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IJO • VOL. 14 • NO. 3 • FALL 2003 17
The Significance of Cranial Factors in
Diagnosis and Treatment with the
Advanced Lightwire Functional Appliance
This article has been peer reviewed.
By Gavin A. James, MDS, FDS and Dennis Strokon, DDS
Osteopaths have known for many years that the
skull moves in a rhythmic cycle approximately
eight to twelve times per minute and that this
movement is present throughout life.1This idea contradicts
current dental thinking, which implies that the skull, at
least in adults, is a solid structure acting as a rigid founda-
tion for the facial and dental structures. For the dentist,
therefore, there are two obvious questions. First, does the
skull really move in this way and if it does, what, if any,
significance does this have for the dental profession?
The original work in this field was done by an osteopath,
Dr. William Sutherland, starting in 1910. Over three decades,
he studied the question intensely and carried out many
experiments, mostly on himself. As a result of his investiga-
tion, he began to achieve some remarkable results and started
to teach his ideas and methods in the 1940’s. Sutherland
himself wrote very little,2although there are several compila-
tions of his lectures.3,4 The “bible” on the subject was written
by one of his students, H. Magoun.5Interestingly, Magoun
was aware of possible dental implications and published sev-
eral articles relating to dentistry.6,7,8 These were published in
the osteopathic literature and understandably did not come
to the attention of the dental profession.
Since then, many osteopaths have addressed the prob-
lem of identifying cranial movement and measuring it.
There is a substantial body of evidence gathered by
Chaitow in his recent book,1which devotes several chapters
to reviewing the literature. His book is an excellent summa-
ry of past and current research. Many of the articles are
reports based on manipulative technique, but there are also
articles describing the use of various recording devices
placed on the skull, for example, transducers for measuring
skull movement9or infra-red markers on the skulls of both
children and adults allowing a three dimensional kinematic
film recording of the skull’s movement.10
An important point to make is that the cranial sutures
remain open even in the elderly.11 Closure can occur later in
life, but this is considered as a pathological change. Retzlaff
has reported that the collagen to elastin ratio is lower in
older primate sutures12 including humans13 than it is in
younger specimens. In other words, the sutures do not
become stiffer with age, but looser. Mitchell14 theorizes that
this is to compensate for the decreased plasticity of the
The continuing presence of the sutures in the adult
skull is one of the best arguments for cranial movement
since these would be obliterated if there were not some
ongoing function. The sutures contain an extension of the
periosteum of the outer layer of the skull as it passes
through the suture to become the dural membrane within
the skull.15 The sutures also contain blood vessels, nerves
and Sharpey’s fibres.16 Movement across any one suture is
very small, but the total effect of the combined movement
of the sutures is to give a detectable flexibility. The anato-
my of each suture reflects what is occurring along that
suture. There are over one hundred and twenty sutures in
the cranium and facial structures. These have recently been
described in exhaustive detail by Pick,17 based on many
hours of anatomical dissection.
Osteopaths have developed a specific terminology for
cranial movement and this will be used throughout the arti-
cle. In the midline of the skull, there are four bones (Figure
1); the occiput, sphenoid, ethmoid and vomer. The vomer
and the central portions of the other three bones move in a
vertical plane. The basilar part of the occiput and the basi-
18 IJO • VOL. 14 • NO. 3 • FALL 2003
lar portion of the sphenoid bone come together at the sphe-
nobasilar synchondrosis. This is a cartilaginous joint, until
approximately twenty-five years-of-age, when the suture
becomes fused. In the classical description of cranial
motion,4in what is called flexion (Figure 2), the basi-sphe-
noid and basi-occiput move upwards at the suture. The pos-
terior part of the occiput or squamous portion, flares down
as the basi-occiput rises. Similarly, as the basi-sphenoid is
elevated, a rotary motion takes place through the body of
the sphenoid. On completion of the upward movement, the
reverse takes place with the basi-occiput and basi-sphenoid
being projected downwards. This is called extension (Figure
3). This process of flexion and extension takes place
approximately eight to twelve times per minute.5As the
sphenoid rotates in flexion, it carries the pterygoid process-
es downwards, outwards and slightly backwards. The
reverse movement occurs in extension.
