Extractions & The Airway

By Ashley Craig

 

When David* recognized his former Orthodontist while vacationing on a tropical island in 2010, he decided to confront him about his treatment as a child.

“Do you remember me?” he asked.  The orthodontist shook his head.  David smiled and pointed to his teeth.

 “Oh, I suppose you’re a former patient,” said the orthodontist.

“Yes.  Do you notice anything about my teeth?” David asked.  The orthodontist shook his head.

“They’ve returned to how they were before.  You really should change your treatment method.”

“Well, that’s your opinion,” the orthodontist responded.

Like many orthodontic patients, David had started with a minor case of crowding as a child.  His orthodontist removed four premolar teeth and subsequently applied fixed braces to close the gaps and align the teeth.  Shortly after their removal, his remaining teeth relapsed.  After enduring two years of his life in braces, thousands of dollars had gone toward a still-crooked smile, now with missing teeth.

Extraction of teeth is a common practice in the dental industry.  According to Orthodontist Chris Norton, over 60% of traditional orthodontic cases in the U.S. and over 80% in the U.K. involve extracting between four and eight permanent teeth. Removing teeth and straightening them into alignment may at first appear to be a simple and effective method of correcting teeth.  With myriad problems resulting from extraction treatment, however, one must question whether this method is an easy way out for the practitioner rather than an optimal solution for the patient.  In the short term extraction is hard on the body, with trauma to the surrounding tissue, use of anesthesia, and potential for complications such as bleeding and dry sockets.   Beyond these immediate issues, extracting teeth and closing the gaps narrows the dental arch, allowing less room for the tongue and potentially reducing the volume of the posterior airway.  The approach can lead to long-term conditions such as sleep apnea, and even damage the facial structure.  A narrow arch provides less bony support for the face, sometimes leading to a dished-in appearance from the side as well as a narrower facial structure and smile.

The difference between extraction and non-extraction treatment is exemplified by a paper published by Dr. H.L. Eirew in the British Dental Journal in 1976.  Two identical twin girls had presented with identical cases of crowded teeth. 

twins.jpg

 One received extraction treatment, while the other had her palate expanded.  The resulting differences are nothing short of profound.

For many years, orthodontists have practiced with the belief that we have evolved to have smaller jaws that are unable to accommodate all 32 teeth. Looking at the history of malocclusion, however, it becomes apparent that the rise of crooked teeth is closely paralleled with the rapid rise of civilization – something that has only taken off in the last four hundred years; a relative blink of an eye with the process of evolution taking millions of years.  This amount of time is simply too short for our genes to have changed significantly.  As such, it seems that crooked teeth are not a result of genetically smaller jaws but rather a developmental effect of our modern lifestyles.

Once we accept that narrow jaws and malocclusion are environmental rather than genetic, the focus of orthodontic treatment necessarily changes from the easy route of extracting teeth to the optimal solution of expanding the jaw to accommodate the teeth.  

What About Wisdom Teeth?

Janet’s* story demonstrates how the dental industry can be overly extraction-happy.  She’s one of the lucky ones, with a wide dental arch and enough room to accommodate all 32 teeth.  Her wisdoms grew in straight without issue, and yet every six months at her dental check-up she receives the same advice from her dentist: “You might as well get your wisdom teeth removed; you don’t need them.”

Even if we were to accept the common “wisdom” that wisdom teeth are vestigial structures, it is alarming to think about the prevalence of wisdom tooth extraction.  After all, we do not have our appendix removed unless it causes us problems.  Why, then, do nearly 85% of adults go through the trauma of surgery for teeth that frequently remain dormant in the bone, or even erupt fully with no issue?  There appears to be a degree of fear mongering, with experts advising patients that problems like decay, infection or cysts will most likely flare up in time.  However, figures cited by organizations with a vested interest in promoting oral surgery are rarely backed by evidence.  In fact, when asked by the New York Times to back up its claim that 80% of young adults who retained wisdom teeth developed problems within seven years, The American Association of Oral and Maxillofacial Surgeons could not produce supporting evidence and deleted the statement from their website.  Critics of routine extraction cite many studies, among them one that found complications occurred for only 12% of 1,756 middle-aged people who did not have their wisdom teeth removed.

