In this lecture, the speaker traces the historical controversy between functional appliances and traditional orthodontic methods, beginning with Dr. John Witzig’s 1980s advocacy for functional appliances and the ensuing "functional appliance war" that culminated in the Brim v. Malloy lawsuit, where a patient won a $1 million judgment alleging TMJ problems from extractions and retraction. The speaker cites Dr. Lyle Johnson’s review, which found both traditional and functional approaches produce similar moderate mid‑facial dento‑alveolar retrusion—i.e., the maxilla and mandible positioned posteriorly. A series of studies from the American Journal of Orthodontics, Finnish pediatric research, the Journal of Clinical Sleep Medicine, and the British Medical Journal are presented to demonstrate that posteriorly positioned jaws, steep occlusal planes, and related craniofacial features are strongly associated with sleep‑disordered breathing and pediatric sleep apnea. Additional evidence links tongue scalloping to airway crowding caused by retruded jaws. The health ramifications are highlighted, including Dr. Ron Harper’s finding that five hours of intermittent hypoxia can damage Purkinje cells, increasing hypertension risk. The speaker argues that orthodontics must shift focus from merely aligning teeth to promoting forward growth of both jaws to improve airway health, and hints at an alternative approach to be discussed in a future segment.
Chapters
Welcome back. This segment is entitled Traditional Versus Functional Orthodontics. During the 1980s, Dr. John Witzig, who was a general dentist from Minneapolis, Minnesota, was lecturing all over North America about use of functional appliances, which were purported to grow the lower face forward, something that he'd learned from Europe. And he felt that these were superior to the traditional retractive approach of traditional orthodontics using a headgear, And braces. This caused what I have termed a functional appliance war to occur. It culminated in a lawsuit called Brim versus Malloy, in which a patient by the name of Brim sued Malloy, alleging that the TMJ problem occurred because of extraction and retraction. The fact is that Brim won the lawsuit to the tune of $1 million, which got the attention of the orthotic profession in a very big way. So, there was a lot of controversy and concern in the profession about the effect of functional appliances versus traditional orthodontics. That spurred an article from Dr. Lyle Johnson at the University of Michigan, which is entitled Growing Jaws for Fun and Profit: A Modest Proposal. In this article, he compared traditional orthodontics, as it was done, with so-called functional orthodontics and reviewed the literature. And he concluded that both groups were about the same, and both approaches resulted in a moderate midfacial dentoalveolar retrusion. In other words, both jaws, the maxilla and the mandible, were back from where they ideally might be in the face. Now, for me, it looks pretty much like these 2 people coming together on the West Side Highway in New York. It's kind of like saying, gee, we tied. In reality, Why would you want to be proud of that, that we tied? Given the fact that, remember, Dr. John Remers says sleep apnea would not exist if the jaws were placed properly forward in the face. The point here is we need to be doing things to get the maxilla and the mandible to develop forward and not be happy with having people have midfacial dentoalveolar retrusion. Further evidence from the literature on the importance of this is needed. Here it states, from the American Journal of Orthodontics in 1986, sleep apnea subjects showed a posteriorly positioned maxilla and mandible, a steep occlusal plane, over-erupted maxillary and mandibular teeth, proclined incisors, steep mandibular plane, a large gonial angle, high upper and lower face heights, and an anterior open bite in association with a long tongue, and a posteriorly placed pharyngeal wall. In other words, this would be a great description of moderate midfacial dentoalveolar retrusion, producing, in essence, sleep apnea. Here's another article about kids. Approximately 10% of 6- to 8-year-olds have sleep-disordered breathing, according to a recent Finnish study. The risk is increased among children with enlarged tonsils, crossed bite, and a convex facial profile. Convex facial profiles are frequently associated with both jaws being back. Another article out of the Journal of Clinical Sleep Medicine states further, after tonsil and adenoidectomy, these findings suggest that the persistence of sleep apnea after adenotonsillectomy may be partly due to the smaller size of the mandible in pediatric patients. And they propose that the maxillomandibular morphology should be carefully examined when a treatment plan is developed for sleep apnea children. In other words, getting the jaws forward, both jaws, is the most important thing. Out of the British Medical Journal, states, the combination of a long face, reduced nose prominence and width, and a retronathic mandible may be diagnostic facial features of sleep-disordered breathing that may warrant a referral to specialists for the evaluation of other clinical symptoms. In other words, the jaws are back, greater chance of sleep apnea. Finally, let's talk about scalloped tongue. High-risk patients, we found tongue scalloping to be predictive of sleep pathology. Tongue scalloping was also associated with pathologic polysomnographic data and abnormal Mallampati grades. The point is that the tongue gets scalloped because it doesn't have enough room. It gets scalloped because both jaws are down and back, and it crowds the tongue. Finally, let's look again at the health implications of sleep apnea in children. We note that Dr. Ron Harper states, 5 hours of intermittent hypoxia can cause brain damage, which kills Purkinje cells responsible for motor coordination, and that a brain injury at this age may result in 3 to 4 times increased risk of hypertension. So, what you have to understand here is This really isn't about teeth. It's about health. It's about faces. It's about airways. And it's very, very important. So, the point here is, is there an alternative to traditional and functional orthodontics? Well, I certainly think there is, and I hope that you'll agree. We'll talk about that in a future segment.