These movements all take place in a vertical plane. The
peripheral portions of these bones and the lateral bones of
the skull move in a lateral plane (Figure 4). In flexion, the
skull shortens anteroposteriorly while widening laterally. In
extension, the reverse takes place. There is strong evidence
in the osteopathic literature that this movement occurs even
in elderly adults.1The fact that the sphenobasilar synchon-
drosis fuses in young adults and yet the cranial movement
continues is a source of some disagreement in the osteo-
There are various theories as to what stimulates this
movement. One of the most popular is that of Upledger.18,19
Cerebrospinal fluid is constantly being secreted by the third
and fourth ventricles of the brain. According to Handoll,20
at any one time, there are approximately 140ml of this fluid
present in the system with a total of more than 500ml being
produced over twenty-four hours. Milne21 agrees with
Handoll as to the amount of fluid present in the system, but
claims that daily production is some 800ml. In any event, it
represents a considerable turnover of cerebrospinal fluid.
Upledger suggests that as the intracranial pressure within
the system rises it stimulates the contraction of the intracra-
nial membrane system. This pushes the fluid through the
intracranial spaces and down the spinal cord. Upledger
describes it as a semi-closed hydraulic system.
Figure 2 Figure 4
Figure 3 Figure 5
IJO • VOL. 14 • NO. 3 • FALL 2003 19
In the mainstream dental literature there are only a few
articles describing the effect of this cranial movement on
the facial structures and on the dentition.22,23,24 The move-
ment of the sphenoid is transmitted throughout the whole
spheno-maxillary complex. In flexion, the movement of the
pterygoid processes downward and outward affects the
palato-maxillary complex. This results in a widening,
descending and flattening of the palate (Figure 5). This is
followed by contraction and elevation of the palate during
the extension phase. Baker, in a meticulous study,25 reported
on permanent expansion of the maxillary arch as a direct
result of cranial adjustments by an osteopath. The temporal
bone also moves around an axis extending from the exter-
nal auditory meatus to the medial tip of the petrous part of
the temporal bone (Figure 6). This carries the glenoid fossa
slightly posteromedially in flexion while the squamous por-
tion of the temporal bone flares anterolaterally. In exten-
sion, the fossa is carried slightly anterolaterally.
At this point, some of the implications of cranial move-
ment for the dentist become evident. The maxillae have to
be seen as two separate bones flexing downwards and out-
wards then contracting again. Any structure crossing the
midline, for example, a cast partial denture, has the potential
to restrict this movement (Figure 7). Similarly, a prosthesis
crossing the midline in the anterior region should allow
some flexibility between the two halves. For the restorative
dentist, failure to recognize this movement can create many
physical complications and even prosthesis failure. Locking
up the maxillae may lead to headaches or facial pain among
other symptoms. An assessment of any temporomandibular
joint disorder must consider that the glenoid fossa is a flexi-
ble mobile structure under the influence of temporal bone
orientation within the cranial mechanism.
So far, what has been described is the normal physio-
logical process of cranial movement, i.e., flexion and exten-
sion, which continues throughout life. The second concept
arising from this work is that distortion can occur across
the sphenobasilar synchondrosis, generally at birth,26 but
occasionally later due to trauma. In a classic paper,27
Frymann, an osteopath, reports her findings on the skulls of
1,250 newborn infants. In almost ninety percent she discov-
ered obvious distortions of the cranium. This is understand-
able given the trauma of birth and the necessary flexibility
of the cranium to allow passage through the birth canal.
However, in many instances, the distortions imposed on the
cranium at birth do not resolve spontaneously with time.
Frymann described these distortions using the terminology
developed by Sutherland.4The basic patterns are hyperflex-
ion, hyperextension, superior vertical strain, inferior vertical
strain, torsion and sidebend (Figure 8).
There are only two articles we could find which examine
the association of cranial lesions and radiographic evidence.
