We have known for a long time  from the Podology (I) that the physiological curvatures of the spine, as they are evaluated from a body profile in an upright static position, are determined from the age of 5, at the end of the process of mielinisation of the sciatic nerve; this last induces the "maturing" of the bariceptors  of the sole of the foot which, as they  begin to work, set off the curving of the arch: stimulus of the baroceptors …sensorial afferences…nervous centers… regulation of the tone of the intrinsic and extrinsic  muscles of the foot. The regulation of the muscle's tone in legs and feet muscles, which is therefore late in coming compared to that of the torso and higher limbs (already present in the first months of life), determines the normalization of the plantar stance and so the physiological stabilization of the spinal curve. At the age of 5,more or less, the child  plantar stance  should be normal; the lumbar lordosis should have formed, leaving the neck area and whole cephalic area free from a state of hypertonicity typical of early infancy (which is necessary until then for the child to be able to stand up, as the bariceptors of the sole of the foot are still not completely functioning).
If all goes well, at 5 years of age the child has a good plantar stance  and a  correct posture. It is not always so and if, for many reasons (traumas, heredity, ligament laxity, socio-environmental conditioning, overweight, etc.) the plantar stance and/or the  position of the tharsic-tibia are not correct, this has repercussions in an ascending manner on the back postural muscles (due to alteration in the reflex mechanism of the muscle played between facilitation-inhibition); these muscles are the maximum gluteus, spinal sacrum and lower, middle and higher trapezium (2).
Orthodontists know however that an alteration in the cervical functioning influences the whole stomatognatic apparatus; this has been said for a long  time even by authorities of the international orthodontic world, such as by Marcel Korn (3) and M.Rocabado (4), (5). The problems of skull - cervical - mandibular dysfunction have been studied in fact by many in the last few years. Among the first we must remember H. Gelb (6) and B. Jenkelson (7), after which other specialists have followed, such as E. Giannì (8), R. Cornalba (9). Professor Paolo Falconi has recently founded, at the University of Cagliari, a study center for skull -cervical- mandibular dysfunctions. We must also remember that since 1979, Professor Angelo Attinà has studied postural - problems of the bite of the ATM (10,11) with reference lately to problems on the whole body posture; studies have been made in this direction also by R. Ridi (12) and by S. De Biase (13).
We must not forget that already in May 1984, during a S.I.R.I.O. conference concerning the topic of recidives, Dr. Giovanni Vanni brought forth complete clinical and radiographic documentation on two cases of  secondary malocclusion and alteration of the posture (14). Having stated this, it is possible to understand   how it is important - in the treatment of a case - to respect the priority of therapeutic intervention.
When a subject with a an incorrect bite is also found to have, from the anamnesis (that must always be done in an accurate and complete way) and from an  objective test, a defect of posture which, through a   full kinesiologic test appears to be of an ascending type, the priority is to correct, within the limits of possibility, the cause of the defect in posture for the  3 following reasons:

1. it comes into the logistics of the development of an incorrect bite, which is secondary to the posture;
2. the bite will also be corrected in full or in part while the posture is corrected;
3. there will be fewer recidives, at the end of the orthodontic treatment. Therefore, it will be possible to avoid or greatly reduce the long period of contention because the correction, completed in the mouth, will come in on a body's structural and stable stance.

Let us consider 32 subjects, actually under study, who have an incorrect bite as well as a defect in posture. Among these, 21 show a plantar stance defect , bilateral and equal: that is, both feet are leaning forwards or backwards, and the back of the feet are inclined inwards or outwards, but  bilaterally and in equal measure. These subjects all have altered inter-jaw bone ratios on the vertical plane, that is deep skeletal bites. Behind the plumb-line of a scoliosismeter they are shown to be balanced or symmetrical on the frontal plane; they do not have a scoliotic attitude, whilst they do have - on the lateral (profile) plane - an alteration of the physiological vertebral curvatures (hyperlordosis or cervical or lumbar kyphosis).
The remaining 11 subjects all are shown by the photopodograph to have an asymmetrical plantar stance : only one foot is set leaning forwards or backwards or one is defective in greater measure compared to the other, or only one heel leans inwards or outwards (while the other heel takes up a position such to compensate its partner). These same subjects have an alteration in the relationship of the jaw bones ratios, mainly on the frontal plane, that is, lateral -deviation of the mandible. Behind the plumb-line of the scoliosisometer they display an asymmetry on the frontal plane: scoliosis or a marked scoliotic attitude as well as variation of the lateral (profile) curvatures of the spine.
In the first 11 subjects, while their plantar stance is gradually corrected using a suitable orthotic with proprioceptive stimulation or with buttons, depending on the case, their posture also corrects itself and, at the same time, the vertical dimension of the mouth also alters (photos 7-8 and table 12, case A ; photo 6,8 and 9, case B). In the other 11 subjects as well, by correcting the defect in plantar stance, both posture and laterality improves and is often corrected (see photos 3 and 8, 4 and 9, 5 and 7, 9, 10, 11, case C).
We can therefore state:

1. that the structural ascending  types caused by an alteration in the footing of both feet, that is a symmetrical and equal alteration, give way to alteration in the inter-jaw bones ratios on a vertical plane (deep -bite). In particular, in equal measure forward leaning feet  can cause a deep-bite in class II or III, depending on whether an anterior wall is first created or not (false class II because the jaw is not free to slide backwards). In these cases, when the ascending deep-bite is blocked, the skeletal class can change completely (because the jaw-bone symmetry changes) and therefore the dental class changes too. It is the change in the vertical dimension that has an effect on, in these cases, the situation of the jaw on the anterior-posterior plane. That is why, in correcting a deep-bite, often class II and III corrects itself (see photo n.13, case A and photos n.6,8,9, case B).
2. that the structural  ascending types caused by an asymmetrical footing, give way to alteration of the inter-jaw situation ratios on a frontal plane (lateral -deviations). In particular, a left  monolateral claw foot  regularly gives cause to - where there are no other interfering factors - right jaw lateral deviation, often with a cross bite in the upper right quadrant. In younger children, that is, between 5 and 9 years of age, when the asymmetrical posture is corrected, their laterality is also corrected in a surprisingly short time, in 40 to 60 days (see photos n.6,10, and 11, case C).

From these clinical studies, we can see how in orthognatodontics, verticality and laterality prevail over sagitality in the ascending structures type and we understand how important it is for prevention and therapy to have a precise diagnosis of the cause.

Case A - G. Daniele, 10 years old.
Diagnosis: III Skeletal class  with predominant mandibular protrusion (body slightly long for his age and in anterior position) and slight jaw regression. III Dental class  with mixed dentition. Anterior inverted bite and upper contracted  bite. Bilateral flat foot, II grade , with bilateral backward footing with outward leaning heel (bow), hypo-tonic lumbar hyper-lordosis, forward set of the head as though from a loss of the physiological cervical lordosis. A careful kinesiological examination shows that it is an ascending type and therefore it was decided to start the therapy by first correcting the cause of incorrect posture, that is, the child's plantar stance (forward leaning feet) using buttons in the orthotics.

Photo 1 - 18/9/89: face (from a frontal view), note the characteristic signs of III class .
Photo 2 - 18/9/89: face ( from the  lateral view), note the mandible protrusion and upper jaw regression
.
Photo 3 - 18/9/89: shoulder posture; head slightly right-leaning, body shifted slightly to the right in relation to the plumb-line, but without serious asymmetry or scoliosis, pelvis reasonably balanced, heels outward leaning (bow).
Photo 4 - 18/9/89: side profile of the body: lumbar hyper-lordosis, straight stance of the cervical area and of the mandible protrusion.
Photo 5 - 18/9/89: complete rachis XR  , corresponding to photo 3, viewed from a frontal view.


Photo 6 - 3/10/89: foot print with a photopodograph: flat feet II class , treatment with buttons started 2 weeks before.
Photo 7 - 18/9/89: bite: III dental class with inverted bite.


Photo 8 - 30/10/89: face (from a frontal view): it has become more harmonious.
Photo 9 - 30/10/89:face ( from the  lateral view): profile more harmony, the chin protrusion  is  less accentuated.
Photo 10 - 30/10/89: bite: within 42 days this has changed from III dental class  with anterior inverted bite, to become almost a dental class I with even bite, this done merely by correcting the posture (correction of the occlusion by an ascending means).

This bite, unstable at this date, became stable after 4 months. At this stage we went on to an orthodontic treatment, starting off now from a completely different jaw bone ratios situation to that of the 18/9/89 and therefore the decided therapy  was also completely different: we applied a quad - the upper helix with light arch in twist along the whole upper arch - to correct the contracted bite and upper crowding.
Photo 11 - September '88: mouth scan: marked crowding in the  the upper jaw.
Table 12 - 30/10/89: lateral teleradiographies: taken at intervals of 1 hour and then overlaid : black -with orthotics, red -without orthotics. Seeing as the inter-jaw bone distribution is still in an unstable position without correcting orthotics, we can evaluate the displacement of the jaws, of the profile, of the cervical spine and of the muscles of the nape of the neck when the correcting support is in place.
Photo 13: profile models of the18/9/89 and the 30/10/89: we see how the distribution of molar  III class is still correcting itself, in an ascending manner.


Case B - Giada,  6 ½ years old
Diagnosis: Skeletal and dental III class  with anterior inverted deep-bite. Contraction of the upper jaw bone (mainly in the pre-maxilla area). Oral breathing due to adenoid growths. Flat feet, I° degree.


