We grow up thinking that our face is what it is, that bones cannot change and so our facial appearance depends exclusively on genetics. Although genetics plays an important role in determining the growth path, environmental factors are those mainly responsible for facial growth. Bones remodel according to forces and so do facial bones. 

The important role of the maxilla can be seen in Figure 1: traits of eyes, nose, cheekbones and occlusion are determined by how maxilla develops. But what are the factors influencing its growth?

Figure 1 – Frontal and medial view of the maxilla. Notice how many facial traits are affected by its development: nose, eyes, cheekbones, occlusion. (From [25])
Bones remodel according to force stimulus, which modulate the activity of osteoblasts and osteoclasts [1,2]. Furthermore, sutures also function as intramembranous bone growth site that respond to force stimuli, contributing to the morphogenesis of the bones of the facial complex [3].

The forces acting on the maxilla are coming primarily from the tongue and teeth in contact (through masseter muscles). As highlighted in Figure 1, when these forces are missing the maxilla drops down and back, reducing the eye support, flattening the cheekbones, narrowing the nasal airway, lengthening the mid facial third, and lowering the palate, which narrows and create malocclusion as a consequence [4].

Figure 2 – Tongue posture directly affects maxilla remodeling. When the tongue is correctly on the roof of the mouth, maxilla is remodeled up and forward (above case). Instead, when the tongue is not in the correct position, maxilla misses its forces and remodels down and back (bottom case). Notice the difference in cheekbones, eyes support, nose shape, length of the face and lips shape. (Adapted from [23] and [30]).
You can see in Figure 3 a patience treated by John Mew with his philosophy of treatment based on the ‘Tropic Premise’: the ideal development of the jaws and teeth is dependent on correct oral posture with the tongue resting on the palate, the lips sealed and the teeth in light contact.

Figure 3 – Cary is an adult case treated by John Mew: even if more difficult since bones take more time to remodel, her facial changes are astonishing. (From [26])
Facial development and malocclusion can vary from being mild to severe. Mouth breathing individuals are often seen with severe malocclusion. Apart from the harming consequences of breathing through the mouth instead of the nose, there is also another big problem: mouth breathing implies a mouth-open, low tongue-rest posture, with maxilla missing all the aforementioned forces, creating malocclusion and with consequences for the entire craniofacial development [5,6].

This is better represented in Figure 4: the photograph on the left shows a boy at the age of ten. He breathes through his nose and he has a decently developed face, with defined eyes, cheekbones, lips and chin. When he was 14, he got a gerbil and developed an allergy that left him with a stuffy nose, which caused him to start breathing through his mouth. The photos in the middle and on the right show the same boy at the age of 17. Breathing through his mouth caused his face to grow downward instead of forward, making his face long and narrow.

Figure 4 – On the left, ten-year-old boy with decent facial development that was breathing through his nose. At the age of 14, he got a gerbil and developed an allergy that caused him to start breathing through his mouth. The photos in the middle and on the right show him at the age of 17: notice his complete different facial shape, with maxilla that grew vertically and backward. (From [27])
When the maxilla grows down and backward, the mandible swings back as its position depends on the maxilla development. This causes TMJ problems, reduces the airways and the head tilts forward in a forward head posture [7,8]. Figure 5 shows the results of an Orthotropics treatment aimed to treat malocclusion by growing the maxilla forward: notice the difference in the airways and neck posture.

Figure 5 – Orthotropics aims to treat malocclusion by growing the maxilla forward. Notice how this affects the airways and the neck posture. (From [28])
When the head tilts forward, the body finds the center of gravity by means of compensations, thanks to muscle chains that run from head to feet: here is where kyphosis, lordosis and pelvic anteversion originate. Unfortunately, these compensations lead to many problems: muscles have an unbalanced tension that propagates in distal locations, with resulting reduced neck mobility [9], neck pain [10,11], migraine [12] and tension-type headache [13].

In cases of cranial distortions, the maxilla is asymmetrical and canted, the mandible deviates and the head is tilted on one side [14]. Then, compensations arise: scoliosis, pelvis rotation and leg length asymmetry [15], with pain in several locations [16,17,18]. Current medicine defines scoliosis as idiopathic. Are we sure scoliosis is so idiopathic?

Changes in the maxilla development leads to tremendous changes in the facial appearance: a more forward and horizontal growth of maxilla is considered more attractive [19]. Ask yourself, who is more attractive between Shanina Shaik (Australian model) and Stefani Joanne Angelina Germanotta (singer, known as Lady Gaga) in Figure 6?

Figure 6 – On the left, Shanina Shaik. Notice her forward and horizontal maxilla development, affecting shape of eyes, nose, lips and cheekbones. On the right, Lady Gaga. Notice in this case the vertical growth of the maxilla. Who is more attractive? Our perception of beauty depends on healthiness of individuals: indeed, Lady Gaga suffers of Fibromyalgia.