Work by Greenman28 suggests a strong correlation between
osteopathic identification and actual cranial morphology, but
only twenty-five subjects were examined. A recent article by
Oleski et al29 compared the pre and post treatment radi-
ographs of twelve subjects and demonstrated significant
Figure 8: Outlines of Cranial Distortion from Frymann. Figure reproduced by
permission of the
Journal of the American Osteopathic Association.
20 IJO • VOL. 14 • NO. 3 • FALL 2003
changes as a result of osteopathic cranial manipulation.
Magoun4describes the distortions of the cranial and
facial structures which are associated with each of the dif-
ferent patterns. He mentions dental consequences in pass-
ing, but not in detail. There are almost no reports in the
dental literature on this topic, except for a number of arti-
cles by Jecmen30,31,32,33,34 published in specialized journals
with a small circulation. Smith, in a thorough presentation,
discusses the movement of the cranial bones and the dental
implications of this.35 There are also recent articles by
Walker,36,37 a chiropractor, explaining a chiropractic
approach to occlusion and posture.
Based on our studies of the literature and clinical materi-
al over a six-year period, we have identified that each of the
cranial distortions or “lesions” as the osteopaths call them,
predisposes to a specific malocclusion. The cranial lesion is
usually the primary etiological factor underlying the different
types of malocclusion. Another possibility is that cranial
compensation can occur subsequent to temporomandibular
joint internal derangement. In this event, the cranial compen-
sation becomes a perpetuating factor that maintains the den-
tal imbalance. Commonly, cranial lesions and temporo-
mandibular joint internal derangements co-exist.
The importance of the airway, tongue behavior, heredi-
tary factors, etc., is acknowledged, but an understanding of
cranial lesions puts these into perspective. The significance
of this is that by applying appropriate force systems which
recognize cranial movement it is possible to achieve correc-
tion of the facial structures to an extent well beyond what is
currently considered possible.
Osteopaths identify the various cranial lesions primarily
by palpation. This skill can be acquired with suitable
instruction and practice, but it is possible, by using a combi-
nation of clinical observation, radiographic evidence and
articulator mounted study models, for a dentist or ortho-
dontist to identify these lesions. Having done so, an
approach to treatment involves firstly, correction of the cra-
nial lesions as far as this is possible, then correction of the
maxilla and maxillary dentition to the cranium, and finally,
correction of the mandible to the maxilla. For many
patients the most effective approach is a combination of
cranial adjustment by an osteopath or a therapist with cra-
nial skills in conjunction with light orthopaedic-type forces
delivered by suitable orthodontic appliances.38,39,40 These
appliances are discussed elsewhere.41 It is our experience
that the force levels presently used in orthodontics can often
restrict the cranial rhythm.
The development of functional orthodontics and partic-
ularly its emphasis on temporomandibular joint evaluation
both in diagnosis and treatment, has had a profound effect
on conventional orthodontic thinking. The recognition of
cranial movement and its importance in both diagnostic
evaluation and the delivery of appropriate forces in ortho-
dontic treatment represent, in our opinion, an even bigger
paradigm shift. It is necessary to recognize the growing
influence of these concepts not only in the osteopathic pro-
fession, but also in physiotherapy, massage therapy and chi-
ropractic as well as dentistry. Courses in cranial osteopathy
are available for dentists and doctors.42 However, it is not
essential to have skills in cranial osteopathy to start using
the underlying principles in diagnosis and treatment of
Cranial osteopathy represents a truly revolutionary idea
for dentistry since it is based on concepts of functional
anatomy and cranial motion which are not recognized in
current dental thinking. We are convinced that an under-
standing of cranial movement together with the use of appli-
ances specifically designed to change cranial, facial and den-
tal structures, represent a profound, exciting and innovative
development in orthodontics. Incorporating cranial assess-
ment into practice requires additional viewing and measure-
ment of dental structures. The patient has to be seen from a
wider perspective than is usual. In addition to conventional
orthodontic diagnosis patients are further assessed by osteo-
pathic description to categorize and explain their cranial and
dental configuration. Having established an osteopathic
description of the patient’s cranial pattern, the extent of the
dental problem may be truly appreciated. The importance of
recognizing dental effects resulting from cranial distortion is
illustrated in the following case reports.
History Case #1
Patient: K.M. Thirty-eight year-old female (Figure 9A).