Treatment plan:
1. To improve breathing
2. To evaluate whether it is of ascending or descending type.
3. To evaluate when to intervene with the orthodontic treatment.

Therapy:
1. Adenoidectomy
2. Treatment for the posture.
Once the adenoidal growths that were preventing breathing through the nose were removed, the type was seen in the kinesiological test to be prevalently of an ascending type.
3. Orthodontic brace once the jaw bone-mandible relationship has been stabilized using ascending means.

Photo 1 - 15/1/90: face (from a frontal view).
Photo 2 - 15/1/90:face ( from the  lateral view): jaw bone protrusion.
Photo 3 - 15/1/90:back profile of the body: there is no asymmetry, good balance of the head, shoulders and pelvis

Photo 4 - 15/1/90: side profile of posture: lumbar hyperlordosis, cervical area tending forward with protruding mandible.
Photo 5 - 16/3/90: photopodograph of foot print. Flat feet, 1° degree, already in treatment with buttons for 2 months.


Photo 6 - 15/1/90: occlusion: anterior inverted deep-bite and  III dental class, milk teeth set.
Photo 7 - 15/1/90: contraction of the upper jaw in the pre-maxilla area with intra-version of incisor milk teeth.

Photo 8 - 16/3/90: occlusion: 2 months after the start of treatment for posture, the bite tends to open up and the mandible to move backwards.
Photo 9 - 15/5/90:occlusion: 4 months after the start of treatment for posture, the vertical dimension is increasing, the mandible is sliding back and the upper jaw is freeing itself from the position in which it had been forced by the mandible. At the same time, the III class  proportions are improving.

At this stage, seeing as the correction to posture has brought the child's plantar stance  to a reasonable condition of stability, and seeing as the occlusion also seems to be stable, that is, it does not recede if the orthotics are removed, it was decided to start with the orthodontic treatment. In this case a removable functional brace is applied to the situation in photo 9 and not in photo 6. This situation has great advantages for us because the inter-jaw bone and occlusion ratios are far better than before and the orthodontic therapy can come in where there is much more stable structural balance compared to the  earlier.


Case C - C. Chiara, 6 years old .


Diagnosis: Right dislocation of the mandible with cross-bite of the right upper  quadrant. Teeth crowding on both jaws, more marked on the upper jaw, and 75 inclusion. Incorrect footing with: right claw foot of I° degree and inward leaning heel, left claw foot of  II° degree and outward leaning (bow) heel.

Upper back scoliostic attitude, right-convex and lumbar hyper-lordosis. The kinesiological exam shows it to be of the ascending type and it is decided to correct the plantar stance's and the heel's defect. Proprioceptive stimulating orthotics are applied and the changes in the foot, heel, spinal column and mouth are observed.


Photo 1 - 16/1/90: face (from a frontal view): left-flexed head, right deviation of the chin.
Photo 2 - 16/1/90: face ( from the  lateral view).
Photo 3 - 16/1/90: shoulder posture: head unbalanced, pelvis unbalanced; in relation to the plumb-line, the spine is tilted right; asymmetrical stance of the knees and heel.
Photo 4 - 16/1/90: body side profile: lumbar hyper-lordosis and right shoulder leaning forward.
Photo 5 - 16/1/90: photopodograph of foot print: claw foot of  I° degree on the right and II° on the left.

Photo 6 - 16/1/90: occlusion: lateral deviation of the right mandible with cross-bite in the right  upper  quadrant starting from the canine. Note the position of the tongue which goes to take up place in the space for the molar milk tooth .
Photo 7 - 28/2/90: photopodograph of foot print: the footing has been corrected, becoming symmetrical (that is, bilateral, but also in equal measure: claw feet by I° degree).
Photo 8 - 28/2/90: shoulder posture: with a symmetrical plantar stance, the right deviation of the spine in relation to the plumb-line disappears and the position of the head, shoulders and pelvis are also corrected.
Photo 9 - 28/2/90: profile of posture: the situation of the lumbar, shoulders and the nape of the  neck improves.

Photo 10 - 28/2/90: occlusion: the mandible has re-centered  by itself through an  ascending means.
Photo 11 - 3/4/90: occlusion: the position of the mandible has become stable and the  right upper central incisor that had come up in the palate - (photo 10) - is now growing correctly (the tongue in the now correct position acts as orthodontic instrument).
Photo 12 - 3/4/90: the 75 is breaking through because it is finally free from the pressure of the tongue that has now re-positioned itself, due to the correction of posture (via ascending means) and has passed from a left inclined and low position to a horizontal one.

The orthodontic brace will be prepared on the basis of this new occlusion and its only aim will be to create enough space for all the new permanent teeth to come through (seeing as there is still crowding with a disproportionate ratio of teeth/jaw bone); the right lateral deviation and the cross-bite had corrected themselves spontaneously, during the correction of posture, because the former was secondary to the latter.