In this lecture, the presenter challenges the conventional orthodontic approach of retracting maxillary teeth in adolescent Class II cases. Instead, he demonstrates a non‑standard protocol that advances the lower dentition using lower appliances and temporary anchorage devices (TADs), thereby eliminating the need for maxillary retraction. Two detailed case studies illustrate the method: a teenage boy with a moderate overjet and a severely narrowed airway, whose lower incisors were advanced, posterior segments moved forward, and airway cross‑section increased from 60.2 mm² to 150.4 mm², reducing his sleep‑apnea risk; and a girl with a repaired cleft palate and early sleep‑apnea, whose arches were expanded without extractions, leading to improved nasal breathing and a larger airway. The presenter addresses the common concern of gingival recession, citing at least eight peer‑reviewed articles that report no recession with such tooth advancement, and draws on his 30‑year clinical experience. He also references Dr. Brendan Stack’s criticism of traditional incisal guidance and the pursuit of ideal overbite/overjet relationships. The talk concludes by questioning why the orthodontic community continues to rely on retraction when viable alternatives exist.
Chapters
Welcome back. This segment is entitled Adolescent Orthodontics Without Retraction. There's a warning we have to give you here. In this particular case, you're going to see some things which are not the standard of care in orthodontics. For instance, treating a Class II patient without retraction. Here's a boy who has an end-on-end Class II occlusion with a moderate overjet and a deepened bite. The normal treatment plan in his case might involve use of a headgear to move his upper teeth back to make him Class I, or even might involve the removal of the maxillary right and left first bicuspid teeth to allow for retraction to reduce the overjet. Others might use temporary anchorage devices to try to distalize the maxillary dentition. We chose to do none of the above. He has an incredibly small airway, which is pictured right here. You can see how small this is. That's barely bigger than a drinking straw in cross-section. You can see his overjet here is probably 6 to 7 millimeters, and yet his chin is forward. He's not really a weak-chinned individual. So, what do we do in his particular case? He was past the age for orthotropics, and his mother indicated that he wouldn't be appropriate for that anyway. So, we inserted a lower appliance, Here, and we're going to open spaces between the lower bicuspid teeth and advance the lower anterior teeth for him. Now, you can see the appliance has been activated here, and a dramatic space has been increased between the 2 bicuspids on each side, and his overjet has been reduced by advancing the lower incisor teeth in his face. This is not the standard of care in the orthodontic profession, but it's doable. Now, you see he's in braces, and you see the spaces which are between the bicuspid teeth. We've placed temporary anchorage devices in the lower anterior segment so that we can move the back teeth forward and bring the entire posterior segments forward to close up these spaces. You can see in a panoramic x-ray taken in the midst of this treatment how far the molars had been moved back. The second molars were actually impacted in the ramus of the mandible as part of the reaction to moving the anterior teeth forward, which is an unpreventable thing using these appliances. Now, you see him following the completion of his treatment where he has— the spaces are completely closed, and he has a Class III molar relationship because we've essentially moved the entire lower dentition forward in his face. And you see that the teeth don't fit the way they normally would, but I'll accept that any day for what we ended up with in his case. The next question you're going to ask is, have we caused recession? Because most of you were taught that advancing the teeth forward dramatically like that would cause gingival recession. There are at least 8 articles in the refereed literature indicating that this will not happen. And I've been doing this kind of thing for more than 30 years and can attest to the fact that it's not a concern. We've closed all the posterior spacing. He has a nice occlusion in the anterior with no overbite, overjet problems at all. You can see his profile is nicely improved from the curl in his lower lip on the left to a better profile on the right, with no retraction whatsoever having been done, because we never did any kind of retractive mechanics in the maxillary arch. We brought the lower dentition to meet the upper dentition, leaving the mandible alone completely. Here he is on Facebook with his sister and his grandmother, celebrating his 20th birthday. More important than that is what happens for his airway. He's gone from having a minimal cross-section of 60.2 square millimeters to a minimal cross-section of 150.4 square millimeters, which places him from a moderate risk category to a less than— to a low-risk category in having sleep apnea. But let's look at how much we moved his lower incisors forward. You can see on the right-hand side where he is after the treatment, and see the amount of bone on the labial aspect of the lower incisors in this case. So, let's look at another patient who had a cleft palate repair at age 10 months, and she had a sleep apnea diagnosis at a very early age at Stanford University. And you look at her terribly crowded dentition and say to yourself, is there any way that you could possibly treat that without removing teeth? You realize that she does snore, and she sleeps with her mouth open, and she has difficulty eating. We recognize that anyone who snores will develop sleep apnea eventually if they live long enough, And kind of think about the fact that the last thing we want to do is to do anything which would increase her chance of having sleep apnea. So, can we treat her without removing any teeth? More than that, let's look at her profile and say, would she be better if we retracted her some and did take some teeth out? Noticing the Bolton profile norm on her face shows that the maxilla and the mandible are both recessed from where they ought to be. And she already is starting out with a minimal cross-section of 65.2 square millimeters, which places her in a moderate risk group for sleep apnea right now at that age. Looking at it in the anteroposterior and the cross-sectional dimension, you decide if you think it would be a good idea to do anything which might reduce her airway even minutely. So, here we are after a series of removable and fixed appliances, We've been able to align the teeth. You can see her with fixed braces on her teeth, and she has an intermolar width of 36 millimeters, starting out from something way lower than that. She can easily get her tongue to her palate now and learn to keep her lips together and become a nasal breather, which is the goal of all treatments. Here's the lower arch after development in both the anteroposterior and the lateral plane of space. Looking at it from the front, those of you who are worried about recession, please, please take a look and realize, again, there are 8 articles in the refereed literature stating that you can advance teeth dramatically without concern for recession. You can look at her profile and say, is her face too full? I don't think so. And she has an overjet and a slight open bite here. And you look at the way her teeth fit and say, well, they don't fit ideally. And I admit that. They don't. But the parents report that her snoring is gone, and she and her parents rejected surgery, which is what I told them they needed to do if they wanted to make the teeth fit properly. But they, they and I rejected any treatment which would retract her teeth at all for the purpose of trying to make her teeth fit together better, just because that is the so-called standard of care. They were informed that the teeth didn't fit together ideally, but they're all Incredibly happy with this result. You can see, here's the maxillary arch before and after, and the mandibular arch before and after. See the nice development in both arches. And you can see her smiling picture with a narrow arch, post-treatment with a nice broad smile. And again, are you worried about recession? I'm not, and the refereed literature tells you not to be as well. I like this lecture from Dr. Brendan Stack, one of the most respected orthodontists in the entire profession, in my opinion, where he stated that incisal guidance is one of the worst concepts foisted on the dental profession. Dr. Stack is well known for his treatment of movement disorders and Tourette's syndrome. He's treated some of the most complex pain patients in the world, and I value his opinion greatly. I put this slide here as just support for not going for the ideal overbite-overjet relationship, which we were all taught we needed to have. So, adolescent orthodontics without retraction. The question here is, if there is an alternative to retraction, why are people still retracting at this point?
