In order to begin the development of an Embouchure Aid for my fellow musicians, I needed to understand deeply all the causes behind the embouchure discomfort caused by irregular teeth. To begin with, I wanted to understand if the pressure of the embouchure can change the position of teeth, followed by some more practical studies involving professional musicians, to finally finish with some considerations on different dental devices that were recommended for helping musicians who suffer from dental problems.
Dr Ernest Herman, an orthodontist, violinist and trumpet player was one of the first to make hypotheses on the use of wind instruments as braces. In ‘Dental Considerations in the Playing of Musical Instruments’ he supports that in cases of malocclusion[1] in young children’s dentition, the choice of the right wind instrument can help to reduce the malocclusion.
Herman was one of the first to divide the wind instruments into 4 groups according to the type of embouchure.
- GROUP A: brass instruments (cup-shaped mouthpiece)
- GROUP B: single-reed instruments (reed attached to a mouthpiece)
- GROUP C: double-reed instruments (double reed goes inside the mouth)
- GROUP D: instruments with a hole or aperture to make sound (flute family)
According to Herman, the position of teeth depends on the forces and pressures exerted on them by the soft tissues of the cheeks and the tongue. The introduction of a musical instrument presents a new set of forces that when used properly can help a child during orthodontic treatment. Two more studies support this theory: Strayer (1939) and Yeo et al. (2002). Strayer was one of the first to recommend the use of a specific instrument to positively affect a certain malocclusion. For Engelmann[2], “the effect of musical wind instruments on the dentition warrants investigation, since the forces produced by them may be of significant magnitude, duration, and direction to help produce a malocclusion or conceivably to help correct one”. “Investigations showed that about 500 g of lip pressure is required to play middle C on the trumpet. And we know that less than 100 g of pressure is required to move a tooth” (Herman 1976). In the clarinet embouchure, for example, the lower teeth and lips are subjected to the weight of the instrument that is resting on them, while the upper teeth, which are already pressing on a hard inclined plane, are subjected to the pressure of the strong levator muscles of the jaw. The sum of those forces is really similar to thumb sucking and it can be really harmful.
Herman also describes a series of problems that clarinet players can encounter during their career like problems at the gums and bones that support the teeth, a greater accumulation of plaque and calculus, because of the excessive salivation of musicians of this group, and finally, he supports the theory that the clarinet's mouthpiece, with its wedged shape, operates forces that pull the upper incisors to the front (lingual pressure) and forces that push the lower incisors towards the tongue (labial pressure), thus resulting in the development or increase of the overbite. Indeed, if every type of malocclusion has a specific instrument as a cure, the contrary exists too, in other words, there are also combinations that heighten pre-existing problems.
“The number of professional clarinet or saxophone players whose upper front teeth are either mobile, spaced, protruded, or replaced with bridgework has always disturbed me” (Herman 1976).
I personally belong to Class II with an overbite and reading this article made me quickly realize the circumstances that caused my embouchure issue. In a case study, Herman took dental impressions of a boy with a deep overbite. After four years in which the young boy played the trumpet a new impression was taken, and the result was a significant reduction of the initial overbite. Herman explained that the labial forces, exerted on the upper teeth through the mouthpiece, forced the upper incisors inwards, while the pressure from the tongue, and the obligation to align the lower incisors with the upper incisors to form a correct embouchure, forced the lower teeth (maxillary) forward. For these reasons to a child with an overbite, Herman would prescribe a brass instrument or a double-reed instrument.
As you already guessed, I chose the clarinet which is considered the instrument that can make things worse rather than fixing my bite. The most indicated people to benefit from a single-reed instrument are those affected by Class III malocclusion or underbite.
