summary, then, it appears that the organs could be stabil’zed ; but one
two major primary factors are involved consistent position normally is main-
in the equilibrium which determines tained by the musculature under con-
the final position of the teeth (Table trol from medullary and hiyh spinal-
I) . These are, first, the resting pressures cord levels. Since postural relationships
of lip or cheel and tongue ; and second, can be and are altered to meet func-
forces produced by metabolic activity tional needs of the moment, they can
within the periodontal membrane. Ex- be difficult to study. Fortunately, the
trinsic pressures also can play an im- three postural relationships which con-
portant part provided that these pres- cern us here, those of the head, mandi-
Vol. 48, No. 3 Equilibrium 183

ble and tongue, tend to vary together tion anteriorly and posteriorly. In short,
in response to the same influences.
altered postural relationships of the
The importance of these postural re- head, jaw and tongue are character-
lationships in ultimately determining istic for patients with the “long face
form has been shown in a number of syndrome.” Can these findings be tied
ways, but most recently and quite inter- together by logical reference to physio-
estingly by Solow and Tallgren.'°'°' logical needs?
These investigators demonstrated a rela- A link between dentofacial morphol-
tionship between the craniocervical an- ogy and respiration has been com-
gulation (the way the head i’s carried mented upon in the orthodontic litera-
on the neck) and both facial propor- ture for many years, going back at least
tions and dentoalveolar proportions. into the early 1900’s. If there is diffi-
The farther the head is carried forward culty in nasal breathing, physiological
on the neck, the more likely the face is adaptations which facilitate mouth
to be long vertically, and vice vena. breathing include a forward positioning
There are corresponding differences in of the head on the neck, a lowered po-
dentoalveolar morphology relating to sition of the mandible, and a low and
head posture. For instance, the more forward tongue posture. It is not coin-
the head is held forward, the more like- cidence that respiratory difficulties are
ly it is that upper dentoalveolar height associated with the long face syndrome.
will be increased, especially in its basal Experimental work with primates and
portion. Forward head posture also cor- observation of human subjects support
relates strongly with a steep occlusal the concept that postural relationships
plane. are changed to meet respiratory needs.
Solow and Tallgren point out that Alterations in the growth of the jaws and
normally the dentition and alveolar teeth can be produced experimentally by
process compensate for deviations in requ'ring mouth breathing. Both Har-
jaw relationships so that normal dental vold" and McNamara” have produced
occlusion is maintained. When these dentofacial deformities in monkeys in
compensations have not been possible, this way. Pathologic conditions in hu-
head posture also correlates with the mans which alter postural relationships
other facial and dental characteristics can produce bizarre types of malocclu-
of the “long face syndrome” which has sions which resemble the primate mod-
been the subject of considerable recent els. An excellent example is the ex-
discussion in the surgical-orthodontic tremely long face and excessive erup-
literature. It seems highly likely, though tion of the teeth found in patients with
it has not been definitely demonstrated, severe muscle weakness ( Fig. 5). In
that a forward position of the head on such patients the mandible literally
the neck is linked with a low position drops away from the maxilla creating
of the mandible relative to the maxilla an exceptionally steep mandibular
and low tongue posture. Low mandibu- plane angle and severe anterior open
lar and tongue posture would tend to bite related to excessive eruption of
favor increased eruption of the poste- posterior teeth. Anatomic changes of
rior teeth. This posture also could lead this extent require physiologic adapta-
to constriction of the maxillary d•ntal tions in speaking and swallowing. These
arch because of the removal of resting functions adapt to the altered form
pressure of the tongue due to the low rather than causing the anatomic
tongue posture, and perhaps to anterior changes. The clinical significance of an
open bite because of differential erup- altered pattern of swallow probably
184 Profht July 1978