Perhaps many of us get along fine without our wisdom teeth, but are we really in optimal condition without them?  It’s certainly a thought to chew on.

Want to fight unnecessary extraction and help save the wisdom teeth of the world?  Click here to donate to our research fund and receive a free T-shirt with a donation of $30 or more.

*Name changed 

Showing 38 reactions

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  • Kim Henry
    commented 2020-10-24 16:23:42 -0700 · Flag
    Ricky,

    Speaking of shoes, if you were an adult and had finished growth, and you wore tight shoes, would it make your feet smaller? No, because growth was completed and you can’t influence it anymore. All it would do is cramp your toes and cause blisters.

    Palatal expansion is not a “new” technique. There is nothing “new” about TRYING to direct and potentiate growth. I have done it all my career. But it has its limitations, and timing is critical.

    For the millionth time, premolar extraction does not appreciably influence the width or length of the maxilla or mandible. It typically makes room so the anteriors can be decrowded. Any extra space is consumed by translating molars forward, which often makes room for wisdom teeth to erupt.

    For goodness sakes, stop with the “extraction pushes the jaws backward and impinges on the airway” nonsense. There is no net forward or backward force on the maxilla with extraction mechanics. The forces applied WITHIN the maxilla counteract one another. The only way to influence maxillary position is by 24-hour headgear. Kids never cooperated in wearing it that way, and we have not used headgear in about 20 years.
  • Ricky James
    commented 2020-10-24 15:12:57 -0700 · Flag
    Kim. If you had tight fitting shoes, you would not cut off a toe to fit the shoe, you would buy bigger shoes.

    Having new techniques nowadays which enable palate expansion in order to accommodate the teeth DOES NOT excuse the removal of teeth in the past.

    You state modern jaws are smaller. Then why on earth would you make them even smaller by extracting teeth?!
  • Ricky James
    followed this page 2020-10-24 15:08:14 -0700
  • Kim Henry
    commented 2020-10-11 09:14:42 -0700 · Flag
    Then send the TRACED cephs, along with photos, to henrius@mindspring.com. And give a synopsis of what kind of biomechanics were used. Hope I don’t get hate mail from other posters this time.
  • Inquisitive
    commented 2020-10-11 02:33:27 -0700 · Flag
    Email is fine.
  • Kim Henry
    commented 2020-10-10 15:48:12 -0700 · Flag
    Also photos would be helpful.
  • Kim Henry
    commented 2020-10-10 15:47:55 -0700 · Flag
    Fine Inquisitive. By e-mail or snail mail?
  • Inquisitive
    commented 2020-10-10 11:36:12 -0700
    I’ll send you an PAN and CEPH of before and after whereby this happened if you like?
  • Kim Henry
    commented 2020-10-10 10:40:16 -0700
    Not sure I know what you think is negligent.

    When I traced cephs post-operatively all all patients, I never detected any appreciable increase in mandibular plane angle. Even brachyfacal patients, which would look better with longer faces, are hard to achieve mandibular plane angle increases.

    The way you would get appreciable mandibular plane angle increases was trying molar distalizations on clockwise growers. That is why we were taught to do extractions rather than molar distalizations in crowded high mandibular plane angle patients. Sure don’t want to open the mandible anymore by distalizing molars. Of course if the arch is constricted and the patient has the potential, I will expand the palate using a Hyrax with the mandible as a template as to how far I can expand.

