In this presentation, the speaker examines whether orthodontic tooth retraction—whether through extraction, canine substitution, or premolar removal—is acceptable given its potential impact on the pharyngeal airway and the risk of sleep‑disordered breathing. The talk opens with a reminder that structural narrowing of the pharynx is a central factor in sleep apnea and that proper forward jaw positioning could prevent the condition. Several clinical cases are reviewed: a child with missing lateral incisors who, after maxillary expansion, experiences forward mandibular growth, but later loses that growth when the upper incisors are retracted during canine substitution; an adult in his 50s with a history of early lateral‑incisor space closure who now shows a backward‑tilted forehead, a forward‑positioned chin, and a stroke likely linked to undiagnosed sleep apnea; and multiple bicuspid‑extraction patients whose facial profiles recede, chin and tongue move posteriorly, and airway dimensions shrink, culminating in diagnosed sleep apnea. One patient who underwent double‑jaw advancement surgery demonstrates that surgical correction can resolve the apnea, underscoring the seriousness of the problem. The speaker then cites three peer‑reviewed studies (from China, Turkey, and another source) that quantitatively document reduced velopharyngeal, glossopharyngeal, and hypopharyngeal airway volumes, as well as altered hyoid bone position, after extraction‑based retraction treatments. The overarching question posed is whether orthodontic retraction can be justified when it may predispose patients to sleep apnea, suggesting a need to reconsider treatment philosophies that prioritize retraction.
Chapters
Welcome back. This segment is entitled, Is Retraction Really Acceptable? Before we go into retraction, let's review a bit about sleep apnea. Remember that John Remers tells us sleep apnea will become the most common chronic disease in all industrialized countries. He further states that a structural narrowing of the pharynx plays a critical role in most, if not all, cases of sleep apnea. And most importantly, he says that sleep apnea would not exist if the jaws were placed properly forward in the face. For those familiar with orthodontics, you know that orthodontics is basically retractive in nature. Things are done purposely, or sometimes not purposely, which result in retraction of the teeth. Let's look then from the refereed literature to see if that will change, if retracting can actually change the growth of the entire lower face. What better kind of a case to look at than that of a patient missing lateral incisors? And here's a boy who's 8 years of age, months of age when he has expansion of the maxillary arch done. So, notice he goes from 8 years, 8 months to 12 years, 10 months and has— and undergoes maxillary expansion. See that his upper incisors come downward and forward dramatically as we expect them to. And he gets lots of wonderful forward growth of the lower jaw, which brings his tongue forward and opens his airway up. Dramatic forward growth of the lower face as we've been taught And as we would expect. The next part of the treatment, however, involves what is known as canine substitution, and bringing the cuspids forward into the space. In reality, what happens is shown on this slide here. The upper incisor is retracted back. And as it's retracted back, what's happened in this case is that the formerly forward-growing mandible— ceases growing forward at all, and over this 2-year timeframe, grows only vertically. And you can imagine what effect this has down the road. We look at the refereed literature and look at a reference on maxillary space closure in missing lateral incisor cases and how it affects the need for surgery in cleft palate patients. They concluded there's a strong association between the orthodontic canine substitution and maxillary hypoplasia and the subsequent need to surgically advance the maxilla in cleft palate patients. This isn't really too astonishing given the fact that we've just seen that the central incisors get retracted. In reality, closing those spaces has retracted them enough, the teeth enough, to cause the need for maxillary advancement surgery. Hardly seems sensible. Let's look then at what might happen for an adult who's had missing lateral incisor teeth space closure. And this is what's happened for this gentleman. And he's in his mid-50s, and by this time in his life, he's now disabled because he's had a stroke and he can no longer work. You notice that his forehead is tilted back dramatically. This is because he needs to keep his chin forward just to keep his airway open. And you can see that his face has fallen back from where it ideally might be. The fact of the matter is, People like this usually don't even know why they have this stroke. In reality, it's almost always caused by sleep apnea. Let's look at a young individual here who has bicuspid teeth extracted about the time the picture on the left was taken. He was less than 10 years of age at that point. And you see subsequent pictures of him here, post-orthodontically, 1 year post-orthodontically, and 2 years post-orthodontically. A routine Class I 4-bicuspid extraction case. But let's look a little deeper than that. Let's look at what happens to his face. Look at the tangent from his eyelid to tangent to his cheek and see how his cheek is falling back over a period of just 2 or 3 years. More important than that, however, is the distance between his neck and his chin. What that really says is that his chin is back dramatically, and if his chin is back, His tongue is back, and his airway is substantially smaller than it might ideally be. In the picture on the right-hand side, you see a young man who does not have even a hint of a whisker. In other words, he's probably not gone through puberty, and he has most of his pubertal growth to go forward now. And the fact is that his mandible will probably drop down and will have more vertical growth of his lower face, increasing his chances for— Snoring. problems with sleep apnea. Here then is a grown individual who has already had bicuspids extracted when he was a child, and he is suffering from sleep apnea. And if we compare him with the Bolton norm superimposed on his face, showing his entire maxilla and mandible back substantially from where it should be, and with the boy, you realize that the boy is very likely to have the same thing happen if his airway is similarly as compromised as the man's. Now, you can look at the man on the right-hand side. He's had double jaw surgery to advance both jaws, and indeed, this has, in his case, eliminated his sleep apnea. But certainly, we don't want to be doing surgery for every patient. Wouldn't it be nice if we avoided the problem to begin with by not doing the treatment in the first place? Let's look at what happens from the refereed literature about changes of pharyngeal airway size and hyoid bone position following orthotic treatment of Class I bimaxillary protrusive patients. This is from China, and it talks about the fact that the pharyngeal airway size became narrower after the treatment. In other words, extraction of 4 premolars with retraction of incisors did affect the velopharyngeal, glossopharyngeal, hypopharyngeal, and hyoid position. Another study out of the refereed literature over the same thing concludes that large incisor retraction leads to narrowing of the upper airway in adult bimaxillary protrusion Finally, another study, this one from Turkey, states that extraction treatment using maximum anchorage has a reducing effect on the middle and inferior airway dimensions. The point here is, can we still justify retracting patients when sleep apnea is a possible outcome?
