In this YouTube presentation, orthodontist Bill Hang challenges the prevailing standard of care that advocates early retraction of protruding maxillary incisors in Class II Division I malocclusion. He begins by summarizing the conventional rationale—reducing incisor protrusion to prevent trauma and improve self‑esteem—citing the American Journal of Orthodontics. He then details a compelling case of a child whose maxillary incisors were minimally retracted with fixed braces, resulting in a dramatically narrowed airway, severe insomnia, low energy, and suicidal thoughts. Imaging shows the airway reduction and the tiny tooth movement. After conventional treatment failed to alleviate symptoms, the patient underwent a maxillomandibular advancement (MMA) surgery, which restored airway patency and resolved her systemic symptoms. Hang supports his argument with a 1981 study by James McNamara, which found that most Class II cases exhibit a neutral or retruded maxilla and that mandibular retrusion is the predominant skeletal issue. He argues that treatment protocols should focus on addressing mandibular deficiency rather than retracting the maxilla, and he asks the audience whether the standard of care should be revised. The talk combines clinical imaging, patient outcomes, literature review, and a call for re‑evaluation of orthodontic guidelines.
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Welcome back. This segment is entitled, Is This Standard of Care Really Acceptable? Let's first look at what is the standard of care for protruding maxillary incisors. What better place to look at that than from the American Journal of Orthodontics and the editor, where he's discussing what cases should be treated early and what should be treated later. Here he states, for example, there's now clear and compelling evidence that early treatment, i.e., the first of 2 phases, should be performed when a patient has protruding maxillary incisors. Such treatment is justified because reducing the protrusion actually protects the incisors from trauma and also improves self-esteem and social adjustment. This is simple to explain to patients and parents. It is simple to do, and it is justified by the available evidence. Here we then have an example of a patient who has a Class II Division I malocclusion. When she was a child, her parents lived in Seattle, and her dentist there actually had referred her to me, but I never saw her. The family never contacted me. They moved to another city, and they sought the services of another orthodontist to help her get her lips together. When she was that— at this age, she had all the energy in the world, was a very active child like most other kids. If you look at her face with the nose-lip angle indicating where the position, the proper position of the maxilla, her maxilla, by this definition, is way too far back already, and not protrusive. In reality, her mandible is severely recessed, which is really her problem. Here then is what she looks like after she's had retraction of the upper incisor teeth with fixed braces, You see a bonded retainer holding the 4 incisors together, and these teeth have been retracted very minutely. Her lips are together a little bit better, but they still are apart most of the time. The standard of care has been achieved because the protrusion has been diminished to some degree. The problem is she immediately has problems breathing. She has no energy. She can't sleep, and she has suicide thoughts. And her parents are very worried about her. She sees doctors who have no solution for her. Looking at the lateral head x-ray, you can see her pretreatment airway on the left-hand side between the arrows being diminished to the right-hand side between the arrows. And you can see the amount of protrusion which was changed. You can see the red line between the upper and lower incisors on the left, And on the right-hand side, I've superimposed the same red line on the lower incisor, and you can see how much the upper incisor has been moved back. Very, very, very minutely. And yet, this very big change in the symptom pattern changed for her. In this picture, she's had the bonded retainer removed, but it didn't change any of the symptoms she was still suffering from. Here you see another depiction from the side. Apparently, minor retraction of the maxillary anterior teeth caused her to have an inability to breathe, She lost energy, couldn't sleep, and she began having suicide thoughts. Here she is about the time we did a long-distance consultation for her. In that consultation, we learned that she'd seen a pediatric cardiologist when she was in the 2nd grade who said she was absolutely fine, but at the point when I was talking to her, she says, I can't run at all, and she said, I never sleep, I have terrible insomnia. We suggested a sleep test. We suggested myofunctional therapy and probable double jaw advancement surgery if she was going to get her jaws forward, since it was well beyond the age when orthotropics might be expected to develop the lower face forward for her. If you look at her face relative to the Bolton norm, you can see how absolutely recessed both the maxilla and the mandible are from where they ought to be. Here she is, 5 months after she's had maxillomandibular advancement surgery for her sleep apnea. You can see her here in profile before her original treatment and after her retractive treatment on the right-hand side. Now you see her after her retractive treatment on the left-hand side, and before we did any treatment for her, with both jaws still recessed rather massively. Here you see after she's had surgery to advance both upper and lower jaws forward and open her airway. And get rid of her symptom pattern, which it did. So, my question to you is, do you think the standard of care for protruding maxillary incisors needs to change? Maybe we should answer that by looking at the refereed literature from July of 1981. Dr. James McNamara, one of the best-known names of all of orthodontics, wrote this article published in the Angle Orthodontist on components of Class II malocclusion in children aged 8 to 10. And he stated, only a small percentage of the cases in this study exhibited maxillary skeletal protrusion relative to cranial and cranial base structures. On the average, the maxilla was in a neutral position. It was more often in a retruded than protruded position. Suggested that mandibular skeletal retrusion was the most common single characteristic of the Class II example. Suggested that maxillary skeletal protrusion is not a common finding. In fact, more cases of maxillary retrusion were observed. Thus, it appears that in designing the ideal treatment regime, those approaches which might alter the amount and direction of mandibular growth could be more appropriate in many cases than those which restrict maxillary development. This was many years ago, more than 35 years ago, in the refereed literature, where it was basically recognized that the maxilla does not protrude in Class II cases. So, I ask you the question, do you think the standard of care for Class II patients should change?