History: The patient’s chief complaint was the appear-
ance of her teeth. The missing upper right second
bicuspid was replaced by fixed bridge seven years prior
to her request for orthodontic treatment.
Other symptoms were mild and included occa-
sional clicking of the right TM joint and occasional
Diagnosis: The dental malocclusion is described as a Class
Figure 9A Figure 9B
IJO • VOL. 14 • NO. 3 • FALL 2003 21
II/Division I with an anterior open bite (Figure 10a, b,
c). The cephalometric readings indicate an excessive A-
B distance when measured in a horizontal plane. The
pattern is of a severe Skeletal Class II with an anterior
tongue thrust. The malocclusion is complicated by the
asymmetry of the dentition. There is a Class I molar
relationship on the right and Class II on the left. The
maxillary and mandibular center lines are off, with dis-
placement of the maxillary arch to the right and the
mandibular arch to the left. There is lateral constriction
of both arches with the periodontium on the labial
aspect of the mandibular anteriors being fragile.
A less than ideal result following orthopaedic
and orthodontic correction was anticipated in view of the
severe anteroposterior discrepancy. It was explained to
the patient that surgical correction of the Class II prob-
lem might be required given her age and the severity of
the discrepancy. The patient declined surgical correction.
The osteopathic description is of a left
sidebend. There are several components to a sidebend,
but the key factors are as follows:
• If a vertical axis is imagined through the sella turcica
of the sphenoid and one through the middle of the
foramen magnum of the occiput, the two bones
rotate around the vertical axes away from each other
to give a characteristic shape of the cranium. The left
side of the head becomes longer and more convex.
There is a corresponding shortening and concavity
on the right side. The vertex view of a sidebend is
illustrated in Figure 8, but note that this is for a right
and not a left sidebend as is the case here.
• As the left greater wing of the sphenoid swings for-
ward and rotates to the right, it carries the maxilla
with it. As the occiput rotates distally, it carries the
temporal bone together with the glenoid fossa distal-
ly. This brings the mandibular condyle back on the
left with the chin subsequently swinging to the left.
• The pre-treatment photograph (Figure 9a) illus-
trates the facial effects. The nose and the philtrum
of the lip are deviated to the right while the chin is
displaced to the left.
Treatment: The first phase of treatment was aimed at cor-
recting the lateral contraction of the maxilla and
mandible and levelling the maxillary cant up to the left.
As this was developed, the rotation of the maxilla and
the mandible towards the mid-line was undertaken by
placement of light Class III elastic forces on the right
side (opposite sidebend) and Class II elastics forces on
the sidebend side. Advanced Lightwire Force (ALF)
appliances were used. The severe crowding of the
mandibular anterior segment was relieved by use of a
lip bumper attached to the ALF appliance.
Once the lateral distortions and rotation of the
arches had been corrected the Class II problem was
treated by Twin Block appliances constructed on an
ALF framework. Final alignment of the teeth was done
with straight wire brackets and arches.
Results: Results achieved by use of ALF appliance
therapy are dramatic both from a dental and
Facially, there has been centering of the nose
and philtrum. The chin is also centered and the cant of
the lips up to the left has been leveled (Figure 9B).
Dentally, there has been correction of the cen-
ter lines with reduction of the overjet (Figure 11a, b, c).
The occlusion is now an Angle Class I both in terms of
the molar and cuspid relationship. Despite the severe
pre-treatment lateral contraction of both arches, there
has been good lateral development without loss of the
supporting alveolar bone. In particular, the healthy
appearance of the periodontal tissues around the
mandibular anterior teeth should be noted.
Conclusions: Treatment was over a four-year period.
This is unusually lengthy, but reflects the severity of the
underlying skeletal and dental discrepancies. One
Figure 10A, B, C
Figure 11A, B, C
22 IJO • VOL. 14 • NO. 3 • FALL 2003
advantage to the time factor was to allow development
of the alveolar bone to ensure healthy periodontium. It
also helps to develop stability following retention.
History Case #2
Patient: C.B. Twenty-six year-old female (Figure 12A).