    In the old days we tried to treat high mandibular plane angle patients with high-pull headgear. Cooperation was alway dicey. With high-pull seldom if ever used, I’m not sure anyone tries to control the vertical anymore. Just wait until surgery is possible if the patient wants it fixed.
  • Inquisitive
    commented 2020-10-10 07:29:48 -0700
    Pretty negligent thing to do, isn’t it? It can be done during retraction of retruding teeth if control is lost during space closure.

    I am speaking of the increase in mandbular plane angle, yes, which is not a direct effect of the extractions themselves, no. I agree, of course.

    What do you think could be the cause of this to happen in what happens to be an extraction case, however?
  • Kim Henry
    commented 2020-10-10 06:23:57 -0700
    I don’t know how anyone would “severely narrow” the maxilla non-surgically. Widening it is easy in a child using a Hyrax or similar device . The maxilla is two bones connected by a suture in the middle, until the suture fuses in the late teens. We cannot narrow maxillas without surgery. Why would we want to when arches are crowded anyway?

    Again, I have measured many ceph x-rays, and I do not find “recessed maxillas by the norms in class IIIs,” except in the occasional Mongol patient. What you are alleging is in fact not correct. I use Nasion Peripinduluar on cephs as an indication of antero-posterior maxillary position.

    By mandibular “falling open” are you saying increasing mandibular plane angle? I don’t get your terminology. Increasing mandibular plane angle is not a result of premolar extraction.
  • Inquisitive
    commented 2020-10-10 06:07:19 -0700 · Flag
    So, then the only way that what i mentioned below could happen to someone durung treatment is to severely narrow the maxilla. I suppose this is happening to this particular person’s mandible because the severe narrowing of the maxilla restricted the growth of the mandible. Would you agree?
  • Inquisitive
    commented 2020-10-10 06:04:03 -0700 · Flag
    You’ll often find that the maxilla is extemely recessed in a class three patient.

    I said “the lower jaw falls open and swings back”. So down and back. You’re telling me that you don’t think that is possible from negligent orthodontics treatment?
  • Kim Henry
    commented 2020-10-10 05:54:52 -0700
    A mandible falling open does not “squash” anyone’s airway. When we are short on breath, we open our jaws to breathe, do we not?

    I would have that teenager imaged via CAT scan and examined by an ENT to find the true cause.

    You are wrong about class III. True maxillary retrognathism is very rare except in Asians. In Negroes and Caucasians, the problem is almost always an overly large mandible. We used to used chin-cups early to try to stunt mandibular growth but they never worked. To this day we cannot retard the growth of someone showing a tendency to mandibular prognathism. It is a highly heritable trait. Almost always one parent, or at least one grandparent, has the trait.

    Restraining mandibular growth is very difficult. Potentiating possible growth via unlocking a deep bite is easier.
  • Inquisitive
    commented 2020-10-10 04:13:40 -0700
    “IF WE COULD, WE WOULD PREVENT CLASS III PROGNATHISM. Everything we have tried to stem that seems to have failed!”

    Generally a class three patient doesn’t have a mandible which is too large – that’s the case sometimes, but rare. Generally the maxilla is narrow and set back.

    Do you think it is possible for poor extractuon treatment to force the mandible back? And do you think it is possible for extraction treatment to go so wrong that a 15 year teenager complains midway through treatment, that when lying on his or her side during sleep, the lower jaw falls open and swings back, squashing that teen’s airway? And if you do think it is possible, what are some of the likely causes?
  • Kim Henry
    commented 2020-10-09 18:38:08 -0700 · Flag
    Orthodontic treatment, poor or not, has a limited ability to affect antero-posterior growth. Growth potential is mostly genetically determined. Lateral growth is one thing that can be influenced by tongue posture. Premaxially growth can be potentiated by thumb-sucking.

    That being said, I recently encountered a boy whose maxilla was overly expanded by a Hyrax by trying to do orthodontics non-extraction. The damage is irreversible. That case is an outlier, though.