Excessive biting on natural teeth does

not result in their intrusion. Successful
orthodontic intrusion requires relative-
ly light but long-lasting forces, and so
it is likely that both the magnitude and
duration of occlusal forces are wrong
for producing tooth movement. Yet it
is obvious from the renewed eruption
when an antagonist tooth is removed
that occlusal forces do play a role in
determining the vertical level of teeth,
and how this is mediated simply is not
understood.
Occasional patients are seen in whom
there has been an apparent primary
failure of eruption. This is a feature of
cleidocranial dysostosis, but it occurs in
patients who do not have this syndrome
(Fig. 6) . The teeth are not ankylosed,
or at least cannot be demonstrated to
be ankylosed either radiographically or
on clinical examination. For some rea-
son they just do not erupt. Patients
with this problem have an over-closed
appearance with a short lower face
height. Prcsumably, there is a defect in
F'ig. 5 Above, severe anterior open bite the eruptive mechanism Itself. Clinical
(26 mm) in ten year old girl with a gen- investigations of the eruptive mecha-
eralized muscular weakness syndrome ;
below, cephalometric radiograph show- nism in such patients might well shed
sorrie !igf:I on II:e norrr:a!
tation of the mandible.
mechanism and on the role of tooth
lies in its relationship to a different eruption in determining vertical height
resting posture rather than with the of the face. Whether there is a parallel
swallowing act itself. The same is true syndrome of hyperactivity of the erup-
for other aspects of oral function such tive mechanism, which easily could re-
as speaking, chewing, sucking, etc. sult in excessive vertical dimension be-
cause of the known adaptation of the
fiiecondary E'act ore Relatizzg musculature to the position of teeth
to E m ption Forces once they have erupted, simply is not
The vertical position of the jaws is known.
linked to eruption of the teeth, but ex- It is difficult to place the components
actly how remains almost totally un- of the dental equilibrium in perspec-
known. It seems reasonable to presume tive as etiologic factors in malocclusion
that, with growth, the mandible moves and dentofacial deformity. Every pa-
away from the maxilla creating a space tient, unfortunately, does not have the
into which the teeth erupt. Once erup- innate potential to have normal dental
tion has occurred, pressure receptors and facial relationships. Inherited dis-
and proprioceptors in the periodontal proportions are a major influence on
membrane serve to protect the teeth. all types of malocclusion including the
Vol. 48, No. 3 Equilibrium 185

TABLE II
Comparison of incidence of open bite and
deep bite problems in American white
and black children. The large racial dif-
ferences in type of vertical problems
probably reflect racial differences in fa-
cial proportions rather than only envi-
ronmental differences (From Kelley et
al.).•
” DEEP BITE—OVERBITE
INCIDENCE
Overbite > 6 mm. 6.6% White 7.69c
Black 0.8 to
Open bite > 2 mm. 2.69« White 1.4 to
Black 9.6'to

reflect underlying differences in inher-

, ited skeletal proportions. Perhaps envi-
ronmental influences on dentofacial
development are important primarily
in patients whose inherited facial and
dental characteristics make them par-
ticularly susceptible. For the orthodon-
tist, subtleties of inherited facial pro-
portions still are a vital part, perhaps
the more important part, of the “sim-
ple invisible” cause of clinical problems.

SUM ARv
The major primary factors in the
dental equilibrium appear to be resting
Fig. 6 Above, complete posterior open pressures of tongue and lips, and forces
bite in an eight year old boy with a pos-
sible eruption failure syndrome. Only created within the periodontal mem-
the central incisors are in occlusion. Be- brane, analogous to the forces of erup-
low, failure of molar eruption in a thir- tion. Forces from occlusion probably
teen year old girl. The teeth did not ap-
pear ankylosed when exposed, but be- also play a role in the vertical position
came ankylosed after moving a short of teeth by affecting eruption. Respi-
distance. ratory needs influence head, jaw and
tongue posture and thereby alter the
vertical dysplasias which also are capa- equilibrium. “Deviate swallowing” is
ble of being produced environmentally. more likely to be an adaptation than a
One measure of the importance of in- cause of tooth changes. Patients with
herited characteristics is the different failure of eruption have been recog-
incidence of vertical problems in the nized and alterations in the eruption
black and white populations of the mechanism may be more important
United States.’ Clinically significant clinically than has been recognized pre-
open bite problems occur ten times viously.
more frequently in blacks ; deep bite school of Dentistry
problems are six times more frequent Univ. o| North Carolina
in white (Table II ) . These differences Cha pet Hill, N.C. 27514
106 Proffit July 1978

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