Another question arises: what defines our perception of beauty and attractiveness?  Although the matter is really complex, many clues bring to the following answer: beauty is health! Our deeper instinct guides us toward the selection of the healthier individuals for the survival of the species. This is not so far from the concepts of ‘Natural Selection‘ and ‘Survival of The Fittest‘ that Charles Darwin discusses about in his On the Origin of Species (1859) [20].

The maxilla has a huge influence on our health. Not surprisingly, Lady Gaga suffers of Fibromyalgia that current medicine marks with unknown etiology. But, are we sure that causes of Fibromyalgia are so unknown?

By looking to Figure 7, ask yourself again: who looks more attractive? Both individuals are 20 years old, but there is no doubts in deciding who could be also healthier. Individual on the left probably mouth breathes. Notice the impact this has on his general appearance: the maxilla has grown back, bringing back the mandible. The head then tilts forward, causing the body to compensate with increased kyphosis and rounded shoulders. Notice also his hair loss.

Figure 7 – On the left, Ali Gaboose, 20 years old. On the right, Igge Karbaashe, 20 years old as well. Notice the difference in the maxilla development and how this affects the body posture. (From [29])
Now, let us see the bigger picture. What happens when abnormal muscle tensions are chronic? What happens when our spine is out of alignment? Our body is a complex system composed by many parts, among them nerves, blood vessels, glands and organs that can be compressed by these compensatory mechanisms. Think for example to arteries that can be compressed by vertebrae rotation (Figure 8) or to large blood vessels going to the brain that can be compressed by neck muscle tension [21,22].  Could be this the cause of the cognitive difficulties in patients suffering of Fibromyalgia, like Lady Gaga? Probably, you should know the answer.

Figure 8 – Example of rotational vertebral artery occlusion. On the left, stenosis (narrowing) or anomaly of the vertebral artery on one side. On the right, compression of the dominant vertebral artery at the C1-2 level during contraversive head rotation. (From [24])


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[8] Gonzalez, Humberto E., and Arturo Manns. “Forward head posture: its structural and functional influence on the stomatognathic system, a conceptual study.” CRANIO® 14.1 (1996): 71-80.

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[11] Fernández-de-Las-Peñas, C., C. Alonso-Blanco, and J. C. Miangolarra. “Myofascial trigger points in subjects presenting with mechanical neck pain: a blinded, controlled study.” Manual therapy 12.1 (2007): 29-33.

[12] Fernández‐de‐las‐Peñas, C., M. L. Cuadrado, and J. A. Pareja. “Myofascial trigger points, neck mobility and forward head posture in unilateral migraine.” Cephalalgia 26.9 (2006): 1061-1070.

[13] Fernández‐de‐las‐Peñas, César, et al. “Trigger Points in the Suboccipital Muscles and Forward Head Posture in Tension‐Type Headache.” Headache: The Journal of Head and Face Pain 46.3 (2006): 454-460.

[14] Strokon, Dennis. “Correction of Dental and Cranial Sidebend with ALF.” IJOM 21 (2010): 3.

[15] Strokon, Dennis. “ALF Correction of Facial and Postural Asymmetry.” IJO 21.1 (2010).

[16] Jackson, Roger P., Edward H. Simmons, and Daniel Stripinis. “Incidence and severity of back pain in adult idiopathic scoliosis.” Spine 8.7 (1983): 749-756.

[17] Aebi, Max. “The adult scoliosis.” European Spine Journal14.10 (2005): 925-948.

[18] Glassman, Steven D., et al. “Correlation of radiographic parameters and clinical symptoms in adult scoliosis.” Spine30.6 (2005): 682-688.

[19] Mew, John. “Suggestions for forecasting and monitoring facial growth.” American Journal of Orthodontics and Dentofacial Orthopedics 104.2 (1993): 105-120.

[20] Darwin, Charles. “The origin of species. 6th.” (1859).

[21] Gray, Sarah Delcenia, Erik Carlsson, and Norman C. Staub. “Site of increased vascular resistance during isometric muscle contraction.” American Journal of Physiology–Legacy Content213.3 (1967): 683-689.

[22] TOOLE, JAMES F., and SAMUEL H. TUCKER. “Influence of head position upon cerebral circulation: studies on blood flow in cadavers.” AMA Archives of Neurology 2.6 (1960): 616-623.

[23] Artese, Alderico, et al. “Criteria for diagnosing and treating anterior open bite with stability.” Dental Press Journal of Orthodontics 16.3 (2011): 136-161.

[24] Choi, Kwang-Dong, et al. “Rotational vertebral artery occlusion: mechanisms and long-term outcome.” Stroke 44.7 (2013): 1817-1824.

Other websites

[25] The Maxilla, by Kenhub

[26] The Tongue – What part does it play?, by International Association of Facial Growth Guidance (Orthotropics)

[27] Mouth breathing negatively affect children’s smile, teeth, face and airways, by Conscious Breathing

[28] What Is Orthotropics?, by Boise Dentists

[29] Oldest photographs of Somalis, by The Apricity

[30] Maxilla, single most important bone in the body?, by Claiming Power