    A natural deep bite has a greater tendency to restrict mandibular development than anything we do orthodontically. If we get lucky, when we unlock deep bites, sometimes we see mandibular growth forward. But not always. One can never know what genetic growth potential the kid had. If both parents were retrognathic, you’d better do some praying.

    Headgear was never applied to the mandible. We can only potentiate genetically programmed growth in the mandible by unlocking deep bites. We cannot do much to restrict mandibular growth. IF WE COULD, WE WOULD PREVENT CLASS III PROGNATHISM. Everything we have tried to stem that seems to have failed!
  • Inquisitive
    commented 2020-10-09 17:14:48 -0700
    Do you agree or disagree that poor orthodontic treatment has the abiliity to negatively effect growth? Do you agree or disagree that poor orthodontic treatment has the ability to push a mandible too far back?
  • Kim Henry
    commented 2020-10-09 16:07:44 -0700 · Flag
    I am not trying to “defend” anything. I am debunking hocus-pocus blame games.

    There are a lot of factors that go into the final shape of a patient’s face and airway. The top ones are genetics and allergies. You seem to forget that ugly smiles are debilitating to many people. They want them improved. The fact is we cannot always fix ugly smiles without extractions. The way to REALLY retard the maxilla would be not to extract teeth, but to try to distalize the molars via 24 hour headgear. Which would you want? Pick your poison. That is why distalization headgear was so rarely tried back when I started doing fixed cases.

    Plenty of people have sleep apnea and other airway problems who have never had orthodontics. It is impossible to know in a particular patient whether orthodontics contributed to airway problems or not. The closest thing we can do is look at airway space on x-ray pre-op, then look at it post-op to see if there are any changes. Rarely do I see any.

    “Children and adults know their bodies. A 7 year old is extremely aware, often more so than an adult. "

    This is pure nonsense. No 7 year olds can understand their orthodontic diagnosis, or even have a clue what caused their ugly smile. All they know is they have an ugly smile and are teased by other children. And they usually want it corrected. And it can’t always be corrected non-extraction. Even IF orthodontics caused airway restriction, the average kid with ugly teeth would want it corrected.

    When I comment, I am referencing about the standard of care in the US. I have to admit relative ignorance of the standards in the UK. From what I have seen, it appears like the Brit orthodontic standard of care, particularly under NHS, is far below that of in the US.
  • Inquisitive
    commented 2020-10-09 11:38:41 -0700
    Thank you for; “You completely misunderstand what is happening in orthodontic mechanics. You actually do not have a clue what is going on from reading website drivel”

    That makes me understand your ignorance.

    Personally, i have reviewed the orthodontic literature, papers on the importance of space closure technique and mechanisms, what can go wrong during space closure technique, how this can then inpede on growth, how the maxilla can held back from growth or pushed back during growth or after, how bone loss effects growth, how elastics can pull a maxilla down and back, the link between the maxilla and nasal cavity, the importance of nose breathig etc. I’ve read books, spoken to professors. I’ve also seen a case where by a child’s face was completely destroyed in a matter of 6 months from too much pressure being put on the maxillae and how the elastics pulled maxilla back into the face of a 14 year old boy. This child was then diagnosed with sleep apnea and he is being offered no help to put this case right.

    Extractions will always cause some kind of damage, but if handled correctly, the damage will be negligible. They will always narrow a palate. Non extraction treatment can also be harmful.

    There are few studies on whether the damage is a direct cause of the narrowed arches and bone loss, but we do know that bone loss and a narrow arch has some negative effect on growth. Its not rocket science. This is biology.

    You’ve builled these people on here instead of trying to help them. People, ‘professionals’ who defend themselves in this way are not generally interested in further education but rather their ego. I am not sure what you are trying ro achieve.

    Children and adults know their bodies. A 7 year old is extremely aware, often more so than an adult.