In “A Study of the Effects of Playing a Wind Instrument on the Occlusion”, Doctor Ektor Grammatopoulos and Dr Ashish Dhopatkar from Birmingham Dental School and hospital, tried to make a more empirical study and aimed at demonstrating that the pressure applied in the embouchure of all wind groups is usually not enough to significantly affect the position of the teeth, arguing against what was previously believed amongst musicians and music teachers. For this cross-sessional [3] study, doctor Grammatopoulos recruited one hundred and seventy professional musicians from twenty-one professional orchestras and organizations. In this group, thirty-seven were single reed woodwind players and fifty-nine were strings and percussion players; these lasts were taken as Control Group. The statistical result was that there was no significant difference in overjet, overbite, crowding and other malocclusions between the wind musicians and the control group [4]. Therefore, it was concluded that “playing a wind instrument has none or only a minor influence on the facial morphology and the occlusion”. The main goal of this study was to collect tangible data since until that moment it was just theoretical or based on single cases, and to prove the veracity of the Dental Equilibrium Theory first proposed by Weinstein (1963) and later revised by Proffit (1977), which affirms that “the forces exerted by the surrounding soft tissues may be sufficient to cause tooth movement in the same manner as that produced by orthodontic appliances. Therefore, the surrounding musculature envelops and consequently shapes the dental arch forms” (Grammatopoulos 2009). I.e., in other words, as long as there are forces applied even when very low in magnitude but for a considerable period of time, they can cause changes in tooth position. The theory was further developed by Proffit (2004) who suggested some values of the pressures required to cause orthodontic tooth movement, however, the dental equilibrium theory is not accepted by the study of Dr Grammatopoulos since its base is fully anecdotal and not the result of research [5].
Unfortunately, certain factors of this study were found to be inaccurate by a later study. In a systematic review by van der Weijden, F. N. et al. published in 2020 in the Journal of Orofacial Orthopedics, the authors affirm that by using string players as the control group, Grammatopoulos might have influenced the statistical result of the study, since a study by Kovero Könönen, and Pirinen (1997) found that “violin players had a larger face height (especially on the right side of the lower face and in the right mandibular ramus) and more proclined upper and lower incisors than controls” (van der Weijden et al. 2020).
I personally would have appreciated more this study if it was structured on a longitudinal study system (with repeated observations over a bigger period) rather than being cross-sectional. Studying the players from the beginning of their rapport with their instrument and not when they are already professionals, since a lot of the changes may have occurred already before the observations of Grammatopoulos. The study should have determined first the type of malocclusion of the patient with the relationship with the wind instrument, and then measured the gravity of the changes by testing every five years or so, at least until the end of the patient growth phase.
The review conducted by van der Weijden et al. (2020), offers an incredible report of all the studies ever made on this topic. I think it’s the most complete and neutral review I’ve found during my research. The authors included every single article or study on the topic “Does playing a wind instrument influence tooth position and facial morphology”; and excluded only those publications that didn’t fulfil their quality or statistical standards. However, also the authors of this very meticulous review, found many discrepancies in the studies conducted until now, concluding that a bigger longitudinal study should be conducted. Until this moment only three included studies were longitudinal. Based on 10 observational studies, van der Weijden et al. conclude that playing a wind instrument can influence the tooth position and that the increase of the overjet stands out particularly. In cases of single-reed players was found a particular predisposition to overjet rather than an increase of the overbite, although in (Strayer 1939) this was considered a consequence of playing a single reed instrument.
A particular exception occurs when we consider a different cause-effect relation. Many times, it may have been the case that the young children chose a specific instrument just because it would fit just right (Herman 1976), this would affect the results of many studies since there could be a relationship between people with an overbite choosing the clarinet [6].
To conclude, reading all these research studies cleared my thoughts on what were the effects of playing the clarinet on my overbite. Rather than pushing my teeth outwards, it changed their inclination, increasing the overjet.
[1] A malocclusion is a non-ideal arrangement of the teeth.
[2] J. A. Engelman, ‘Measurement of Perioral Pressures during Playing of Musical Wind Instruments’, American Journal of Orthodontics 51, no. 11 (November 1965): 856–64.