History: Headaches for the past ten years. Headaches
have been persistent for the past three years. Other
symptoms include facial pain, especially over the left
temporomandibular joint, bilateral reciprocal clicking
of the temporomandibular joint and extensive myofas-
cial pain throughout the face and head. There has been
recent onset of diaphragmatic breathing problems and
episodes of dizziness.
The chief complaint is of headaches and inabili-
ty to continue her career as an opera singer because of
breathing difficulty. There is a history of severe bruxing,
head trauma at age 23 and Bell’s palsy at age 20.
Previous treatment included orthodontic treat-
ment from age 13 to 19. Treatment included wearing a
gear-activated acrylic plate to widen the maxillary arch,
a course of treatment in fixed braces, and an appliance
worn at night to advance the lower jaw position.
At the time of the most recent diagnosis the patient
was aware that the upper right quadrant was collapsing
inward toward the palate. She was required to move
her jaw to the left in order to occlude her teeth.
Diagnosis: In dental terms, there is an Angle Class I
with lower incisor proclination. The discs are displaced
anteriorly with luxation of both condyles in occlusion.
The luxation is reduced on opening.
In osteopathic terms, there is a left torsion.
This means that in an anteroposterior axis from
between the eyes to the posterior edge of the foramen
magnum the sphenoid rotates around this so that the
left greater wing goes up, carrying the orbit and the left
maxilla with it. This gives a characteristic facial appear-
ance of the ocular and occlusal planes running upward
to the left in parallel.
Treatment: Advanced Lightwire Functional
Appliances were used to free up the maxilla, intrude
the maxillary right buccal segment and extrude the left
maxillary buccal segment. These appliances included a
pad over the right posterior mandibular teeth and verti-
cal elastics from the first maxillary and mandibular
molars on the left. Adjunctive osteopathic adjustments
were made over the course of treatment.
Results: Over a nine-month period, the maxillary
plane was completely leveled and the ocular plane also
responded. All symptoms were resolved. The bruxing
pattern ceased and the myofascial tenderness disap-
peared. The eyes are now level as well as the maxillary
plane. The relationship of the maxilla to mandible is
corrected so that both the maxilla and mandible are
aligned with the facial midline (Figures 13A and 13B).
Conclusions: In osteopathic terms, bruxing and clench-
ing represented a subconscious attempt by the body to
level the head using the mandible as a platform from
which to exert force, i.e., the needs of the cranial mech-
anism dominated to the point of creating dysfunction
of the temporomandibular apparatus. The temporo-
mandibular joint and myofascial signs and symptoms
were as a result of the intense force generated.
Correction of the left torsion of the sphe-
noid, i.e., bringing the greater wing down, removed the
need for the compensatory adaptive patterns. The health of
the cranial mechanism and its normal function is central to
the overall health of the body.
These two cases have been chosen to illustrate the very
considerable potential for change once the cranial lesions
have been identified and their correction is planned as part
Figure 12A Figure 12B
Figure 13A Figure 13B
IJO • VOL. 14 • NO. 3 • FALL 2003 23
1. Chaitow, Leon, Cranial Manipulation, Theory and Practice,
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41. James/Strokon Seminars. Information from: Telephone:
(705) 721-0350, Fax: (705) 721-8153.
42. The Cranial Academy. Component Society of the American
Academy of Osteopathy. Telephone: (317) 594-0411, Fax:
Dr. James is an Orthodontic Specialist in
Barrie, Ontario. A major part of his practice
is concerned with the management of tem-
poromandibular joint and craniomandibular
disorders. His interest in cranial movement
has developed as a part of a more compre-
hensive examination of the problem of head
and neck pain.
Dr. Strokon is a general dentist in Ottawa,
Ontario. He received his dental degree from
the University of Western Ontario in 1972.
For the past twenty-five years he has taken an
interest in treating symptomatic patients using
both restorative and orthodontic techniques in
his practice. Dr. Strokon and Dr. James lecture
on the philosophy, treatment concepts and
design of the ALF appliance. They will be
presenting a session at the IAO’s annual meet-
ing in Savannah, Georgia in 2004.
Dennis Strokon, DDS
Gavin A. James, MDS, FDS