    You are very aware of what damage CAN be caused by treatment, so stop defending it and let these people express themselves and allow others to learn from their experiences, to enable them to make informed decisions about their future treatment.
  • Kim Henry
    commented 2020-10-08 17:35:41 -0700
    We don’t typically retract anterior teeth in an extraction case unless they are demonstrably procumbent and the patient is unhappy with them that way. We extract teeth to decrowd the anteriors, not retract them. Once aligned, we “burn anchorage” by moving molar teeth forward, if there is any leftover space. We don’t retract molars like you keep saying we do. Molars usually end up going forward in extraction cases. These days we anchor molars during decrowding via transpalatal arches and TADs and not headgear.

    You completely misunderstand what is happening in orthodontic mechanics. You actually do not have a clue what is going on from reading website drivel.

    Nothing is clear from the above photos of the twins. To understand what has happened, we would need traced cephalometric x-rays.
  • Kim Henry
    commented 2020-03-31 15:21:33 -0700 · Flag
    You and politicians are not competent to judge whether children need orthodontics or what type they may have, despite the inflated knowledge you think you gained from reading this website. You may pursue your former orthodontist in a court of law if he is still alive.
  • Alexander Illi
    commented 2020-03-31 08:05:16 -0700 · Flag
    Kim, you are trying to talk a simple matter to death, in a manner reminiscent of psychological harrassment.
    I had healthy teeth, and no-one complained about them before the dentist.
    I may petition lawmakers for whatever I like.
    If you continue addressing me here, I will treat is as stlking attempt.
  • Kim Henry
    commented 2020-03-30 18:56:03 -0700
    Again, a positive overbite and overjet are normal. You still are confused about terms.

    I cannot Monday morning quarterback without examining your treatment records pre- and post-op. You do not clearly say whether you were maxillary prognathic or mandibular retrognathic or neither.

    Esthetics cannot be internationally legislated, as beauty varies from culture to culture. There is a trip in Africa that extracts the lower permanent incisors on all boys and thinks it looks great.

    So you think governments should legislate orthodontic treatment? Wow, you have a lot of faith in government that you think it should supervise lower craniofacial esthetics.

    If you have photos of your childhood “perfect teeth,” why not post them? Please include occlusal mirror shots of the upper and lower arches, as well as mirror views of both sides. Front smile views alone do not tell much.
  • Alexander Illi
    commented 2020-03-30 03:37:45 -0700
    The dentist proposed to my mother, that I had an overbite and “would not look well” when I became adult. That’s why I’m here – I don’t want dentists to be allowed to suggest such interferences to parents, when there are no medical reasons*. My mum was very busy, a little bit distracted maybe due to her large work load, and just trusted the dentist, so she gave her consent. A few years later, I myself would have vigorously objected to such a treatment, but at about ten years of age I was not mature enough to do so.

    Now, I don’t even have an overbite, my front row of teeth meet head-on.

    *In my opinion, medical reasons have to be legally defined internationally, before treatments of children are allowed to be suggested to parents or caretakers.

    I have childhood fotos to prove that I had perfect teeth.
  • Kim Henry
    commented 2020-03-26 18:27:34 -0700
    If you did not have crooked or crowded teeth, why did you parents seek orthodontic treatment for you? A phenomenon called “mesial drift” during life tends to close spaces and create crowding as time goes on. This happens with or without orthodontics.

    Everyone has overbite. They should. Our treatment goal in orthodontics is 2mm overbite and 2mm overjet.

    One person’s “natural” smile is another person’s “hideous” smile. Parents often ask me if their child “needs” orthodontics. I tell them nobody has ever died from crooked teeth. So if they and their child wants straighter teeth, I can help them. SOMETIMES it takes extractions to do this.
  • Alexander Illi
    commented 2020-03-25 05:02:05 -0700
    Kim, I didn’t have crooked or crowded teeth – now I have crowded teeth, pulled together by the brace, so that no tooth silk will fit in between. Please stop throwing my experience together with whatever random allegations you have. It seems you didn’t have patience to read my comments correctly – since the beginning you are accusing me of things I did not write.

