Barry Raphael, DMD: Achieving a new equilibrium

What can you tell us about your background?
JWM, age 64, spent my summers “down the shore” in New Jersey. Oh, you mean in ortho? Penn Dental. Fairleigh-Dickinson Ortho. Had 14 instructors and 14 different techniques. Came out using a combination bracket so I could use any technique that suited the case. I called it “thinking-man’s ortho.” I kept up with the times, using functionals, self-ligating, lingual, aligners, etc., until I learned that orthodontics was not just about moving teeth. Then things changed.

I own the Raphael Center for Integrative Orthodontics and the Raphael Center for Integrative Education in Clifton, New Jersey, and teach myofunctional orthodontics at the Mount Sinai School of Medicine in New York City and for the Myofunctional Research Company (no financial interest). I lecture in and out of the U.S. on Airway Orthodontics and wrote every word of my website at www.alignmine.com. Ever active in organized dentistry, I started my turn as President of the New Jersey Association of Orthodontists in April 2016.

Why did you decide to focus on orthodontics?
The truth? Because trying to make money in a band was no fun — and my dad was getting tired of waiting for me. But that’s only part of the story. Once my residency started, I was hooked. I became the best student I’d ever been and haven’t stopped learning since. In fact, orthodontics is now more exciting to me than ever. Now I can help patients with more than a smile. I can help them grow and be healthier, too. In fact, I believe orthodontics is (or can be) on the forefront of something very important for the health and welfare of coming generations.

Is your practice limited solely to orthodontics, or do you practice other types of dentistry?
My passion is for “airway orthodontics”  — that is, how we get a child to grow up with the best possible airway at the earliest possible age. For the past 8 years, I’ve been changing my thinking about the definition of malocclusion. Since malocclusion is really a modern disease — not identifiable in anthropological records to any great degree before just a few hundred years ago — its etiology must be more epigenetic than genetic and, therefore, based on things we, as humans, do. And like the other myriad chronic diseases we deal with today (e.g., obesity, diabetes, heart disease, etc.), there are things we can do to mitigate malocclusion as well. And believe it or not, there are LOTS of ways in which we can change the course of growth and development for every child with malocclusion.

What do you think is unique about your practice?
We take care of the child attached to the teeth as well as the teeth attached to the child. Orthodontics is not just about straightening teeth anymore. It’s about helping the child achieve a new equilibrium where the teeth are in balance with the rest of the body. We help each child deal with the habits that create imbalances and replace them with habits that will maintain balance. We do our best to “peel the onion” of root causes until the teeth can find their way straight. Yes, often I have to undo the damage that’s been caused by years of bad habits, but then we still have to replace the old habits with new. And, no, I can’t do that alone. We work with physicians, health educators, body therapists, and all manner of collaborators, including parents. But what we try not to do is force teeth into a further compromise against other imbalances.

I will also say that nothing I do is mine alone. If our practice is unique, it’s because we’ve taken the brilliant work of others and put it into a package that works. Furthermore, I don’t want it to be unique. I want it to serve as a model for others to copy. We are here to be in service to the profession as well as our patients.

How long have you been practicing orthodontics, and what systems do you use?
I have been practicing for 33 years total. The first 27 were about moving teeth. I was up to using Damon® Q™ and the mandibular anterior repositioning appliance (MARA) with expansion when I sat down to lunch one day and read an article that changed everything for me. I had been struggling with some open-bite cases that I couldn’t close no matter what I threw at them. Everyone knows about tongue thrust, sure, but this article by German Ramirez said, “Soft tissue dysfunction is THE etiology of malocclusion.” Right, I thought. But it slowly began to sink in, and now I know it’s correct. Almost every malocclusion (except for extra, missing, or decayed teeth) is the result of the muscles (active or at rest) having their way. And once I began to see this in my patients’ faces, there was no turning back.

We use systems that were designed by the Myofunctional Research Company specifically to educate patients and parents — custom lightwire expanders like Advanced Lightwire Functionals (ALF) and Farrell Bent Wire System (BWS); functional appliances like Biobloc™ and MARA; and yes, Damon for light-force, low-friction mechanics.

I also help adults with breathing-disordered sleep back away from needing CPAP and mandibular advancement devices (MADs), but that’s another story.

What training have you undertaken?
For years, I loved CE courses. But it began to get boring — same old stuff over and over. When I learned that crooked teeth are just a symptom of another imbalance and not just the “problem” to be solved, I had to start “re-learning,” and it got really exciting again.