[3] Cross-sectional study: Data collected in one moment in time (opposite to longitudinal study).
[4] Statistical analysis was undertaken for interval variables with one-way analysis of variance and for categorical variables with Chi-square tests. (Grammatopoulos 2009)
[5] Ren, Maltha, and Kuijpers-Jagtman, ‘Optimum Force Magnitude for Orthodontic Tooth Movement’, a systematic literature review.
[6] (Grammatopoulos 2009).
From those studies has clearly emerged that playing the clarinet can trigger two reactions. They are both related to the pressure of the embouchure, but they can happen regardless of one another. The first is an attack on dental stability and the second is to lip’s health. And, as one would expect, the repercussions get worse the more irregular the teeth are.
The following paragraphs aim to understand more precisely the problems I’m addressing with my Embouchure Aid and refine my target customers.
Dental Instability
Dental instability is a relevant result of the embouchure pressure. In a study that measured the amount of pressure for each wind instrument, the clarinet got the highest result, with maximum pressure averaging about 118 grams on the upper sensor and 120 for the lower one.[1] Another critical problem is that the pressure is exerted mainly through the incisors, and because of the vibrations, it can destabilize pre-occurred restorations. When a clarinet player, as well as other single or double reed players, breaks their teeth and is forced to adopt an implant or a crown, they will be often sceptical to play again, since the original strength of their teeth is compromised. In those cases, different types of orthodontics appliances can be used to support the weakened tooth.
Lip Abrasion
All reed players are required to fold their lips inward on their teeth to create a soft cushion for the reed. Unfortunately, in cases of very sharp teeth, this position can cause lip abrasion and pain. When the injury occurs, it is excruciating, and in some cases, it can also cause nerve damage. However, most of the time the swelling and the impaired sensibility will heal in several days. Often players use very creative precautions like a thin paper or a plastic foil to protect their lips from the sharp angles of their teeth. There are also some commercial producers of these sorts of remedies that could be interesting to further investigate.
The musicians most affected by this problem are clarinet, saxophone, and oboe players.
Previously Adopted Aids (Gervase de Peyer)
In line with the studies on the anatomical changes of teeth and jaw caused by embouchure pressure, dentists have already widely thought of different devices to contain such forces. Metal casts and acrylic shields were regularly used to give support to mobile teeth or crowns. Amongst older musicians who have lost already many of their teeth, it was common practice the adoption of an embouchure denture. This is what the famous Clarinet player Gervase de Peyer started using after beginning to have huge problems with his teeth and soft palate. Unfortunately though, like many other cases, Gervase had to sacrifice his sound flexibility and overall embouchure comfort. [2]
[1] For each measurement, 3 essays were done in different tone pitches: high, medium and low. For each participant, the tables are presenting the average of force applied at the upper part of the mouthpiece and at the lower part of the mouthpiece. For woodwind instruments the upper part of the mouthpiece had 2 sensors contacting both upper central incisors when in brass wind instruments only one sensor was applied for the upper lip (Fig.4). All wind instruments had a piezoresistive sensor to record the pressure applied to the lower lip (Fig. 5). Miguel P. Clemente et al., ‘Wind Instrumentalist Embouchure and the Applied Forces on the Perioral Structures’, The Open Dentistry Journal 13, no. 1 (28 March 2019).
[2] “His biggest regret was the problems he had with his teeth, which certainly had a major negative impact on his capacity to play the clarinet in tune and with the sound quality he had in his head. He had a punctured palate, which meant that air escaped through holes in his palate. Roy Jowitt, who was co-principal in the LSO with Gervase from 1967 until Gervase left in around 1972, mentioned that Gervase used to put little bits of cork into the holes. He had also lost some teeth and was therefore obliged to use a denture”. ‘Gervase de Peyer by Peter Eaton’, https://www.eatonclarinets.com/gervaseandme.html.