    BTW, I’m not one of those who like a standardized ideal of beauty, I personally found slighty irregular teeth (to a certain extent) attractive – and I never spoke of clinical cases with extraordinary deformities, but about obviously lacking standards for “aesthetic” orthodontics.
    I was speaking about a healthy boy (me) with a miniscule “overbite”.
  • Kim Henry
    commented 2020-03-24 19:00:06 -0700
    So you call orthodontics “unwarranted mutiliation of minors?” So parents who want their kid’s smile to be attractive want their children MUTILATED? So you are saying parents are accessories to some crime???

    Tooth size/arch length discrepancy is a FACT. If you don’t believe it look at some of my pre-op casts. Some kids have large teeth and short jaws. You can gain SOME space by stripping and/or expansion, but not 9millimeters or more. Just not possible. A few months back I had a kid ruined by some goofball dentist like you idolize. He expanded the maxilla so much just to fit all the teeth in without extractions. Guess what? The kid’s mandible will never be as wide as his maxilla. There is NO WAY, even with surgery, to make upper and lower teeth fit. The parents are desperate. I had to tell them their kids lower face is ruined for life. All because of ignorance like the type you recite.

    You don’t want kids to be “mutilated” by orthodontics? Then convince parents that crowded, crooked teeth should not be a concern!
  • Alexander Illi
    commented 2020-02-27 23:34:03 -0800 · Flag
    Aesthetic orthodontics ( extractions & braces ) are an unwarranted mutilation of minors, potentially none less disastrous in later life than the often maligned FGM (Female Genital Mutilation).

    They alter the facial structure enough to outwardly change the face form, which is the “reason” dentists and orthodontists prescribe it in the first place.

    The stunting of the jaws leads to slackened tissue in the whole oral and nasal area, e.g. the velum, which in turn can lead to chronically blocked airways (including a higher incidence of infections), snoring and on-set of sleep apnoe. Furthermore it can shove the teeth together, so that not even tooth silk will fit in between them, which is of course optimal for pathogens (bacteria etc.) to settle there. If the top row of teeth recedes, the nose will appear more jutting out, and the upper lip and the labial angle (upper mouth corners) will wrinkle earlier. Since a slight ‘overbite’ is a natural protection against the teeth hitting together, the lower jaw will be held receded, leading to the impression of a fleeting chin.

    For what “reason” are aesthetic orthodontics usually applied on children?
    The dentist tells the parents their child will be disfigured later. That’s basically all – even though they often use terms like “correction of an overbite” instead.
    Parents, being concerned about their childrens’ well-being, then usually agree to the professional advice. Then teeth get pulled out, and so on…

    It’s a perfect money-making device for dentists and orthodontists.

    All of theses have been my experiences, and the negative effects become more apparent once one gets older.

    As a child, I was trusting to have been born in more enlightened times, but basically it’s a system very well comparable to e.g. FGM practised in so-called primitive cultures.
  • Alexander Illi
    commented 2020-02-03 09:52:51 -0800 · Flag
    Thank you, Kim.
  • Kim Henry
    commented 2020-02-02 18:41:00 -0800
    Alexander, if you “feel” your tongue is about 7mm too long, convince an oral surgeon to reduce the size. WARNING: It is a very difficult surgery.

    You may be in fact CARRYING your tongue further forward due to pharyngeal muscle collapse.

    It is impossible for extraction orthodontics with or without headgear to shorten the maxilla by 7mm. Sorry, just not possible.

    Treatment is not based on “feeling,” but facts. Have you traced your airway on a ceph x-ray or cone beam image? Have you compared pre and post treatment cephalometric films to assess the REAL changes by orthodontics? I have on many cases, and relative bone changes are usually very small.

    Finally, if you have missing teeth the tongue can enlarge by compensation, and this makes apnea more likely.

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