First, I learned myofunctional orthodontics and myofunctional therapy, then Orthotropics®. Then cranial osteopathy and lightwire osteogenesis. I learned about breathing and posture, nutrition and sleep. Some of what I learned has been around for many, many years. Perhaps we weren’t ready for this knowledge before. But now, with our children becoming sicker with allergies, asthma, chronic inflammatory and immune issues, neurocognitive and attention problems, we really need to pay attention.

We take care of the child attached to the teeth as well as the teeth attached to the child.

Who has inspired you?
At first it was my dad, Jerry, who gave me the treatment planning and a retirement date from day one. Then it was Jim McNamara, who got me to look beyond brackets and wires. In the last 8 years, though, the list has become very, very long. I now stand on the shoulders of forward thinkers who took a chance to do something new and make things better despite what others thought. Here’s the short list: John Mew, Chris Farrell, John Flutter, Roger Price, Joy Moeller, Kevin Boyd, Mark Cruz, Brian Palmer, Bill Hang, Gavin James, Christian Guilleminault, and a Philadelphia lawyer from the 19th century named George Catlin, who wrote a book in 1879 that was recommended by Edward Angle in 1925 called Shut Your Mouth and Save Your Life.  A must-read even now.

What is the most satisfying aspect of your practice?
To the best of my ability, I am fighting daily for the health and welfare of my patients, well beyond their smiles. But to be honest, it is also the most challenging thing I’ve ever done. While my profession continues to search for ways to do things faster, more predictably, without compliance, I have moved toward changing behavior, requiring the daily cooperation of the child and family. I work hard to improve the protocols every day. I figure if someone else can get kids to excel at soccer, piano, dance, and gymnastics, which they do to an amazing degree, the least I can do is figure out how to get kids to breathe through their nose, close their lips, and keep their tongue on their palate, right?  And when they do, the trajectory of their lives changes. That is very satisfying.

Professionally, what are you most proud of?
Despite the challenges, I journey on. I figure I’m doing it for my great-grandchildren (yet to come).

Do your patients come through referrals?
I used to have a typical 50/50 mix of patient/GP referral pattern. Now I have people traveling distances because I offer services that others don’t. They may pass 50 offices to get to me. I shake my head in bewilderment because any well-trained orthodontists can do what I do. It’s simple. (But it’s not easy.)

What is the future of orthodontics and dentistry?
My professional organization is afraid that the future lies in the hands of those who do ortho faster, cheaper, and on a bigger scale based on providing a great smile. I say the future of orthodontics lies in giving a more thorough service based on providing better health with a great smile as icing on the cake. Face it; we have a population that is getting sicker, more often, and at younger ages. We have a responsibility to help our children grow up in a world where they don’t have to suffer disfigurement and chronic disease. We must reestablish ourselves as physicians of the face. That may sound pie-in-the-sky to many, but there is so much we can do — so much that is already being done — that we just have to stand up and do it.

What are your tips for maintaining a successful specialty practice?
Did I say I was successful? If you’re looking for enrollment percentages, dollars/visit, or patients-per-day, don’t ask me that question. If you’re looking for how I make a difference in people’s lives, well, that’s what I’m talking about.

What advice would you give to a budding orthodontist?
First, there is a long and important thread of thinking in your profession that you are not learning about in your program. Really read Angle. Read about Al Rogers who corrected Class II malocclusions with exercise alone. Read what Tweed thought about early treatment (he predicted it would be the future of orthodontics). Read Graber’s chapters on the etiology of malocclusion (it’s been in front of our face all along). Read what Ricketts said about the relevance of the rest of the body to malocclusion. Figure out why Harvold’s work has fallen on deaf ears.

Second, don’t be a “Barker” (someone who stands so close they don’t even see the tree let alone the forest). It’s not about “finishing” that 2-degree rotation on the lower lateral or accelerating your treatment (especially if you’re going in the wrong direction in the first place). And don’t think that “plaster on the table” is what makes you a wo/man. There is a precious child attached to those teeth. Stand back and look at the big picture. You’ll be amazed at what you see (good and bad).

What are your hobbies, and what do you do in your spare time?

I still play bass. My grown kids love me, but they do laugh at me when they say, “It’s all about Barry and the World of Mouth Breathing.”

Airway Orthodontics for the Orthodontic Specialist courses available:

• July 22-23, 2016
• November 18-19, 2016

at the Raphael Center for Integrative Education in the NYC metro area. Visit learnairwayortho.com to register or for more information.