When Will the Insanity of Retraction End?
It wasn’t long after starting to practice that I recognized the irritation and additional stress I experienced from the shrill of the handpiece and the shrieks from the suction; it can truly drive you crazy! I also noticed that many of my colleagues complained of tinnitus (ringing in ears) and hearing difficulties, and I knew there was a serious problem that was not being recognized.
“You can kill a 12 year old boy with a headgear!” This statement was made by Dr. Christian Guilleminault, head of sleep at Stanford University until his death in July and arguably the best known name in the sleep arena. He was speaking at the AAO meeting on the subject of Orthodontics and OSA in January, 2019. I was in the audience and resisted the urge to stand on my chair and cheer. I’ve heard Dr. Guilleminault speak many times and know he was a passionate opponent of any type of retractive orthodontics due to the the effect he felt it had on patients’ airways.
I’ve spent the past 30 years reversing orthodontic retraction in its various forms and was thrilled to have someone of his stature in the sleep world say what my experience with patients leads me to believe is true. A day later, an extremely well known orthodontist spoke at the same meeting and apparently was quite dismissive of Guilleminault’s statement. I was disappointed, but not surprised to hear someone be so dismissive. Headgears specifically, as well as other forms of retraction, have been part of orthodontics for at least a hundred years despite the fact that 38 years ago an article from one of the best known names in orthodontics appeared in the refereed literature stating that the maxilla rarely protrudes in Class II cases. In reality we now know that the maxilla is always back in Class II patients.
It was my pleasure to share my experience about non-retractive orthodontics at the most recent AAOSH meeting in Nashville. We showed effective ways to straighten teeth without retracting, adding extra bicuspid teeth, re-opening previous orthodontic extraction spaces, mesializing the entire lower arch to reduce overjets in Class II cases, and massively expanding both arches laterally. We illustrated how carefully planned orthognathic surgery to advance both jaws and reverse previous retraction may eliminate OSA. We were careful to say there are no guarantees, but the approaches we present are always non-retractive. This gives every patient the possibility of having the best airway possible. Every dentist has patients in their practice who have serious airway issues and can benefit from proven treatment approaches to help them. I was thrilled to see the excellent response to my lecture.
Like everyone, we return to the real world of our practices on Monday morning. In my world I have people from all over the world seeking treatment to reverse previous retraction. Some may think I overdramatize the importance of breathing and airway. I’m nothing more than a spokesman for patients who consult with me and can’t find people who understand their problems, believe them, and have the knowledge and treatment strategies to help them. I did a long distance consultation on Skype recently with a 40 year old man from the suburbs of Sao Paulo, Brazil. I spent an entire hour on the phone with him listening to the sad tale of his retractive headgear orthodontic treatment and how he feels his life has been severely impacted. He is in such pain that he doesn’t even feel that he could endure travel to the U.S. He still lives with his parents and has had a very limited life because of his pain. I take notes as I listen to patients relate their story and here are some direct quotes. “It is a torture I live… it is like being trapped in your own body. It is a very difficult situation.. it is very lonely. I feel pressure in and around my neck like I’m being hanged by a rope all the time. My symptoms vary so much that it is difficult to describe them in Cartesian terms.” He has not had a sleep study, but is knowledgeable from his internet research and believes he suffers from UARS. He has severely worn his teeth from bruxing. Dentists without airway training might easily diagnose an acute lack of porcelain on his teeth. Airway trained dentists would immediately suspect an airway/sleep problem and have a series of questions to ask him to determine if a sleep study might be in order.
Before he contacted us he’d done extensive research on the internet and had seen many doctors over the years (including many orthodontists who dismissed him as crazy). He’d been told many times he needed surgery to advance both jaws. Most people initially reject surgery and try all conservative methods first. By the time he contacted us he’d tried all the conservative (non-surgical) solutions and had pretty much decided surgery was his only way to a more normal life. When he asked about the cost of surgery in the U.S. and I gave him an approximate number he sighed deeply and said that would the life savings for someone in Brazil. Unable to come to the US, I offered him some thoughts on how he might find a well trained surgeon in Brazil who understands how to properly reverse the retraction to open his airway.
We use Dr. Jeffrey Hindin’s autonomic testing equipment and protocol to assess heart rate variability in such patients, and I imagined how poor his HRV would be as I spoke with him on Skype. I ended the call hoping this gentleman, who has lived most of his life in sympathetic nervous system overload and knows his health is going downhill, will somehow find the resources and treatment he needs and not commit suicide.
Do you think Guilleminault was being dramatic…or realistic? How long does the insanity of retraction which can reduce a patient’s tongue space/airway have to go on before the profession wakes up? This Brazilian man is not a crazy man and an outlier. There are others all over the world who are in similar situations. What will we as a profession do to help them?
Written by William Hang, DDS
After completing his orthodontic training at the University of Minnesota, Dr. Hang joined the faculty there to teach orthodontics. He later established an orthodontic practice in rural Vermont. After practicing traditional orthodontics for 7 years, he saw serious limitations in esthetics and function with the traditional approach to orthodontics.
In 1981 Dr. Hang embarked on a continuing education odyssey which has so far taken him to 50 states and over 30 foreign countries in a quest for a better way to do orthodontics. In the process he moved to Southern California and developed a truly unique orthodontic practice with strong emphasis on facial esthetics achieved with innovative early treatment and adult treatment. More than 20 years ago he became aware of the significant positive affect some of his treatments were having on the airway. This opened up a whole new aspect of orthodontics – maximizing the airway for ALL orthodontic patients and specifically treating patients with SDB (sleep disordered breathing) or OSA (obstructive sleep apnea).
Having been reopening previous extraction spaces since 1989, Dr Hang recognized a syndrome he named Extraction Retraction Regret Syndrome™ or E.R.R.S.™
Dr. Hang’s approach to orthodontics is a result of blending the best ideas from the best practitioners. He has spoken on orthodontics, facial esthetics and airway locally, nationally, and internationally and appeared on the British equivalent of “Sixty Minutes”. He was the Founding President of the North American Association of Facial Orthotropics®, is a board member of the American Association of Physiological Medicine and Dentistry, and is an advisor to the Academy of Orofacial Myofunctional Therapy.